RESUMO
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.
Assuntos
Promoção da Saúde/métodos , Motivação , Cuidado Pré-Natal/economia , Abandono do Hábito de Fumar/economia , Adolescente , Adulto , Peso ao Nascer , Testes Respiratórios , Monóxido de Carbono/análise , Cotinina/análise , Feminino , Promoção da Saúde/economia , Humanos , Gravidez , Recompensa , Saliva/química , Escócia , Abandono do Hábito de Fumar/métodos , Adulto JovemRESUMO
BACKGROUND: The 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). METHODS: All 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. RESULTS: Quit 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. CONCLUSIONS: Uptake 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.
Assuntos
Gestantes/psicologia , Abandono do Hábito de Fumar/estatística & dados numéricos , Fumar/terapia , Adulto , Feminino , Doações , Comportamentos Relacionados com a Saúde , Promoção da Saúde , Humanos , Relações Mãe-Filho , Motivação , Projetos Piloto , Gravidez , Cuidado Pré-Natal , Escócia , Abandono do Hábito de Fumar/economia , Abandono do Hábito de Fumar/psicologia , Resultado do Tratamento , Adulto JovemRESUMO
AIMS: To examine the barriers and facilitators to effective operation of a regional tobacco control coordinator working within and across criminal justice and public health, whose goal was to raise tobacco control awareness and support the development of smoking cessation treatment for offenders. DESIGN: A reflexive, mixed-methods case study approach using in-depth interviews, project reports and observation of advisory board meetings. SETTING: The coordinator worked with prisons, probation and police custody, where there are high levels of social disadvantage and smoking. PARTICIPANTS: Interviews (n = 34) at different stages of project with the coordinator, project advisers and local stakeholders from criminal justice and public health. MEASUREMENTS: Analysis of facilitators and barriers and the coordinator role from different perspectives. FINDINGS: Readiness to develop cessation services was a critical predictor of different criminal justice settings' engagement with the coordinator role. The coordinator enhanced cessation service delivery in individual prisons where there was a requirement and infrastructure in place to provide such services. In police custody, where there was no central guidance or pre-existing requirements, efforts to establish smoking cessation on the local agenda proved ineffective. In probation settings, the coordinator documented examples of good practice and supported brief intervention training. Variability in willingness to engage limited the project's ability to create joined-up working across criminal justice settings. CONCLUSIONS: In the English criminal justice system, the prison service appears to provide a favourable context for development of smoking cessation support and a means of accessing hard-to-reach groups. Other criminal justice settings, most specifically police custody, appear less responsive to such activity. A coordinator role can improve smoking cessation support in the prison setting, and develop local improvements in tobacco control interventions in other settings such as probation, but as configured here, does not have the capacity to effect change across the criminal justice system.
Assuntos
Relações Interinstitucionais , Aplicação da Lei , Desenvolvimento de Programas , Saúde Pública , Abandono do Hábito de Fumar/métodos , Prevenção do Hábito de Fumar , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Política de Saúde , Necessidades e Demandas de Serviços de Saúde , Disparidades nos Níveis de Saúde , Humanos , Masculino , Organização e Administração , Polícia , Prisioneiros/estatística & dados numéricos , Prisões , Papel Profissional , Pesquisa Qualitativa , Fumar/epidemiologia , Condições Sociais , Fatores Socioeconômicos , Dispositivos para o Abandono do Uso de Tabaco , Reino Unido/epidemiologiaRESUMO
BACKGROUND: Seventy 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 METHODS: This 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? DISCUSSION: This 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 REGISTRATION: Current Controlled Trials ISRCTN87508788.
Assuntos
Protocolos Clínicos , Complicações na Gravidez/prevenção & controle , Abandono do Hábito de Fumar , Adulto , Feminino , Humanos , Recém-Nascido , Gravidez , Pesquisa Qualitativa , Projetos de Pesquisa , Escócia , Abandono do Hábito de Fumar/economiaRESUMO
BACKGROUND: Alcohol problems are a major UK and international public health issue. The prevalence of alcohol problems is markedly higher among prisoners than the general population. However, studies suggest alcohol problems among prisoners are under-detected, under-recorded and under-treated. Identifying offenders with alcohol problems is fundamental to providing high quality healthcare. This paper reports use of the AUDIT screening tool to assess alcohol problems among prisoners. METHODS: Universal screening was undertaken over ten weeks with all entrants to one male Scottish prison using the AUDIT standardised screening tool and supplementary contextual questions. The questionnaire was administered by trained prison officers during routine admission procedures. Overall 259 anonymised completed questionnaires were analysed. RESULTS: AUDIT scores showed a high prevalence of alcohol problems with 73% of prisoner scores indicating an alcohol use disorder (8+), including 36% having scores indicating 'possible dependence' (20-40). AUDIT scores indicating 'possible dependence' were most apparent among 18-24 and 40-64 year-olds (40% and 56% respectively). However, individual questions showed important differences, with younger drinkers less likely to demonstrate habitual and addictive behaviours than the older age group. Disparity between high levels of harmful/hazardous/dependent drinking and low levels of 'treatment' emerged (only 27% of prisoners with scores indicating 'possible dependence' reported being 'in treatment'). Self-reported associations between drinking alcohol and the index crime were identified among two-fifths of respondents, rising to half of those reporting violent crimes. CONCLUSIONS: To our knowledge, this is the first study to identify differing behaviours and needs among prisoners with high AUDIT score ranges, through additional analysis of individual questions. The study has identified high prevalence of alcohol use, varied problem behaviours, and links across drinking, crime and recidivism, supporting the argument for more extensive provision of alcohol-focused interventions in prisons. These should be carefully targeted based on initial screening and assessment, responsive, and include care pathways linking prisoners to community services. Finally, findings confirm the value and feasibility of routine use of the AUDIT screening tool in prison settings, to considerably enhance practice in the detection and understanding of alcohol problems, improving on current more limited questioning (e.g. 'yes or no' questions).
