COVID-19 and tobacco cessation: lessons from India

OBJECTIVES

The Government of India prohibited the sale of tobacco products during the COVID-19 lockdown to prevent the spread of the SARS-CoV-2 virus. This study assessed the tobacco cessation behaviour and its predictors among adult tobacco users during the initial COVID-19 lockdown period in India.

METHODS

A cross-sectional study was conducted with 801 adult tobacco users (both smoking and smokeless tobacco) in two urban metropolitan cities of India over a 2-month period (July to August 2020). The study assessed complete tobacco cessation and quit attempts during the lockdown period. Logistic and negative binomial regression models were used to study the correlates of tobacco cessation and quit attempts, respectively.

RESULTS

In total, 90 (11.3%) tobacco users reported that they had quit using tobacco after the COVID-19 lockdown period. Overall, a median of two quit attempts (interquartile range 0-6) was made by tobacco users. Participants with good knowledge on the harmful effects of tobacco use and COVID-19 were significantly more likely to quit tobacco use (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.2-4.0) and reported more quit attempts (incidence risk ratio 5.7; 95% CI 2.8-11.8) compared to those with poor knowledge. Participants who had access to tobacco products were less likely to quit tobacco use compared to those who had no access (OR 0.3; 95% CI 0.2-0.5].

CONCLUSIONS

Access restrictions and correct knowledge on the harmful effects of tobacco use and COVID-19 can play an important role in creating a conducive environment for tobacco cessation among users.

The knowledge exchange and dissemination plan of the We Can Quit2 community-based stop-smoking trial

Background

We Can Quit2 was a community-based randomised controlled trial which determined the feasibility and acceptability of We Can Quit (WCQ), a peer delivered stop-smoking programme comprising group support and free Nicotine Replacement Therapy (NRT) tailored to women living in socioeconomically disadvantaged areas in Ireland. Reengagement with key stakeholders took place as part of the trial Knowledge Exchange and Dissemination plan, to discuss strategies to optimise community engagement, recruitment and retention in a future definitive trial (DT), and the policy priorities arising from the trial.

Methods

Community stakeholders involved in trial recruitment and planning, Irish Cancer Society and Health Service Executive representatives were invited to an online interactive workshop in November 2020. Key trial findings were presented. Workshop discussion (field notes) and responses to a post-event anonymous questionnaire informed a list of challenges and suggestions for a future DT and policy development from a community perspective.

Results

Forty-one stakeholders attended the workshop, six completed the questionnaire. Dedicated additional time for community engagement and use of social prescribing as a recruitment tool were recommended. Greater adaptation of trial data and assistance to complete forms were suggested to address low literacy, which was a barrier to recruitment and retention. An intervention boost after WCQ delivery and encouragement of women to join other healthy community programmes to maintain their group, were recommended to facilitate retention and enhance sustainability. Policy priorities were to remove cost and administrative barriers to access NRT and ongoing provision of cessation services tailored to disadvantaged groups.

Conclusions

Important strategies to optimise design of a DT of WCQ effectiveness were recommended. Lessons learned may be relevant to other community-based health interventions in socioeconomically disadvantaged areas.

Key messages

The workshop provided a suitable forum for engagement of community and statutory stakeholders. Knowledge exchange activities facilitated an enhanced research design from a community perspective.

Financial Incentives for Preventing Postpartum return to Smoking (FIPPS): study protocol for a three-arm randomised controlled trial

Background

Financial incentives are an effective way of helping women to stop smoking during pregnancy. Unfortunately, most women who stop smoking at this time return to smoking within 12 months of the infant’s birth. There is no evidence for interventions that are effective at preventing postpartum smoking relapse. Financial incentives provided after the birth may help women to sustain cessation. This randomised controlled trial will assess the effectiveness and cost-effectiveness of financial incentives to help women who are abstinent from smoking at end-of-pregnancy to avoid return to smoking up to 12 months postpartum.

