Centre for Population Health SciencesUniversity of Edinburgh
A systematic review of the effectiveness of individual cessation support interventions in Europe to reduce socio-economic inequalities in smoking among adults.
Final Report June 2013Amanda AmosTamara BrownStephen Platt
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SILNE - Tackling socio-economic inequalities in smoking: learning from natural experiments by time trend analyses and cross-national comparisons
Project team
Amanda Amos, Professor of Health Promotion
Tamara Brown, Research Fellow
Stephen Platt, Professor of Health Policy Research
Centre for Population Health Sciences
School of Molecular, Genetic and Population Health Sciences
The University of Edinburgh
Medical School
Teviot Place
Edinburgh
Scotland
EH8 9AG
Phone: (+44)-(0)131-650-3237
Fax: (+44)-(0)131-650-6909
Acknowledgements
The project team would like to thank members of the SILNE project and members of the European
Network for Smoking and Tobacco Prevention (ENSP) who helped in the search for grey literature
and a study author who helped with data clarification (Jamie Brown).
2
Table of ContentsEXECUTIVE SUMMARY......................................................................................................5
1 INTRODUCTION............................................................................................................7
1.1 Background..................................................................................................................7
1.2 Aims and objectives....................................................................................................9
2 METHODS.......................................................................................................................9
2.1 Search strategy............................................................................................................9
2.2 Study selection...........................................................................................................102.2.1 Study selection process...........................................................................................102.2.2 Inclusion criteria.....................................................................................................112.2.3 Data extraction........................................................................................................122.2.4 Quality assessment..................................................................................................122.2.5 Data synthesis.........................................................................................................13
3 RESULTS........................................................................................................................14
3.1 Introduction...................................................................................................................14
3.2 Combined behavioural and pharmacological interventions.....................................18
3.3 Behavioural interventions............................................................................................30
3.4 Pharmacological interventions.....................................................................................36
3.5 Brief interventions.........................................................................................................37
3.6 Mass media – Quitlines and Quit & Win campaigns.................................................38
3.7 Text-based interventions..............................................................................................41
3.8 Internet-based interventions.....................................................................................42
4 DISCUSSION.................................................................................................................44
4.1 Strengths and limitations of the review.......................................................................44
4.2 Strengths and limitations of the available evidence...................................................46
4.3 Main findings and conclusions.....................................................................................46
4.4 Equity impact................................................................................................................47
5 CONCLUSIONS............................................................................................................47
6 REFERENCES...............................................................................................................49
7 APPENDICES................................................................................................................54
3
7.1 APPENDIX A Search strategies: electronic searches, handsearching and searching for grey literature..................................................................................................................54
7.2 APPENDIX B WHO European countries..................................................................66
7.3 APPENDIX C Inclusion/exclusion form.....................................................................67
7.4 APPENDIX D Included studies...................................................................................69
7.5 APPENDIX E Excluded studies...................................................................................71
7.6 APPENDIX F Quality assessment...............................................................................73
7.7 APPENDIX G Equity Impact......................................................................................76
7.8 APPENDIX H Summary of Equity Impact................................................................95
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EXECUTIVE SUMMARY Smoking is the single most important preventable cause of premature mortality in
Europe and a major cause of inequalities in health. Adult smoking prevalence in the
EU is declining but the social gradient in smoking is not. Reducing inequalities in
smoking is therefore a key public health priority.
Some progress has been made in tobacco control in many EU countries in recent
years. However, there is considerable variation in tobacco control policies and their
implementation including the provision of smoking cessation support.
While there is good evidence on which types of cessation support are effective in
reducing adult smoking, little is known about what is effective in reducing
inequalities in smoking.
The aim of this report was to undertake a systematic review of the effectiveness of
individual cessation support in Europe to reduce socioeconomic inequalities in
smoking in adults.
The systematic review included primary studies carried out in Europe involving
adults (18 years and older), published between January 1995 and January 2013,
which assessed the impact of individual-level cessation interventions/support by
socioeconomic status (SES).
The search strategy included searches of 10 electronic databases, papers ‘in press’ in
four key journals, and contacting tobacco control experts for grey literature.
Any type of individual-level smoking cessation intervention, of any length of follow-
up, with a measure of cessation was included. All primary studies based in a WHO
Europe country were eligible. SES variables included education, income, occupation
and area deprivation.
A quality assessment tool was adapted to enable appraisal of the diverse range of
intervention types and study designs in the included studies. The results are presented
in the form of a narrative synthesis and according to intervention type.
The equity impact of each cessation intervention on quit rates was assessed as being:
positive (reduced inequality), neutral (no difference by SES), negative (increased
inequality) or unclear (not possible to assess the equity impact).
Twenty-seven studies were included which evaluated 27 interventions. Electronic
searches produced 22 studies and 5 studies were identified through hand-searching,
grey literature, key reviews and contacting experts.
5
There was considerable variation in study design and quality: thirteen studies were
population-based observational studies, seven studies were intervention-based
observational studies and seven studies were intervention-based experimental studies.
The majority (16) of the studies were based in the UK and these mainly evaluated the
NHS Stop Smoking Services (SSS). Two studies each were from Denmark, France,
the Netherlands and Poland. One study each was from Israel, Spain and Turkey. This
limited geographical coverage raises concerns about the generalisability and potential
transferability to, or relevance for, countries in Europe with different social and
cultural contexts and/or levels of tobacco control.
The majority of study samples were derived from the general population, two studies
were in pregnant women, one in mothers, one in participants with Crohn’s disease,
one in men at high risk for CHD and one in men screened for lung cancer. Settings
included hospitals, community, pharmacies, and general practices.
The types of interventions/cessation support included were: combined behavioural
and pharmacological (15); behavioural only (5); pharmacological only (1); brief
interventions (1); mass media campaigns (2); text interventions (1) and internet
interventions (2).
The equity impacts of the 27 included interventions based on quit rates were: 10
neutral, 16 negative and 1 unclear. The ten neutral equity impact studies showed
similar beneficial impacts across SES groups.
The bulk of the evidence is of behavioural and pharmacological interventions (15),
most of which had a negative (10) equity impact. Eleven of these fifteen studies were
of the UK NHS SSS.
There was evidence from the UK NHS SSS studies that when cessation services,
which use combined behavioural and pharmacological support, are targeted at low
SES smokers, a higher relative uptake of services can more than compensate for the
relatively lower quit rate in low SES groups. Thus, the overall equity impact in terms
of reduced smoking prevalence by SES can be positive.
There were too few studies in the other types of intervention categories to draw any
conclusions regarding the equity impact.
Untargeted smoking cessation interventions and support in Europe may have
contributed to reducing adult smoking but are, on balance, likely to have increased
inequalities in smoking.
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1 INTRODUCTION1.1 BackgroundSmoking prevalence rates differ substantially within European countries according to
people’s educational level, occupational class and income level; and smoking is a major
cause of socioeconomic inequalities in mortality in the European Union (EU). The patterning
of smoking by socioeconomic status (SES) within a country reflects the stage of the tobacco
epidemic in that country. In general smoking is initially taken up by higher SES groups,
followed by lower SES groups. Higher SES groups are then the first to show declines in
smoking, followed by lower SES groups.1 The tobacco epidemic is also gendered in that men
first take up smoking, followed by women.2 Most countries in the EU are characterised as
being in the fourth (last) stage of the epidemic. In these countries lower SES groups have
higher rates of smoking prevalence, higher levels of cigarette consumption and lower rates of
quitting.3;4 Some EU countries are at a slightly earlier stage. This is reflected in the
differential patterning of smoking by SES and gender, where the clear relationship between
low SES and smoking found in men is only starting to emerge in women.
