A community member calls the smoking cessation hotline. this community resource is an example of:
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Written Reply by Ms Grace Fu, Minister for Sustainability and the Environment, to Parliamentary Question on Disamenities from Secondhand SmokeMr Shawn Huang Wei Zhong: To ask the Minister for Sustainability and the Environment what are the further measures to be considered in 2021 to ensure that disamenities such as secondhand cigarette smoke that causes long-term medical problems does not affect other homeowners who are non-smokers in their own homes. Answer:
Journal Article Rachael L. Murray, Rachael L. Murray Cancer Research UK Graduate Training Fellow 1 Division of Epidemiology and Public Health, UK Centre for Tobacco Control Studies , University of Nottingham , Clinical Sciences Building, Nottingham City Hospital, Nottingham , UK Search for other works by this author on: Linda Bauld,Linda Bauld Reader in Social Policy 2 Department of Social and Policy Sciences, UK Centre for Tobacco Control Studies , University of Bath, Bath , UK Search for other works by this author on: Lucy E. Hackshaw,Lucy E. Hackshaw PhD Research Psychologist 2 Department of Social and Policy Sciences, UK Centre for Tobacco Control Studies , University of Bath, Bath , UK Search for other works by this author on: Ann McNeillAnn McNeill Professor of Health Policy and Promotion 1 Division of Epidemiology and Public Health, UK Centre for Tobacco Control Studies , University of Nottingham , Clinical Sciences Building, Nottingham City Hospital, Nottingham , UK Search for other works by this author on: Published: 10 February 2009
Close Navbar Search Filter Microsite Search Term Search AbstractBackground 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 A wide range of electronic databases were searched and unpublished reports were identified from the national research register and key experts.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 Physician's 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. IntroductionAs in most industrialized countries, smoking prevalence in the UK is considerably higher among less affluent groups. In 2007, smoking prevalence was 36% for men and 25% for women in routine and manual occupations, compared with 15% for men and 18% for women in managerial and professional groups.1 Although smoking has declined considerably since the 1970s for all groups, there has been no significant narrowing of the gap between manual and non-manual rates.2 Smoking is one of the main contributors to health inequalities in industrial countries3 and a recent analysis of causes of death in England and Wales by the Office for National Statistics argued that smoking played a key role in the relationship between deprivation and mortality.4 Among men, smoking is responsible for over half of the excess risk of premature death between the highest and lowest socioeconomic groups.5 For these reasons, addressing smoking-related inequalities in health has become a policy priority in the UK and targets have been established nationwide to reduce smoking rates among more deprived groups. In England, the key target concerning smoking is to ‘reduce adult smoking prevalence in routine and manual groups to 26% or less by 2010’. Significant health gains are likely to be achieved by reducing the proportion of current smokers and if more of these smokers are drawn from disadvantaged groups, then this could make a significant contribution to reducing inequalities in health.6 A number of government policies have therefore been implemented to encourage smokers to quit smoking, with considerable emphasis on those in lower socioeconomic groups.7 Delivering evidence-based smoking cessation services to less affluent communities was one of the key government strategies to help reduce smoking in disadvantaged groups. Following the publication of the 1998 White Paper, Smoking Kills,7 smoking cessation services, now known as National Health Service (NHS) stop-smoking services, were established in the UK. The services were initially set up in 26 deprived areas known as Health Action Zones in 1999 and rolled out to the rest of the country from 2000.8 NHS stop-smoking services now exist in all parts of the UK and provide free at the point of use access to behavioural support from a trained adviser (one-to-one or group) in a range of settings, plus access to appropriate pharmacotherapies which are available on prescription. This intensive specialist support has been demonstrated to increase the chances of quitting four-fold over the use of willpower alone.9 From their inception, disadvantaged smokers were one of the key target groups for the services, the others being pregnant women and young people.10 However, there are a number of barriers to reaching and supporting more disadvantaged smokers in their quit attempts. Health services in the UK are traditionally more accessible