Impact of UK National Health Service smoking cessation services: variations in outcomes in England

Prehabilitation and Rehabilitation for Patients with Lung Cancer: A Review of Where we are Today

Lung cancer is the third most common type of cancer in the UK, with nearly 50 000 new cases diagnosed a year. Treatments for lung cancer have improved in recent years with the advent of new surgical and radiotherapy techniques and the increased use of immunotherapies. These advances have resulted in increasing numbers of patients surviving beyond the completion of their treatment. Lung cancer patients are now not dying from their cancer diagnosis, but from other co-existing pathologies. Lung cancer patients commonly present with multiple comorbidities. Mitigating the effects of poor lifestyles and changing behaviours may improve the efficacy of treatments, reduce side-effects and improve the quality of life for lung cancer patients. Published evidence supports the use of interventions to manage behavioural habits, to optimise the health of patients. There is no consensus as to what, when or how to embed these into the patient pathway. Supporting patients before, during and after their cancer treatments to increase activity, eat well and stop smoking have been seen to decrease side-effects and improve patient outcomes and wellbeing. The challenge is to provide a package of interventions that is acceptable to patients and fits within the patient pathway so as not to conflict with diagnostic and therapeutic activities. This article reviews where we are today with providing behavioural support to optimise the health of lung cancer patients undergoing treatment.

Start2quit: a randomised clinical controlled trial to evaluate the effectiveness and cost-effectiveness of using personal tailored risk information and taster sessions to increase the uptake of the NHS Stop Smoking Services

BACKGROUND

The NHS Stop Smoking Services (SSSs) offer help to smokers who want to quit. However, the proportion of smokers attending the SSSs is low and current figures show a continuing downward trend. This research addressed the problem of how to motivate more smokers to accept help to quit.

OBJECTIVES

To assess the relative effectiveness, and cost-effectiveness, of an intervention consisting of proactive recruitment by a brief computer-tailored personal risk letter and an invitation to a 'Come and Try it' taster session to provide information about the SSSs, compared with a standard generic letter advertising the service, in terms of attendance at the SSSs of at least one session and validated 7-day point prevalent abstinence at the 6-month follow-up.

DESIGN

Randomised controlled trial of a complex intervention with follow-up 6 months after the date of randomisation.

SETTING

SSSs and general practices in England.

PARTICIPANTS

All smokers aged ≥ 16 years identified from medical records in participating practices who were motivated to quit and who had not attended the SSS in the previous 12 months. Participants were randomised in the ratio 3 : 2 (intervention to control) by a computer program.

INTERVENTIONS

Intervention - brief personalised and tailored letter sent from the general practitioner using information obtained from the screening questionnaire and from medical records, and an invitation to attend a taster session, run by the local SSS. Control - standard generic letter from the general practice advertising the local SSS and the therapies available, and asking the smoker to contact the service to make an appointment.

MAIN OUTCOME MEASURES

(1) Proportion of people attending the first session of a 6-week course over a period of 6 months from the receipt of the invitation letter, measured by records of attendance at the SSSs; (2) 7-day point prevalent abstinence at the 6-month follow-up, validated by salivary cotinine analysis; and (3) cost-effectiveness of the intervention.

RESULTS

Eighteen SSSs and 99 practices within the SSS areas participated; 4384 participants were randomised to the intervention (n = 2636) or control (n = 1748). One participant withdrew and 4383 were analysed. The proportion of people attending the first session of a SSS course was significantly higher in the intervention group than in the control group [17.4% vs. 9.0%; unadjusted odds ratio (OR) 2.12, 95% confidence interval (CI) 1.75 to 2.57; p < 0.001]. The validated 7-day point prevalent abstinence at the 6-month follow-up was significantly higher in the intervention group than in the control group (9.0% vs. 5.6%; unadjusted OR 1.68, 95% CI 1.32 to 2.15; p < 0.001), as was the validated 3-month prolonged abstinence and all other periods of abstinence measured by self-report. Using the National Institute for Health and Care Excellence decision-making threshold range of £20,000-30,000 per quality-adjusted life-year gained, the probability that the intervention was more cost-effective than the control was up to 27% at 6 months and > 86% over a lifetime horizon.

LIMITATIONS

Participating SSSs may not be representative of all SSSs in England. Recruitment was low, at 4%.

CONCLUSIONS

The Start2quit trial added to evidence that a proactive approach with an intensive intervention to deliver personalised risk information and offer a no-commitment introductory session can be successful in reaching more smokers and increasing the uptake of the SSS and quit rates. The intervention appears less likely to be cost-effective in the short term, but is highly likely to be cost-effective over a lifetime horizon.

FUTURE WORK

Further research could assess the separate effects of these components.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN76561916.

FUNDING DETAILS

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 3. See the NIHR Journals Library website for further project information.

Factors associated with the effectiveness and reach of NHS stop smoking services for pregnant women in England

BACKGROUND

The UK National Health Service provides Stop Smoking Services for pregnant women (SSSP) but there is a lack of evidence concerning how these are best organised. This study investigates influences on services' effectiveness and also on their propensity to engage pregnant smokers with support in stopping smoking.

METHODS

Survey data collected from 121/141 (86%) of SSSP were augmented with data from Hospital Episode Statistics and the 2011 UK National Census. 'Reach' or propensity to engage smokers with support was defined as the percentage of pregnant smokers setting a quit date with SSSP support, and 'Effectiveness' as the percentage of women who set a quit date who also reported abstinence at four weeks later. A bivariate (i.e. two outcome variable) response Markov Chain Monte Carlo model was used to identify service-level factors associated with the Reach and Effectiveness of SSSP.