Since the 1990s, many European countries have intensified tobacco control policies and
introduced measures such as legislation on smokefree public places, bans on tobacco
promotion and tax increases. There is good evidence on what is effective in reducing adult
smoking amongst the general population. A review of the international evidence by the
World Bank in 20035 identified six cost-effective policies which they concluded should be
prioritised in comprehensive tobacco control programmes:
price increases through higher taxes on cigarettes and other tobacco products including measures to combat smuggling
comprehensive smokefree public and work places better consumer information including mass media campaigns comprehensive bans on the advertising and promotion of all tobacco products, logos
and brand names large, direct health warnings on cigarette packs and other tobacco products treatment to help dependent smokers stop, including increased access to medications
These priorities have been endorsed by World Health Organisation (WHO)6 and form the
basis of the Framework Convention on Tobacco Control (FCTC), the first international
public health treaty.7
7
What is much less certain is how ‘real world’ policies and interventions that reduce overall
smoking prevalence within the general population impact on socioeconomic inequalities in
smoking. Tackling these socioeconomic inequalities in smoking is central to reducing the
health inequalities gap and is the fundamental underpinning aim of the “SILNE” project,8
funded by the EU entitled: “Tackling socioeconomic inequalities in smoking: learning from
natural experiments by time trend analyses and cross-national comparisons”. The SILNE
project is a three-year European project co-ordinated by the University of Amsterdam,
Department of Public Health, Academic Medical Centre, the Netherlands, with financial
support from the European Commission Seventh Framework Programme; ‘Developing
methodologies to reduce inequities in the determinants of health’ programme (grant
agreement no. 278273). The SILNE project involves twelve European partners who will
deliver the seven work packages which make up the project. This systematic review is part
of Work Package 6 of the SILNE project.
Few reviews have addressed the equity impact of tobacco control measures; two key reviews
have previously been carried out on the equity impact of tobacco control interventions.9;10 In
2008 the Centre for Reviews and Dissemination (CRD) at the University of York, published
a systematic review of the equity impact of tobacco control on young people and adults,9
focussing on population-level interventions (not individual smoking cessation interventions)
published up to January 2006. In 2010 the Department of Health’s Policy Research
Programme, through the Public Health Research Consortium (PHRC), funded a study of
tobacco control and inequalities in health in England.10 This study included a review of the
evidence on the efficacy of interventions to reduce adult smoking amongst
socioeconomically deprived populations, which built on the CRD review and included
evidence published from January 2006 until November 2010. It included both population
level interventions and individual level cessation support interventions. The PHRC review
concluded that there was limited evidence to inform tobacco control policy and interventions
that are aimed at reducing socioeconomic inequalities in smoking behaviour.
While considerable progress has been made in tobacco control in many countries in the EU
in recent years, there is considerable variation in the strength and comprehensiveness of
tobacco control policies and their implementation.11 However, while overall smoking
prevalence is reducing; the social gradient is not. Addressing inequalities in smoking is a key
public health priority, starting with improving our understanding of the equity impact of
existing policies and interventions.
8
1.2 Aims and objectivesThe overarching aims of Work Package 6 are to undertake a systematic review of the
effectiveness of policies and interventions to reduce socioeconomic inequalities in smoking
among youth and adults, and to assess the implications of this evidence for understanding the
effects of such policies and interventions in countries within the EU. This report focuses on
the findings of the systematic review of the effectiveness of individual-level cessation
interventions and support in Europe to reduce socio-economic inequalities in smoking
among adults. This report’s objectives are to identify and review the strengths and
limitations of the published evidence on the effectiveness of cessation interventions and
support in Europe delivered at the individual level to reduce smoking among
socioeconomically deprived populations as compared to higher socioeconomic groups, and
the implications for European and other countries at stage 4a of the tobacco epidemic.
2 METHODS2.1 Search strategy The papers included in this review were identified from the larger systematic review
undertaken for Work Package 6. A comprehensive search strategy was developed to
encompass studies published from January 1995 to May 2012. The search included
published papers identified through searches of relevant electronic databases, and papers
pending publication identified through handsearching of key journals, and contacting key
tobacco control experts. A database of relevant references was produced using Reference
Manager 12 software package and details of the search strategies, including hand-searching
and searching for grey literature, are in Appendix A.
The following databases were searched:
BIOSIS
CINAHL Plus
a The 4 stages of the tobacco epidemic are described: Stage 1, characterized by low uptake of smoking and low cessation rates; Stage 2, characterized by increases in smoking rates among women and an increase to 50% or more among men; Stage 3, typified by a marked downturn in smoking prevalence among men, and a plateau and then gradual decline in women; and Stage 4, marked by further declines in smoking prevalence among men and women, with numbers of new smokers starting to decrease. Richmond, R. Addiction 2003;98 (5).
9
Cochrane Library (Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects; Cochrane Central Register of Controlled Trials; Health Technology Assessment Database)
EMBASE
ERIC
Conference Proceedings Citation Index
MEDLINE
PsycINFO
Science Citation Index Expanded
Social Science Citation Index
This search was supplemented by hand-searching of four key journals from January 2012 to
the end of July 2012 to identify articles ‘in press’ published on the journals’ websites:
Addiction
Nicotine and Tobacco Research
Social Science and Medicine
Tobacco Control
Three key reviews were also searched for relevant primary studies: the York review,9 the
PHRC review,10 and a report by the US Surgeon General on Preventing Tobacco Use Among
Youth and Young Adults12 which was published during the production of this review.
Bibliographies of included studies were also searched for further relevant studies. Members
of SILNE and members of the ENSP were asked to identify any relevant studies not
identified by the extensive searching of the electronic databases and the handsearching.
Update search
The electronic search strategy was rerun in all the databases used in the initial search to
identify studies published between May 2012 and end of December/start of January 2013. In
February 2013, the same four key journals were hand-searched to identify articles published
on the journals’ websites but not yet listed in electronic databases. See appendix A for
details.
2.2 Study selection
2.2.1 Study selection process
10
Articles retrieved from the searches were screened by title and abstract, to identify potentially
relevant studies. An initial screen of the first 200 references imported into Reference Manager
from MEDLINE were screened by title and abstract by two reviewers (AAb and TBc) to clarify
inclusion and exclusion criteria and establish consistency. The remaining references were screened
by title and abstract by one reviewer (TB) and checked by a second reviewer (AA). A second
screen of full text articles was then carried out by one reviewer (TB) and checked by a
second reviewer (AA). Any disagreements between reviewers were resolved by discussion at
each stage and, if necessary, a third reviewer (SPd) was consulted.
2.2.2 Inclusion criteriaAll primary study designs based in a WHO European country were eligible for inclusion (see
Appendix B for list of included countries).
The inclusion ages for the youth review were 11-25 years and for the adult reviews 18+
years.
In order to be included in this individual-level cessation review an article must have assessed
the equity impact of a cessation intervention delivered at the individual level and have
presented results with a differentiation between high and low socioeconomic groups. In other
words, the review only included studies which reported quit rates for at least two
(contrasting) socioeconomic groups.
Any type of smoking cessation intervention or support was included with any length of
follow-up. Socioeconomic variables included income, education, occupational social class,
area level socio-economic deprivation, housing tenure, subjective social status and health
insurance.
b AA=Amanda Amos, c TB=Tamara Brown, dSP=Stephen Platt
c
11
A measure of SES had to be reported in the abstract of the electronic references in order to
be included. Evidence identified through handsearching, searching of key reviews, or
contacting experts, could be included if a measure of SES was reported in the main body of
the text even if the abstract did not report that SES was assessed. If grey literature, such as
reports not published as journal articles, was identified by experts as assessing equity impact,
this evidence could be included even if the abstract did not report that SES was assessed. In
addition, such reports not written in English were included if an English synopsis was
provided (and otherwise met the inclusion criteria). Only studies published since 1995 in
full-text and in English language were included. No settings were excluded. See Appendix C
for inclusion/exclusion form.
The SILNE review excluded interventions targeted exclusively at one socioeconomic group
and also excluded studies which reported only socio-demographic data (without any
socioeconomic data). For example, ethnicity alone was not considered to be an appropriate
indicator of SES for this review as the smoking patterns associated with ethnicity differ from
one country to another. Interventions that focused solely on tobacco products other than
cigarettes (e.g. cigars, smokeless tobacco, waterpipes) or tobacco replacement products were
excluded, unless used as part of a smoking cessation programme. Interventions that focused
solely on outcomes for providers of a smoking cessation intervention were excluded unless
results were also reported for high versus low socioeconomic participant groups. Papers
reporting study protocol and design only without reporting the impact of the intervention or
policy were excluded.
