Rachael Murray

Improving access to smoking cessation services for disadvantaged groups: a systematic review

BACKGROUND Smoking is a main contributor to health inequalities. Identifying strategies to find and support smokers from disadvantaged groups is, therefore, of key importance. METHODS A systematic review was carried out of studies identifying and supporting smokers from disadvantaged groups for smoking cessation, and providing and improving their access to smoking-cessation services. A wide range of electronic databases were searched and unpublished reports were identified from the national research register and key experts. RESULTS Over 7500 studies were screened and 48 were included. Some papers were of poor quality, most were observational studies and many did not report findings for disadvantaged smokers. Nevertheless, several methods of recruiting smokers, including proactively targeting patients on General Physicians registers, routine screening or other hospital appointments, were identified. Barriers to service use for disadvantaged groups were identified and providing cessation services in different settings appeared to improve access. We found preliminary evidence of the effectiveness of some interventions in increasing quitting behaviour in disadvantaged groups. CONCLUSIONS There is limited evidence on effective strategies to increase access to cessation services for disadvantaged smokers. While many studies collected socioeconomic data, very few analysed its contribution to the results. However, some potentially promising interventions were identified which merit further research.

A survey of tobacco dependence treatment services in 121 countries: Tobacco treatment services in 121 countries

Aims To report progress among Parties to the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in developing tobacco dependence treatment systems in accordance with FCTC Article 14 and the Article 14 guidelines recommendations. Design Cross-sectional study. Setting Electronic survey from December 2011 to August 2012. Participants One hundred and sixty-three of the 174 Parties to the FCTC at the time of our survey. Measurements The 51-item questionnaire contained 21 items specifically on treatment systems. Questions covered the availability of basic treatment infrastructure and national cessation support systems. Findings We received responses from 121 (73%) of the 166 countries surveyed. Fewer than half of the countries had national treatment guidelines (n = 53, 44%), a government official responsible for tobacco dependence treatment (n = 49, 41%), an official national treatment strategy (n = 53, 44%) or provided tobacco cessation support for health workers (n = 55, 46%). More than half encouraged brief advice in existing health care services (n = 68, 56%), while only 44 (36%) had quitlines and only 20 (17%) had a network of treatment support covering the whole country. Low- and middle-income countries had less tobacco dependence treatment provision than high-income countries. Conclusion Most countries, especially low- and middle-income countries, have not yet implemented the recommendations of FCTC Article 14 or the FCTC Article 14 guidelines.

Second hand smoke exposure and the risk of invasive meningococcal disease in children: systematic review and meta-analysis

BackgroundInvasive meningococcal disease remains an important cause of serious morbidity and mortality in children and young people. There is a growing body of literature to suggest that exposure to passive smoke may play a role in the development of the disease, therefore we have performed a systematic review to provide a comprehensive estimate of the magnitude of this effect for smoking by any household member, by individual family members, and of maternal smoking before and after birth.MethodsFour databases (Medline, Embase, PsychINFO and CAB Abstracts database) were searched to identify studies (to June 2012) and reference lists scanned for further studies. Titles, abstracts and full texts were checked for eligibility independently by two authors. Quality of included studies was assessed using the Newcastle-Ottawa Scale. Pooled odds ratios (OR) with 95% confidence intervals (CI) were estimated using random effect models, with heterogeneity quantified using I2.ResultsWe identified 18 studies which assessed the effects of SHS on the risk of invasive meningococcal disease in children. SHS in the home doubled the risk of invasive meningococcal disease (OR 2.18, 95% CI 1.63 to 2.92, I2 = 72%), with some evidence of an exposure-response gradient. The strongest effect was seen in children under 5 years (OR 2.48, 95% CI 1.51 to 4.09, I2 = 47%). Maternal smoking significantly increased the risk of invasive meningococcal disease by 3 times during pregnancy (OR 2.93, 95% CI 1.52-5.66) and by 2 times after birth (OR 2.26, 95% CI 1.54-3.31).ConclusionsSHS exposure, and particularly passive foetal exposure to maternal smoking during pregnancy, significantly increases the risk of childhood invasive meningococcal disease. It is likely that an extra 630 cases of invasive meningococcal disease annually in children under 16 are directly attributable to SHS exposure in UK homes.