RESULTS

Beta coefficients represent a percentage change in Reach and Effectiveness by the covariate. Providing the majority of one-to-one contacts in a clinic rather than at home increased both Reach (%) (β: 6.97, 95% CI: 3.34, 10.60) and Effectiveness (%) (β: 7.37, 95% CI: 3.03, 11.70). Reach of SSSP was also increased when the population served was more deprived (β for increase in Reach with a one unit increase in IMD score: 0.55, 95% CI: 0.25, 0.85), had a lower proportion of people with dependent children (β: -2.52, 95% CI: -3.82, -1.22), and a lower proportion of people in managerial or professional occupations (β: -0.31, 95% CI: -0.59, -0.03). The Effectiveness of SSSP was decreased in those areas that had a greater percentage of people >16 years with no educational qualifications (β: -0.51, 95% CI: -0.95, -0.07).

CONCLUSIONS

To engage pregnant smokers and to encourage them to quit, it may be more efficient for SSSP support to be focussed around clinics, rather than women's homes. Reach of SSSP is inversely associated with disadvantage and efforts should be made to contact these women as they are less likely to achieve abstinence in the short and longer term.

Neighbourhood Deprivation and Outcomes of Stop Smoking Support--An Observational Study

Background

Rates of smoking and smoking cessation vary with socio-economic status. The objectives were to assess the association between neighbourhood deprivation, completion of treatment to support quit attempts and success of quit attempts—while taking into account other predictors of outcome.

Methods

555,744 quit attempts supported by English Stop Smoking Services in 2009–2012 were linked to the Index of Multiple Deprivation (IMD) 2010 ranks for the clients’ neighbourhood and split into deciles relative to the national IMD. Logistic regressions tested the association between neighbourhood deprivation and completion (4-week follow-up) of treatment and biochemically validated success (expired-air carbon monoxide <10ppm) while adjusting for demographics and intervention characteristics. Sensitivity analyses assessed subsamples: first supported attempts (n = 364,397), those with recorded cigarette dependence (n = 98,659) and completed treatment (n = 416,436).

Results

Higher neighbourhood deprivation was associated with reduced completion (OR_adj = 0.949, 95% CI: 0.947 to 0.951) and success (OR_adj = 0.957, 95% CI: 0.955 to 0.959). Results of sensitivity analyses were consistent with those of the main analysis.

Conclusions

Neighbourhood deprivation was associated with small but consistent reductions in completion and success of evidence-based interventions. These associations were not explained by intervention characteristics, demographics or dependence and reduced completion did not fully account for reduced success.

A comparative study of perceptions on tobacco in vulnerable populations between India and France

Perceptions of tobacco are a relatively unexplored issue in disadvantaged populations in India and France. The objectives of this study included the following: obtain qualitative information on representations of tobacco use and cessation within two vulnerable populations; identify cultural factors that influence tobacco use and cessation; and acquire information for the development of effective tobacco cessation strategies. A total of 21 focus groups were conducted in India and France. All study participants were disadvantaged adults 18 years old or older. Sixty women resided in South Delhi in India and 163 adults with disabilities resided in the south of France. They were all current tobacco users. Data were collected by focus group and analysed with thematic coding. In both samples, the most relevant reasons of tobacco use were daily life circumstances, which were also a major barrier to quitting. None of the participants reported that quitting difficulties could be due to dependence or nicotine addiction. The data also suggested that whilst some participants wanted to stop, they also anticipated quitting would be extremely challenging. In addition, there were a number of cross-cultural differences between Indian and French disadvantaged people: level of information concerning the health risk related to tobacco use and level of demand for support to quit from health professionals were most often cited. Recommendations are made for a specific approach among disadvantaged people. The paper concludes that in order to facilitate cessation, tobacco control interventions need to focus on coping strategies to deal with feelings of distress, withdrawal symptoms, and the circumstances of everyday life experienced by disadvantaged tobacco users.

Equity impact of European individual-level smoking cessation interventions to reduce smoking in adults: a systematic review

BACKGROUND

Smoking is the leading cause of health inequalities in Europe. Adults from lower socioeconomic status (SES) groups are more likely to smoke and less likely to quit than adults from higher SES groups. Smoking cessation support is an important element of tobacco control; however, the equity impact of individual-level cessation support is uncertain.

METHODS

Systematic review of individual-level smoking cessation interventions delivered in European countries, reporting a smoking cessation outcome (quit) in adults of lower compared with higher SES. Equity impact was assessed as positive (reduced inequality), neutral (no difference by SES), negative (increased inequality) or unclear.

RESULTS

Twenty-nine studies were included using different types of support: behavioural and pharmacological (17); behavioural only (11), including specialist (5), brief advice (1), mass media (2), text-based (1) and Internet-based (2); and pharmacological only (1). The distribution of equity effects on quitting was 10 neutral, 18 negative and 1 unclear. Two national studies of UK National Health Service (NHS) stop-smoking services showed overall positive equity impact on smoking prevalence. The evidence suggests that UK NHS services that target low-SES smokers achieve a relatively higher service uptake among low-SES smokers, which can compensate for their lower quit rates.

CONCLUSIONS

Untargeted smoking cessation interventions in Europe may have contributed to reducing adult smoking but are, on balance, likely to have increased inequalities in smoking. However, UK NHS stop-smoking services appear to reduce inequalities in smoking through increased relative reach through targeting services to low-SES smokers. More research is needed to strengthen the evidence-base for reducing smoking inequalities.

Equity impact of population-level interventions and policies to reduce smoking in adults: a systematic review

BACKGROUND AND AIMS

There is strong evidence about which tobacco control policies reduce smoking. However, their equity impact is uncertain. The aim was to assess the effectiveness of population-level interventions/policies to reduce socioeconomic inequalities in adult smoking.

METHODS

Systematic review of studies of population-level interventions/policies reporting smoking-related outcomes in adults of lower compared to higher socioeconomic status (SES). References were screened and independently checked. Studies were quality assessed. Results are presented in a narrative synthesis. Equity impact was assessed as: positive (reduced inequality), neutral (no difference by SES), negative (increased inequality), mixed (equity impact varied) or unclear.