2.2.3 Data extractionData from the included studies were extracted by one reviewer (TB) and independently
checked by another reviewer (AA). Data relating to population characteristics, study design
and outcomes were extracted into data extraction forms. Data from studies presented in
multiple publications were extracted and reported as a single study with all other relevant
publications listed in the report. Data extraction from non-English reports (grey literature)
was limited because it was derived from an English synopsis provided by an expert;
therefore the synopsis is reported directly in the text (not in data extraction tables).
2.2.4 Quality assessment
12
All included studies were assessed for methodological quality by one reviewer (TB) and
independently checked by another reviewer (SP). The exception to this was non-English
reports (grey literature); where any reference to quality was derived from an English
synopsis and reported directly in the text. Methodological quality was assessed by adapting
the method used in the York review.9 Each study was assessed on a scale of quality of
execution using the six item checklist of quality of execution adapted from the criteria
developed for the Effective Public Health Practice Project in Hamilton, Ontario.13 Certain
items of quality are not applicable to all study designs, for example, randomisation and
comparability are not applicable to cross-sectional study designs. We added a new criterion
of ‘generalisability’ (external validity) and assessed whether the findings of each study were
generalisable at a national, regional, or local level.
2.2.5 Data synthesisGiven the variations in study methodologies, intervention types and outcome measures, the
results are presented in the form of a narrative synthesis and according to intervention type.
In order to provide a simple basis for comparing the methodology of each study a typology
of study designs was devised (Table 1).
Table 1 Typology of study designsCode Study design
1.0 Population-based observational1.1 Cross-sectional1.2 Repeat cross-sectional1.3 Cohort longitudinal1.4 Econometric analyses (cross-sectional data)2.0 Intervention-based observational2.1 Single intervention (before and after, same participants)2.2 Single intervention with internal comparison2.3 Comparison between different types of intervention3.0 Intervention-based experimental3.1 Randomised controlled trial (individual or cluster)3.2 Non-randomised controlled trial3.3 Quasi-experimental trial4.0 Qualitative4.1 Cross-sectional4.2 Repeat cross-sectional4.3 Longitudinal
13
The equity impact of each population-level intervention/policy is summarised by adapting a
model used in the York review14:
The null hypothesis that for any given socio-economic characteristic related to education, occupation or income, there is no social gradient in the effectiveness of the intervention i.e. a neutral equity impact.
The hypothesis of a positive equity impact defined as evidence that groups such as lower occupational groups, those with a lower level of educational attainment, the less affluent, those living in more deprived areas, are more responsive to the intervention.
The hypothesis of a negative equity impact defined as evidence that groups such as higher occupational groups, those with a higher level of educational attainment, the more affluent, or those who live in more affluent areas are more responsive to the intervention.
The main strengths and limitations of each study, particularly internal and external validity,
are considered when discussing the equity impact of each intervention. Particular attention is
given to the issue of generalisability: to what extent are results from interventions carried out
in various countries transferable across Europe despite differences in tobacco control
policies, socioeconomic conditions, and other factors? We draw conclusions about the
strengths and weaknesses of the current evidence of the impact of smoking cessation
interventions in Europe on reducing socioeconomic inequalities in smoking in adults (equity
impact) and identify the most effective and promising interventions.
3 RESULTS3.1 IntroductionA total of 27 studies were included in the review of adult individual-level cessation support
interventions.
14
The initial electronic search produced 12,605 references after duplicates were removed. Two
hundred and eighty-seven references were identified as potentially relevant to the reviews
and 286 references were successfully obtained as full-text journal articles. Of these 286 full-
text articles, 115 were included and 171 were excluded. See Figure 1 for flow chart of study
inclusion. Twenty of the 115 papers focused on adult individual-level cessation support
interventions and were included in this review from the initial searching of the electronic
database. In addition five studies were identified through hand-searching, searching of grey
literature, key reviews and contacting experts. An update of the electronic searches were
carried out in 2013 which identified a further two relevant studies published up until January
2013. Appendix D contains bibliographic details for all the included adult individual-level
cessation support interventions including details of source. The details of studies that were
excluded at the stage of screening of full-text articles (n=11) are listed in Appendix E with
reasons for exclusion.
The findings of these 27 included studies are presented by intervention type. A summary of
studies by design and type of intervention are summarised in Table 2. Individual-level
cessation support interventions included: combined behavioural and pharmacological;
behavioural only, pharmacological only, behavioural and pharmacological, brief
interventions, quitlines, Quit & Win contests, text-based and internet-based interventions.
Quality assessment and equity impact tables, grouped by intervention type, can be found in
Appendices F and G respectively. A summary of the equity impact can be found in
Appendix H.
15
Figure 1 Study selection flow chart
16
Electronic search May 2012
Titles and abstracts screened
n = 12,605
excluded from title and abstract
n = 12,318
Full papers ordered n = 287
screenedn = 286
excluded (full-text) n = 173
includedn = 115
individual-level cessation interventions
n = 20
update electronic search*n = 2
handsearch, reviews, experts
n = 5
total number individual-level cessation studies
n = 27
update electronic search December/January 2013
titles and abstractsn = 1309
update full papers screened
n = 44
update includedn = 3*
update excluded n = 41
Table 2 Summary of studies by intervention type
Intervention type Number of studiesBehavioural and pharmacological 15Behavioural 5Pharmacological 1Brief interventions 1Mass media campaigns - quitlines and Quit & Win 2Text based 1Internet based 2Total 27
17
3.2 Combined behavioural and pharmacological interventionsFifteen combined behavioural and pharmacological studies were included of which eleven
studies were of UK NHS Smoking Cessation Services (SSS) and one was of a Danish
nationally disseminated ‘Gold Standard Programme’ for smoking cessation interventions.15
Studies of the UK NHS SSS included various areas across England (North Cumbria,
Nottingham, Liverpool and Knowsley, Derbyshire and London) and also Glasgow, Scotland.
Areas of interest were defined by local authority region and Primary Care Trusts, and also
areas of disadvantage including Health Action Zones and Spearhead areas. One study
evaluated pharmacy-led versus group-based SSS, another study assessed a rolling-group
drop-in model of behavioural support service, and another study assessed NRT versus
Buproprion. A secondary analyses study16 analysed data collected from two separate studies
of service users, one set in Glasgow17 and one set in North Cumbria and Nottingham which
had both short-term follow-up18 and longer-term follow-up data19 of NHS SSS programmes.
All four papers are included here. 16-19
Three studies assessed various behavioural and pharmacological interventions including: an
observational study20 using Zyban (PATCH 3) amongst smokers who had relapsed or failed
in the original PATCH study (smokers of 15+ cigarettes a day who were given behavioural
support and free NRT patches) set in general practices in Oxford, England; a French
study21 that investigated the role of physical activity as a predictor of maintaining smoking
abstinence after a smoking-cessation programme in participants with a depressive disorder
and reported smoking relapse by SES; and a study set in Israel22 that assessed the efficacy of
smoking cessation support groups based on behaviour modification and peer support where
participants could also receive NRT.
The majority of the studies of the NHS SSS were observational studies using administrative
data routinely collected from the services and linked with survey data (cross-sectional study
design). Eight of the eleven NHS SSS reported attrition rates and these were greater than
30% in three studies. Only six of the fifteen studies had representative study samples with
results that could be generalisable on a national scale.
18
UK NHS smoking cessation services
A study of NHS SSS23aimed to evaluate the reach of the service and quit rates at four weeks
in 76 of 99 health authorities in England during 2000/2001 when the service was relatively
new. There was considerable variation in outcomes across the health authorities including
those sampled and not sampled.
Cessation services based in health action zones (HAZ, areas of high deprivation) reached
140% more smokers compared to other more affluent areas, and the number of people who
reported quitting at four weeks was 90% greater in HAZ areas. However, there was an
inverse relationship between reach and cessation rates (the number of smokers who reported
quitting at four weeks as a percentage of those setting a quit date). Cessation rates were
lower in deprived areas compared with more advantaged areas. Typically the cessation rate
in an area with an upper quartile deprivation score was 6% lower than that in an area in the
lower quartile. Loss to follow-up rate at 4 weeks as a percentage of those setting a quit date
was 21%. Services operating in deprived areas were more likely to lose clients between
setting a quit date and reporting outcomes at four weeks. The study did not assess the overall
equity impact of the services (ie whether the higher reach in deprived areas compensated for
lower quit rates). However, the equity impact in terms of quit rates was negative.