A survey of tobacco dependence treatment guidelines in 121 countries

Aims To report progress among Parties to the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in developing national tobacco treatment guidelines in accordance with FCTC Article 14 guideline recommendations. Design Cross-sectional study. Setting Electronic survey from December 2011 to August 2012; participants were asked to complete either an online or attached Microsoft Word questionnaire. Participants One hundred and sixty-three of the 173 Parties to the FCTC at the time of our survey. Measurements The 51-item questionnaire contained 30 items specifically on guidelines. Questions covered the areas of guidelines writing process, content, key recommendations and other characteristics. Findings One hundred and twenty-one countries (73%) responded. Fifty-three countries (44%) had guidelines, ranging from 75% among high-income countries to 11% among low-income countries. Nearly all guidelines recommended brief advice (93%), intensive specialist support (93%) and medications (96%), while 66% recommended quitlines. Fifty-seven percent had a dissemination strategy, 76% stated funding source and 68% had professional endorsement. Conclusion Fewer than half of the Parties to the WHO FCTC have developed national tobacco treatment guidelines, but, where guidelines exist, they broadly follow FCTC Article 14 guideline recommendations.

Unplanned attempts to quit smoking: missed opportunities for health promotion?

OBJECTIVES To investigate the occurrence, determinants and reported success of unplanned and planned attempts to quit smoking, and sources of support used in these attempts. DESIGN Cross-sectional questionnaire survey of 3512 current and ex-smokers. SETTING Twenty-four general practices in Nottinghamshire, UK. PARTICIPANTS Individuals who reported making a quit attempt within the last 6 months. MEASUREMENTS Occurrence, triggers for, support used and success of planned and unplanned quit attempts. RESULTS A total of 1805 (51.4%) participants returned completed questionnaires, reporting 394 quit attempts made within the previous 6 months of which 37% were unplanned. Males were significantly more likely to make an unplanned quit attempt [adjusted odds ratio (OR) 1.60, 95% confidence interval (CI) 1.04-2.46], but the occurrence of unplanned quit attempts did not differ significantly by socio-economic group or amount smoked. The most common triggers for unplanned quit attempts were advice from a general practitioner or health professional (27.9%) and health problems (24.5%). 5.4% and 4.1% of unplanned quit attempts used National Health Service cessation services on a one to one and group basis, respectively, and more than half (51.7%) were made without any support. Nevertheless, unplanned attempts were more likely to be reported to be successful (adjusted OR 2.01, 95% CI 1.23-3.27, P < 0.01). CONCLUSIONS Unplanned quit attempts are common among smokers in all socio-demographic groups, are triggered commonly by advice from a health professional and are more likely to succeed; however, the majority of these unplanned attempts are unsupported. It is important to develop methods of providing behavioural and/or pharmacological support for these attempts, and determine whether these increase cessation rates still further.

The effect of proactively identifying smokers and offering smoking cessation support in primary care populations: a cluster-randomized trial.

AIMS To establish whether proactively identifying all smokers in primary care populations and offering smoking cessation support is effective in increasing long-term abstinence from smoking. DESIGN Cluster randomized controlled trial. SETTING Twenty-four general practices in Nottinghamshire, randomized by practice to active or control intervention. PARTICIPANTS All adult patients registered with the practices who returned a questionnaire confirming that they were current smokers (n = 6856). INTERVENTION Participants were offered smoking cessation support by letter and those interested in receiving it were contacted and referred into National Health Service (NHS) stop smoking services if required. MEASUREMENTS Validated abstinence from smoking, use of smoking cessation services and number of quit attempts in continuing smokers at 6 months. FINDINGS Smokers in the intervention group were more likely than controls to report that they had used local cessation services during the study period [16.6% and 8.9%, respectively, adjusted odds ratio (OR) 2.09, 95% confidence interval (CI) 1.57-2.78], and continuing smokers (in the intervention group) were more likely to have made a quit attempt in the last 6 months (37.4% and 33.3%, respectively, adjusted OR 1.23, 95% CI 1.01-1.51). Validated point prevalence abstinence from smoking at 6 months was higher in the intervention than the control groups (3.5% and 2.5%, respectively) but the difference was not statistically significant (adjusted OR controlling for covariates: 1.64, 95% CI 0.92-2.89). CONCLUSIONS Proactively identifying smokers who want to quit in primary care populations, and referring them to a cessation service, increased contacts with cessation services and the number of quit attempts. We were unable to detect a significant effect on long-term cessation rates, but the study was not powered to detect the kind of difference that might be expected.