RESULTS

117 studies of 130 interventions/policies were included: smokefree (44); price/tax (27); mass media campaigns (30); advertising controls (9); cessation support (9); settings-based interventions (7); multiple policies (4). The distribution of equity effects was: 33 positive, 36 neutral, 38 negative, 6 mixed, 17 unclear. Most neutral equity studies benefited all SES groups. Fourteen price/tax studies were equity positive. Voluntary, regional and partial smokefree policies were more likely to be equity negative than national, comprehensive smokefree policies. Mass media campaigns had inconsistent equity effects. Cigarette marketing controls were equity positive or neutral. Targeted national smoking cessation services can be equity positive by achieving higher reach among low SES, compensating for lower quit rates.

CONCLUSIONS

Few studies have assessed the equity impact of tobacco control policy/interventions. Price/tax increases had the most consistent positive equity impact. More research is needed to strengthen the evidence-base for reducing smoking inequalities and to develop effective equity-orientated tobacco control strategies.

A randomized controlled trial of two different lengths of nicotine replacement therapy for smoking cessation

This study examined if 2-week free nicotine replacement therapy (NRT) would be more effective than 1-week free NRT to help smokers quit smoking at 6 and 12 months. In a single-blinded randomized controlled trial design, 562 Chinese smokers who attended a smoking cessation clinic in Hong Kong, China, were randomly allocated into two groups (A1 and A2): A1 (n = 284) received behavioural counselling with free NRT for 1 week; A2 (n = 278) received similar counselling with free NRT for 2 weeks. All subjects received printed self-help materials to support their quitting efforts. A structured questionnaire was used for data collection, including pattern of NRT use and self-reported 7-day point prevalence quit rate at 6 months and 12 months. Among the participants, the mean number of cigarettes smoked per day was 18.8 (SD = 10.9). By intention-to-treat analysis, 7-day point prevalence quit rates were not significantly different between A1 and A2 groups at 6-month (27.5% versus 27.3%; P = 0.97) and 12-month (21.1% versus 21.2%; P = 0.98) followup. The findings suggest that two-week free NRT was not more effective than 1-week free NRT to increase smoking cessation rate among Chinese smokers.

ESCAPE: a randomised controlled trial of computer-tailored smoking cessation advice in primary care

AIMS

To evaluate the effectiveness of tailored cessation advice reports, including levels of reading ability, compared with a generic self-help booklet.

DESIGN

Participants were randomised to receive standard non-tailored information or to receive standard information plus a cessation advice report and a progress report, both tailored to individual characteristics.

SETTING

One hundred and twenty-three general practices located throughout the UK.

PARTICIPANTS

Questionnaires were mailed to 58 660 current cigarette smokers aged 18-65 years, identified from general practitioner records. Of the 6911 (11.8%) who completed the questionnaire, provided consent and were enrolled into the study, 6697 (11.4%) were included in the analysis.

MEASUREMENTS

Follow-up was by postal questionnaire sent six months after randomisation, or by telephone interview for participants failing to return the questionnaire. The primary outcome was self-reported prolonged abstinence for at least three months at the six-month follow-up.

FINDINGS

Quit rates on the primary outcome were not significantly different (3.2% versus 2.7%) (OR = 1.20, 95% CI [0.94, 1.54], P = 0.15). A significantly higher proportion of intervention group participants made a quit attempt during the follow-up period (32.3% versus 29.6%; OR = 1.13, 95% CI [1.01, 1.26], P = 0.026).

CONCLUSION

ESCAPE, a brief tailored smoking cessation intervention delivered by post and designed to reach a wide population of smokers, appears to increase the rate at which smokers try to stop, but if there is an effect on prolonged abstinence it is small.

Evaluation of Face-to-Face Courses in Behavioural Support for Stop Smoking Practitioners

Introduction: In English National Health Service (NHS) Stop Smoking Services, stop smoking practitioners provide behavioural support and medication to support smokers wanting to quit. There is a need to develop an evidence base for the training of such practitioners. This study evaluated a national face-to-face skills training course in behavioural support for practitioners. Methods: Data were gathered from 169 trainees attending the NHS Centre for Smoking Cessation and Training (NCSCT) courses between October 2010 and August 2011. They provided confidence in competence ratings for 16 core competences before, immediately following and 3 months after training. At 3-month follow-up, they also described what they believed were the most important learning outcomes. Trainees also provided course evaluations in the form of ratings (n = 386, courses not yet followed up included). Results: Confidence ratings increased overall by 40% immediately after the course and the higher level of confidence was maintained at 3-month follow-up; 92% agreed or strongly agreed that the course was very useful and very interesting; 90% that it was very enjoyable; 88% that it improved their skills and 87% that they would recommend it. The learning outcomes rated as most important reflected the relevant behaviour change techniques. Conclusion: The NCSCT skills training course appears to result in a substantial improvement in confidence in ability to deliver smoking cessation support and trainees evaluate it highly. The next step is to assess improvements in observed practice and success rates.

The Roy Castle Fag Ends Stop Smoking Service: A Successful Client-Led Approach to Smoking Cessation

The Roy Castle Fag Ends Community Stop Smoking Service (RCFE) is commissioned by three primary care trusts (PCTs) to provide the adult smoking-cessation service across Liverpool. The service is not theoretically driven but there are several principles governing RCFE, which maintain the client-led, person-centred philosophy. Unique aspects are that the service is provided by trained lay advisors with a nonmedical background and there is no waiting list — clients can self-refer by calling a helpline or walking into a meeting. At RCFE, clients control their own quit attempt as well as self-regulating attendance at meetings and discharge from the service. Relapsed clients are also welcomed back without fear of criticism or the need for an appointment. Possible reasons for the success of RCFE include the client-led methodology, the community approach that removes doctor–patient barriers that may exist, and the nature of the group meetings, which allows interaction between clients who are at different stages of the quit process. Introducing some of the RCFE principles into other stop-smoking services may help to increase the overall smoking-cessation rate in England.

Behavior change techniques used by the English Stop Smoking Services and their associations with short-term quit outcomes

OBJECTIVE

To help identify effective components of behavioral support for smoking cessation, this study identified the behavior change techniques (BCTs) specified in the treatment manuals of 43 English Stop Smoking Services (SSSs) and assessed association between inclusion of specific BCTs and SSS success rates.