A wide range of service characteristics (individual sessions, stronger service relationships,
service operating at full capacity, smoking cessation co-ordinator hours, location of service)
were significantly associated with the outcome measures: reach, absolute success, cessation
rate, and loss to follow up. A number of area characteristics were also significantly
associated with outcome measures. Area characteristics accounted for a large proportion of
the variation in reach (81%) and the absolute number of successful self-reported four week
quits (79%). Study authors argue this was due to the service being more developed and better
funded in HAZ areas. Service characteristics were substantially more important in
accounting for the cessation rate (78%) and loss to follow up (98%).
Two studies assessed the NHS SSS in Nottingham and Cumbria, England.18;19
A study assessed CO-validated 4-week quit rates for 6959 service users who set a quit date
between October 2001 and March 2003 in two contrasting areas of England, Nottingham and
North Cumbria and compared the results with those for self-reported quitters.18 In general,
smokers were seen by smoking cessation advisers one week (maximum 2 weeks) before
quitting and at weekly intervals for four weeks after quitting. NRT treatment started on the
quit date, and bupropion treatment 10 days before the quit date for 8 weeks with weekly 19
intervals. The sample of 6959 represented 82% of the total number of cases recorded in the
two study areas.
Self-reported 4-week cessation rates (had not smoked at all since 2 weeks after the quit date)
were slightly above the average for England (53%) in Nottingham (56%) and rather more
above this average in North Cumbria (65%). CO-validated 4-week cessation rates were
above the average for England (35%) in Nottingham (46%) and even more above this
average in North Cumbria (57%).
More than half the clients (53%) were CO-validated as quitters at 4 weeks, rising to 60.7%
when self-reported cases not receiving a CO validation test, were included. There were
18.6% non-quitters (including 0.5% whose self-reported quit was refuted by CO≥10 p.p.m.),
with a further 20.6% lost to follow-up. Although the vast majority of users received one-to-
one support, those who had group counselling were more likely to be successful in their quit
attempt (OR 1.38; CI 1.09–1.76). Self-report and CO-validated quitters were similar in terms
of their characteristics. Users with lower SES were less likely to quit at four weeks (OR
0.92; CI 0.88–0.95). The CO-validated rate ranging from 59.8% for group 1 (least deprived
areas) to 43.1% for group 6 (most deprived areas, P<0.001). The study authors emphasise
that although there were social inequalities in cessation rates within the study sample, the
study sample as a whole was relatively disadvantaged. Based on quit rates this intervention
was associated with a negative equity impact.
A further study assessed CO-validated quit rates at 52-weeks follow-up, of the same service
in the same area (Nottingham and North Cumbria) by following up approximately one-third
(2069) of the users in the previous study18 who had successfully quit at four weeks and who
set a quit date between May and November 2002.19 Clients were referred to a local smoking
treatment service where they were seen by a trained adviser and set a quit date. Treatment
was on a weekly basis for typically 8 weeks, either with one-to-one or group-based
behavioural support plus NRT or bupropion. The sample of 2069 represented 80.7% of the
total number of cases recorded in the two study areas setting a quit date during the study
period.
One out of seven users (14.6%) reported prolonged abstinence and was CO-validated as a
successful quitter at 52 weeks. This rose to 17.7% when self-report cases were included.
Non-quitters (including self-report quit refuted by CO-validation test) was 44.7% and loss to
follow up was 37.5%. Relapse rates between 4 and 52 weeks were about 75% in both study
areas and were most likely to occur in the first 6 months following treatment. Users who
20
self-reported quitting at 4 weeks were less likely (13.7%) than those with biochemical
verification of smoking status at 4 weeks (25.2%) to be CO-validated quitters at 52 weeks (P
= 0.004). None of the key characteristics of intervention, such as group or one-to-one
counselling or type of pharmacotherapy were significantly associated with cessation at 52-
weeks. Service users with lower SES were less likely to be quitters at 52-weeks (OR 0.86; CI
0.78–0.96). 52-week cessation rate ranged from 17.4% for group 1 (relatively advantaged) to
just 8.7% for group 6 (relatively disadvantaged). Loss to follow-up rate increased from
38.4% for group 1 (relatively advantaged) to 43.3% for group 6 (relatively disadvantaged).
This intervention was associated with a negative equity impact.
One cross-sectional study24 examined the impact of NHS SSS in Spearhead areas which are
officially designated disadvantaged local authority areas that account for about 30% of the
adult population in England. Estimates of smoking prevalence were compared with national
monitoring data from the NHS SSS to evaluate reach of services and impact on inequalities
using data from 2003/4 and 2005/6.
Self-reported four-week quit rates were lower in disadvantaged areas (52.6%) than elsewhere
(57.9%) (p<0.001), but the proportion of smokers being treated was higher (16.7% compared
with 13.4%) (p<0.001). Overall, the proportion of all smokers who were estimated to have
quit at 4 week and 52 week follow up was higher in the Spearhead areas (8.8% and 2.2%)
than elsewhere (7.8% and 1.9%) (p<0.001). Assuming 75% of 4 week quitters would relapse
(across all areas) within one year, the absolute and relative rate gaps in smoking prevalence
between Spearhead areas and others were estimated to fall by small but statistically
significant amounts from 5.2 and 1.215 (CIs: 1.216 to 1.213) to 5.0 and 1.212 (CIs: 1.213 to
1.210) between 2003-4 and 2005-6.
The study found that although disadvantaged groups had proportionately lower quitting
success rates than their more affluent neighbours, services were treating many more clients
in disadvantaged communities. Overall, therefore, the net effect of service intervention was
to achieve a greater proportion of quitters among smokers living in the most disadvantaged
areas. In summary, NHS SSS were having a slight narrowing i.e. positive effect on
inequalities in smoking prevalence. However, based on quit rates alone NHS SSS had a
negative equity impact.
An observational study of administrative information linked with survey data17 assessed the
impact of NHS SSS by comparing outcomes for pharmacy-led with group-based cessation
support in Glasgow, Scotland, in service users who set a quit date in between March and
21
May 2007. Group support based in the community included seven weeks behavioural
support with a choice of pharmacological product. Smoking treatment services based in
pharmacies included 12 weeks of NRT and 5-10 minute one-to-one behavioural sessions.
The initial sample that accessed the pharmacy-based service during the study period was
1508 compared with 471 for the group-based services. Loss to follow-up was 57% for the
pharmacy-led service and 42% for the group based service. Carbon monoxide (CO)
validated 4-week quit rates were 18.6% in pharmacy-based services and 35.5% in group-
based services. In a multivariate model, restricted to participants (n = 1366) with data
allowing adjustment for socio-demographic and behavioural characteristics and including
interaction terms, users who accessed the group-based services were almost twice as likely
(OR 1.980; CI 1.50 to 2.62) as those who used pharmacy-based support to have quit
smoking at 4-week follow-up.
The Scottish Deprivation quintiles were used as a measure of SES as well as a socio-
economic group score was used and is a summary measure based on whether education
finished by 16, single parent, rented housing, unemployed or permanently sick/disabled,
whether eligible for free prescriptions and aged under 60, lowest Scottish deprivation decile:
range 1 (least deprived) to 6 (most deprived).
A high proportion of clients in both groups were from disadvantaged areas, with 58.0% of
pharmacy-based clients in the bottom Scottish deprivation quintile, compared with 45.5% in
group-based community support. The quit rates were measured by a number of
socioeconomic indicators, and all showed lower cessation rates in low SES groups, but the
difference was only significant for smokers using pharmacy services (25.2% vs 14.9%,
p=0.001). In multivariate analysis low socioeconomic status was significantly associated
with lower 4 –week quit rates (OR 0.677, p=0.015). In summary, the NHS SSS had a
negative equity impact (in terms of quit rates).
Another study16 analysed data collected from two separate studies17-19 of NHS SSS
programmes (also included within this review). The studies employed an identical research
design and were conducted by the same research team. The smoking cessation programmes
studied were an intensive group programme and one-to-one support in a pharmacy setting in
Glasgow, Scotland17 and primary care-based programmes in Nottingham and North
Cumbria, England18;19 both of which offered one-to-one behavioural support with some
group support (98% English clients received one-to-one support). All clients were also
22
offered pharmacotherapy during their quit attempt which was free except for a small
prescription charge paid by some clients.