Methods

This is a UK-based, multi-centre, three-arm, superiority, parallel group, individually randomised controlled trial, with 1:1:1 allocation. It will compare the effectiveness of two financial incentive interventions with each other (one intervention for up to 3 months postpartum offering up to £120 of incentives (£60 for the participant and £60 for a significant other support); the other for up to 12 months postpartum with up to £300 of incentives (£240 for the participant and £60 for a significant other support) and with a no incentives/usual care control group. Eligible women will be between 34 weeks gestation and 2 weeks postpartum, abstinent from smoking for at least 4 weeks, have an expired carbon monoxide (CO) reading < 4 parts per million (ppm), aged at least 16 years, intend remaining abstinent from smoking after the birth and able to speak and read English.

The primary outcome is self-reported, lapse-free, smoking abstinence from the last quit attempt in pregnancy until 12 months postpartum, biochemically validated by expired CO and/or salivary cotinine or anabasine. Outcomes will be analysed by intention-to-treat and regression models used to compare the proportion of abstinent women between the two intervention groups and between each intervention group and the control group. An economic evaluation will assess the cost-effectiveness of offering incentives and a qualitative process evaluation will examine barriers and facilitators to trial retention, effectiveness and implementation.

Discussion

This pragmatic randomised controlled trial will test whether offering financial incentives is effective and cost-effective for helping women to avoid smoking relapse during the 12 months after the birth of their baby.

Trial registration

International Standard Randomised Controlled Trial Number 55218215. Registered retrospectively on 5th June 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05480-6.

Pregnant women's use of e-cigarettes in the UK: a cross-sectional survey

OBJECTIVE

To estimate prevalence of vaping in pregnancy. Compare characteristics and attitudes between exclusive smokers and vapers, and between exclusive vapers and dual users (smoke and vape).

DESIGN

Cross-sectional survey.

SETTING

Hospitals across England and Scotland.

POPULATION

Pregnant women attending antenatal clinics in 2017.

METHODS

Women at 8-24 weeks' gestation completed screening questions about their smoking and vaping. Current or recent ex-smokers and/or vapers completed a full detailed survey about vaping and smoking.

MAIN OUTCOME MEASURES

The prevalence of vaping, characteristics and attitudes of women who vape and/or smoke.

RESULTS

Of 3360 pregnant women who completed screening questions, 515 (15.3%, 95% CI 14.1-16.6) were exclusive smokers, 44 (1.3%, 95% CI 1.0-1.8) exclusive vapers and 118 (3.5%, 95% CI 2.9-4.2) dual users. In total, 867 (25.8%) women completed the full survey; compared with smokers (n = 434), vapers (n = 140) were more likely to hold higher educational qualifications (odds ratio [OR) 1.51, 95% CI 1.01-2.25). Compared with exclusive vapers (n = 33), dual users (n = 107) were younger (OR 0.91 95% CI 0.85-0.98) and less likely to hold high qualifications (OR 0.43, 95% CI 0.20-0.96). Compared with smokers, dual users were more likely to be planning to quit smoking (OR 2.27, 95% CI 1.24-4.18). Compared with smokers, vapers were more likely to think vaping was safer than smoking (78.6% versus 36.4%).

CONCLUSIONS

One in 20 pregnant women report vaping, and most also smoke. Dual users are more motivated towards stopping smoking than smokers. Where women have tried but cannot stop smoking, clinicians could encourage them to consider vaping for smoking cessation.

TWEETABLE EXTRACT

One in 20 women report vaping during pregnancy but of those that do vape, most also smoke, despite having intentions to quit.

Opinions and experiences of a national smokefree prison policy: evidence from the TIPs study

Background

Removal of tobacco from prisons poses distinct challenges, as prisons are 'homes' and smoking rates are high. TIPs is unique in comprehensively studying a smoking ban using data collected before, during and after the ban. This paper presents opinions and experiences of people in custody (PiC) and staff in Scotland, and identifies implementation success factors and lessons that are highly relevant for other jurisdictions and areas of public health.

Methods

Surveys of staff and PiC (response rates) were conducted in Nov-Dec 2016 (27%, 34%), May-Jul 2018 (31%, 26%) and May-Jul 2019 (16%, 18%), with questions on smoking, smoking cessation/abstinence and smoking restrictions in the prison context. Topics were also explored qualitatively with staff/PiC at similar time points (34 focus groups, 99 interviews). Survey responses were analysed using descriptive statistics and logistic regression analyses. Qualitative data were thematically analysed to identify the diversity of views and experiences.