METHODS

SSSs (n = 144) were contacted to request their treatment manuals. BCTs included in the manuals were identified using a previously established taxonomy. Associations between inclusion of specific BCTs and short-term (4-week) quit outcomes were assessed.

RESULTS

Ninety-eight services responded, of which 43 had suitable treatment manuals. Out of 43 possible BCTs, SSS manuals included a mean of 22 (range 9-37). The number of sessions used for delivery of the smoking cessation intervention differed markedly (range 1-13) across services. Nine of the BCTs were significantly associated with both self-reported and carbon monoxide (CO)-verified 4-week quit rates (e.g., strengthen ex-smoker identity, provide rewards contingent on abstinence, advise on medication, measure CO) and a further 5 were associated with CO-verified 4-week quit rates but not self-reported quit rates (e.g., advise on/facilitate use of social support, provide reassurance). SSSs that scheduled in more sessions had higher quit rates.

CONCLUSIONS

English SSSs vary widely in how far their treatment manuals include specific behavior change techniques and how many do not have manuals. It is possible to identify BCTs that are reliably associated with better quit outcomes. Behavioral support for smoking cessation could be improved by a more systematic approach to identifying and applying BCTs that are associated with better quit outcomes.

The effectiveness of NHS smoking cessation services: a systematic review

OBJECTIVES

To analyse evidence on the effectiveness of intensive NHS treatments for smoking cessation in helping smokers to quit.

METHODS

A systematic review of studies published between 1990 and 2007. Electronic databases were searched for published studies. Unpublished reports were identified from the national research register and experts.

RESULTS

Twenty studies were included. They suggest that intensive NHS treatments for smoking cessation are effective in helping smokers to quit. The national evaluation found 4-week carbon monoxide monitoring validated quit rates of 53%, falling to 15% at 1 year. There is some evidence that group treatment may be more effective than one-to-one treatment, and the impact of 'buddy support' varies based on treatment type. Evidence on the effectiveness of in-patient interventions is currently very limited. Younger smokers, females, pregnant smokers and more deprived smokers appear to have lower short-term quit rates than other groups.

CONCLUSION

Further research is needed to determine the most effective models of NHS treatment for smoking cessation and the efficacy of those models with subgroups. Factors such as gender, age, socio-economic status and ethnicity appear to influence outcomes, but a current lack of diversity-specific analysis of results makes it impossible to ascertain the differential impact of intervention types on particular subpopulations.

National survey of the smoking cessation services in Italy

This investigation is aimed at providing information about structural and organizational characteristics of smoking cessation services (SCS) set up within the Italian National Health Service. Local health units and hospitals are the main institutions connected with SCS which are mainly located within the Department of Drug Addiction and the Department of Lung and Breath Care. SCS provide different tobacco-use cessation programs. Although pharmacotherapy is always used, a combination of therapeutic treatments is highly preferred. This study shows the importance of maintaining a national coordination among different SCS supporting their activity and encouraging the start up of additional services throughout the country.

Smoking cessation in England: intentionality, anticipated ease of quitting and advice provision

Smoking prevalence in England continues to reduce but further reduction is increasingly difficult. Cessation policy has successfully targeted those who want to quit but further reduction will need to shift attention to more difficult 'core smoker' populations. Following the established 'stages of change' perspective, this paper considers the characteristics of people who do not intend to quit smoking, anticipate difficulties in quitting and have not received advice about quitting. We deploy multilevel models of data drawn from the Health Survey for England years 2002-2004, and the NHS Primary Care Trust Patient Surveys for 2004 and 2005. It was found that variations in intentionality and anticipated ease of quitting are associated with individual factors such as smoking intensity, parental smoking, age/length of time as a smoker and the nature of the advice-giving consultation. Household composition and household income are also implicated in the intention to quit and anticipated difficulties in quitting. Once individual and household factors are taken into account the only identifiable area-level variation is reduced intentionality towards quitting in rural areas. We conclude by arguing that further gains in smoking cessation must focus on understanding the characteristics of 'hard-to-engage' populations.

A Scotland-wide pilot programme of smoking cessation services for young people: process and outcome evaluation

AIM

To conduct an independent, external evaluation of a Scotland-wide youth cessation pilot programme, focusing upon service uptake and effectiveness.

INTERVENTION

National Health Service (NHS) Health Scotland and Action on Smoking and Health (ASH) Scotland funded a 3-year (2002-2005) national pilot programme comprising eight projects which aimed to engage with and support young smokers (aged 12-25 years) to quit.

DESIGN, PARTICIPANTS AND MEASUREMENTS

Process evaluation was undertaken via detailed case studies comprising qualitative interviews, observation and documentary analysis. Outcomes were assessed by following project participants (n=470 at baseline) at 3 and 12 months and measuring changes in smoking behaviour, including carbon monoxide (CO)-validated quit status.

FINDINGS

Recruitment proved difficult. Considerable time and effort were needed to attract young smokers. Advertising and recruitment had to be tailored to project settings and educational activities proved essential to raise the profile of smoking as an issue. Thirty-nine participants [8.6%, 95% confidence interval (CI) 5.0-11.2%] were CO-validated quitters at 3 months and 11 of these (2.4%, 95% CI 1.90-3.8%) were also validated quitters at 12 months. Older participants were more likely to be abstinent at 3 months.

CONCLUSIONS

The overall quit rate was disappointing. As a result of low participant numbers, it was impossible to draw conclusions about the relative effectiveness of different project approaches. These findings give little support to the case for developing dedicated youth cessation services in Scotland. They also highlight the difficulties of undertaking 'real-world' evaluations of pilot youth cessation projects. More action is needed to develop environments which enhance young smokers' motivation to quit and their ability to sustain quit attempts.

