Amanda Amos

Socioeconomic status and smoking: A review

Smoking prevalence is higher among disadvantaged groups, and disadvantaged smokers may face higher exposure to tobaccos harms. Uptake may also be higher among those with low socioeconomic status (SES), and quit attempts are less likely to be successful. Studies have suggested that this may be the result of reduced social support for quitting, low motivation to quit, stronger addiction to tobacco, increased likelihood of not completing courses of pharmacotherapy or behavioral support sessions, psychological differences such as lack of self‐efficacy, and tobacco industry marketing. Evidence of interventions that work among lower socioeconomic groups is sparse. Raising the price of tobacco products appears to be the tobacco control intervention with the most potential to reduce health inequalities from tobacco. Targeted cessation programs and mass media interventions can also contribute to reducing inequalities. To tackle the high prevalence of smoking among disadvantaged groups, a combination of tobacco control measures is required, and these should be delivered in conjunction with wider attempts to address inequalities in health.

Women and tobacco.

Abstract:u2003 Smoking prevalence is lower among women than men in most countries, yet there are about 200 million women in the world who smoke, and in addition, there are millions more who chew tobacco. Approximately 22% of women in developed countries and 9% of women in developing countries smoke, but because most women live in developing countries, there are numerically more women smokers in developing countries. Unless effective, comprehensive and sustained initiatives are implemented to reduce smoking uptake among young women and increase cessation rates among women, the prevalence of female smoking in developed and developing countries is likely to rise to 20% by 2025. This would mean that by 2025 there could be 532 million women smokers. Even if prevalence levels do not rise, the number of women who smoke will increase because the population of women in the world is predicted to rise from the current 3.1 billion to 4.2 billion by 2025. Thus, while the epidemic of tobacco use among men is in slow decline, the epidemic among women will not reach its peak until well into the 21st century. This will have enormous consequences not only for womens health and economic wellbeing but also for that of their families. The health effects of smoking for women are more serious than for men. In addition to the general health problems common to both genders, women face additional hazards in pregnancy, female‐specific cancers such as cancer of the cervix, and exposure to passive smoking. In Asia, although there are currently lower levels of tobacco use among women, smoking among girls is already on the rise in some areas. The spending power of girls and women is increasing so that cigarettes are becoming more affordable. The social and cultural constraints that previously prevented many women from smoking are weakening; and women‐specific health education and quitting programmes are rare. Furthermore, evidence suggests that women find it harder to quit smoking. The tobacco companies are targeting women by marketing light, mild, and menthol cigarettes, and introducing advertising directed at women. The greatest challenge and opportunity in primary preventive health in Asia and in other developing areas is to avert the predicted rise in smoking among women.

Women and tobacco: a call for including gender in tobacco control research, policy and practice

Objectives Female smoking is predicted to double between 2005 and 2025. There have been numerous calls for action on womens tobacco use over the past two decades. In the present work, evidence about female tobacco use, progress, challenges and ways forward for developing gendered tobacco control is reviewed. Methods Literature on girls, women and tobacco was reviewed to identify trends and determinants of tobacco use and exposure, the application of gender analysis, tobacco marketing, the impact of tobacco control on girls and women and ways to address these issues particularly in low-income and middle-income countries. Results Global female tobacco use is increasingly complex, involving diverse products and factors including tobacco marketing, globalisation and changes in womens status. In high-income countries female smoking is declining but is increasingly concentrated among disadvantaged women. In low-income and middle-income countries the pattern is more complex; in several regions the gap between girls and boys smoking is narrow. Gendered analyses and approaches to tobacco control are uncommon, especially in low-income and middle-income countries. Conclusions Tobacco control has remained largely gender blind, with little recognition of the importance of understanding the context and challenges of girls and womens smoking and secondhand smoke exposure. There has been little integration of gender considerations in research, policy and programmes. The present work makes a case for gender and diversity analyses in tobacco control to reflect and identify intersecting factors affecting womens tobacco use. This will help animate the WHO Framework Convention on Tobacco Controls concern for gender specificity and womens leadership, and reduce the impact of tobacco on women.