Results

Smokefree policy is widely accepted as the new 'norm', but support was higher among staff than PiC before, during and after implementation. Surveys and qualitative data suggest perceptions of some of the potential difficulties (e.g. 'hard to enforce') and negative consequences (e.g. 'cause a lot of trouble') of smokefree policy reduced post implementation. Participants identified several implementation success factors relating to: planning and communication, smoking abstinence/cessation products/services, and partnership working.

Conclusions

Smokefree prison polices can be successfully implemented, providing the removal of tobacco is well managed and support measures are available for smokers. Some factors shaping the successful introduction of smokefree prisons in Scotland are relevant to other areas of public health transformation e.g. setting clear objectives and timescales; collaboration and teamwork; and involving staff at all levels and end-users.

Incentives for smoking cessation in pregnancy

Issue/problem

Most pregnant smokers reply ‘Yes' when asked ‘Do you want to stop smoking?'. This is usually an honest answer but often without intention. About 10% who intend to quit are likely to attend smoking cessation services. Even with good quality counselling and the offer of nicotine replacement therapy only about 3-5% quit. How can the other 90% be reached?

There are two approaches: Redirect counselling away from specialist cessation practitioners and build capacity among all health care workers. This is attractive spreading counselling to health care workers who meet pregnant smokers during routine consultations requiring little resource after training for example General Practitioners, Midwives and Obstetricians. However limited time for training and subsequent counselling endangers the quality and quantity of counselling delivered.Increase the proportion of women who intend to quit smoking during pregnancy by providing a financial incentive payment for engaging with specialist cessation practitioners and quitting.

This policy allows counselling to be delivered by specialists and potentially draws in a larger proportion of pregnant smokers, as many as 50%.

Results

Financial incentives have increased the proportion of smokers who quit by late pregnancy in two large randomised controlled trials. The proportion increased by more than 100%. Local service pilots of financial incentives have seen marked increases in smokers who attend and quit.

Lessons

There are a number of ways to increase smoking cessation among pregnant women. Research evidence should be translated into effective service models to decide which strategy is most cost-effective.

Key messages

Counselling is important; however, it has to be sufficient and of good quality. Drawing more pregnant smokers into cessation services will increase the proportion who intend and manage to quit. This may work better than expecting all health care workers to give effective counselling.

A qualitative study of e-cigarette emergence and the potential for renormalisation of smoking in UK youth

Background

Growth of e-cigarette use among smokers has raised concerns over uptake by non-smokers, particularly young people. Legislative changes aimed in part at reducing youth exposure to e-cigarettes include the EU Tobacco Products Directive (TPD). A core justification for such measures is the belief that e-cigarettes can lead to tobacco smoking through mechanisms of renormalisation including: mimicking and normalizing the act of smoking; increasing product acceptability via marketing; nicotine exposure. These mechanisms are here explored in relation to findings from qualitative research.

Methods

This paper reports results from twenty-one group interviews with 14–15 year olds in Wales, England and Scotland, conducted as part of an ongoing evaluation of the impact of the TPD on youth smoking and e-cigarette use. Interviews were conducted around the end of the transitional period for TPD implementation, and explored perceptions of e-cigarettes and tobacco, as well as similarities and differences between them.

Results

Young people differentiated between tobacco and e-cigarettes, rejecting the term e-cigarette in favour of alternatives such as ‘vapes’. Experimental or occasional use was common and generally approved of where occurring within social activity with peers. However, regular use outside of this context was widely disapproved of, unless for the purpose of stopping smoking. Increased prevalence of e-cigarettes did not challenge strongly negative views of smoking or reduce perceived harms caused by it, with disapproval of smoking remaining high. Nicotine use was variable, with flavour a stronger driver for choice of e-liquid, and interest more generally.

Conclusion

The extent to which participants differentiated between vaping and smoking, including styles and reasons for use in adults and young people; absence of marketing awareness; and continued strong disapproval of smoking provides limited support for some of the potential mechanisms through which e-cigarettes may renormalise smoking. However caution over nicotine exposure is still necessary.