Effectiveness of computer-tailored Smoking Cessation Advice in Primary Care (ESCAPE): a randomised trial

BACKGROUND

Smoking remains a major public health problem; developing effective interventions to encourage more quit attempts, and to improve the success rate of self-quit attempts, is essential to reduce the numbers of people who smoke. Interventions for smoking cessation can be characterised in two extremes: the intensive face-to face therapy of the clinical approach, and large-scale, public health interventions and policy initiatives. Computer-based systems offer a method for generating highly tailored behavioural feedback letters, and can bridge the gap between these two extremes. Proactive mailing and recruitment can also serve as a prompt to motivate smokers to make quit attempts or to seek more intensive help. The aim of this study is to evaluate the effect of personally tailored feedback reports, sent to smokers identified from general practitioners lists on quit rates and quitting activity. The trial uses a modified version of a computer-based system developed by two of the authors to generate individually tailored feedback reports.

METHOD

A random sample of cigarette smokers, aged between 18 and 65, identified from GP records at a representative selection of practices registered with the GPRF are sent a questionnaire. Smokers returning the questionnaire are randomly allocated to a control group to receive usual care and standard information, or to an intervention group to receive usual care and standard information plus tailored feedback reports. Smoking status and cognitive change will be assessed by postal questionnaire at 6-months.

DISCUSSION

Computer tailored personal feedback, adapted to reading levels and motivation to quit, is a simple and inexpensive intervention which could be widely replicated and delivered cost effectively to a large proportion of the smoking population. Given its recruitment potential, a modest success rate could have a large effect on public health. The intervention also fits into the broader scope of tobacco control, by prompting more quit attempts, and increasing referrals to specialised services. The provision of this option to smokers in primary care can complement existing services, and work synergistically with other measures to produce more quitters and reduce the prevalence of smoking in the UK.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN05385712.

CATCH: development of a home-based midwifery intervention to support young pregnant smokers to quit

OBJECTIVE

to develop, implement and evaluate a supportive midwifery intervention, Community Action on Tobacco for Children's Health (CATCH), to help young pregnant smokers to quit.

DESIGN

action research project funded from April 2002 to June 2005.

SETTING AND PARTICIPANTS

CATCH was based in a single hospital maternity unit in the West of Scotland and targeted a deprived population of pregnant smokers aged 25 years and under. Outreach work was undertaken in the local community and cessation support was provided in women's own homes.

INTERVENTION

CATCH aimed to meet the particular needs of young pregnant women through a tailored, non-judgmental approach. The service was distinctive as it employed a holistic approach to smoking cessation which focused not only on individual choices and motivations, but on the wider life circumstances that may preclude behaviour change.

MEASURES

internal and external teams collaborated to ensure a comprehensive evaluation, gathering of both process and outcome data. Outcomes (including self-reported and carbon monoxide validated quit status) were assessed by quantitative surveys undertaken at enrolment to the service and at 3- and 12-month follow-up. All those lost to follow-up were assumed to still be smoking. Participants' views of the service were gathered independently by an external evaluation team, and a detailed qualitative case study, capturing ongoing learning, was undertaken. Data were collected from participants who joined the project over a 16-month period (November 2002-February 2004).

FINDINGS

the study demonstrated a feasible approach to engaging young pregnant smokers to help them quit. Obstetricians and midwives were willing to refer to a service based in their maternity unit run by a specially trained midwife, and users reported a positive experience of the service. Of 152 eligible clients referred within the 16-month period, 79 (52%) joined CATCH. Of those who joined, 18 (22.8%) were self-reported non-smokers at 3 months, of whom 16 (20.3%) were validated as non-smokers using carbon monoxide monitoring. Thirteen (16.5%) clients reported being smoke free at 12 months, of whom 10 (12.7%) were validated as non-smokers at 12 months.

IMPLICATIONS FOR PRACTICE

CATCH suggests that close partnership with the multi-disciplinary maternity team and integration into the maternity system is invaluable for smoking cessation services targeting pregnant women. It points to the benefits of the service being delivered by a trained midwife in clients' own homes. Flexibility and a non-judgmental approach are essential to engagement. Attention to the context and wider circumstances of clients' lives and involving friends and family enables clients to focus on their own smoking.

[Quitting and prevalence of smoking: gender, social class, and primary health care]

OBJECTIVE

To analyse the joint role of social class and primary health care in giving up smoking.

DESIGN

Cross-sectional study.

SETTING

Barcelona (Catalonia, Spain), 2000-2001.

PARTICIPANTS

A sample of the resident non-institutionalized population, restricted to people aged 15-50 who have a habitual primary care source (n=4178).

MAIN MEASUREMENTS

These were obtained from the Barcelona Health Interview Survey. Independent variables include sex, social class and usual source of primary health care. Dependent variables are having ever been a smoker, having quit, and being a current smoker. Age-adjusted proportions were calculated (95% CI).

RESULTS

Social class shows that more manual workers have been smokers. Men smoked more than women. Overall quitting is similar in both sexes. Quitting showed a social gradient in men. Measurement of source of care showed quitting was higher among users of private clinics, but CI overlapped. On stratifying the source of primary care by social class, an effect seemed to emerge for men, but the CI overlapped. Prevalence at the time of the survey was higher for men; a class gradient in current prevalence emerged for men, but was less visible for women, where CI overlapped.

CONCLUSIONS

Social class is a powerful determinant of smoking. Men in low-classed jobs are at greater risk of starting to smoke, are less likely to give up, and smoke more. The proportion of quitting seems lower in of public clinics users. Health advice is efficacious, but in population terms other factors seem to have greater influence.

An exploration of the smoking-related health beliefs of older people with chronic obstructive pulmonary disease

AIM

To explore the smoking-related health beliefs of older people with chronic obstructive pulmonary disease (COPD).

BACKGROUND

Globally, smoking is a major cause of COPD and symptoms present typically mid to later life. Substantial numbers of people with COPD continue to smoke even though smoking cessation is known to slow the rate of disease progression and prevent further deterioration in lung function. There is evidence to suggest that, although older long-term smokers can successfully quit smoking with the help of specialist structured programmes, those with COPD find it more difficult to achieve sustained cessation. An understanding of the health beliefs of people with COPD will assist professionals to provide the most appropriate support with cessation attempts.