Smoking and socioeconomic status in England: the rise of the never smoker and the disadvantaged smoker

BACKGROUNDnSince 2000 various tobacco control measures have been implemented in the UK. Changes in the smoking status of low and high socioeconomic status (SES) groups in England during this period (2001-08) are explored.nnnMETHODSnSecondary analysis of the Health Survey for England general population samples was undertaken. Over 88 000 adults, age 16 or over, living in England were included. Smoking status (current, ex or never) was reported. SES was assessed through a count of seven possible indicators of disadvantage: National Statistics Socio-Economic Classification (NSSEC), neighbourhood index of multiple deprivation, lone parenting, car availability, housing tenure, income and unemployment.nnnRESULTSnSmoking rates were four times higher among the most disadvantaged [60.7% (95% CI: 58.2-63.3)] than the most affluent [15.3% (95% CI: 14.8-15.8)]. Smoking prevalence declined between 2001 and 2008 except among the multiply disadvantaged. This trend appeared to be due to an increase in never smoking rather than an increase in quitting. Disadvantage declined among non-smokers but not smokers.nnnCONCLUSIONSnIn general never smoking and affluence increased in England over this period. The disadvantaged, however, did not experience the decline in smoking and smokers missed out from the increase in affluence. Smoking and disadvantage may increasingly coexist.

Promoting smoking cessation through smoking reduction during Ramadan

Ramadan restricts smoking and leads to reduction. Recent research on reduction has focused upon using nicotine replacement therapy (NRT) as a substitute for missed cigarettes and behavioural approaches have been neglected, despite evidence of efficacy. Ramadan reminds us of the need to harness these natural experiments to enhance smoking reduction and hence cessation.

Experiences of outreach workers in promoting smoking cessation to Bangladeshi and Pakistani men: longitudinal qualitative evaluation

BackgroundDespite having high smoking rates, there have been few tailored cessation programmes for male Bangladeshi and Pakistani smokers in the UK. We report on a qualitative evaluation of a community-based, outreach worker delivered, intervention that aimed to increase uptake of NHS smoking cessation services and tailor services to meet the needs of Bangladeshi and Pakistani men.MethodsThis was a longitudinal, qualitative study, nested within a phase II cluster randomised controlled trial of a complex intervention. We explored the perspectives and experiences of five outreach workers, two stop smoking service managers and a specialist stop smoking advisor. Data were collected through focus group discussions, weekly diaries, observations of management meetings, shadowing of outreach workers, and one-to-one interviews with outreach workers and their managers. Analysis was undertaken using a modified Framework approach.ResultsOutreach workers promoted cessation services by word of mouth on the streets, in health service premises, in local businesses and at a wide range of community events. They emphasised the reasons for cessation, especially health effects, financial implications, and the impact of smoking on the family. Many smokers agreed to be referred to cessation services, but few attended, this in part being explained by concerns about the relative inflexibility of existing service provision. Although outreach workers successfully expanded service reach, they faced the challenges of perceived lack of awareness of the health risks associated with smoking in older smokers and apathy in younger smokers. These were compounded by perceptions of lip service being given to their role by community organisations and tensions both amongst the outreach workers and with the wider management team.ConclusionsOutreach workers expanded reach of the service through taking it to diverse locations of relevance to Pakistani and Bangladeshi communities. The optimum method of outreach to retain and treat Bangladeshi and Pakistani smokers effectively in cessation programmes needs further development.

The re-shaping of the life-world: male British Bangladeshi smokers and the English smoke-free legislation

Objective. To explore how male Bangladeshi smokers adapted to the English smoke-free legislation. Design. We draw on data derived from the Evaluation of Smoke-free England (ESME), a qualitative, longitudinal study conducted between 2007 and 2008 in two English metropolitan areas. Repeat interviews (n=34) were conducted before and after the legislation with 15 male Bangladeshi panel informants and from two focus groups: one with Bangladeshi men and the other with Bangladeshi women. Results. Bangladeshi smokers who participated in this study had largely accommodated to the smoke-free legislation and most had reduced their consumption of cigarettes, albeit to a modest degree. However, at the same time some Bangladeshi smokers appeared to have increased their use of shisha, a popular alternative method of smoking tobacco in this community. Smoke-free legislation also had an impact on the social and cultural forces that shape smoking behaviour in this group. In particular, family homes continued to be a key space where tobacco is consumed, although the legislation may have helped to shift the balance in favour of forces that oppose smoking and against enduring cultural pro-smoking norms. Smoking in public was also less socially acceptable, especially in the vicinity of local mosques and at community events. In some older groups, however, smoking remains a deeply embedded social habit which can undermine smokers’ efforts to quit. Conclusion. For maximum impact, tobacco control interventions aimed at whole populations may need to be supplemented by culturally sensitive measures in local areas where there is a high concentration of Bangladeshi people. Similar considerations may apply to other minority communities with a high prevalence of smoking.

