Susan MacAskill

Financial incentives for smoking cessation in pregnancy: Randomised controlled trial

Objective To assess the efficacy of a financial incentive added to routine specialist pregnancy stop smoking services versus routine care to help pregnant smokers quit. Design Phase II therapeutic exploratory single centre, individually randomised controlled parallel group superiority trial. Setting One large health board area with a materially deprived, inner city population in the west of Scotland, United Kingdom. Participants 612 self reported pregnant smokers in NHS Greater Glasgow and Clyde who were English speaking, at least 16 years of age, less than 24 weeks pregnant, and had an exhaled carbon monoxide breath test result of 7 ppm or more. 306 women were randomised to incentives and 306 to control. Interventions The control group received routine care, which was the offer of a face to face appointment to discuss smoking and cessation and, for those who attended and set a quit date, the offer of free nicotine replacement therapy for 10 weeks provided by pharmacy services, and four, weekly support phone calls. The intervention group received routine care plus the offer of up to £400 of shopping vouchers: £50 for attending a face to face appointment and setting a quit date; then another £50 if at four weeks’ post-quit date exhaled carbon monoxide confirmed quitting; a further £100 was provided for continued validated abstinence of exhaled carbon monoxide after 12 weeks; a final £200 voucher was provided for validated abstinence of exhaled carbon monoxide at 34-38 weeks’ gestation. Main outcome measure The primary outcome was cotinine verified cessation at 34-38 weeks’ gestation through saliva (<14.2 ng/mL) or urine (<44.7 ng/mL). Secondary outcomes included birth weight, engagement, and self reported quit at four weeks. Results Recruitment was extended from 12 to 15 months to achieve the target sample size. Follow-up continued until September 2013. Of the 306 women randomised, three controls opted out soon after enrolment; these women did not want their data to be used, leaving 306 intervention and 303 control group participants in the intention to treat analysis. No harms of financial incentives were documented. Significantly more smokers in the incentives group than control group stopped smoking: 69 (22.5%) versus 26 (8.6%). The relative risk of not smoking at the end of pregnancy was 2.63 (95% confidence interval 1.73 to 4.01) P<0.001. The absolute risk difference was 14.0% (95% confidence interval 8.2% to 19.7%). The number needed to treat (where financial incentives need to be offered to achieve one extra quitter in late pregnancy) was 7.2 (95% confidence interval 5.1 to 12.2). The mean birth weight was 3140 g (SD 600 g) in the incentives group and 3120 (SD 590) g in the control group (P=0.67). Conclusion This phase II randomised controlled trial provides substantial evidence for the efficacy of incentives for smoking cessation in pregnancy; as this was only a single centre trial, incentives should now be tested in different types of pregnancy cessation services and in different parts of the United Kingdom. Trial registration Current Controlled Trials ISRCTN87508788.

Smoking prevalence and smoking cessation services for pregnant women in Scotland

BackgroundOver 20% of women smoke throughout pregnancy despite the known risks to mother and child. Engagement in face-to-face support is a good measure of service reach. The Scottish Government has set a target that by 2010 8% of smokers will have quit via NHS cessation services. At present less than 4% stop during pregnancy. We aimed to establish a denominator for pregnant smokers in Scotland and describe the proportion who are referred to specialist services, engage in one-to-one counselling, set a quit date and quit 4 weeks later.MethodsThis was a descriptive epidemiological study using routinely collected data supplemented by questionnaire information from specialist pregnancy cessation services.Results13266 of 52370 (25%) pregnant women reported being current smokers at maternity booking and 3133/13266 (24%) were referred to specialist cessation services in 2005/6. Two main types of specialist smoking cessation support for pregnant women were in place in Scotland. The first involved identification using self-report and carbon monoxide breath test for all pregnant women with routine referral (1936/3352, 58% referred) to clinic based support (386, 11.5% engaged). 370 (11%) women set a quit date and 116 (3.5%) had quit 4 weeks later. The second involved identification by self report and referral of women who wanted help (1195/2776, 43% referred) for home based support (377/1954, 19% engaged). 409(15%) smokers set a quit date and 119 (4.3%) had quit 4 weeks later. Cost of home-based support was greater. In Scotland only 265/8062 (3.2%) pregnant smokers identified at maternity booking, living in areas with recognised specialist or good generic services, quit smoking during 2006.ConclusionsIn Scotland, a small proportion of pregnant smokers are supported to stop. Poor outcomes are a product of current limitations to each step of service provision - identification, referral, engagement and treatment. Many smokers are not asked about smoking at maternity booking or provide false information. Carbon monoxide breath testing can bypass this difficulty. Identified smokers may not be referred but an opt-out referral policy can remove this barrier. Engagement at home allowed a greater proportion to set a quit date and quit, but costs were higher.