Use of e-cigarettes by young people in Great Britain before and after Tobacco Products Directive

Background

Young people’s experimentation with e-cigarettes has increased in recent years, although regular use remains rare. In May 2016, the EU Tobacco Products Directive (TPD) introduced regulations aimed in part at preventing use by young people. It imposed warnings on e-cigarette packets, banned many forms of advertising, and restricted nicotine strength. This paper examines change in young people’s e-cigarette use after TPD, as well as complementary and alternative causal explanations for change, from young people’s perspectives.

Methods

Quantitative data sources were 2013, 2015 and 2017 School Health Research Network/Health Behaviour in School-aged Children surveys in Wales and 2014 and 2016 Smoking Drinking and Drug Use surveys in England. Data were analysed using segmented binary logistic regression in Wales, with simpler before and after analyses in England. Results were considered alongside qualitative interview data from young people aged 14-15 years in England, Wales and Scotland, collected in 2017 and 2018.

Results

Ever-use of e-cigarettes almost doubled from 2013-15, though subsequent increases were smaller. In Wales, where pre-legislation time series data were available, under a range of assumptions, prior growth in e-cigarette ever-use did not continue post-TPD. Change in trend post-TPD did not reach significance (OR = 0.96; 95%CI=0.91 to 1.01), but became significant after adjusting for change in smoking rates across the time-series (OR = 0.93; 95%CI=0.88 to 0.98). Regular use did not increase significantly from 2015 to 2017 in Wales, although ever and regular use in England both increased from 2014 to 2016. Young people described limited interactions with core components of TPD, while commonly describing e-cigarette use as a fad which was beginning to run its course.

Conclusions

Growth in youth experimentation with e-cigarettes may be slowing. Qualitative data from young people provide a range of explanations which appear largely unrelated to TPD itself.

Key messages

Survey data provide preliminary evidence that use of e-cigarettes may be plateauing among young people in the UK after a rapid initial increase in experimentation. Explanations position e-cigarettes as a passing fad which is beginning to lose its appeal in UK youth. Longer term monitoring of trends and perceptions remain vital.

Dental professionals' opinions and knowledge of smoking cessation and electronic cigarettes: a cross-sectional survey in the north of England

Aims

To determine the current level of knowledge and opinions of UK dental professionals with regards to smoking cessation and e-cigarettes.

Method

A self-administered online survey was distributed by postal invitation to all dental practices in the north of England registered on the National Health Service (NHS) Choices website.

Findings

One hundred and ninety completed questionnaires were received. Seventy-nine percent of respondents reported always enquiring about the smoking status of their patients with 17% completing referrals to a specialist stop smoking service. Just under half of respondents reported not receiving any smoking cessation advice training. Lack of time during appointments, lack of training and lack of perceived interest by patients were reported as the most important barriers. The importance of a lack of remuneration, as a barrier, varied considerably with professional role. Approximately a third (31%) of respondents were of the opinion that e-cigarettes are more or equally harmful than cigarettes with the majority not aware of any guidance documents or recommendations regarding e-cigarettes.

Conclusion

The majority of dental professionals in the north of England reported providing smoking cessation advice, although only half had training on this. Opinions on electronic cigarettes were mixed, with a third having negative views.

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.

Effectiveness and cost-effectiveness of computer and other electronic aids for smoking cessation: a systematic review and network meta-analysis

BACKGROUND

Smoking is harmful to health. On average, lifelong smokers lose 10 years of life, and about half of all lifelong smokers have their lives shortened by smoking. Stopping smoking reverses or prevents many of these harms. However, cessation services in the NHS achieve variable success rates with smokers who want to quit. Approaches to behaviour change can be supplemented with electronic aids, and this may significantly increase quit rates and prevent a proportion of cases that relapse.

OBJECTIVE

The primary research question we sought to answer was: What is the effectiveness and cost-effectiveness of internet, pc and other electronic aids to help people stop smoking? We addressed the following three questions: (1) What is the effectiveness of internet sites, computer programs, mobile telephone text messages and other electronic aids for smoking cessation and/or reducing relapse? (2) What is the cost-effectiveness of incorporating internet sites, computer programs, mobile telephone text messages and other electronic aids into current nhs smoking cessation programmes? and (3) What are the current gaps in research into the effectiveness of internet sites, computer programs, mobile telephone text messages and other electronic aids to help people stop smoking?

