Murray, Rachael L.
(2009)
Investigating and increasing smokers’ use of effective cessation support.
PhD thesis, University of Nottingham.
Abstract
Tobacco smoking is the leading avoidable cause of death and disability in the world. The UK is unique in that it offers a dedicated smoking cessation service providing behavioural support to all smokers, freely available through the National Health Service and with pharmacotherapy available at prescription cost. The service has been proven effective and cost-effective, yet only a small minority of smokers are currently using these services. The research in this thesis examines smokers’ use of support and how more smokers might be identified and encouraged to use it.
The first study investigated whether proactive identification of smokers in a primary care setting and referral into such services is a potential means by which awareness and use of services may be increased. As such a study is reliant on the identification of smokers from primary care records and the accuracy of this data, a precursor to this study investigated the completeness and accuracy of smoking status recording in primary care medical records. General practices in this study had a smoking status recorded for between 42.4 and 100% of patients, and comparison of medical records with responses to self-completion questionnaires revealed that this recording is likely to be inaccurate in approximately 20% of cases. Even so, approximately 40% of smokers who responded to the questionnaire were interested in speaking to a smoking cessation advisor when asked, indicating that there is potential to intervene with smokers identified in this way in primary care and that there is a need which is currently not being met.
In the trial, all smokers in 12 intervention practices were proactively identified and offered referral into evidence based support, and compared to 12 ‘usual care’ control practices, a significantly greater proportion of these smokers reported using local smoking cessation services (16.6% and 8.9% respectively). Validated 7-day point prevalence from smoking at 6 months was higher in the intervention than the control groups, although this difference was not statistically significant (3.5% and 2.5% respectively). Post-hoc analysis in the sub-group of smokers who had initially reported that they wanted to speak to a smoking cessation advisor did, however, reveal a significant difference between intervention and control groups (4.0% and 2.2% respectively). A proactive approach to enrolling smokers in smoking cessation services is, therefore, effective if you can identify smokers who want support for their quit attempt.
Use of an NHS support service traditionally involves some degree of pre-planning. Anecdotal evidence from the proactive trial indicated that many smokers did not pre-plan their quit attempts and as recent evidence from elsewhere has indicated that a large proportion of smokers make an attempt to quit smoking without any pre-planning, this may in part explain the relatively low proportion of smokers accessin0g services. The next study therefore was a questionnaire survey designed to investigate the occurrence, determinants and use of support in planned and unplanned quit attempts. The study findings revealed that over one third of quit attempts were made without pre-planning, and over half of these unplanned attempts were made without the use of any support and unplanned quit attempts appeared to be more likely to be successful, in line with previous findings. However, the use of evidence-based support is known to increase the likelihood of a quit attempt being successful and thus for each successful unplanned and unsupported quitter there are likely to be many more who are unsuccessful.
There has been no detailed exploration of how unplanned quitters engage in quit attempts, why they may or may not choose to use support and their attitudes to the support currently available. Gaining a greater insight into these factors may result in the identification of better ways to support those who make unplanned quit attempts. The final study therefore involved qualitative research with a group of unplanned quit attempters and revealed that smokers’ reports of ‘unplanned’ quit attempts may indeed involve elements of planning and delay, and often this delay is in order to gain access to cessation support. The majority of smokers and ex-smokers interviewed were receptive to the idea of support being immediately available whether or not their last quit attempt had involved support. Engaging smokers in using support at an appropriate time, without the need to delay their quit attempt in order to achieve this, may be a potential means of increasing smokers’ uptake of effective cessation support and subsequently improving quit rates. It is therefore important to investigate ways in which smoking cessation support can be made available to potential quitters within a much shorter timescale.
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