DESIGN

A secondary analysis of qualitative interview data.

METHODS

Twenty-two current and former smokers with COPD who used the outreach service of an inner city hospital in Scotland were interviewed in their own homes using semi-structured interviews which were transcribed verbatim. The main concepts of the Health Belief Model were used as an analysis framework.

FINDINGS

Interviews were carried out with 15 women and seven men with a median age of 68 years. Almost 90% lived in areas of the highest socio-economic deprivation according to DEPCAT scores. Almost two-thirds of the individuals in this study continued to smoke even though they largely perceived smoking as a threat to health. Individuals who continued to smoke cited various barriers to quitting smoking and all had, at some time, attempted smoking cessation. Over half were still attempting to quit. Cues to action came from external sources rather than increasing disease severity.

CONCLUSIONS

Cessation is challenging and knowledge of a person's health beliefs is a prerequisite to supporting behaviour change.

RELEVANCE TO CLINICAL PRACTICE

Findings emphasize the need for frontline health professionals to reflect on their current practice with a view to providing sustained encouragement and support towards smoking cessation and relapse prevention for people with COPD.

Avoiding the danger that stop smoking services may exacerbate health inequalities: building equity into performance assessment

Background

The UK is the only developed country to have established a nation-wide stop smoking treatment service. Apart from addressing tobacco dependence, which is the leading preventable cause of ill health and premature death, smoking cessation has been identified by the UK department of health as a service priority for reducing gaps in health between disadvantaged groups and the country as a whole. However smoking cessation tends to be more successful among affluent than disadvantaged groups. This means that for stop smoking services there is a trade-off to be had in terms of maximising the number of quitters and reducing socioeconomic inequalities in smoking prevalence. Current performance targets for the national stop smoking services in the UK are set only in terms of numbers of quitters, which does not encourage the adoption of strategies to reduce socioeconomic inequalities in smoking prevalence.

Discussion

This paper proposes an assessment framework, which allows the two dimensions of overall reduction in smoking prevalence and reductions of inequalities in smoking prevalence to be assessed together. The framework is used to assess the performance over time of a stop smoking service in Derwentside, a former Primary Care Trust in the North East of England, both in terms of meeting targets for the overall number of quitters and in terms of reducing socioeconomic inequalities in smoking prevalence.

The example demonstrates how the proposed assessment framework can be applied in practice given existing records kept by stop smoking services in England and the available information on smoking prevalence at small area level. For Derwentside it is shown that although service expansion was successful in increasing the overall number of quitters, the service continued to exacerbate inequality in smoking prevalence between deprived and affluent wards.

Summary

The Secretary of State for Health in the UK has warned about the dangers of health promotion services and messages being taken up more readily by the better-off, thus exacerbating health inequalities. Because smokers from affluent backgrounds are more successful at quitting than those living in deprived circumstances, it is important to build an equity element into the monitoring of individual stop smoking services. Otherwise the danger highlighted by the Secretary of State for Health will go undetected and unaddressed.

Smoking, smoking cessation, and use of smoking cessation aids and support services in South Derbyshire, England

OBJECTIVES

To describe smoking behaviour, motivation to quit and quit rates, and the effect of advice and support for smoking cessation among smokers from more and less disadvantaged socio-economic groups in South Derbyshire, a mixed urban and rural area of central England.

STUDY DESIGN

Cross-sectional study.

METHODS

A cross-sectional study with a random, stratified sample of people aged 25-44 years and people aged 65-74 years with over-sampling of populations living in disadvantaged areas. Main outcome measures included the proportion of smokers wishing to quit and quitting in the last year; reported advice to quit from family and friends and health professionals; and awareness and use of NHS smoking-cessation services.

RESULTS

Over half of smokers aged 25-44 years, about one-third of women smokers and 40% of male smokers aged 65-74 years wished to quit. This varied little by socio-economic status. Quit rates were generally lower among smokers of lower socio-economic status (SES), especially among people aged 25-44 years. Smokers of lower SES reported slightly less advice to quit from family and friends, and more so from health professionals. Awareness and use of cessation services was about 30% and 5%, respectively, among smokers and recent quitters. Awareness varied little but accessing services was generally higher among smokers of lower SES.

CONCLUSIONS

Despite evidence that health professionals and cessation services were targeting smokers with lower SES and of similar motivation to quit, quit rates were lower. Broader tobacco control interventions targeting the social and environmental contexts that create and maintain socio-economic differentials in smoking are required.

UK health policy and ‘underage’ smokers: The case for smoking cessation services

The UK government's White Paper titled 'Smoking Kills' set explicit targets for reductions in the prevalence of smoking. As well as targets for the population as a whole, specific targets were set for sub-groups in the population: children were identified as one such sub-group. Following the publication of the White Paper, smoking cessation services were established nationwide as part of the strategy to meet the targets. Considerable resources have been put into these smoking cessation services and evaluations of the service tend to conclude that they are relatively successful and cost effective in terms of getting people to quit smoking. However, this article argues that one group of smokers has been marginalised in terms of access to the service. The evidence indicates that 'underage' smokers - those aged less than 16 years - have not had the level of access to smoking cessation services that is warranted in terms of the prevalence of smoking among children, in terms of their apparent willingness to use such services and in terms of the particular value of quitting smoking while still so young. This article explores the potential for underage smokers to benefit from smoking cessation services and considers the possibilities for widening access to the cessation services to 11-15 years old.

Randomized controlled trial of a social support ('buddy') intervention for smoking cessation

OBJECTIVE

To assess the effectiveness of including a social support intervention ('buddy system') in a group treatment programme to aid smoking cessation.

METHODS

Five hundred and sixty-three smokers attended groups at a smokers' clinic. These groups were randomized either to be (a) groups in which smokers were paired with another person to provide mutual support (buddy condition: n=237 in 14 groups) or (b) to receive the same treatment without the buddy component (control: n=326 in 20 groups). Participants were seen weekly for the first 4 weeks after stopping then followed up again after 26 weeks.

