The effectiveness of NHS smoking cessation services: a systematic review.

OBJECTIVES: To analyse evidence on the effectiveness of intensive NHS treatments for smoking cessation in helping smokers to quit. METHODS: A systematic review of studies published between 1990 and 2007. Electronic databases were searched for published studies. Unpublished reports were identified from the national research register and experts. RESULTS: Twenty studies were included. They suggest that intensive NHS treatments for smoking cessation are effective in helping smokers to quit. The national evaluation found 4-week carbon monoxide monitoring validated quit rates of 53%, falling to 15% at 1 year. There is some evidence that group treatment may be more effective than one-to-one treatment, and the impact of 'buddy support' varies based on treatment type. Evidence on the effectiveness of in-patient interventions is currently very limited. Younger smokers, females, pregnant smokers and more deprived smokers appear to have lower short-term quit rates than other groups. CONCLUSION: Further research is needed to determine the most effective models of NHS treatment for smoking cessation and the efficacy of those models with subgroups. Factors such as gender, age, socio-economic status and ethnicity appear to influence outcomes, but a current lack of diversity-specific analysis of results makes it impossible to ascertain the differential impact of intervention types on particular subpopulations.

'Every space is claimed': smokers' experiences of tobacco denormalisation.

Over the past decade, the strategy of 'denormalising' tobacco use has become one of the cornerstones of the global tobacco control movement. Although tobacco denormalisation policies primarily affect people on the lowest rungs of the social ladder, few qualitative studies have explicitly set out to explore how smokers have experienced and responded to these legislative and social changes in attitudes towards tobacco use. Drawing on a qualitative study of interviews with 25 current and ex-smokers living in Vancouver, Canada, this paper examines the ways they interpret and respond to the new socio-political environment in which they must manage the increasingly problematised practice of tobacco smoking. Overall, while not opposed to smoking restrictions per se, study participants felt that recent legislation, particularly efforts to prohibit smoking in a variety of outdoor settings, was overly restrictive and that all public space had increasingly been 'claimed' by non-smokers. Also apparent from participants' accounts was the high degree of stigma attached to smoking. However, although the 'denormalisation' environment had encouraged several participants to quit smoking, the majority continued to smoke, raising ethical and practical questions about the value of denormalisation strategies as a way of reducing smoking-related mortality and morbidity.

Location restrictions on smoking: assessing their differential impacts and consequences in the workplace.

OBJECTIVES: To analyze existing evidence on the impact of two types of location restrictions on smoking: workplace bans and bans in hospitality settings, and to assess the extent to which they differentially affect subpopulations. METHODS: A review of international studies on location restrictions on smoking published between 1990-2007. RESULTS: Although workplace smoking bans reduce exposure to second-hand smoke (SHS) at work, their effects on overall cigarette consumption and smoking prevalence may be uneven across the population. Bans in hospitality settings reduce SHS exposure among workers, but have potentially uneven effects based on the interactions between gender, socio-economic status (SES) and ethnicity. The unintended consequences of smoking bans are also more likely to be experienced by low SES groups. CONCLUSIONS: Although location restrictions on smoking reduce SHS exposure and may serve to positively impact smoking behaviours, there is preliminary evidence that they may have a reduced impact on subpopulations such as low-income groups, although further research is needed.

Substance use among women in shelters for abused women and children. Programming opportunities.

OBJECTIVE: This study explores changes in the use of alcohol and other substances by women in British Columbia as they moved into shelters for abused women and again three months later. We see this time as a key life transition, and potentially a rich opportunity for influencing women's substance use behaviour. The purpose of this study was to document changes in the level of use of alcohol and other substances and the levels of stress among women as they moved through shelters for abused women. METHODS: Standardized questionnaires augmented by qualitative interviews were employed to measure alcohol and substance use, experiences of abuse, and levels and types of stressors facing women in this situation. FINDINGS: Significant reductions in women's use of alcohol and stimulants were observed from Interview I to Interview II, but there was no significant reduction in use of other depressants or tobacco use. Levels of stress decreased and sources of stress changed for the women after the shelter experience. Stress connected to relationship with partners had the most significant decrease, followed by mental health, housing, and legal issues. Women reported barriers to accessing financial aid and services for substance use outside of the shelter. CONCLUSIONS: Women's experiences of violence and substance use were found to be interconnected in complex ways and changes in substance use were affected by a range of influences, such as financial concerns, mothering, relationships, levels of social support, and physical and mental health issues. Substance-using women who have experienced violence are an underserved population and a multi-sectoral response designed to address psychosocial, relational, and structural issues could better help them improve their overall health.

