Preferences for deinfibulation (opening) surgery and female genital mutilation service provision: A qualitative study.

OBJECTIVE: To explore the views of female genital mutilation (FGM) survivors, men and healthcare professionals (HCPs) on the timing of deinfibulation surgery and NHS service provision. DESIGN: Qualitative study informed by the sound of silence framework. SETTING: Survivors and men were recruited from three FGM prevalent areas of England. HCPs and stakeholders were from across the UK. SAMPLE: Forty-four survivors, 13 men and 44 HCPs. Ten participants at two community workshops and 30 stakeholders at a national workshop. METHODS: Hybrid framework analysis of 101 interviews and three workshops. RESULTS: There was no consensus across groups on the optimal timing of deinfibulation for survivors who wished to be deinfibulated. Within group, survivors expressed a preference for deinfibulation pre-pregnancy and HCPs antenatal deinfibulation. There was no consensus for men. Participants reported that deinfibulation should take place in a hospital setting and be undertaken by a suitable HCP. Decision making around deinfibulation was complex but for those who underwent surgery it helped to mitigate FGM impacts. Although there were examples of good practice, in general, FGM service provision was suboptimal. CONCLUSION: Deinfibulation services need to be widely advertised. Information should highlight that the procedure can be carried out at different time points, according to preference, and in a hospital by suitable HCPs. Future services should ideally be developed with survivors, to ensure that they are clinically and culturally appropriate. Guidelines would benefit from being updated to reflect the needs of survivors and to ensure consistency in provision.

Interventions for preventing weight gain after smoking cessation.

BACKGROUND: Most people who stop smoking gain weight. This can discourage some people from making a quit attempt and risks offsetting some, but not all, of the health advantages of quitting. Interventions to prevent weight gain could improve health outcomes, but there is a concern that they may undermine quitting. OBJECTIVES: To systematically review the effects of: (1) interventions targeting post-cessation weight gain on weight change and smoking cessation (referred to as 'Part 1') and (2) interventions designed to aid smoking cessation that plausibly affect post-cessation weight gain (referred to as 'Part 2'). SEARCH METHODS: Part 1 - We searched the Cochrane Tobacco Addiction Group's Specialized Register and CENTRAL; latest search 16 October 2020. Part 2 - We searched included studies in the following 'parent' Cochrane reviews: nicotine replacement therapy (NRT), antidepressants, nicotine receptor partial agonists, e-cigarettes, and exercise interventions for smoking cessation published in Issue 10, 2020 of the Cochrane Library. We updated register searches for the review of nicotine receptor partial agonists. SELECTION CRITERIA: Part 1 - trials of interventions that targeted post-cessation weight gain and had measured weight at any follow-up point or smoking cessation, or both, six or more months after quit day. Part 2 - trials included in the selected parent Cochrane reviews reporting weight change at any time point. DATA COLLECTION AND ANALYSIS: Screening and data extraction followed standard Cochrane methods. Change in weight was expressed as difference in weight change from baseline to follow-up between trial arms and was reported only in people abstinent from smoking. Abstinence from smoking was expressed as a risk ratio (RR). Where appropriate, we performed meta-analysis using the inverse variance method for weight, and Mantel-Haenszel method for smoking. MAIN RESULTS: Part 1: We include 37 completed studies; 21 are new to this update. We judged five studies to be at low risk of bias, 17 to be at unclear risk and the remainder at high risk.  An intermittent very low calorie diet (VLCD) comprising full meal replacement provided free of charge and accompanied by intensive dietitian support significantly reduced weight gain at end of treatment compared with education on how to avoid weight gain (mean difference (MD) -3.70 kg, 95% confidence interval (CI) -4.82 to -2.58; 1 study, 121 participants), but there was no evidence of benefit at 12 months (MD -1.30 kg, 95% CI -3.49 to 0.89; 1 study, 62 participants). The VLCD increased the chances of abstinence at 12 months (RR 1.73, 95% CI 1.10 to 2.73; 1 study, 287 participants). However, a second study  found that no-one completed the VLCD intervention or achieved abstinence. Interventions aimed at increasing acceptance of weight gain reported mixed effects at end of treatment, 6 months and 12 months with confidence intervals including both increases and decreases in weight gain compared with no advice or health education. Due to high heterogeneity, we did not combine the data. These interventions increased quit rates at 6 months (RR 1.42, 95% CI 1.03 to 1.96; 4 studies, 619 participants; I2 = 21%), but there was no evidence at 12 months (RR 1.25, 95% CI 0.76 to 2.06; 2 studies, 496 participants; I2 = 26%). Some pharmacological interventions tested for limiting post-cessation weight gain (PCWG) reduced weight gain at the end of treatment (dexfenfluramine, phenylpropanolamine, naltrexone). The effects of ephedrine and caffeine combined, lorcaserin, and chromium were too imprecise to give useful estimates of treatment effects. There was very low-certainty evidence that personalized weight management support reduced weight gain at end of treatment (MD -1.11 kg, 95% CI -1.93 to -0.29; 3 studies, 121 participants; I2 = 0%), but no evidence in the longer-term 12 months (MD -0.44 kg, 95% CI -2.34 to 1.46; 4 studies, 530 participants; I2 = 41%). There was low to very low-certainty evidence that detailed weight management education without personalized assessment, planning and feedback did not reduce weight gain and may have reduced smoking cessation rates (12 months: MD -0.21 kg, 95% CI -2.28 to 1.86; 2 studies, 61 participants; I2 = 0%; RR for smoking cessation 0.66, 95% CI 0.48 to 0.90; 2 studies, 522 participants; I2 = 0%). Part 2: We include 83 completed studies, 27 of which are new to this update. There was low certainty that exercise interventions led to minimal or no weight reduction compared with standard care at end of treatment (MD -0.25 kg, 95% CI -0.78 to 0.29; 4 studies, 404 participants; I2 = 0%). However, weight was reduced at 12 months (MD -2.07 kg, 95% CI -3.78 to -0.36; 3 studies, 182 participants; I2 = 0%). Both bupropion and fluoxetine limited weight gain at end of treatment (bupropion MD -1.01 kg, 95% CI -1.35 to -0.67; 10 studies, 1098 participants; I2 = 3%); (fluoxetine MD -1.01 kg, 95% CI -1.49 to -0.53; 2 studies, 144 participants; I2 = 38%; low- and very low-certainty evidence, respectively). There was no evidence of benefit at 12 months for bupropion, but estimates were imprecise (bupropion MD -0.26 kg, 95% CI -1.31 to 0.78; 7 studies, 471 participants; I2 = 0%). No studies of fluoxetine provided data at 12 months. There was moderate-certainty that NRT reduced weight at end of treatment (MD -0.52 kg, 95% CI -0.99 to -0.05; 21 studies, 2784 participants; I2 = 81%) and moderate-certainty that the effect may be similar at 12 months (MD -0.37 kg, 95% CI -0.86 to 0.11; 17 studies, 1463 participants; I2 = 0%), although the estimates are too imprecise to assess long-term benefit. There was mixed evidence of the effect of varenicline on weight, with high-certainty evidence that weight change was very modestly lower at the end of treatment (MD -0.23 kg, 95% CI -0.53 to 0.06; 14 studies, 2566 participants; I2 = 32%); a low-certainty estimate gave an imprecise estimate of higher weight at 12 months (MD 1.05 kg, 95% CI -0.58 to 2.69; 3 studies, 237 participants; I2 = 0%). AUTHORS' CONCLUSIONS: Overall, there is no intervention for which there is moderate certainty of a clinically useful effect on long-term weight gain. There is also no moderate- or high-certainty evidence that interventions designed to limit weight gain reduce the chances of people achieving abstinence from smoking.