This secondary analyses paper16 evaluated CO-validated quit status at 52-weeks in 2397
NHS SSS users in Glasgow, North Cumbria and Nottingham between the ages of 25 and 59
years. At 52-week follow-up, 14.3% of the most affluent smokers remained quit compared
with only 5.1% of the most disadvantaged. After adjustment for demographic factors, the
most advantaged clients at the North Cumbria and Nottingham sites and the Glasgow one-to-
one programme (but not the group intervention) were significantly more likely to have
remained abstinent than those who were most disadvantaged (OR 2.5, 95% CI 1.4 to 4.7; and
OR 7.5, 95% CI 1.4 to 40.3 respectively). During the study period relatively few smokers
from disadvantaged backgrounds attended the group service.
Continuous abstinence rates at 1 year were higher in England (average 14%) than Glasgow
(average 3%). In England those with 4 or 5 affluent indicators had rather higher quit rates
than the other groups. In the Glasgow one-to-one service the quit rate was fairly stable
except for the most affluent group whose quit rate was double that of the next highest
category. The data showed variance by SES within and across service sites and between the
types of services within the Glasgow site. The relationship between SES and quitting was
influenced by treatment compliance, household smokers and referral source. Disadvantaged
clients were less likely to quit and less compliant with treatment (negative equity).
The study authors state that there was also a time lag between data collection in England and
Scotland that may have influenced the results, with smokefree legislation in Scotland
occurring during the two data collection periods.
A cohort study25 examined the long term impact of an NHS SSS rolling-group drop-in model
of behavioural support service in Liverpool and Knowsley, England. The Roy Castle Lung
Cancer Foundation ‘Fag Ends’ NHS Stop Smoking Service is an alternative intervention
type with support centred on drop-in rolling groups. Quit dates can be different for attendees
and can be determined by the client. There are no waiting lists, no appointments and no
requirement to be referred by a third party, although referral systems are in place. Weekly
sessions run continuously, clients can attend as many sessions as they wish and can continue
to attend even if they relapse.
The study collected data from clients who accessed the service during a ten week period in
2009. In terms of reach, the study sample was particularly disadvantaged, 68% resided in the
most deprived decile of the English Index of Multiple Deprivation. ‘Fag Ends’ clients were 23
drawn from particularly disadvantaged groups when compared to the general population.
Only 20% had finished their education after age 16, whereas in England, 49% had
qualifications obtained after age 16 in 2009. Nearly two-thirds were eligible for free
prescriptions, compared to 50% in the general population. A third of ‘Fag Ends’ clients were
long-term unemployed, whereas the General Lifestyle Survey 2008 estimate for UK over-
16s unemployment was 4.2%.
The study was only able to biochemically validate the quit status of approximately two-
thirds of the clients and the CO-validated quit rate at 1 year was 5.6% compared with 30.7%
at 4 weeks (a relapse rate of 78.2%). In terms of effectiveness, in general, more affluent
clients were more likely to be quitters at 12 months. 4.7% of clients living in more deprived
areas (Index of multiple deprivation deciles 1 to 5 for Liverpool postcode area) had a CO-
validated quit rate at 12 months compared with 7.4% in more affluent areas (deciles 6 to 10).
Stepwise analysis suggested that CO-validated quitters were more likely to be more affluent
(OR 1.33; CI: 1.07 to 1.65, for each extra indicator of high socio-economic status). In
summary this study had a negative equity impact for quit rates.
A cross-sectional study using a random, stratified sample of people aged 25–44 years and
people aged 65–74 years with over-sampling of populations living in disadvantaged areas,
described the use of NHS SSS ‘Fresh Start’ in South Derbyshire, England.26 Over half of
smokers aged 25–44 years, about one-third of women smokers and 40% of male smokers
aged 65–74 years wished to quit, and the prevalence ratio of wanting to quit was
significantly reduced for the group living in a disadvantaged area for men aged 25-44 year
only. Thus overall, motivation to quit did not vary by SES.
Quit rates (self-report quitting in the previous year) were generally lower among smokers of
lower SES, but only significantly so for men aged 25–44 years. Smokers of lower SES
reported slightly less advice to quit from family and friends, and more so from health
professionals. Awareness and use of cessation services was about 30% and 5%, respectively,
among smokers and recent quitters. Awareness varied little but accessing services was
generally higher among smokers of lower SES. There were lower quit rates in users of NHS
SSS who were from disadvantaged areas and of low SES. However, the numbers were small
(n=79) and these differences were not significant. In summary, use of the NHS SSS was
associated with a neutral equity impact in terms of quit rates.
A short report of a study which evaluated the NHS SSS used data from seven health
authorities of all people (n=22,753) who attended smoking cessation services between April
24
2000 and March 2001.27 The report shows that disproportionately more people living in
deprived areas were contacting smoking cessation services. However, with increasing
deprivation smaller proportions of those who have contacted services managed to set quit
dates. In the most deprived quintile, only 40.2% of males accessing the services set a quit
date compared with over 50% for all other quintiles. Despite this trend, greater proportions
of people from deprived quintiles set quit dates. However, the percentage of those accessing
the services who quit was lowest among the most deprived quintile of smokers, but the paper
does not state whether this difference was significant. Among those who set a quit date there
was no apparent pattern by deprivation group, but again no significance tests were reported.
The relative proportion of the total population quitting smoking increased as deprivation
increased. In the least deprived quintile, only 0.05% of the total population quit smoking
compared with 0.25% in the most deprived areas. In summary, the equity impact in terms of
rates of quitting was unclear.
A proposal for a framework to assess equity is applied to Derwentside Stop Smoking
Service, a former Primary Care Trust (PCT) in England.28 The service was launched in
January 2001 with clients predominantly from GP referrals, receiving either group support or
one-to-one sessions. In 2004, the service was expanded and moved to a model of delivery
focussed around intermediate advisors, paying GP practices and pharmacists for their input.
In order to assess the equity effects of these changes, data for the two periods 2001/02 and
2004/05 were analysed.
The 22 wards in Derwentside were ranked from most deprived to most affluent based on the
income domain of the Index of Multiple Deprivation 2004. The size of the absolute gap in
rates across all wards arranged from most affluent to most deprived was calculated using the
slope index of inequality. The relative gap was then estimated as the absolute gap divided by
the average rate across all wards. This method was used to calculate access, quit and
prevalence rates.
The study showed that service expansion was successful in increasing the overall number of
quitters, however the service continued to exacerbate inequality in smoking prevalence
between deprived and affluent wards. Service changes and expansion resulted in the percent
of adults in Derwentside quitting through the SSS increasing from 0.33% to 0.8%. The
relative gap between affluent and deprived wards was 71%, based on synthetic estimates of
prevalence using 2004/05 data.
25
The study authors state that their analysis suggests that the Derwentside Stop Smoking
Service is operating at a position between equity of access and equity of outcome. Between
2001/02 and 2004/05 there had been some movement towards equity of outcome (ie neutral
equity impact), but equity of outcome was not yet being achieved ie quit rates remained
lower in more deprived wards. The gap in quit rates per adult between affluent and deprived
areas was smaller than the gap in smoking prevalence. This means that the Stop Smoking
Service in Derwentside was not contributing to a reduction of inequality in smoking
prevalence between deprived and affluent areas. The services were having a negative equity
impact in terms of quit rates.
A study evaluated whether issues of implementation influence the effectiveness of NRT and
bupropion in 2626 clients setting a quit date (82% of those who registered) with two London
NHS SSS that offered behavioural support plus a choice of NRT or bupropion.29Logistic
regression analyses looked at the relationship between 3-4 week smoking abstinence and
educational achievement and eligibility for free prescriptions.
All 2626 clients were asked which medication they were going to use: 15% (388/2238)
chose to use bupropion, 69% (1810/2238) NRT and for 17% (428/2238) their decision was
unrecorded. 55% of clients choosing bupropion had education after 16 years of age,
compared with 41% of clients choosing NRT.
Self-reported quitters who were not CO-validated, plus non-quitters (n =291) and clients lost
to follow up (n = 126) were all classed as smokers. The CO-validated 3–4 week abstinence
rate was 41% (865/2129); for clients using bupropion it was 34% (129/377) and for those
using NRT it was 42% (736/1752) (χ2 = 7.81, p = .005). The study authors argue that
obtaining NRT was relatively easy for clients throughout the study period whilst this was not
the case for bupropion and this might have influenced the effectiveness of buproprion. There
were no differences in abstinence rates according to the level of education of the client and
so this NHS SSS is associated with a neutral equity impact.