Adolescents’ exposure to tobacco and alcohol content in YouTube music videos

Abstract Aims To quantify tobacco and alcohol content, including branding, in popular contemporary YouTube music videos; and measure adolescent exposure to such content. Design Ten‐second interval content analysis of alcohol, tobacco or electronic cigarette imagery in all UK Top 40 YouTube music videos during a 12‐week period in 2013/14; on‐line national survey of adolescent viewing of the 32 most popular high‐content videos. Setting Great Britain. Participants A total of 2068 adolescents aged 11–18 years who completed an on‐line survey. Measurements Occurrence of alcohol, tobacco and electronic cigarette use, implied use, paraphernalia or branding in music videos and proportions and estimated numbers of adolescents who had watched sampled videos. Findings Alcohol imagery appeared in 45% [95% confidence interval (CI) = 33–51%] of all videos, tobacco in 22% (95% CI = 13–27%) and electronic cigarettes in 2% (95% CI = 0–4%). Alcohol branding appeared in 7% (95% CI = 2–11%) of videos, tobacco branding in 4% (95% CI = 0–7%) and electronic cigarettes in 1% (95% CI = 0–3%). The most frequently observed alcohol, tobacco and electronic cigarette brands were, respectively, Absolut Tune, Marlboro and E‐Lites. At least one of the 32 most popular music videos containing alcohol or tobacco content had been seen by 81% (95% CI = 79%, 83%) of adolescents surveyed, and of these 87% (95% CI = 85%, 89%) had re‐watched at least one video. The average number of videos seen was 7.1 (95% CI = 6.8, 7.4). Girls were more likely to watch and also re‐watch the videos than boys, P < 0.001. Conclusions Popular YouTube music videos watched by a large number of British adolescents, particularly girls, include significant tobacco and alcohol content, including branding.

The impact of the United Kingdom's national smoking cessation strategy on quit attempts and use of cessation services: Findings from the International Tobacco Control Four Country Survey

INTRODUCTION The World Health Organization Framework Convention on Tobacco Control recommends that provision of cessation support should be included in national tobacco control strategies. This study examines the impact of the United Kingdoms national smoking cessation strategy on quit attempts, use of treatment and short-term abstinence, relative to the United States, Canada, and Australia where less support is provided. METHODS Data on quitting behavior and use of support were obtained for all smokers enrolled in the International Tobacco Control 4 Country Survey between 2002 and 2005. Generalized estimating equations were used to calculate the relative odds (adjusted by age, sex, and Heaviness of Smoking Index) that smokers in each country made quit attempts, used behavioral or pharmacological support, and to compare rates of short-term (28 days) abstinence between countries and users of different forms of support. RESULTS U.K. smokers were less likely to have attempted to quit smoking than those in Australia (odds ratio [OR] = 1.25, 95% CI: 1.12-1.40), Canada (OR = 1.50, 95% CI: 1.34-1.67), and the United States (OR = 1.25, 95% CI: 1.11-1.40) but were more likely to use pharmacotherapy and/or support from a clinic, helpline, or health professional when attempting to quit than smokers in the other countries. U.K. smokers making quit attempts were significantly more likely to achieve 28-day abstinence than those in Australia (OR = 0.59, 95% CI: 0.49-0.71), Canada (OR = 0.72, 95% CI: 0.61-0.87), and the United States (OR = 0.51, 95% CI: 0.42-0.62). CONCLUSIONS U.K. smokers report fewer quit attempts but are more likely to use support when quitting and to achieve short-term abstinence.

Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial

Objectives To investigate the effectiveness of the systematic default provision of smoking cessation support to all adult smokers admitted to hospital, relative to usual care. Design Open, cluster randomised controlled trial. Setting Acute medical wards in one large teaching hospital in the United Kingdom. Participants 264 patients randomised to intervention and 229 to usual care; primary outcome data were available at four weeks for 260 and 224 patients, respectively. All adult smokers and recent ex-smokers able to give informed consent were eligible for entry into the study. Interventions The intervention comprised systematic smoking ascertainment and default provision of behavioural support and cessation pharmacotherapy for the duration of the hospital stay for all smokers and recent ex-smokers, with follow-up and referral to community services after discharge. Usual care comprised cessation support delivered at the initiative and discretion of clinical staff. All staff and patients were aware of group assignment. Main outcome measures Smoking cessation at four weeks, validated by measuring exhaled carbon monoxide. Secondary outcomes were uptake of inpatient behavioural support, use of cessation pharmacotherapy, referral to and uptake of community support after discharge, and validated smoking cessation at six months. Participants lost to follow-up were assumed to have reverted to smoking. Results All patients in the intervention group received at least brief advice to quit smoking, compared to 106 (46%) patients in the usual care group. Cessation at four weeks was achieved by 38% (n=98) of intervention patients and 17% (n=37) of usual care patients (adjusted odds ratio 2.10 (95% confidence interval 0.96 to 4.61), P=0.06, number of patients needed to treat 8). Uptake of inpatient behavioural support, use of pharmacotherapy, and referral to and uptake of community support after discharge were all substantially and statistically significantly higher in the intervention group than in the usual care group. Cessation at six months was achieved by 19% (n=47) of intervention and 9% (n=19) of usual care patients, although this difference was not significant (adjusted odds ratio 1.53 (95% confidence interval 0.60 to 3.91); P=0.37). Conclusions Substantial improvements in smoking cessation among smokers admitted to hospital can be achieved by systematic ascertainment and delivery of cessation support in secondary care. Trial registration International Standard Randomised Controlled Trial Number ISRCTN25441641.

Cigarette price, affordability and smoking prevalence in the European Union

AIMS To describe current and recent changes in cigarette affordability across the current 27 European Union (EU) Member States, and to assess the impact of these changes on smoking prevalence in countries that were EU members in 2004 (old Member States) compared to countries that have joined since 2004 (new Member States). DESIGN Investigation of cigarette affordability using the minutes of labour measure, and comparisons of changes in affordability, tax and smoking prevalence in old and new EU Member States. PARTICIPANTS Current 27 EU Member States. SETTINGS European Union. MEASUREMENTS Cigarette prices, overall tax yield and incidence, hourly wages and smoking prevalence in the EU were obtained from published sources, and the affordability of the EU Most Popular Price Category (MPPC) cigarettes estimated as the number of minutes of labour required to earn the price of 20 cigarettes in the years 2003, 2006 and 2009. FINDINGS The mean [standard deviation (SD)] number of minutes of labour required to purchase 20 MPPC cigarettes in EU Member States in 2009 was 31.3 (SD 10.7), but ranged fourfold across the EU, and was significantly higher in new than old Member States. The number of minutes of labour measure increased more, although not significantly so, between 2003 and 2009 in new [mean (SD) 12.1 (10.9)] than in old [6.7 (4.0)] Member States, largely because of proportionately higher increases in taxation. However, there was no correlation between change in affordability and change in smoking prevalence in recent years. CONCLUSIONS Cigarette affordability varies substantially and cigarettes are generally becoming less affordable in European Union Member States. However, these reductions in affordability do not appear to have impacted substantially on smoking prevalence in recent years.