A Mixed-Methods Systematic Review and Synthesis of Secondary Care Interventions to Reduce Secondhand Smoke Exposure Among Children and Young People.

INTRODUCTION: Childhood secondhand smoke exposure (SHSe) is linked with increased morbidity and mortality. Hospital or secondary care contact presents a "teachable moment" to support parents to change their home smoking behaviors to reduce children's SHSe. AIMS AND METHODS: This mixed-methods review explores: (1) if existing interventions in this context are effective, (2) if they are reported in sufficient detail to be replicated, (3) the experiences of health care professionals delivering such interventions, and (4) the experiences of parents receiving such interventions. Five electronic databases and the gray literature were searched for relevant literature published and indexed January 1980 to February 2020. Fourteen papers reporting 12 studies (nine quantitative and five qualitative) were included. Aligned with the Joanna Briggs Institute method, a segregated approach was used involving independent syntheses of the quantitative and qualitative data followed by an overall mixed-methods synthesis. RESULTS: There was some evidence of effective interventions that resulted in a short-term (<6 months) reduction in children's SHSe when SHSe was subjectively measured. This was not seen in longer-term follow-up (>6 months) or when SHSe was measured objectively. Inconsistencies with reporting make replication challenging. Experiential evidence suggests a mismatch between stakeholder preferences and interventions being offered. CONCLUSIONS: The pediatric secondary care interventions included in this analysis failed to show statistically significant evidence of longer-term effectiveness to reduce children's SHSe in all but one low-quality study. There was also inadequate reporting of interventions limiting assessment of effectiveness. It offers further insights into areas to target to develop effective interventions. IMPLICATIONS: This review used rigorous methods to explore the current, global literature on how children's exposure to secondhand smoke is being tackled in secondary care. This review identified only one low-quality intervention study showing a statistically significant reduction in children's SHSe beyond 6 months. Synthesis with qualitative research identifies a mismatch between what parents want in an intervention and what has been delivered to date. Reporting quality needs to be improved to ensure that interventions can be replicated and studies conducted within the National Health Service to ensure suitability to this setting.

Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial.

BACKGROUND: The anti-progesterone drug mifepristone and the prostaglandin misoprostol can be used to treat missed miscarriage. However, it is unclear whether a combination of mifepristone and misoprostol is more effective than administering misoprostol alone. We investigated whether treatment with mifepristone plus misoprostol would result in a higher rate of completion of missed miscarriage compared with misoprostol alone. METHODS: MifeMiso was a multicentre, double-blind, placebo-controlled, randomised trial in 28 UK hospitals. Women were eligible for enrolment if they were aged 16 years and older, diagnosed with a missed miscarriage by pelvic ultrasound scan in the first 14 weeks of pregnancy, chose to have medical management of miscarriage, and were willing and able to give informed consent. Participants were randomly assigned (1:1) to a single dose of oral mifepristone 200 mg or an oral placebo tablet, both followed by a single dose of vaginal, oral, or sublingual misoprostol 800 µg 2 days later. Randomisation was managed via a secure web-based randomisation program, with minimisation to balance study group assignments according to maternal age (<30 years vs ≥30 years), body-mass index (<35 kg/m2vs ≥35 kg/m2), previous parity (nulliparous women vs parous women), gestational age (<70 days vs ≥70 days), amount of bleeding (Pictorial Blood Assessment Chart score; ≤2 vs ≥3), and randomising centre. Participants, clinicians, pharmacists, trial nurses, and midwives were masked to study group assignment throughout the trial. The primary outcome was failure to spontaneously pass the gestational sac within 7 days after random assignment. Primary analyses were done according to intention-to-treat principles. The trial is registered with the ISRCTN registry, ISRCTN17405024. FINDINGS: Between Oct 3, 2017, and July 22, 2019, 2595 women were identified as being eligible for the MifeMiso trial. 711 women were randomly assigned to receive either mifepristone and misoprostol (357 women) or placebo and misoprostol (354 women). 696 (98%) of 711 women had available data for the primary outcome. 59 (17%) of 348 women in the mifepristone plus misoprostol group did not pass the gestational sac spontaneously within 7 days versus 82 (24%) of 348 women in the placebo plus misoprostol group (risk ratio [RR] 0·73, 95% CI 0·54-0·99; p=0·043). 62 (17%) of 355 women in the mifepristone plus misoprostol group required surgical intervention to complete the miscarriage versus 87 (25%) of 353 women in the placebo plus misoprostol group (0·71, 0·53-0·95; p=0·021). We found no difference in incidence of adverse events between the study groups. INTERPRETATION: Treatment with mifepristone plus misoprostol was more effective than misoprostol alone in the management of missed miscarriage. Women with missed miscarriage should be offered mifepristone pretreatment before misoprostol to increase the chance of successful miscarriage management, while reducing the need for miscarriage surgery. FUNDING: UK National Institute for Health Research Health Technology Assessment Programme.

Smoking behaviours and attitudes towards campus-wide tobacco control policies among staff and students: a cross-sectional survey at the University of Birmingham.

BACKGROUND: Tobacco control policies have potential to be an effective strategy for the reduction of smoking prevalence and secondhand smoke (SHS) exposure in tertiary educational settings worldwide. The aims of this study were to collect baseline data among staff and students, to measure smoking behaviours and attitudes towards introduction of campus-wide tobacco control policies within a UK higher education setting. METHODS: Cross-sectional study using data collected by web-based questionnaire administered to employed staff and enrolled students (undergraduate/postgraduate) at the University of Birmingham from May 2016 to April 2017. Information was obtained regarding demographic characteristics, tobacco usage patterns and attitudes towards a revised campus tobacco control policy using a 21-item survey tool. Logistic regression analyses were used to explore associations between participant characteristics and support for smoke-free or tobacco-free campus policy options, evaluated by crude and adjusted Odds Radios (OR) after controlling for confounding factors (significance level: P < 0.05). RESULTS: A total of 934 survey responses were received, of whom 780 participants provided complete information on staff or student status and were included in the present analysis. Current smoking prevalence was 14% (N = 109; 95% confidence interval (CI) 11.6-16.6). Overall, 66.3% (95% CI: 62.9-69.7) of participants supported a smoke-free campus; 68.5% (95% CI: 65.2-71.8) endorsed restrictions for tobacco sales and just under half of respondents (47.3%; 95% CI: 43.8-50.9) supported a ban for electronic cigarettes/vaping device use on campus. Smoking status was an independent predictor of support for tobacco control, with the lowest level of support for a smoke-free campus among daily (adjusted OR 0.02; 95% CI: 0.01-0.05) and intermittent smokers (adjusted OR 0.06; 95% CI: 0.02-0.16). CONCLUSIONS: Overall, the majority of staff and students participating in this baseline survey supported implementation of a smoke-free or comprehensive tobacco-free campus policy. These findings may inform the development and future implementation of a revised tobacco control policy at the university which reflects contemporary attitudes and considers a broad range of implementation issues, including behaviour change and environmental adaptations.