Other combined behavioural and pharmacotherapy interventions
A Danish study15evaluated a ‘Gold Standard Programme’ (GSP) for smoking cessation
interventions in disadvantaged patients in all five Danish regions by more than 350 units in
hospitals and primary care facilities, using data from a national registry (2001 to 2011). The
GSP has been the standard intervention in Denmark since 2001 and was developed with the
26
guidance of the National Cancer Institute. The programme consisted of five meetings over 6
weeks, with a clearly structured patient education programme, including a motivational
conversation at the beginning, reflections on benefits and costs of continuous smoking
versus cessation, date of cessation, teaching and training about risk situations and relapse
prevention, withdrawal symptoms and medical support, and planning for the future. Nicotine
replacement therapy was provided and patients were free to choose different kinds of
nicotine products. A hotline was available during daytime hours on working days. GSP was
delivered either in a group or in an individual format. The group size varied, with the median
being 12 registered participants (range 2 to 26 participants). Of the 20 588 patients, 19 185
(93%) received the course for free. Some patients received free medication, while others had
to pay themselves. The study included patients aged 18 years or older undergoing the GSP in
Denmark, regardless of smoking severity, motivation to quit, comorbidity or whether a quit
date were set.
Continuous abstinence of the 16 377 responders was 34% (of all 20 588 smokers: continuous
abstinence was 27%, when all non-responders were considered to be smokers). Of the 16
377 responding to follow-up, 27% had a lower level of education. Continuous abstinence
was lower in 5738 smokers with a lower educational level (30% of responders, 23% of all)
compared with those with a higher education level (35% of responders, 28% of all). The
overall difference in continuous abstinence between disadvantaged and non-disadvantaged
patients was 5% (with respect to education). In respect to modifiable factors, continuous
abstinence was found more often after programmes in one-on-one formats (vs group
formats) among patients with a lower educational level, 34% (vs 25%, p=0.037). The
variable ‘format’ stayed in the final model of multivariable analyses in patients with a lower
educational level, OR=1.31 (95% CI 1.05 to 1.63).
Among lower educated smokers participating in the Danish GSP for smoking cessation,
there were relatively high continuous abstinence rates of those responding (30%) and 23% of
all registered for treatment. This was 5% lower than higher educated smokers although the
absolute difference was small. Patients who participated in a programme with an individual
format showed a favourable outcome regardless of being disadvantaged. The study authors
report that patients with a lower educational level seemed to have been under-represented: in
the study there were 27% compared with 37% in the Danish population. In summary this
smoking cessation programme is associated with a negative equity impact.
27
PATCH 320 was an observational study of quit rates amongst smokers (from the PATCH 1
and PATCH 2 studies) who had relapsed or failed in the past, using the new drug Zyban. The
inclusion criteria for the original PATCH study were smokers of 15+ cigarettes a day who
were given behavioural support and free NRT patches in 19 general practices in Oxford,
England. PATCH 2 involved genotyping. In PATCH 3 the GP prepared two signed
prescriptions for Zyban (each for 60 x 150 mg SR tablets), one to be issued by the study
nurse at the baseline visit (week 0) and at week 4 (2 weeks post quit date). The study
schedule followed was 150 mg once daily for six days increasing to twice daily (total 300
mg/day) from day 7, if tolerated, followed by then making the quit attempt. The study nurse
(either from the research team or from within the practice) then took over the support and
monitoring of the participant. Smoking status was biochemically verified and participants
were encouraged to remain abstinent at clinic visits (at least 5) and by phone calls (at least 5)
with the nurse throughout the study period.
239 out of 479 PATCH 2 participants were found to be eligible for the study and 54 of the
239 (23%) made an attempt to stop smoking on the agreed quit date. Sixty-three percent
(34/54) complied fully with the scheduled programme, making ten or more formal contacts
with the support staff by phone or in person. At 6 months, 21/54 (39%) claimed to be
abstinent, and 16/54 (30%) had biochemically verified abstinence. At 12 months, 14/54
(26%) claimed to be abstinent and 12/54 (22%) were biochemically-validated continuously
abstinent at 12 months (point prevalence rates).
When those who attempted to quit were stratified by deprivation score (low, medium, high;
less deprivation higher social class), females had significantly less deprivation than males (p
= 0.03). This difference in deprivation score persisted among the successful quitters (mean
deprivation score at 12 months in females =6.7, in males= 12.1).
Nearly half (42.4%) of adults invited to join the study were in manual work and 44% of
those who accepted were in manual work. There were no significant differences between
those who accepted the invitation to participate and those who did not in terms of SES.
There were slightly higher numbers of manual workers among the successful quitters (55.6%
at six months and 46.2% at 12 months), than among those who made a quit attempt (42.6%).
However, these differences were not statistically significant and the numbers were relatively
small. In terms of quit rates the equity impact of this study was neutral.
A French study21 investigated the role of physical activity as a predictor of maintaining non-
smoking behaviour after a smoking-cessation programme, in participants with a depressive
28
disorder and reported smoking relapse by SES. One hundred and thirty-three non-selected
and consecutive current daily smokers with current major depressive disorders (score ≥10 on
the Depression subscale of Hospital Anxiety and Depression Scale) who were consulting for
smoking cessation at a University in France, were recruited from a large prospective cohort
of smokers (n = 1,119) between 2000 and 2004.
The hospital’s smoking-cessation intervention included counselling and pharmacotherapy
approaches (NRT). Other possible pharmacotherapies were anxiolytic and antidepressant
(only selective serotonin reuptake inhibitors, SSRIs). The counselling intervention was brief
and the session lasted 45 minutes. The duration of treatment was at least 12 weeks with NRT
or a maximum of 12 weeks with bupropion. The patients were seen at least 4 times in the
first 3 months after the first visit. The primary outcome of the study was whether physical
activity could predict smoking abstinence.
Smoking relapse was defined as daily cigarette consumption. The smoking relapse rate was
77.4% up to a period of three years (n=103) and the median time until relapse was 309 days.
The paper reports that the study sample was ‘not systematically followed-up’ and the
patients lost during follow-up period were considered as relapsed. Education level included
two categories: up to high school or high-school certificate, or college or postgraduate
degree. Level of education was significantly associated with relapse (relapse rate=0.80, 95%
CI: 0.64 to 0.99, p = 0.04) and so this study is associated with a negative equity impact.
A before-and-after study set in Israel22assessed the efficacy of smoking cessation support
groups. The groups met weekly for eight to ten meetings lasting one to two hours each.
Groups consisted of 12 to 15 participants and the meetings were based on behaviour
modification and peer support. Participants could receive NRT. One of the study authors
moderated the groups. Eighty-nine adults participated in at least one meeting during 1994 to
1995 and 76 (85%) participated in follow-up (which ranged from 12 to 36 months).
Thirty-three percent reported that they did not smoke at follow-up and there was 95%
agreement rate with carbon monoxide breath tests. Belief in the ability to quit before the
intervention and active support of a spouse, contributed significantly to success in quitting
smoking. There was no difference between quitters and non-quitters in use of NRT and in
years of education. This study is associated with a neutral equity impact although the study
sample was small.
29
Summary of combined behavioural and pharmacological interventions
Fifteen studies of combined behavioural and pharmacological interventions were included
and assessed for equity impact in terms of quit rates. Ten studies were ‘negative’, four
studies were ‘neutral’, and one study had an ‘unclear’ equity impact. Eight of the ten
‘negative’ studies were of UK NHS SSS, another was the only nationally disseminated
behavioural and pharmacological intervention outside of the UK (Denmark) and the other
was a hospital based study in France. However, in several of the UK studies, which also
measured the reach of the cessation service by SES, there were indications that uptake
(reach) was relatively higher among low SES smokers, which more than compensated for
lower quit rates. Thus, the overall equity impact in terms of reduced smoking prevalence by
SES was positive. Three of the four ‘neutral’ studies were of UK NHS SSS, though two had
small numbers, and the fourth involved a small study in Israel. The one ‘unclear’ study was
of UK NHS SSS.