DATA SOURCES

For the effectiveness review, relevant primary studies were sought from The Cochrane Library [Cochrane Central Register of Controlled Trials (CENTRAL)] 2009, Issue 4, and MEDLINE (Ovid), EMBASE (Ovid), PsycINFO (Ovid), Health Management Information Consortium (HMIC) (Ovid) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost) from 1980 to December 2009. In addition, NHS Economic Evaluation Database (NHS EED) and Database of Abstracts of Reviews of Effects (DARE) were searched for information on cost-effectiveness and modelling for the same period. Reference lists of included studies and of relevant systematic reviews were examined to identify further potentially relevant studies. Research registries of ongoing studies including National Institute for Health Research (NIHR) Clinical Research Network Portfolio Database, Current Controlled Trials and ClinicalTrials.gov were also searched, and further information was sought from contacts with experts.

REVIEW METHODS

Randomised controlled trials (RCTs) and quasi-RCTs evaluating smoking cessation programmes that utilise computer, internet, mobile telephone or other electronic aids in adult smokers were included in the effectiveness review. Relevant studies of other design were included in the cost-effectiveness review and supplementary review. Pair-wise meta-analyses using both random- and fixed-effects models were carried out. Bayesian mixed-treatment comparisons (MTCs) were also performed. A de novo decision-analytical model was constructed for estimating the cost-effectiveness of interventions. Expected value of perfect information (EVPI) was calculated. Narrative synthesis of key themes and issues that may influence the acceptability and usability of electronic aids was provided in the supplementary review.

RESULTS

This effectiveness review included 60 RCTs/quasi-RCTs reported in 77 publications. Pooled estimate for prolonged abstinence [relative risk (RR) = 1.32, 95% confidence interval (CI) 1.21 to 1.45] and point prevalence abstinence (RR = 1.14, 95% CI 1.07 to 1.22) suggested that computer and other electronic aids increase the likelihood of cessation compared with no intervention or generic self-help materials. There was no significant difference in effect sizes between aid to cessation studies (which provide support to smokers who are ready to quit) and cessation induction studies (which attempt to encourage a cessation attempt in smokers who are not yet ready to quit). Results from MTC also showed small but significant intervention effect (time to relapse, mean hazard ratio 0.87, 95% credible interval 0.83 to 0.92). Cost-threshold analyses indicated some form of electronic intervention is likely to be cost-effective when added to non-electronic behavioural support, but there is substantial uncertainty with regard to what the most effective (thus most cost-effective) type of electronic intervention is, which warrants further research. EVPI calculations suggested the upper limit for the benefit of this research is around £ 2000-3000 per person.

LIMITATIONS

The review focuses on smoking cessation programmes in the adult population, but does not cover smoking cessation in adolescents. Most available evidence relates to interventions with a single tailored component, while evidence for different modes of delivery (e.g. e-mail, text messaging) is limited. Therefore, the findings of lack of sufficient evidence for proving or refuting effectiveness should not be regarded as evidence of ineffectiveness. We have examined only a small number of factors that could potentially influence the effectiveness of the interventions. A comprehensive evaluation of potential effect modifiers at study level in a systematic review of complex interventions remains challenging. Information presented in published papers is often insufficient to allow accurate coding of each intervention or comparator. A limitation of the cost-effectiveness analysis, shared with several previous cost-effectiveness analyses of smoking cessation interventions, is that intervention benefit is restricted to the first quit attempt. Exploring the impact of interventions on subsequent attempts requires more detailed information on patient event histories than is available from current evidence.

CONCLUSIONS

Our effectiveness review concluded that computer and other electronic aids increase the likelihood of cessation compared with no intervention or generic self-help materials, but the effect is small. The effectiveness does not appear to vary with respect to mode of delivery and concurrent non-electronic co-interventions. Our cost-effectiveness review suggests that making some form of electronic support available to smokers actively seeking to quit is highly likely to be cost-effective. This is true whether the electronic intervention is delivered alongside brief advice or more intensive counselling. The key source of uncertainty is that around the comparative effectiveness of different types of electronic interventions. Our review suggests that further research is needed on the relative benefits of different forms of delivery for electronic aids, the content of delivery, and the acceptability of these technologies for smoking cessation with subpopulations of smokers, particularly disadvantaged groups. More evidence is also required on the relationship between involving users in the design of interventions and the impact this has on effectiveness, and finally on how electronic aids developed and tested in research settings are applied in routine practice and in the community.