Primary Care Healthcare Professionals' Knowledge, Attitudes, and Practices Towards Promoting the Reduction of Children's Secondhand Smoke Exposure: A Mixed-Methods Review and Synthesis.

INTRODUCTION: Secondhand smoke exposure (SHSe) leads to increased mortality and morbidity. Primary care healthcare professionals (HCPs) are well placed to support patients to reduce SHSe. This paper explores HCPs': (1) knowledge around SHSe; (2) current practices to promote SHSe reduction; (3) beliefs and experiences regarding delivering interventions to reduce SHSe; and (4) identified factors that influence the delivery of SHSe-related interventions. METHODS: Six electronic databases were searched for relevant literature published January 1980-February 2016. 17 quantitative and 3 qualitative studies were included in this mixed-methods review. Data synthesis followed the method outlined by the Joanna Briggs Institute. This segregated approach involved independent syntheses of the quantitative and qualitative data followed by an overall mixed-methods synthesis. RESULTS: Primary care HCPs had a basic understanding of the risks associated with SHSe but required training to help them intervene. It was more common for HCPs to ask about SHSe or provide advice than to act to facilitate SHSe reduction. SHSe was viewed as an issue of high importance and considered relevant to the role of the primary care HCPs. However, barriers such as the priority given to the issue and the desire to protect the professional relationship with patients prevented HCPs from intervening around SHSe. CONCLUSIONS: Primary care HCPs require training, guidance, and support to enable them to intervene and support patients to effectively reduce SHSe. IMPLICATIONS: This review used rigorous methods to explore the current, global literature on how children's exposure to secondhand smoke is being addressed in primary care settings. The review findings highlight healthcare professionals' need for further training and support, which would enable them to better translate their knowledge of the risks associated with secondhand smoke exposure into actual clinical practices. The review identified a lack of practical action taken to address secondhand smoke exposure, even once it has been identified as an issue.

The role of self-management in burns aftercare: a qualitative research study.

INTRODUCTION: For severe burns patient care presents a considerable challenge, necessitating an integrated multi-disciplinary approach that utilises a range of treatments. The period of care post-discharge can be lengthy and complex, and include scar management, occupational and physiotherapies, psychological support, and further surgery. How successfully the patient negotiates this complex care regimen is critical to their long-term recovery and in doing so they would appear to employ approaches recognised as "self-management" in other chronic conditions. However their exact nature and how they are used has yet to be explicitly explored amongst chronic burn patients. METHODS: Semi-structured interviews were conducted with 24 patients to discuss their experiences of long-term burn treatment as part of a broader mixed- methods feasibility study of the use of pressure garment therapy in preventing hypertrophic scarring after burn injury. The topic guide included questions on the patient experience of their care post discharge, including pressure garment therapy and other scar management techniques; and their expectations and experiences of treatment and recovery. The data were analysed using an established framework of self-management processes. RESULTS: Burns patients employ many of the same processes of self-management as those experiencing more widely recognised chronic diseases or illnesses. This is despite the prospect of gradual improvement amongst burns patients absent in those with incurable chronic conditions. The key processes of self-management they share are the ability to focus on their illness needs, activate the appropriate resources and coming to terms with the consequences of living with either the physical or psychological consequences of their condition. CONCLUSION: Modern burn care is technologically advanced and delivered by a highly trained, multi-disciplinary team, yet the level of its success relies on the ability of the patient to independently fulfil a number of health-related tasks and activities once leaving hospital. Considering the potential cost-savings to health services and the prospect of improved outcomes for patients capable of self-management our work is an important first step in more precisely understanding the use of self-management amongst burns patients, and the level of implicit or explicit support currently offered by their care providers.

Evaluation of a novel intervention providing insight into the tobacco industry to prevent the uptake of smoking in school-aged children: a mixed-methods study.

OBJECTIVES: Evidence from the US Truth campaign suggests that interventions focusing on tobacco industry practices and ethics may be effective in preventing youth smoking uptake. We developed, piloted and evaluated a school-based intervention based on this premise. METHODS: Exploratory study students in years 7-8 (aged 11-13) in two UK schools received Operation Smoke Storm, comprising three 50 min classroom-based sessions in year 7, an accompanying family booklet and a 1-hour classroom-based booster session in year 8. We compared the risk and odds of ever smoking and susceptibility to smoking in year 8 students in study schools postintervention with students in control schools. Focus groups and interviews with students, teachers and parents evaluated the acceptability of the intervention. RESULTS: In intervention schools, the combined prevalence of ever smoking and susceptibility increased from 18.2% in year 7 to 33.8% in year 8. There was no significant difference in the odds of a year 8 student in an intervention school being an ever smoker or susceptible never smoker compared with controls (adjusted OR (aOR) 1.28, 95% CI 0.83 to 1.97, p=0.263) and no significant difference in the odds of ever smoking (aOR 0.82, 95% CI 0.42 to 1.58, p=0.549). Teachers highlighted differences by academic ability in how well the messages presented were understood. Use of the family component was low but was received positively by parents who engaged with it. CONCLUSIONS: Operation Smoke Storm is an acceptable resource for delivering smoking-prevention education, but it does not appear to have reduced smoking and susceptibility.