Rethinking drinking cultures: A review of drinking cultures and a reconstructed dimensional approach

OBJECTIVES This paper presents the synthesis of findings from a literature review study of drinking cultures across five West European countries (France, Germany, Spain, Sweden and the UK), examining the nature and features of drinking typologies before proposing a new dimensional approach. STUDY DESIGN The study incorporated a systematic literature search covering the period 1980-2010 for literature from each of the five countries. METHODS Researchers reviewed abstracts and selected relevant material, leading to the inclusion of 203 articles from database searches plus 26 records from other sources. A summary of key findings are presented here. Intercoder reliability checks were performed to ensure consistency in inclusion in the review according to pre-ordained selection criteria. The review was further supplemented by the inclusion of gray literature including policy documents obtained from a range of sources. RESULTS It was found that sociocultural contexts have a major influence on drinking cultures, and this is an area in which there have been dramatic changes over the past 30 years. Differences were found between the countries in terms of drinking cultures, the way in which alcohol is viewed, and how alcohol-related policy and practice operates. However, there seems to be an increasing homogenization of drinking cultures across many countries, strongly influenced by Anglo-US cultural zeitgeist. Modern drinking patterns have emerged, offering a complex and often overlapping schema of drinking typologies. CONCLUSIONS The study suggests that the wet-dry dichotomy is no longer relevant and that a revised version of a more recent dimensional approach featuring three dimensions - hedonism, function and control - may be better placed to describe and measure contemporary drinking cultures.

“It makes you feel so full of life” LiveWell, a feasibility study of a personalised lifestyle programme for colorectal cancer survivors

GoalsThe acceptability and feasibility of a 3-month personalised lifestyle (diet, exercise and weight management) intervention in overweight adults who had completed curative treatment for colorectal cancer were assessed by qualitative interviews, quality-of-life questionnaires and subjective and objective measures of diet and activity.Main resultsOver a 4-month period, 28 of 37 (75%) patients met the inclusion criteria and 20 (71%) of the eligible patients agreed to participate in the study and 18 (90%) completed the 3-month study. Reported adherence related to tailored advice, personalised feedback and family support. Reported barriers included time following surgery, fatigue, having a stoma or chronic diarrhoea and conflicting advice from clinicians. A weight change of −1.2 (±4.4) kg was achieved overall and −4.1 (±3.7) kg in the ten who had lost weight.ConclusionsColorectal cancer survivors will participate in a lifestyle change initiative. Interventions should be personalised to suit abilities, provide feedback on personal goals and encourage social support. Intervention timing and attaining greater support from clinicians should be explored prior to the development of an efficacy trial.

Development and evaluation of an early detection intervention for mouth cancer using a mass media approach

Background:Scotland has a high incidence of mouth cancer, but public awareness and knowledge are low compared with other cancers. The West of Scotland Cancer Awareness Project sought to increase public awareness and knowledge of mouth cancer and to encourage early detection of symptoms among an at-risk population of people aged over 40 years from lower socio-economic groups using a mass media approach. The media campaign aimed to increase peoples feelings of personal risk, while also enhancing feelings of efficacy and control. To achieve this, a testimonial approach (using real people to tell their own stories) was adopted.Methods:Campaign impact and reach was assessed using in-home interviews with a representative sample of the target population in both the campaign area and controls outside of the target area. Surveys were conducted at three stages: at baseline before the campaign was launched, and at 7 and 12 months thereafter.Results:Awareness of media coverage was higher at both follow-up points in the intervention area than in the control area, the differences largely being accounted for by television advertising. The campaign had a short-term, but not a long-term impact on awareness of the disease and intention to respond to the symptoms targeted by the campaign. Awareness of two of the symptoms featured in the campaign (ulcers and lumps) increased, post-campaign, among the intervention group.Conclusions:While the study provides evidence for the effectiveness of the self-referral model, further work is needed to assess its ability to build public capacity to respond appropriately to symptoms and to compare the cost-effectiveness of a mass media approach against alternative communication approaches and more conventional mass screening.

Give It Up For Baby: outcomes and factors influencing uptake of a pilot smoking cessation incentive scheme for pregnant women

BackgroundThe use of incentives to promote smoking cessation is a promising technique for increasing the effectiveness of interventions. This study evaluated the smoking cessation outcomes and factors associated with success for pregnant smokers who registered with a pilot incentivised smoking cessation scheme in a Scottish health board area (NHS Tayside).MethodsAll pregnant smokers who engaged with the scheme between March 2007 and December 2009 were included in the outcome evaluation which used routinely collected data. Data utilised included: the Scottish National Smoking Cessation Dataset; weekly and periodic carbon monoxide (CO) breath tests; status of smoking cessation quit attempts; and amount of incentive paid. Process evaluation incorporated in-depth interviews with a cross-sectional sample of service users, stratified according to level of engagement.ResultsQuit rates for those registering with Give It Up For Baby were 54% at 4 weeks, 32% at 12 weeks and 17% at 3 months post partum (all data validated by CO breath test). Among the population of women identified as smoking at first booking over a one year period, 20.1% engaged with Give It Up For Baby, with 7.8% of pregnant smokers quit at 4 weeks. Pregnant smokers from more affluent areas were more successful with their quit attempt. The process evaluation indicates financial incentives can encourage attendance at routine advisory sessions where they are seen to form part of a wider reward structure, but work less well with those on lowest incomes who demonstrate high reliance on the financial reward.ConclusionsUptake of Give It Up For Baby by the target population was higher than for all other health board areas offering specialist or equivalent cessation services in Scotland. Quit successes also compared favorably with other specialist interventions, adding to evidence of the benefits of incentives in this setting. The process evaluation helped to explain variations in retention and quit rates achieved by the scheme.This study describes a series of positive outcomes achieved through the use of incentives to promote smoking cessation amongst pregnant smokers.