What are the effects of tobacco policies on vulnerable populations? A better practices review.

BACKGROUND: While comprehensive tobacco policies have reduced the prevalence of smoking in Canada, some groups remain vulnerable to tobacco use and display high rates of smoking. This article reviews three types of tobacco policies--tax and price, smoking location restrictions and sales restrictions--and examines the consequences for Aboriginal people, youth and low-income people. METHODS: A better practices review model was used to assess the strength of studies published between 1990 and 2004 that examined the effects of these tobacco policies on the three vulnerable populations of interest. A total of 72 studies were assessed and 42 judged medium or high strength. A gender-based and diversity analysis was applied to assess the differential impacts on females and males and/or diverse characteristics within these populations. Intended and unintended consequences were examined. FINDINGS: Few studies assessed the potential or differential effects of tobacco policies on the three selected populations. In these, it was difficult to disentangle the effects of each policy in a comprehensive tobacco control environment, and there is need for improved indicators and greater attention to sex and gender analysis. CONCLUSIONS: Research is required to measure the intended and unintended impacts of tobacco policies on populations vulnerable to tobacco use. There are problems in assessing these studies that could be resolved with more precise indicator development. An equity-based framework for assessing the effects of tobacco policies is needed that is conceptually linked to health determinants and inequities. The article concludes with a set of recommendations for research, evaluation, policy and ethics arising from this review.

Smoking, stigma and tobacco 'denormalization': Further reflections on the use of stigma as a public health tool. A commentary on Social Science & Medicine's Stigma, Prejudice, Discrimination and Health Special Issue (67: 3).

In recent years, addictions policy has stressed the need to counteract stigmatization in order to promote public health. However, as recent observers have noted, through the widespread implementation of tobacco 'denormalization' strategies, tobacco control advocates appear to have embraced the use of stigma as an explicit policy tool. In a recent article, Ronald Bayer (2008) argues that the mobilization of stigma may effectively reduce the prevalence of smoking behaviors linked to tobacco-related morbidity and mortality and is therefore not necessarily antithetical to public health goals. This commentary takes up this question of whether stigmatizing smoking may ultimately serve the interests of public health. Through an examination of the unique contours of tobacco control policy, we suggest that stigmatizing smoking will not ultimately help to reduce smoking prevalence amongst disadvantaged smokers - who now represent the majority of tobacco users. Rather, it is likely to exacerbate health-related inequalities by limiting smokers' access to healthcare and inhibiting smoking cessation efforts in primary care settings.

Preventing smoking in young people: a systematic review of the impact of access interventions.

AIMS: To examine existing evidence on the effectiveness of interventions that are designed to prevent the illegal sale of tobacco to young people. The review considers specific sub-questions related to the factors that might influence effectiveness, any differential effects for different sub-populations of youth, and barriers and facilitators to implementation. METHODS: A review of studies on the impact of interventions on young people under the age of 18 was conducted. It included interventions that were designed to prevent the illegal sale of tobacco to children and young people. The review was conducted in July 2007, and included 20 papers on access restriction studies. The quality of the papers was assessed and the relevant data was extracted. RESULTS: The evidence obtained from the review indicates that access restriction interventions may produce significant reductions in the rate of illegal tobacco sales to youth. However, lack of enforcement and the ability of youth to acquire cigarettes from social sources may undermine the effectiveness of these interventions. CONCLUSIONS: When access interventions are applied in a comprehensive manner, they can affect young people's access to tobacco. However, further research is required to examine the effects of access restriction interventions on young people's smoking behaviour.

Substance use by women using domestic violence shelters.

This study investigated the connections between stressors, substance use, and experience of violence among women (N = 125) who accessed help from domestic violence shelters in British Columbia, Canada between October 2001 and June 2003. Changes in substance use and stressors following a shelter stay were explored, using both qualitative and quantitative methods. Women generally decreased their use of alcohol and stimulants, and this change was found to be integrally connected to social and structural supports made available to them. Future research that augments current stress models of addiction by considering social and structural factors that come into play in women's substance use and domestic violence is suggested. The study's limitations are noted.