3.3 Behavioural interventions
Five studies were included of behavioural smoking cessation interventions, one study was a
controlled before and after study in participants with Crohn’s disease,30 two RCTs (one with
a non-random control group) in pregnant women, one RCT of a lifestyle counselling
intervention31 which included smoking cessation advice and one RCT of tailored smoking
cessation brochures given to participants involved in a lung cancer screening programme in
the Netherlands/Belgium ).32 Three of the studies were representative of the study population
and generalisable on a national scale, although the study populations in two cases were
specific (pregnant women and adults with Crohn’s disease). The study of lifestyle
counselling31 had a high rate of attrition. In two studies the results might not be attributable
to the intervention30;31 for example in the study of participants with Crohn’s disease30
participants reported that the risk of surgery influenced them to stop smoking (rather than the
smoking cessation counselling) and those who did stop smoking had better compliance with
the treatments for Crohn’s disease compared with continuing smokers. There were no
included studies of behavioural only smoking cessation interventions in a general population
of smokers.
A study of repeated counselling to stop smoking in participants with Crohn’s disease and a
follow-up of all patients who stopped smoking for one year was carried out in a hospital
outpatient clinic in France between 1995 and 1999.30 At one year post quit each patient with
30
biochemically verified quit status was matched (by age, gender, disease location and disease
activity) with two controls, one non-smoker (patient who never smoked or who had stopped
smoking for more than 5 years) and one continuing smoker. The primary outcome of the
study was to assess the effect of smoking cessation in Crohn’s disease according to the
disease course and therapeutic needs of the participants.
Of 899 consecutive patients, 474 (53%) smoked more than two cigarettes per day and were
recruited and given behavioural counselling for smoking cessation, with presentation of data
showing the harmful effect of current smoking on the disease. Smokers who were considered
physically dependent (daily consumption >15 cigarettes) were offered access to a smoking
cessation programme, conducted by a specialised physician who could be visited every
week. When necessary, management of smoking cessation included nicotine patches and
fluoxetine as antidepressant, but there were no further details about this reported in the
paper.
Fifty-nine (12%) participants remained abstinent for more than one year. Four patients quit
smoking after a single advisory session, and others after repeated advisory sessions. Forty-
six patients attended the smoking cessation program. Among them, 7 (15%) remained
abstinent for more than one year. During follow-up, 11 patients eventually resumed smoking
after 16–52 months of abstinence (median, 42 months). Independent factors associated with
smoking cessation included high SES (adjusted odds ratio, 2.84; 95% CI, 1.43–5.62).
In many cases, surgery or forthcoming surgery convinced patients to stop smoking and those
who did stop smoking had better compliance with the treatments for Crohn’s disease
compared with continuing smokers. The study reports that smoking is highly prevalent
among people with Crohns disease (50%) but cessation was more likely among higher SES
patients. Therefore, this study is associated with a negative equity impact.
A quasi-RCT with pregnant women33 evaluated the effectiveness of individual anti-smoking
counselling (four visits with the midwife during pregnancy and one after delivery) in public
maternity centres in Poland between December 2000 and December 2001. Two hundred and
sixteen women (78.5%) agreed to participate: 158 women reported smoking at least one
cigarette per day and 58 declared that they had quit smoking spontaneously before their
prenatal visit. During the study, 11 (5.1%) women were excluded from the analysis due to
miscarriage, and three (1.4%) were lost to follow-up and assessed as smokers in the analysis.
The final study intervention population consisted of 149 current smokers and 56 spontaneous
quitters. 144 current smokers and 37 spontaneous quitters were assessed in the control group.
31
The control units received standard written information about the health risk from maternal
smoking to the fetus. The intervention included a ‘declaration to quit smoking’ and when a
woman did not manage to quit smoking during the four midwife visits, she was offered the
possibility of continuing the intervention activities during another five visits.
The paper reports that the study population was derived from an urban community of
socially underprivileged women in Lodz, central Poland. At baseline including participants
and those lost to follow-up, 19.5% of the intervention group, and 18.7% of the control group
had ‘12 or 17 years’ of education. After excluding from the analysis spontaneous quitters
and women who refused to participate in the study the proportion of women who quit
smoking was 44.3% in the intervention group and 16.7% in controls (p < 0.001). The quit
rate was almost four times higher in the intervention than in the control group (OR = 3.8;
95% CI: 3.3 to 4.4). The quit rate was significantly higher in the intervention group than in
the control group when including participants, those lost to follow-up, spontaneous quitters
and refusals (OR = 2.5; 95% CI: 1.8 to 3.7). No statistically significant differences were
found in the efficacy of the intervention with regard to the level of education whether
including just participants and those lost to follow-up or also including spontaneous quitters
and refusals. In summary, this Polish study of behavioural intervention in pregnant women
was associated with a neutral equity impact because the intervention was equally effective
for women of all levels of education in terms of self-reported smoking status shortly after
delivery.
An RCT evaluated the effects of smoking cessation counselling provided by midwives to
Dutch pregnant women (not been pregnant more than twice) and their partners.34 The
response rate among chairs of the regional networks of midwives was low at 24%. Four (of
12) provinces with 42 practices including 118 midwives were randomly assigned to the
experimental or control condition following matching of provinces by location and level of
urbanisation. Women were nested within midwife practice; practices were nested within four
provinces. Provinces were used as the unit of randomisation to the experimental and control
conditions. Women were recruited to the study at approximately 12-weeks’ gestation
(February to December 1996). The study was sufficiently powered based on an estimated
quit rate of 20% in the experimental condition and 5% in the control condition.
Midwives in the experimental group provided brief health counselling, self-help materials on
smoking cessation during pregnancy and early postpartum, a raising awareness video
(piloted) and a partner booklet. Controls received routine care. In the experimental group
32
midwives talked twice to their clients about smoking: (a) during their first scheduled contact
when they were approximately 3 months pregnant and (b) at about 8 months during their
regularly scheduled consultations. Midwives dedicated approximately 10 minutes of their
consultation to cessation counselling and they were offered three hours of training.
A total of 318 smokers were included in the study, 141 in the experimental condition and
177 in the control condition. At the second post-test 85.1% and 88.7% of the two groups
remained eligible for inclusion. The majority of women were lower educated although no
further details of how education level was measured were reported. At baseline the
percentage of participants with high level of education was similar between the two groups
(15%) but varied for medium education (38% for experimental and 24% for control) and
varied for low education (47% for experimental and 62% for control).
Study authors report that biochemical validation results were unusable due to problems
experienced in their transportation. Multi-level analysis with patients nested within practices
revealed significant differences between both conditions at 6 weeks post-intervention and 6
weeks postpartum using intention-to-treat analysis. When all dropouts were included as
smokers 19% of the experimental group reported 7-day abstinence compared to 7% of the
control group at 6 weeks post-intervention, and 21% and 12%, respectively, at 6 weeks
postpartum. For continuous abstinence (defined as reporting 7-day abstinence at both time
points) these percentages were 12% in the experimental group and 3% in the control group.
When dropouts were excluded from the analysis these percentages for the experimental
group and the control group were not markedly different. The intervention had no effect on
the smoking behaviour of the partner as reported by the pregnant women (72% of partners
smoked). Having a higher education level was predictive of quit attempts but not 7-day point
prevalence abstinence at 6 weeks post-intervention and was predictive of quit attempts and
7-day point prevalence at 6 weeks postpartum using intention-to-treat analysis. The results of
this study, in general, were associated with a negative equity impact.
A population-level study ‘Inter99’ was an individual face-to-face lifestyle counselling
intervention31 which aimed to prevent cardiovascular disease, type-2-diabetes (and other
lifestyle related diseases) by non-pharmacological intervention. The study focused on
changes in smoking, diet and physical activity. There was no study selection based on
motivation to quit or in risk of disease (all smokers were regarded to be at high risk). A
random sample comprising 13,016 individuals was drawn for the intervention from 61,301
persons aged 30 to 60 years from a defined area of the suburbs of Copenhagen. The sample
33
was a priori randomised into two groups comprising 90% (group A = high intensity
intervention, n = 11,708) and 10% (group B = low intensity intervention, n=1,308),
respectively. From the remaining 48,285 individuals in the study population, a random
sample of 5264 persons (group C=control group), equally distributed on age and sex, was
drawn.