The cessation in pregnancy incentives trial (CPIT): study protocol for a randomized controlled trial.

BackgroundSeventy percent of women in Scotland have at least one baby, making pregnancy an opportunity to help most young women quit smoking before their own health is irreparably compromised. By quitting during pregnancy their infants will be protected from miscarriage and still birth as well as low birth weight, asthma, attention deficit disorder and adult cardiovascular disease. In the UK, the NICE guidelines: ‘How to stop smoking in pregnancy and following childbirth’ (June 2010) highlighted that little evidence exists in the literature to confirm the efficacy of financial incentives to help pregnant smokers to quit. Its first research recommendation was to determine: Within a UK context, are incentives an acceptable, effective and cost-effective way to help pregnant women who smoke to quit?Design and methodsThis study is a phase II exploratory individually randomized controlled trial comparing standard care for pregnant smokers with standard care plus the additional offer of financial voucher incentives to engage with specialist cessation services and/or to quit smoking during pregnancy.Participants (n = 600) will be pregnant smokers identified at maternity booking who, when contacted by specialist cessation services, agree to having their details passed to the NHS Smokefree Pregnancy Study Helpline to discuss the trial. The NHS Smokefree Pregnancy Study Helpline will be responsible for telephone consent and follow-up in late pregnancy. The primary outcome will be self reported smoking in late pregnancy verified by cotinine measurement. An economic evaluation will refine cost data collection and assess potential cost-effectiveness while qualitative research interviews with clients and health professionals will assess the level of acceptance of this form of incentive payment. The research questions are: What is the likely therapeutic efficacy? Are incentives potentially cost-effective? Is individual randomization an efficient trial design without introducing outcome bias? Can incentives be introduced in a way that is feasible and acceptable?DiscussionThis phase II trial will establish a workable design to reduce the risks associated with a future definitive phase III multicenter randomized controlled trial and establish a framework to assess the costs and benefits of financial incentives to help pregnant smokers to quit.Trial registrationCurrent Controlled Trials ISRCTN87508788

Public health or social impacts? A qualitative analysis of attitudes toward the smoke-free legislation in Scotland

INTRODUCTION Introduction of smoke-free legislation presents a unique opportunity to study how population-level interventions can challenge existing smoking norms. Our study examined support and opposition to the Scottish legislation and ascertained the relative importance of social and health factors in shaping attitudes among bar customers. METHODS Repeat (pre-/post-legislation) recorded and transcribed semistructured interviews with customers (n = 67/62) of eight community bars in contrasting settings were conducted, and data were analyzed thematically. RESULTS While the legislation was marketed primarily in terms of gains to public and individual health, supportive and opposing responses to the legislation tended to be framed around libertarian and practical factors. Attitudes tended to be stable across both waves of data collection. DISCUSSION It is concluded that reasons for smoking were not challenged by promotion of the legislation. In addition to a focus on health gains, social marketing of smoke-free legislation and initiatives may therefore benefit from a stronger focus on social and contextual effects of such policies.

Results from an exploratory study of sun protection practice: Implications for the design of health promotion messages

Purpose – The primary aim of the research reported here is to provide strategic guidance for the development of a national communication strategy to improve sun protection practice amongst young people.Design/methodology/approach – The research adopted an exploratory approach, employing qualitative focus groups to represent three population groups, mothers, teenagers and young adults living independently of the family home. A total of 12 focus groups were conducted (with six to eight participants per group) in the UK. Participants were recruited door‐to‐door using quota sampling methods.Findings – Consistent with other studies, awareness of sun protection measures was high compared with actual practice. A number of factors were identified which help to explain this behaviour deficit. These include environment and exposure context, financial cost, understanding of protection process, behavioural influence and control, experiential learning and benefits attached to tanning.Originality/value – While the find...

Symptom Awareness and Cancer Prevention: Exploratory Findings from an At-Risk Population.

Purpose – Secondary prevention programmes have traditionally employed mass screening approaches to assess for asymptomatic signs of cancer. It has been suggested that early detection strategies involving public education and self‐referral may prove more cost‐effective with low risk populations for cancers with symptomatic presentation. This study, which was commissioned to inform the development of a cancer awareness campaign, aims to examine public perceptions of the early detection of cancer, the psycho‐social barriers to self‐referral amongst a key at‐risk population and the implications for patient education.Design/methodology/approach – An exploratory study using qualitative focus groups with an at‐risk population of older people living in deprived communities in west‐central Scotland.Findings – The findings reveal broad support for initiatives designed to raise symptom awareness. However, fear of cancer can lead to apparently irrational responses to symptoms and subsequent delay, particularly amongs...