RESULTS

Smokers in the buddy condition were no more likely than smokers in the control condition to stay abstinent at 1, 4 or 26 weeks. The effect was in the right direction at week one post-quit but after controlling for potential confounders the difference was not significant (odds ratio=1.45 (95% CI; 0.92-2.29), p=0.06).

CONCLUSIONS

We were unable to show that a buddy system improved abstinence rates of group treatment programmes. This might be due to the high level of social support already achieved through the groups.

PRACTICE IMPLICATIONS

The buddy system is a simple and very low cost addition to a group treatment programme; but the results from this study suggest that the kind of buddy system tested may not add substantially to the success rates. However there may be merits in a more intensive or protracted form of buddying.

Barriers and motivators to gaining access to smoking cessation services amongst deprived smokers--a qualitative study

BACKGROUND

Smoking is strongly associated with disadvantage and is an important contributor to inequalities in health. Smoking cessation services have been implemented in the UK targeting disadvantaged smokers, but there is little evidence available on how to design services to attract this priority group.

METHODS

We conducted focus groups with 39 smokers aged 21-75 from the most socio-economically deprived areas of Nottingham UK who had made an unsuccessful attempt to quit within the last year without using smoking cessation services, to identify specific barriers or motivators to gaining access to these services.

RESULTS

Barriers to use of existing services related to fear of being judged, fear of failure, a perceived lack of knowledge about existing services, a perception that available interventions--particularly Nicotine Replacement Therapy--are expensive and ineffective, and negative media publicity about bupropion. Participants expressed a preference for a personalized, non-judgemental approach combining counselling with affordable, accessible and effective pharmacological therapies; convenient and flexible timing of service delivery, and the possibility of subsidized complementary therapies.

CONCLUSION

We conclude that smokers from these deprived areas generally had low awareness of the services available to help them, and misconceptions about their availability and effectiveness. A more personalized approach to promoting services that are non-judgemental, and with free pharmacotherapy and flexible support may encourage more deprived smokers to quit smoking.

Effectiveness of specialist group treatment for smoking cessation vs. one-to-one treatment in primary care

OBJECTIVE

Using a quasi-experimental design, this paper contributes to an important debate about the most effective form of psychological treatment to aid smoking cessation: group treatment provided by specialists or one-to-one treatment provided in the community by primary care nurses or pharmacists.

METHODS

Data were routinely collected from 1501 clients of a large London stop smoking service that offered both group and one-to-one treatment.

RESULTS

A quarter (25%) of the clients were continuously abstinent 4 weeks post-quit: 30% for those receiving group treatment and 19% for one-to-one (Fisher's exact [2-sided]<.001). The difference between the specialist and community-based treatment remained after all possible confounding factors were controlled for (OR: 2.27, p<.001).

CONCLUSIONS

In the same service with the same management structure and training programme, group treatment offered by the specialist service yielded higher success rates than counselling by trained primary care nurses and pharmacists.

Self-reported smoking cessation interventions were not associated with quitting in older women

OBJECTIVE

To determine the extent to which smoking cessation interventions are used in the community and their relative success in older women.

STUDY DESIGN AND SETTING

Prospective cohort study located in 23 general practices in England, Scotland. and Wales and including 3,622 women aged 60 to 79 years at recruitment from the British Women's Heart and Health Study.

RESULTS

Of the 370 smokers at baseline, 77 (21%) had stopped smoking at 3 years, reducing the prevalence of smoking from 10.2% to 8.8%. Women who were light smokers (<10 per day) at baseline were more likely to have quit than heavier smokers. The most common interventions reported by women who smoked at baseline were advice from a general practitioner (GP), family or friend's advice, and use of nicotine replacement, but 42% of the women reported having no intervention to help them to stop smoking. None of the individual interventions were associated with increased odds of quitting smoking over the follow-up period. Women reported finding a GP's advice, referral to a clinic, and nicotine replacement more useful than complementary treatments (acupuncture and hypnotherapy) or advice from family and friends.

CONCLUSION

Smoking cessation rates in this study were in line with national targets and surveys. Self-reports of ever receiving interventions were not associated with quitting smoking among these older women. Different and innovative approaches to smoking cessation may need to be developed, and evaluated in future randomized clinical trials, for individuals who have smoked for a long period of time and for whom other smoking cessation interventions have not proved successful.

Who Calls QUIT®? The characteristics of smokers seeking advice via a telephone helpline compared with smokers attending a clinic and those in the general population

OBJECTIVE

To compare the characteristics of callers to a telephone helpline with those of smokers seeking assistance through a clinic and smokers in a general population sample.

STUDY DESIGN

Data were gathered from callers to the Quitline in May and June 2000. Screening data were used for smokers attending the South London & Maudsley NHS Smokers' Clinic from May 2000 to April 2001. The results of the 2000/2001 General Household Survey (GHS) were used to estimate the characteristics of smokers in the general population.

METHODS

Callers to the Quitline (n=1162) surveyed during the summer of 2000, smokers attending the Maudsley Hospital Smokers' Clinic between May 2000 and April 2001 (n=1127), and smokers surveyed in the GHS between April 2000 and March 2001 (n=14,089) were compared on demographic characteristics, tobacco dependence and readiness to quit.

RESULTS

Women and older smokers are more likely to seek help, but the Quitline attracts more calls from younger smokers. The age profile of helpline callers corresponds more closely to that of the general population of smokers than does the age profile of clinic attenders. Quitline callers are more dependent than the general population of smokers; clinic attenders are even more dependent. In comparison with the general population, the majority of Quitline callers have plans to quit smoking soon or have already stopped smoking.

CONCLUSIONS

Telephone helplines reach a more representative sample of smokers in various states of readiness to quit, and provide a service for a population not reached by clinics.