Developing the evidence base for addressing inequalities and smoking in the United Kingdom

AIMSnSmoking is an increasing cause of health inequalities in high-income countries. This supplement describes pilot projects set up in England to develop and test pathways to ensure that disadvantaged groups, where smoking is frequently the norm, are reached, encouraged and supported to stop their tobacco use. Target groups were: smokers attending centres set up for highly deprived parents; smokers with serious and enduring mental illness; pregnant smokers; prisoners/other offenders who smoked; South Asian tobacco chewers; and recent quitters from routine and manual occupational groups.nnnMETHODSnCommonalities observed across the six projects are summarized, alongside recommendations for implementation.nnnRESULTSnA significant barrier to implementation was the lack of mandatory identification of tobacco users across primary, secondary and community health-care settings and routine use of expired air carbon monoxide monitoring, particularly for high-risk groups. Appropriate use of financial incentives and national guidance is probably necessary to achieve both this and the adoption of joined-up tobacco dependence treatment pathways for these target groups. Further research is needed on the impact of opt out pathways: while resulting in increased referral rates, success rates were lower. In general, smoking cessation service targets were a barrier to implementation. Flexibility and tailoring of interventions were required and most projects trained those already working in relevant settings, given their greater understanding of target groups. Mandatory training of all frontline health-care staff was deemed desirable.nnnCONCLUSIONSnImplementing the findings of these projects will require resources, for training, incentivizing health-care workers and further research. However, continuing with the status quo may result in sustained tobacco use health inequalities for the foreseeable future.

A qualitative study exploring why people do not participate in cardiac rehabilitation and coronary heart disease self-help groups, and their rehabilitation experience without these resources.

BACKGROUNDnSecondary prevention and self-management of coronary heart disease (CHD) are of major importance to people who survive myocardial infarction (MI). This can be facilitated by cardiac rehabilitation (CR; the formal health service programme) and informal CHD self-help groups. Non-participation is an important issue, yet it is poorly understood. Rehabilitation difficulties and prevention challenges have been identified among people following MI, but the particular experience and perspective of CR and CHD group non-participants are largely unknown.nnnAIMnThe study aimed to understand non-participation in CR and CHD self-help groups from the perspectives of the non-participants and to provide insight into their experience and that of their significant others in rehabilitating in the absence of these resources.nnnMETHODSnIn-depth interviews were conducted with 27 people who had not participated in either hospital-based CR or a CHD group, 6-14 months post-MI, and 17 significant others in Lothian, Scotland.nnnFINDINGSnFactors influencing non-participation fell into three broad themes No need/no point, Not worth it, and Not possible. In the latter two categories, non-participation in these resources was often considered a missed opportunity and needs had remained unmet. Shifts between categories could occur over time. Non-participation was linked to rehabilitation difficulties for some people and family members. Recommendations to enhance post-MI support are made.

Evaluation of a programme to increase referrals to stop-smoking services using Children's Centres and smoke-free families schemes.

AIMSnTo assess the feasibility and effectiveness of a new service using referral liaison advisers to increase the number of referrals of parents/carers at selected Childrens Centres to National Health Service (NHS) Stop Smoking Services (SSS) and/or smoke-free families schemes (SFS).nnnDESIGNnThis mixed-methods pilot study collected numerical data on indicators of smoking behaviours and carried out face-to-face and telephone interviews.nnnSETTINGSnThirteen Childrens Centres in Liverpool and Nottingham using local providers of smoking cessation services, from September 2010 to April 2011.nnnPARTICIPANTSnParents and carers registered with, and staff working for, Childrens Centres.nnnMEASURESnNumber of smokers referred to smoking cessation services and/or smoke-free family schemes and the views of service providers and users on the new service.nnnFINDINGSnIn Liverpool, 181 referrals to NHS SSS were made from 331 identified smokers (54.7%); extrapolated to 12 months, this represents a 182% increase in referrals from baseline and a similar extrapolation indicates a 643% increase from baseline of referrals to smoke-free families schemes. There were no reliable baseline data for Nottingham; 31 referrals were made (30.7% of smokers) to SSS and 44 referrals to SFS from 52 contacts (84.6%). The interviews highlighted the need for sustained personal contact with parents/carers to discuss smoking behaviours and concerns and their willingness to be referred to SFS as part of caring for their child.nnnCONCLUSIONSnRoutine recording of smoking status and appropriate follow-up by trained staff in Childrens Centres can lead to significant numbers of clients attending stop-smoking services, although relatively few stop smoking.