in the more affluent areas—a phenomenon known as the ‘inverse care law’,11 and those living in disadvantaged communities may be less willing to seek help from statutory health services.12 Hence, one of the challenges for these services and for other interventions that can help smokers to quit is improving access for disadvantaged groups. Recent research in England suggests that, at the national level, <10% of smokers who make a quit attempt do so with the support of NHS stop-smoking services.1,13 Improving access and increasing reach is therefore essential but it is equally important to maintain smokers in programmes while successfully supporting them to quit. Findings from the Cochrane Library report that individual counselling results in an OR of 1.56 (95% CI 1.32–1.84) compared with minimal contact.14 Developing appropriate strategies to identify, contact, support and keep smokers in treatment is therefore of key importance for the NHS stop-smoking services, particularly in disadvantaged communities where smoking prevalence and tobacco addiction are often higher.15 The review was conducted to inform the development of guidance on ‘The effectiveness of smoking cessation interventions to reduce the rates of premature death in disadvantaged areas through proactive case finding, retention and access to services’ for the National Institute for Health and Clinical Excellence (NICE) and this article describes findings from this review. NICE is the statutory organization responsible for providing guidance on the promotion of good health and the prevention and treatment of ill health in England. MethodsInclusion criteriaInclusion criteria were identified by NICE. Studies examining interventions with a range of disadvantaged groups were to be included. These groups included pregnant women, manual workers, individuals with mental health problems or a learning disability, individuals who were institutionalized, members of some black and minority ethnic groups, homeless people, people on a low income, lone parents, poor families and people on benefits and living in public housing. Identified studies were to examine interventions that aimed to find and support adult smokers, including approaches involving primary and secondary prevention, improving access to services and NHS interventions to help people stop smoking. SearchThe literature search was carried out in May 2007 by the SURE unit at the University of Cardiff. Articles were searched in the following bibliographic databases: Medline, EMBASE, HMIC, the British Nursing Index, PsycInfo, CINAHL, HEED, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, the Cochrane Register of Controlled Trials, ASSIA, Sociological Abstracts, SIGLE, Social Policy and Practice, EPPI Centre Database and the NHS Economic Evaluation Database. Studies from 1995 to 2007 were included and a range of search terms were used, key terms included, for example, smoking, smoking cessation or tobacco and social class or single parent or lone parent, homeless, low income, socioeconomic, inequality, deprived, deprivation, disadvantaged and healthcare, treatment, clinic, health, services, health service. Further details of the full search strategy can be found in the NICE report online.16 All types of studies were included in the review. Because of the nature of the review, it was anticipated that some relevant material would be found in the gray literature. This literature was identified through a web-based search and included unpublished research reports, working papers, conference proceedings and briefing papers, all of this type of literature. In order not to exclude work in progress, we also sought recommendations from tobacco control experts and conducted a search of the UK National Research Register for ongoing or recently completed studies. ScreeningArticles relevant to the review on the basis of title and abstract were identified and copies of each of these were obtained and independently examined by two reviewers to decide on inclusion in the review. Where disagreement occurred regarding the relevance of any particular abstract, a third team member was consulted to reach a final agreement on inclusion/exclusion. Critical appraisalAll studies meeting the inclusion criteria were rated by two reviewers in order to determine the strength of the evidence. Studies were assessed for their methodological rigour and quality based on the critical appraisal checklist of the NICE Public Health Guidance Methods Manual.17 Each study was graded using a code ‘++’, ‘+’ or ‘−’ based on the extent to which the potential sources of bias had been minimized (Table 1). In the NICE guidance that was disseminated after our review,16 the ‘++’, ‘+’ and ‘−’ ratings carry the following rider: ‘This quality rating does not always apply to the way the studies actually identified, supported and improved individuals’ access to services—the areas under investigation for this guidance’.