Assuntos
Alcoolismo/epidemiologia , Programas de Rastreamento/métodos , Prisioneiros , Adolescente , Adulto , Alcoolismo/diagnóstico , Humanos , Pessoa de Meia-Idade , Inquéritos e Questionários , Reino Unido/epidemiologia , Adulto JovemRESUMO
In recent years a number of countries have implemented comprehensive smoking bans to protect workers from adverse effects of exposure to second-hand smoke. It is also well known that many key stakeholders working in hospitality settings are themselves smokers. This paper reports the findings of a longitudinal qualitative study conducted with bar workers following the implementation of smoke-free legislation in Scotland. It examines the effects of smoking prevalence and status on support for smoke-free legislation, and its impact on business and working practices as well as bar workers' smoking behaviour both in and outside of the workplace. The results highlight a need for targeted assistance for businesses serving disadvantaged communities both to adapt commercially to the legislation and to provide cessation support to workers who smoke.
Assuntos
Exposição Ocupacional/legislação & jurisprudência , Exposição Ocupacional/prevenção & controle , Restaurantes/legislação & jurisprudência , Abandono do Hábito de Fumar/estatística & dados numéricos , Fumar/legislação & jurisprudência , Poluição por Fumaça de Tabaco/legislação & jurisprudência , Local de Trabalho/legislação & jurisprudência , Adulto , Consumo de Bebidas Alcoólicas , Feminino , Política de Saúde/legislação & jurisprudência , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/efeitos adversos , Escócia/epidemiologia , Fumar/efeitos adversos , Fumar/epidemiologia , Abandono do Hábito de Fumar/psicologia , Prevenção do Hábito de Fumar , Poluição por Fumaça de Tabaco/efeitos adversos , Poluição por Fumaça de Tabaco/prevenção & controleRESUMO
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.
Assuntos
Atitude Frente a Saúde , Política de Saúde/legislação & jurisprudência , Opinião Pública , Abandono do Hábito de Fumar/legislação & jurisprudência , Fumar/legislação & jurisprudência , Poluição por Fumaça de Tabaco/legislação & jurisprudência , Humanos , Legislação como Assunto , Exposição Ocupacional/legislação & jurisprudência , Pesquisa Qualitativa , Escócia , Fumar/epidemiologia , Prevenção do Hábito de Fumar , Meio Social , Indústria do Tabaco/legislação & jurisprudência , Poluição por Fumaça de Tabaco/prevenção & controle , Local de Trabalho/legislação & jurisprudênciaRESUMO
AIM: To explore compliance with the smoke-free legislation within a cross-section of community bars in Scotland. DESIGN: Ethnographic case study combining unobtrusive observation and in-depth interviews conducted pre- and post-introduction. SETTING: Eight Scottish community bars in three contrasting study communities. PARTICIPANTS: Ten bar proprietors, 16 bar workers and 44 customers. Measurements Observations and participant reports of compliance over the first 12 months of the smoking ban. FINDINGS: All eight study bars endeavoured to enforce the ban, but with varying enthusiasm. Compliance varied, with violations more prevalent in those bars serving deprived communities. Most violations occurred in peripheral areas and generally went unchallenged. Six bars reported some form of complicit behaviour with staff and customers smoking together, either in the entrance area or during 'lock-ins' when access to the bar was restricted to regular customers. Three factors were particularly important to explaining variance between bars: smoking norms, management competency and management attitudes towards the ban. The first and last were related to social disadvantage. CONCLUSIONS: Official data provide only a crude assessment of compliance in licensed premises. Data from this study offer a detailed picture of the nature and levels of compliance, and suggest a need for more sophisticated surveillance methods, greater enforcement and use of prosecutions where merited, and targeted support for bars serving deprived communities to help ensure that the major gains already achieved are retained and built upon. It is also suggested that acceptance of the smoke-free legislation could be enhanced by complementary initiatives targeting support to smokers in deprived communities. Those planning to introduce smoke-free legislation need to set in place these measures in advance in order to realize the benefits of full compliance.