Smoking cessation during pregnancy: the influence of partners, family and friends on quitters and non-quitters

This research compared pregnant quitters' and non-quitters' accounts of how partners, family and friends influenced their smoking cessation attempts. Qualitative secondary data analysis was carried out on a purposive sample of motivational interview transcripts undertaken by research midwives with pregnant women as part of SmokeChange, a smoking cessation intervention. Interviews with all quitters in the intervention group (n = 12) were analysed comparatively with interviews from a matched sample of non-quitters (n = 12).The discourses of both revealed similarity in how their partners, family and friends influenced their cessation efforts: salient others were simultaneously perceived by both groups of women as providing drivers and barriers to quit attempts; close associates who smoked were often perceived to be as supportive as those who did not. However, women who quit smoking during pregnancy talked more about receiving active praise/encouragement than those who did not. While close associates play an important role in women's attempts to stop smoking during pregnancy, the support they provide varies; further research is needed to develop a better understanding of how key relationships help or hinder cessation during pregnancy.

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

OBJECTIVES

To determine the extent to which UK National Health Service (NHS) smoking cessation services in England reach smokers and support them to quit at four weeks, and to identify which service and area characteristics contribute to observed outcomes.

DESIGN

Ordinary least squares regression was used to investigate local smoking outcomes in relation to characteristics of health authorities and their smoking cessation services.

SETTING

76 health authorities (from a total of 99) in England from April 2000 to March 2001.

MAIN OUTCOME MEASURES

REACH--number of smokers attending cessation services and setting a quit date as a percentage of the adult smoking population in each health authority. ABSOLUTE SUCCESS--number of smokers setting a quit date who subsequently reported quitting at four weeks (not having smoked between two and four weeks after quit date). CESSATION RATE--number of smokers who reported quitting at four weeks as a percentage of those setting a quit date. LOSS--percentage lost to follow up.

RESULTS

A range of service and area characteristics was associated with each outcome. For example, group support proved more effective than one to one interventions in helping a greater proportion of smokers to quit at four weeks. Services based in health action zones were reaching larger numbers of smokers. However, services operating in deprived communities achieved lower cessation rates than those in more prosperous areas.

CONCLUSIONS

Well developed, evidence based NHS smoking cessation services, reflecting good practice, are yielding positive outcomes in England. However, most of the data are based on self reported smoking status at four weeks. It will be important to obtain validated data about continuous cessation over one year or more in order to assess longer term impact.

Satisfaction with the care-managed support of older people: an empirical analysis

Modernising Social Services requires the use of satisfaction surveys in monitoring some key aspects of quality of provision, including user/carer perceptions and experiences of services and involvement of users/carers in assessment and review. Using data from the study Evaluating Community Care for Elderly People (ECCEP), of physically and/or mentally frail community-based older people in England and Wales receiving community care services, this investigation examines three crucial aspects of user satisfaction. The measures were: initial satisfaction with the assessment process and help provided by social services; also two measures obtained from a six month follow-up, namely satisfaction with service levels and with the experience of social services. Examination of overall satisfaction levels provided only a partial picture, due to their association with both user characteristics and the effect of life satisfaction. This association was therefore examined firstly by considering each characteristic separately and secondly by modelling the presence of each satisfaction measure in terms of those characteristics having a significant effect, using logistic regression. Arthritis, loneliness, problems keeping warm and an inner city location were all characteristics associated with reduced satisfaction, while most resource inputs, including social work involvement, were positively related to satisfaction. General life satisfaction was also associated with increased satisfaction levels. The role of life satisfaction as a predictor was further investigated through examining its dependence on case characteristics. While older users were more frequently satisfied with life, those with greater functional impairment and below average self-perceived health reported lower life satisfaction. Findings from this study highlight the complexity of interpreting satisfaction data and suggest that those responsible for designing and conducting surveys need to be aware of both the potential and pitfalls associated with using them as a means of assessing the quality of social services for older people.

Smoking. Baccy to front

The government is making 60m pounds available to develop smoking cessation services over three years. This year's funding is concentrated on health action zones where progress has been slow. The cost of nicotine replacement patches is significantly more than many smokers spend on cigarettes.