Free nicotine replacement therapy programs vs implementing smoke-free workplaces: a cost-effectiveness comparison

We compared the cost-effectiveness of a free nicotine replacement therapy (NRT) program with a statewide smoke-free workplace policy in Minnesota. We conducted 1-year simulations of costs and benefits. The number of individuals who quit smoking and the quality-adjusted life years (QALYs) were the measures of benefits. After 1 year, a NRT program generated 18,500 quitters at a cost of 7020 dollars per quitter (4440 dollars per QALY), and a smoke-free workplace policy generated 10,400 quitters at a cost of 799 dollars per quitter (506 dollars per QALY). Smoke-free work-place policies are about 9 times more cost-effective per new nonsmoker than free NRT programs are. Smoke-free workplace policies should be a public health funding priority, even when the primary goal is to promote individual smoking cessation.

The English smoking treatment services: short-term outcomes

AIMS

To examine the impact of socio-demographic factors, smoking-related behaviour and service characteristics on CO-validated quit rates at 4-week follow-up in English smoking treatment services, and to compare the results with those for self-reported quitters.

DESIGN

Observational study of administrative information linked with survey data for 6959 recipients of smoking treatment services who set a quit date between October 2001 and March 2003.

SETTING

Two contrasting areas of England, Nottingham and North Cumbria, consisting of nine primary care trust (PCT) localities.

MEASUREMENTS

Routine monitoring data specified by the Department of Health included information about basic demographic characteristics, postcode of residence from which a deprivation category was identified, nature of intervention and smoking status at 4-week follow-up. These data were supplemented with additional information about referral pathways, socio-economic status and smoking-related behaviours obtained from consenting service recipients by NHS advisers.

FINDINGS

More than one-half of clients (53%) were CO-validated as quitters at 4 weeks, rising to 60.7% when self-reported cases were included. Age (OR 1.026; CI 1.0221.029) and being extremely determined to quit (OR 1.46; CI 1.261.71) were associated positively with CO-validated cessation, whereas women (OR 0.85; CI 0.770.94), users with lower socio-economic status (OR 0.92; CI 0.880.95), those smoking 31 or more cigarettes daily (OR 0.75; CI 0.640.88) and those with relatively poor health status (OR 0.72; CI 0.630.82) were less likely to quit. Although the vast majority of users received one-to-one support, those who had group counselling were more likely to be successful in their quit attempt (OR 1.38; CI 1.091.76). Self-report and CO-validated quitters were similar in terms of their characteristics.

CONCLUSIONS

These results obtained from routine services support those obtained from clinical trials and confirm the effectiveness of counselling combined with pharmacotherapies to assist smokers to quit in the short term. However, the relative effectiveness of group interventions raises questions about why one-to-one counselling is used much more commonly. The importance of socio-demographic and nicotine-related dependency factors also suggests that local service targets for smoking cessation need to take account of the social distribution of these characteristics.

The cost-effectiveness of the English smoking treatment services: evidence from practice

AIMS

To investigate the cost-effectiveness of English specialist smoking cessation services.

DESIGN

Combination of observational cost and outcome data from English smoking cessation services to calculate cost-effectiveness ratios. Multivariate analysis of factors influencing variation in services' cost-effectiveness.

SETTING

Fifty-eight of the 92 specialist smoking cessation services in England in 2000/01.

METHODS

Services' costs were estimated using survey data which described services' configurations, staffing, interventions delivered and development. Information on services' throughput and outcomes (as biochemically validated 4-week smoking cessation rates) were obtained from routine sources. With reference to relevant literature and assumptions about relapse and background cessation rates, 4-week cessation rates were converted first to 1-year rates. One-year cessation rates were adjusted to reflect the likely permanent smoking cessation rate attributable to service intervention and finally attributable life-years gained were calculated. A wide variety of sensitivity analyses was performed to test the robustness of the average cost-effectiveness ratio, calculated by combining the cost and life-year gained estimates, for all services. With additional data on deprivation levels in services' areas, ordinary least-squares regression techniques were used to investigate variations in individual services' costs per client and cost-effectiveness ratios.

FINDINGS

Using an up-to-date estimate for health gain accrued by stopping smoking, the average cost per life gained was pound 684 (95% CI 557811), falling to pound 438 when savings in future health-care costs were counted. With the worst case assumptions, the estimate of cost-effectiveness rose to pound 2693 per life-year saved (pound 2293 including future health-care costs) and fell to pound 227 (pound 102) under the most favourable assumptions. Findings are comparable to previous published studies. The regression results suggest that different factors influence cost per client and the net cost per life-year saved, indicating that decision makers should be careful in setting performance targets for these services.

CONCLUSIONS

In 2000/01, English smoking cessation services provided cost-effective services operating well below the benchmark of pound 20,000 per quality-adjusted life-year saved (QALY) that is used by the National Institute for Clinical Excellence in the United Kingdom.

How effective are the English smoking treatment services in reaching disadvantaged smokers?

AIMS

To determine the effectiveness of smoking cessation services in enabling smokers living in disadvantaged areas to access treatment services, and to assess the extent of variations between areas.

DESIGN

Observational study of administrative information linked with survey data.

SETTING

A representative sample of 19 of the 95 English health areas in 2001.

MEASUREMENTS

All England smoking data by deprivation category obtained from the Health Survey of England were used to estimate neighbourhood smoking prevalence rates. Area of residence data from smokers setting a quit date were used to calculate the proportion of smokers in receipt of treatment services in different economic deprivation categories.

FINDINGS

In general, treatment services were seeing smokers from the most disadvantaged areas where smoking prevalence rates were highest; 32.3% of all smokers in receipt of treatment services lived in the most disadvantaged quintile of areas compared with 9.6% resident in the most advantaged quintile. An indicator of 'positive discrimination' was calculated for each health authority area to quantify the extent to which the proportion of disadvantaged smokers being treated was greater than the proportion in the local population. This figure ranged from just under 0% to 18%.

CONCLUSIONS

National Health Service (NHS) smoking cessation services have been successful in reaching smokers from disadvantaged communities. If improved access to support for smokers living in the poorest communities can be extended, sustained and translated into long-term quitting then smoking cessation services have the potential to make a useful contribution to addressing inequalities in health.