In the small number of cases where studies received a discrepant rating, the article was passed to a third reviewer for final evaluation. Unpublished data were subject to the same quality assessment as published data. Data extraction and analysisThe studies included in the review were heterogeneous in their research designs and outcomes were highly variable and not always quantifiable. As a result, it was not possible to conduct data synthesis in the traditional way by, for example, pooling intervention effects between studies and generating forest plots to illustrate effects. Instead a narrative synthesis is presented with the main results in Table 2.
NRT, nicotine replacement therapy; RCT, randomized controlled trial; CHD, coronary heart disease; NHS, National Health Service; GP, general physician; QOF, Quality and Outcomes Framework; NHS SSS, NHS stop-smoking services.
NRT, nicotine replacement therapy; RCT, randomized controlled trial; CHD, coronary heart disease; NHS, National Health Service; GP, general physician; QOF, Quality and Outcomes Framework; NHS SSS, NHS stop-smoking services. ResultsThe initial search produced 7842 international articles from which 46 UK and 44 international articles appeared potentially relevant and were read in full. Of these, 23 UK and 25 international articles met the inclusion criteria for the review, with a further 15 papers being used to inform the context of the review. Role of NHS stop-smoking servicesTwo observational studies [++]18,19 demonstrated that the NHS stop-smoking services have been effective in reaching smokers living in disadvantaged areas of England. One study [++]18 showed that services in 19 Primary Care Trust areas in England were accessed by a higher proportion of smokers from deprived postcode areas than more affluent areas, and a second study [++]19 employing similar methods produced the same finding when examining data from services in the north west region of England. Role of incentives in primary careTwo observational studies from the UK examined the impact of the ‘General Physician's (GP) contract’ (in particular, the Quality and Outcomes Framework, QOF) which includes targets, relating to additional income for GPs, for determining smoking status and recording brief smoking cessation advice for patients with some illnesses. One study [++]20 suggested that the QOF component of the 2004 GP contract may have continued, rather than reversed, differences in the quality of care delivered between primary-care practices in deprived and less-deprived areas. The second study [++]21 suggested that the new 2004 GP contract had resulted in an improvement in the recording of smoking status and the recording of the delivery of brief cessation advice in primary care, but not the prescribing of smoking cessation medication. Proactive identification of smokers and recruitment into treatmentOne cluster randomized controlled trial (RCT) in the UK [++]22 found that proactively identifying smokers through primary care records was feasible, and providing these smokers with brief advice and referral to NHS stop-smoking services increased contact with services and quit attempts but did not increase rates of cessation. One observational study [−],23 one descriptive study [−],24 one cluster-controlled trial [+]25 and one RCT [+]26 (all conducted in the USA) demonstrated that proactively identifying smokers in a number of ways, for example, through primary care, using a screening tool or through cold calling, is possible and that these provide an effective way of recruiting smokers to cessation interventions. One observational study in Sweden [+]27 demonstrated that direct mail to smoking mothers can be successful in increasing both participation in smoking-cessation programmes and quit rates. The evidence for these methods affecting quit rates was, however, mixed and only one of the studies specifically focused on disadvantaged smokers. Utilization of social marketing techniquesEvidence from four studies suggested that social marketing has a role to play in delivering client-centred approaches to smoking cessation in disadvantaged groups (one UK-based observational study [−],28 one US RCT [+],29 one US population-based study [+]30 and one US controlled before and after study [−]31). A variety of approaches were employed including media campaigns, community outreach, cessation materials, quiz nights and the outcomes varied from calls to quit lines, changes in readiness to stop smoking or quit rates. Tailoring interventions to populationsTwo US studies suggest the need to test existing cessation interventions to determine their suitability for the specific group, to receive feedback from that group and to make amendments to any aspects that are unsuitable. In order for the client group to benefit, the intervention must fit their level of need and understanding, and be suitably accessible (one RCT [++],32 and one cohort study [−]33). Combining cessation interventions with other approachesSeven studies were identified which illustrated the value of recruiting smokers who are attending non-smoking-related appointments in a variety of health-care settings, into cessation interventions. All these studies included other health-care interventions (such as screening appointments)—the review did not identify any studies that explored the effectiveness of combining smoking cessation interventions with other services in non-health care settings. One RCT in