A qualitative evaluation of a novel intervention using insight into tobacco industry tactics to prevent the uptake of smoking in school-aged children.

BACKGROUND: Evidence from the US Truth campaign suggests that interventions focusing on tobacco industry tactics can be effective in preventing smoking uptake by children. Operation Smoke Storm is the first school-based intervention based on this premise and comprises three classroom sessions in which students act as secret agents uncovering tobacco industry tactics through videos, quizzes, discussions, and presentations. We report a qualitative evaluation of its acceptability. METHODS: We conducted eight focus groups with 79 students aged 11-12 who participated in Operation Smoke Storm at two UK schools in Autumn 2013, and 20 interviews with teachers who delivered the intervention. These were digitally audio-recorded, transcribed verbatim and analysed using the framework method. RESULTS: Students enjoyed the secret agent scenario and reported acquiring new knowledge about smoking and the tobacco industry, which seemed to strengthen their aversion to smoking. Teachers felt confident delivering the 'off the shelf' resource, although they would have welcomed more background information about the topic and guidance on steering discussions. Teachers highlighted a need for the resource to be flexible and not dependent on lesson length, teacher confidence, or expertise. Students and teachers endorsed the idea of developing a booster component for older students and supported the development of printed information complementing the resource to encourage parents to support their child not to smoke. CONCLUSIONS: These findings demonstrate that Operation Smoke Storm can be delivered by teachers to raise awareness about smoking-related issues. The ideas and issues raised are now being used to improve and extend the resource for further evaluation.

"I Was a Full Time Proper Smoker": A Qualitative Exploration of Smoking in the Home after Childbirth among Women Who Relapse Postpartum.

BACKGROUND: Many women stop smoking during pregnancy but relapse shortly afterwards, potentially putting their infants at risk of secondhand smoke (SHS) exposure. Women who were able to stop during pregnancy may be a motivated group, receptive to making behaviour changes postpartum to protect their infant from SHS exposure. Understanding more about their experiences of relapse, and if this influences home smoking behaviours and children's exposure to SHS in the home may help to inform intervention development to prevent infant SHS exposure. METHODS: Guided by interpretative phenomenological methodology we conducted and analysed nine semi-structured interviews with women who quit smoking during pregnancy, but relapsed ≤3 months postpartum. FINDINGS: Central to mothers' accounts of their smoking behaviours during pregnancy and postpartum was their desire to be a 'responsible mother'. Mothers described using strategies to protect their infant from SHS exposure, and held strong negative attitudes towards other smoking parents. After relapsing, mothers appeared to reposition themselves as 'social' or 'occasional' smokers rather than 'regular' smokers. CONCLUSIONS: Findings suggest that interventions to prevent/reduce infants' home SHS exposure should build on mothers' intentions to be responsible parents. As mothers who relapse principally view themselves as 'social' or 'occasional' smokers, interventions that are highlighted as relevant for women with these types of smoking patterns may be more likely to be responded to, and, ultimately, be effective.

Smoke-free homes: what are the barriers, motivators and enablers? A qualitative systematic review and thematic synthesis.

OBJECTIVE: To thematically synthesise primary qualitative studies of the barriers, motivators and enablers of smoke-free homes (SFHs). DESIGN: Systematic review and thematic synthesis. DATA SOURCES: Searches of MEDLINE, EBM Reviews (Cochrane Database of Systematic Reviews), PsycINFO, Global Health, CINAHL, Web of Science, Informit and EMBASE, combining terms for families, households and vulnerable populations; SFH and secondhand smoke; and qualitative research, were supplemented by searches of PhD theses, key authors, specialist journals and reference lists. STUDY SELECTION: We included 22 articles, reporting on 18 studies, involving 646 participants. INCLUSION CRITERIA: peer-reviewed; English language; published from 1990 onwards (to week 3 of April 2014); used qualitative data collection methods; explored participants' perspectives of home smoking behaviours; and the barriers, motivators and enablers to initiating and/or maintaining a SFH. DATA EXTRACTION: 1 of 3 authors extracted data with checking by a second. DATA SYNTHESIS: A thematic synthesis was performed to develop 7 core analytic themes: (1) knowledge, awareness and risk perception; (2) agency and personal skills/attributes; (3) wider community norms and personal moral responsibilities; (4) social relationships and influence of others; (5) perceived benefits, preferences and priorities; (6) addiction and habit; (7) practicalities. CONCLUSIONS: This synthesis highlights the complexity faced by many households in having a SFH, the practical, social, cultural and personal issues that need to be addressed and balanced by households, and that while some of these are common across study settings, specific social and cultural factors play a critical role in shaping household smoking behaviours. The findings can inform policy and practice and the development of interventions aimed at increasing SFHs. TRIAL REGISTRATION NUMBER: CRD42014014115.

Evaluating an online training module on protecting children from secondhand smoke exposure: impact on knowledge, confidence and self-reported practice of health and social care professionals.

BACKGROUND: Healthcare professionals report that a lack of training is the primary barrier to raising the issue of secondhand smoke (SHS). An open access online training module was therefore developed for those working with smoking families to deliver effective very brief advice on SHS. The current study aimed to evaluate the following: (1) does knowledge increase as a result of participating in the online training module, and (2) does the module impact on participant confidence and self-reported practice relating to SHS. METHODS: Those accessing the module were invited to participate in an evaluation to assess participants' knowledge about, and confidence in, delivering very brief advice on SHS. Change in knowledge was assessed via ten multiple choice questions and confidence was assessed by Likert scale responses to three statements. Data were collected across three time points: pre-training, post-training and after 3 months. Data were also collected at 3 months post module completion on self-reported changes in practice and key learning points. RESULTS: Data at all three time points were available for 178 participants (~1 % of those who visited the module homepage over a 2 year period). Knowledge and confidence to deliver effective very brief advice for SHS significantly increased between the pre- and post-training assessments and was maintained at 3 months. Eighty-four percent self-reported that they perceived taking part in the training had led to positive changes in their clinical practice. CONCLUSIONS: There is potential for this module to be embedded within training programmes across health and social care professions, which may help to increase the knowledge and confidence of health and social care professionals to deliver very brief advice for SHS to smoking families. Future research needs to explore whether the smoking families who receive very brief advice for SHS are motivated to make changes to their home smoking behaviours and whether roll-out of this intervention would be cost-effective.

Smoking in the home after childbirth: prevalence and determinants in an English cohort.

OBJECTIVES: Children's exposure to secondhand smoke (SHS) is causally linked to childhood morbidity and mortality. Over 38% of English children (aged 4-15) whose parents are smokers are exposed to SHS in the home. Little is known about the prevalence of SHS exposure in the homes of young infants (≤3 months). This study aimed to estimate maternal self-reported prevalence of SHS exposure among infants of women who smoked just before or during pregnancy, and identify factors associated with exposure. SETTING: Primary Care, Nottingham, England. PARTICIPANTS: Current and recent ex-smoking pregnant women (n=850) were recruited in Nottingham, England. Women completed questionnaires at 8-26 weeks gestation and 3 months after childbirth. Data on smoking in the home 3 months after childbirth was available for 471 households. PRIMARY AND SECONDARY OUTCOME MEASURES: Maternal-reported smoking in the home 3 months after childbirth. RESULTS: The prevalence of smoking in the home 3 months after childbirth was 16.3% (95% CI 13.2% to 19.8%) and after multiple imputation controlling for non-response 18.2% (95% CI 14.0% to 22.5%). 59% of mothers were current smokers; of these, 24% reported that smoking occurred in their home compared to 4.7% of non-smokers. In multivariable logistic regression, mothers smoking ≥11 cigarettes per day were 8.2 times (95% CI 3.4 to 19.6) more likely to report smoking in the home. Younger age, being of non-white ethnicity, increased deprivation and less negative attitudes towards SHS were also associated with smoking in the home. CONCLUSIONS: This survey of smoking in the home 3 months after childbirth found a lower prevalence than has been reported in older children. Interventions to support smoking mothers to quit, or to help them restrict smoking in the home, should target attitudinal change and address inequality relating to social disadvantage, younger age and non-white ethnic groups.

Predictors of children's secondhand smoke exposure at home: a systematic review and narrative synthesis of the evidence.