the UK [++]34 found little evidence for a change in smoking behaviour. However, two RCTs in the UK [+]35 and [−],36 two US RCTs [+],37,38 one observational US study [+]39 and one US cohort study [+]40 found some evidence for a potential benefit of combining smoking cessation interventions with other health-care services. Exploring barriers to servicesThe review identified a number of studies that explored smokers' views about accessing support to quit. Two UK qualitative studies [++]12,41 provided evidence to suggest that barriers such as fear of being judged, fear of failure and lack of knowledge need to be tackled in order to motivate smokers from lower socioeconomic groups to access cessation services. Interventions need to be multidimensional in order to tackle social and psychological barriers to quitting as well as dealing with the physiological addiction. Basing smoking cessation services in pharmaciesEvidence from one UK systematic review and two other studies indicated that smoking cessation interventions can be successfully delivered in a pharmacy setting. These studies also provide preliminary evidence that pharmacy-based support has the potential to reach a large number of smokers, including those in disadvantaged areas due to the accessibility of pharmacy venues (one UK systematic review comprising two RCTs and three non-randomized experimental studies [++],42 one UK observational study [++]43 and one US pilot study [+]44). Basing smoking cessation services in dental settingsThree reviews found evidence that training dental professionals to deliver smoking cessation interventions is important, and this setting has the potential to reach large numbers of smokers and increase cessation rates (one international systematic review comprising six RCTs from the USA [−],45 one UK review of mixed study designs [−]46 and one international review of seven RCTs in the US [+]47). Work-based cessation activitiesOne USA cohort study [+]48 provided evidence of the potential benefit of basing smoking-cessation services in the workplace of manual groups to increase cessation rates. Adapting interventions to facilitate accessThree UK studies [−]49–51provided limited evidence of the potential benefits of adapting smoking cessation interventions to increase access. Two studies found some evidence that a service which uses lay advisors and a drop-in system, so that clients do not need to pre-book appointments, was valued, acceptable to clients and in some cases increased recruitment and quit rates. Other incentive schemesAn review [+]52 of 17 studies (conducted worldwide) of population based smoking cessation interventions that used a range of incentives found that larger incentives were more effective both in improving recruitment and cessation. The review included studies of mixed designs, and did not discuss the socioeconomic characteristics of participants. A UK cohort study [+]53 which proactively identified smokers from deprived areas and offered subsidized nicotine replacement therapy (NRT) found some evidence for an increase in quit rates, as well as a reduction in consumption. Two US cohort studies [+]54,55 of free NRT for helpline callers provided evidence for an increase in the number of calls, and some evidence in one study of greater quit rates. One US RCT [+]56 of workplace smoking-cessation programmes and incentives found that the latter increased participation but not cessation. DiscussionMain findings of this studyThis review examined a diverse range of studies and found some evidence of effective means of proactively identifying and recruiting disadvantaged smokers into smoking cessation services, and of improving access to these services. There is evidence to suggest that NHS stop-smoking services have been successful in reaching smokers living in more disadvantaged areas of the UK and supporting them to set a quit date. This is an important finding and since these studies were published services have begun to use similar approaches, such as ‘health equity audits’ to examine their own client data in order to identify the extent to which they are making contact with disadvantaged groups.57 There is limited, mixed evidence concerning the role of incentives in primary care to provide smoking cessation support and what evidence exists suggests that the QOF has not led to an improvement in standardizing care delivered between general practices in deprived and less deprived areas or the prescribing of smoking cessation medication. Aside from incentives, however, primary care does offer an opportunity for smokers to be proactively identified and targeted for smoking-cessation interventions. There seems to be a potential benefit of this approach, although the evidence for the effect on disadvantaged smokers and overall quit rates is limited and needs further investigation. The utilization of social marketing techniques and tailoring interventions to populations to make the approach more ‘client-centred’ have both been suggested to play a role in making smoking cessation interventions more relevant to the needs of the individual smoker and thus more effective, although the evidence is again limited. Likewise, combining smoking cessation interventions with other interventions shows promise for improving effectiveness, although evidence is limited to other health-care interventions and has not examined the effect of combining smoking-cessation interventions with other non-healthcare