BACKGROUND: Children's exposure to secondhand smoke (SHS) has been causally linked to a number of childhood morbidities and mortalities. Over 50% of UK children whose parents are smokers are regularly exposed to SHS at home. No previous review has identified the factors associated with children's SHS exposure in the home. AIM: To identify by systematic review, the factors which are associated with children's SHS exposure in the home, determined by parent or child reports and/or biochemically validated measures including cotinine, carbon monoxide or home air particulate matter. METHODS: Electronic searches of MEDLINE, EMBASE, PsychINFO, CINAHL and Web of Knowledge to July 2014, and hand searches of reference lists from publications included in the review were conducted. FINDINGS: Forty one studies were included in the review. Parental smoking, low socioeconomic status and being less educated were all frequently and consistently found to be independently associated with children's SHS exposure in the home. Children whose parents held more negative attitudes towards SHS were less likely to be exposed. Associations were strongest for parental cigarette smoking status; compared to children of non-smokers, those whose mothers or both parents smoked were between two and 13 times more likely to be exposed to SHS. CONCLUSION: Multiple factors are associated with child SHS exposure in the home; the best way to reduce child SHS exposure in the home is for smoking parents to quit. If parents are unable or unwilling to stop smoking, they should instigate smoke-free homes. Interventions targeted towards the socially disadvantaged parents aiming to change attitudes to smoking in the presence of children and providing practical support to help parents smoke outside the home may be beneficial.

"Pictures don't lie, seeing is believing": exploring attitudes to the introduction of pictorial warnings on cigarette packs in Ghana.

PURPOSE: To compare perceptions of text and pictorial warning labels on cigarette packs among Ghanaian smokers and nonsmokers and to explore their views on the introduction of pictorial warnings in Ghana. METHODS: Qualitative study involving 12 focus group discussions with 50 smokers and 35 nonsmokers aged 15 years and older in Kumasi, Ghana. Semistructured discussion guides along with visual discussant aids were used to explore the perception, acceptance, and potential use of pictorial warning labels in Ghana. RESULTS: Health warnings combining text and a picture were perceived by both smokers and nonsmokers to communicate health messages more effectively than text-only or picture-only warnings. The effect of text-only warnings was considered limited by low levels of literacy and by the common practice of single stick sales rather than sales of packs. Of the 6 health warnings tested, lung cancer, blindness, stroke, and throat/mouth cancer messages were perceived to have the most impact on smoking behavior, including uptake and quit attempts. CONCLUSIONS: Warning labels combining pictures and text have the potential to reduce smoking uptake, increase quit attempts, and reduce smoking appeal among smokers and nonsmokers in Ghana. Measures to prevent single stick sales, or to promote health messages to purchasers of single sticks, are required.

The role of nicotine replacement therapy for temporary abstinence in the home to protect children from environmental tobacco smoke exposure: a qualitative study with disadvantaged smokers.

BACKGROUND: Nicotine replacement therapy (NRT) has recently been licensed to help smokers to abstain from smoking for short time periods and recent studies have shown that 8-14% of smokers are regularly using NRT to cope when they cannot or are not allowed to smoke. These data suggest that, potentially, NRT for temporary abstinence might be an acceptable method to help smoking caregivers, who are not able to stop smoking completely, to avoid smoking whilst inside their home in order to protect their children from the harms of environmental tobacco smoke (ETS). The aim of this study was therefore to explore the concept of using NRT for temporary abstinence in the home, to protect children from exposure to ETS. METHODS: Qualitative in-depth interviews were conducted with thirty six disadvantaged smoking parents who were currently, or had recently stopped smoking in the home with at least one child under the age of five. Parents were recruited from Children's Centres and Health Visitor Clinics in Nottingham, UK. Interviews were audio recorded and transcribed verbatim. Data were coded and analysed thematically to identify emergent main and subthemes. RESULTS: Overall, participants responded negatively to the concept of attempting temporary abstinence in the home in general and more specifically to the use of NRT whilst at home to reduce children's exposure to ETS. Many parents would prefer to either attempt cutting down or quitting completely to make a substantial effort to change their smoking behaviour. There was limited interest in the use of NRT for temporary abstinence in the home as a first step to quitting, although some parents did express a willingness to use NRT to cut down as a first step to quitting. CONCLUSION: Disadvantaged smoking parents were reluctant to initiate and maintain temporary abstinence with or without NRT as a way of making their homes smoke free to protect their children's health. More education about the specific risks of ETS to their children and the utility of NRT for use in the home might be needed to have a public health impact on children's health.

Parental smoking and the risk of middle ear disease in children: a systematic review and meta-analysis.

OBJECTIVE: A systematic review and meta-analysis of studies of the association between secondhand tobacco smoke (SHTS) and middle ear disease (MED) in children. DATA SOURCES: MEDLINE, EMBASE, and CAB abstracts (through December 2010) and reference lists. STUDY SELECTION: Sixty-one epidemiological studies of children assessing the effect of SHTS on outcomes of MED. Articles were reviewed, and the data were extracted and synthesized by 2 researchers. MAIN OUTCOME EXPOSURES: Children's SHTS exposure. MAIN OUTCOME MEASURES: Middle ear disease in children. RESULTS: Living with a smoker was associated with an increased risk of MED in children by an odds ratio (OR) of 1.62 (95% CI, 1.33-1.97) for maternal postnatal smoking and by 1.37 (95% CI, 1.25-1.50) for any household member smoking. Prenatal maternal smoking (OR, 1.11; 95% CI, 0.93-1.31) and paternal smoking (OR, 1.24; 95% CI, 0.98-1.57) were associated with a nonsignificant increase in the risk of MED. The strongest effect was on the risk of surgery for MED, where maternal postnatal smoking increased the risk by an OR of 1.86 (95% CI, 1.31-2.63) and paternal smoking by 1.83 (95% CI, 1.61-2.07). CONCLUSIONS: Exposure to SHTS, particularly to smoking by the mother, significantly increases the risk of MED in childhood; this risk is particularly strong for MED requiring surgery. We have shown that per year 130 200 of child MED episodes in the United Kingdom and 292 950 of child frequent ear infections in the United States are directly attributable to SHTS exposure in the home.