services. Although limited, there is evidence to suggest that barriers to accessing services are an important factor for smokers attempting to quit, particularly in lower socioeconomic groups and an intervention which addresses social and psychological barriers to quitting is important in this group. Pharmacies and dental settings are potentially a useful way to reach a wide variety of smokers as they provide access to trained health professionals without a pre-booked appointment. Only one study was identified which looked at work-based cessation activities, it provided evidence of a potential benefit of this approach in manual groups. Studies looking at adapting interventions to increase access found that this approach was valued and acceptable to clients and may have a positive effect on quit rates. A variety of incentive schemes designed to motivate smokers to make a quit attempt or engage with smoking cessation support were shown to have a potential benefit in both increasing recruitment to smoking-cessation services and improving quit rates. Limitations of this studyThe evidence that was identified in this review was mixed. Studies employed a range of research designs which often had poorly specified outcomes. Whereas, conclusions from a systematic review will usually rely on evidence from research employing a controlled design, much of the evidence included in this review was drawn from observational studies and thus clear comparisons could not be made between interventions. The quality of the evidence was often poor and/or not presented in a way that allowed clear statements to be made about its applicability to the UK context and the NHS. Many studies did not examine disadvantaged smokers in particular, frequently failing to analyse socioeconomic data, although they were often collected and reported at baseline. In addition, there were not enough studies looking at specific sub-groups within ‘disadvantaged groups’ such as different minority ethnic groups. These omissions made it exceedingly difficult to state with any confidence how different interventions affect different groups. A large number of papers were therefore included that did not directly address the research questions with disadvantaged smokers but rather with smokers in general, in order to try to identify strategies which could be tested with disadvantaged smokers in the future. Consequently, much of the evidence may only be seen as examples of promising practice rather than proof of the effectiveness of an intervention. What is already known on this topic?Smoking prevalence is higher among disadvantaged smokers. NHS stop-smoking services have been successful in reaching smokers living in disadvantaged areas58 but quit attempts are less likely to be successful in this group than more affluent groups.59,60 What this study adds?This is the first review of evidence relating to the effectiveness of finding and supporting adults and providing and improving access to smoking-cessation services in disadvantaged groups. The results from this review suggest that there is a limited body of evidence on the effectiveness of interventions to reduce the rates of premature death in disadvantaged areas through proactive case finding, retention and access to services. However, some interventions are promising and merit further research. The review found a lack of reporting of socioeconomic data both at baseline and in the reporting of results. This made it difficult to draw firm conclusions for subgroups of smokers, rather than smokers in general, in this review. However, it is clearly an important priority for future research that there should be greater attention to disaggregated data collection, reporting and analysis. This is essential in order to learn more in the future about how smoking cessation interventions can help to reduce death rates in those communities where tobacco has taken its highest toll. FundingThe review was funded by the National Institute for Health and Clinical Excellence. 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© The Author 2009, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved What is a community needs assessment?A community needs assessment identifies the strengths and resources available in the community to meet the needs of children, youth, and families. The assessment focuses on the capabilities of the community, including its citizens, agencies, and organizations.
Which type of secondary data is essential in a community assessment?Which type of secondary data is essential in a community assessment? Sociodemographic data is essential because they best describe the population. Census data provides numbers of people and households in a community, information related to age, gender, marital status, occupation, income, education, and race/ethnicity.
What are the reasons why you need to conduct community needs assessment?Doing a Community Needs Assessment. help to establish program priorities, objectives, and goals.. help prioritize which education and outreach services to conduct with a priority population.. improve a health center's quality of care.. What are the community needs?Community needs are gaps between what services currently exist in a community and what should exist. It may be helpful to categorize gaps based on these four types of community needs— perceived needs, expressed needs, absolute needs, and relative needs.
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