A qualitative exploration of smokers' views regarding aspects of a community-based mobile stop smoking service in the United Kingdom.

BACKGROUND: Developing more accessible stop smoking services (SSS) is important, particularly for reaching smokers from socio-economically deprived groups who are more likely to smoke and less likely to quit in comparison to their more affluent counterparts. A drop-in mobile SSS (MSSS) was piloted across 13 locations in socio-economically deprived areas of Nottingham. METHODS: Semi-structured telephone interviews were conducted to explore the views of 40 smokers who registered with the MSSS. RESULTS: The MSSS appeared to trigger quit attempts. For some of the participants the attempt was totally unplanned; for others, it built on pre-existing thoughts about quitting which had not yet been acted upon. Smokers interested in quitting were comfortable about approaching the MSSS, whilst acknowledging that they did not feel pressured to register with the service. The drop-in format of the MSSS was found to be more appealing than making an appointment. In addition, several participants articulated that they may not have utilised other SSS had they not come across the MSSS. CONCLUSIONS: A MSSS may be an effective way to prompt quit attempts for smokers not planning to quit and also reach smokers who would not engage with SSS.

The motivators and barriers to a smoke-free home among disadvantaged caregivers: identifying the positive levers for change.

INTRODUCTION: The aims of this study were to explore home smoking behaviors and the motivators and barriers to smoke-free homes among a group of disadvantaged caregivers for young children and to identify the positive levers that health care professionals can utilize when supporting smoking behavior change. METHODS: In-depth qualitative interviews were conducted between July and September 2009, with 22 disadvantaged smoking caregivers, accessing Children's Centre Services in Nottingham, UK. Interviews were audiorecorded and transcribed verbatim. Data were coded and analyzed thematically to identify emergent main and subthemes. RESULTS: Caregivers had some general understanding of the dangers of secondhand smoke (SHS), but their knowledge appeared incomplete and confused. All interviewees described rules around smoking in the home; however, these tended to be transient and fluid and unlikely to be effective. Caregivers were often living in difficult and complex circumstances and experienced significant barriers to creating a smoke-free home. The motivators for change were more strongly linked to house decor and smell than children's health, suggesting that visible evidence of the harm done by SHS to children might help promote smoke-free homes. CONCLUSIONS: Findings suggest that further tailored information on the effect of SHS is required, but to instigate caregiver behavior change, providing demonstrable evidence of the impact that their smoking is having on their children's health is more likely to be effective.

Parental and household smoking and the increased risk of bronchitis, bronchiolitis and other lower respiratory infections in infancy: systematic review and meta-analysis.

BACKGROUND: Passive smoke exposure increases the risk of lower respiratory infection (LRI) in infants, but the extensive literature on this association has not been systematically reviewed for nearly ten years. The aim of this paper is to provide an updated systematic review and meta-analysis of studies of the association between passive smoking and LRI, and with diagnostic subcategories including bronchiolitis, in infants aged two years and under. METHODS: We searched MEDLINE and EMBASE (to November 2010), reference lists from publications and abstracts from major conference proceedings to identify all relevant publications. Random effect pooled odds ratios (OR) with 95% confidence intervals (CI) were estimated. RESULTS: We identified 60 studies suitable for inclusion in the meta-analysis. Smoking by either parent or other household members significantly increased the risk of LRI; odds ratios (OR) were 1.22 (95% CI 1.10 to 1.35) for paternal smoking, 1.62 (95% CI 1.38 to 1.89) if both parents smoked, and 1.54 (95% CI 1.40 to 1.69) for any household member smoking. Pre-natal maternal smoking (OR 1.24, 95% CI 1.11 to 1.38) had a weaker effect than post-natal smoking (OR 1.58, 95% CI 1.45 to 1.73). The strongest effect was on bronchiolitis, where the risk of any household smoking was increased by an OR of 2.51 (95% CI 1.96 to 3.21). CONCLUSIONS: Passive smoking in the family home is a major influence on the risk of LRI in infants, and especially on bronchiolitis. Risk is particularly strong in relation to post-natal maternal smoking. Strategies to prevent passive smoke exposure in young children are an urgent public and child health priority.