This paper is based on adults who reported to be daily smokers at baseline. Thirty six percent
of the participants in the intervention groups A (n=2168) and B (n=240) reported to be daily
smokers. In the control group C, 39% (n=1276) reported to be daily smokers at baseline.
Daily smokers in high-intensity group A and low intensity group B received the same
lifestyle consultation. All daily smokers in high-intensity group A were offered participation
in a smoking cessation group at baseline, 1-year and 3-year follow up. Daily smokers in low
intensity group B were not offered smoking cessation in groups. At baseline 22.5% of the
daily smokers in group A accepted participation in smoking cessation groups.
When baseline differences between the groups were adjusted for, the difference in self-
reported point abstinence group A (OR: 2.19; 95% CI: 1.7 to 2.8; p=0.001) and group B
(OR: 1.71; 95% CI: 1.1 to 2.6; p=0.016) were significant when compared separately with
group C. The validated point abstinence rates at 5-year follow-up were 11.6% in group A
and 9.2% in group B. Smoking status could not be validated in group C. Logistic analyses,
adjusted for baseline differences, showed a significant effect of the intervention, even when
validated point abstinence in groups AB was compared with the self-reported point
abstinence in group C (OR: 1.38; 95% CI: 1.1–1.8; p=0.014). Vocational training predicted
abstinence at 5-year follow-up in the combined intervention groups AB: OR 1.77 (95% CI:
1.2 to 2.6, p=0.003). In summary, this population-level study was associated with a negative
equity impact because having vocational training (compared to not having vocational
training) was predictive of validated point abstinence at 5-year follow-up in the combined
intervention groups.
A RCT assessed the effectiveness of a computer-tailored self-help smoking cessation
intervention for male smokers which was conducted as a sub-cohort of the Dutch-Belgium
lung cancer screening trial (NELSON trial).32 In the NELSON trial, all current smokers were
randomised to receive a standard brochure or a tailored questionnaire necessary to provide
individualised smoking cessation information. All smoking male participants who were
included during the first recruitment round (n = 4687) were selected. From this population,
two random samples were selected from those who received the standard brochure (n = 642)
34
(brochure group) and those who received the tailored questionnaire (n = 642) (tailored
information group). Male smokers in the screen arm who received a positive screening result
were excluded. A second questionnaire that measured smoking behaviour was sent to both
samples of male smokers (n = 1284) 2.2 years after randomisation.
Eighty-five per cent (546/642) of the standard brochure group and 84% (538/642) of the
tailored questionnaire responded to both the first and second questionnaire. The median age
in both groups was 57 years and they smoked on average 18 cigarettes a day for 38 years. A
large proportion of the participants – 47.6% (301/633) of the brochure group and 48.8%
(309/633) of the tailored information group – were classed as ‘lower educated’ (primary,
lower secondary general or lower vocational education).
Twenty-three percent of the male smokers in the tailored information group returned a
completed questionnaire and received the tailored advice. Prolonged smoking abstinence
was slightly, but not significantly, lower among the tailored information group (12.5%)
compared with the brochure group (15.6%) (OR = 0.77 (95%-CI: 0.56–1.06) as was
continued smoking abstinence (OR=0.78; 95% CI: 0.56 to 1.07). Participants in the tailored
information group had to complete an individual assessment before the smoking cessation
advice could be tailored and send out.
Multivariate analysis showed that those who were higher educated and motivated to quit
smoking were more likely to quit smoking at follow-up. The majority of the respondents did
not recall whether and which smoking cessation intervention they had received at
randomisation after two years of follow-up. The low percentage participants who actually
received the tailored advice limited the impact of the intervention. The study authors argue
that the overall quit rate amongst lung cancer screening participants (14%) was higher than
quit rates in the general population. This study was associated with a negative equity impact,
with a standard brochure being equally effective as tailored cessation advice.
35
Summary of behavioural interventions.
Five behavioural interventions for smoking cessation were included, four studies were
smoking cessation alone and one study incorporated smoking cessation advice into lifestyle
counselling. Only the lifestyle counselling intervention included a national sample from the
general population, two studies focussed on pregnant women, one intervention included only
participants with Crohn’s disease and one intervention included only men screened for lung
cancer. Four of the interventions used education as a measure of SES and in one study the
measure was not reported.30 Follow-up in the two interventions during pregnancy was only
until 6-weeks postpartum. The intervention in participants with Crohn’s disease followed
participants for one year, the lifestyle intervention followed participants for five years and
the lung cancer screening followed participants for two years. The Crohn’s disease and
lifestyle interventions included biochemical validation of smoking status.
In three of the interventions with a control group the intervention was effective in terms of
quitting smoking. Fifty-nine (12%) of participants with Crohn’s disease remained abstinent
for more than one year. None of the five behavioural interventions were associated with a
positive equity impact: four interventions were ‘negative’ with higher SES associated with
higher quit rates; one intervention was ‘neutral’.
3.4 Pharmacological interventions
One pharmacological intervention was included. A cohort study followed 1,516 smokers
who were treated at a specialised smoking cessation clinic in a university teaching hospital in
Barcelona, Spain between 1995 and 2001.35 Patients were offered one of a range of
cessation products and were followed for a year after their treatment ended, with a final
survey administered in 2003, a mean follow-up period of 52 months. Follow-up visits were
every 2 weeks during the first 2 months, with control visits at 3, 6, and 12 months.
During the study period 2,123 smokers received treatment for smoking cessation (70.0%
with nicotine patch, 13.5% nicotine gum, 6.3% patch plus gum, 5.3% anxiolytics, 3.6%
antidepressants, and 0.6% antidepressants plus some type of nicotine replacement therapy).
At final survey 1,516 (71.4%) patients of the 2,123 patients initially treated were followed-
up and analyses were based on these completers. Eighteen percent of men and 27% of
women were classified in social classes’ I–II, and 18% of men and 32% of women had a
university degree.
36
The study found that among both men and women, lower SES (whether measured by social
class or education) was associated with a higher rate of relapse. This association persisted
after adjustment for confounders and despite motivation to quit being equal among all social
groups. Both men and women in affluent social classes or with higher educational levels had
a higher probability of abstinence at 1 year and 8 years. Overall abstinence probability was
0.412 (95% CI 0.387 to 0.437) at 1-year and 0.277 (95% CI 0.254 to 0.301) at 8 years. Men
and women in social classes IV–V had significant hazard ratios of relapse after 8 years
follow-up (men: 1.36, 95% CI 1.07 to 1.72; women: 1.60, 95% CI 1.24 to 2.06), as
compared with patients in social classes I–II. The same independent effect was observed for
education: men and women with primary or less than primary education had higher hazard
ratios of relapse (men: 1.75, 95% CI 1.35 to 2.25; women: 1.92, 95% CI 1.51 to 2.46), as
compared with patients with a university degree.
In summary, patients of lower SES were at higher risk of relapse at 8 year follow-up after a
smoking cessation intervention based in a clinical setting (negative equity). However, during
this lengthy follow-up period it is possible that changing tobacco control policies and social
perceptions of smoking also influenced study outcomes.
3.5 Brief interventions
One brief intervention was included. An RCT set in Turkey36 randomly assigned mothers to
a smoking cessation intervention either aimed at their children’s health (n=111) or their own
health (n=131), or to a control group receiving no smoking cessation advice (n=121). The
trial was set in a well-child baby clinic in a large urban children’s hospital. The target
population consisted of mothers who accompanied a child (<16 years) to the hospital for a
healthcare visit for any primary complaint, or a well-child examination in 2003.
Three hundred and seventy-five (of 380) mothers consented to the intervention. In each of
the intervention groups a nurse gave the mothers information about health risks of smoking
for 10 minutes. In the child intervention group, risks to children’s health were explained. In
the mother intervention group, the risk of tobacco to the mother’s own health was discussed.
A written document about how to quit smoking was provided to both intervention groups.
The control group received only general personal health information. Low-income families
were defined as those who had a monthly income of less than 250 US dollars. 90% of them
had government health insurance, whereas 10% of them did not have any health insurance.
37
At six month follow-up 363 participants completed a questionnaire by telephone. At baseline
50.5%, 47.3% and 53.7% of the child intervention, mother intervention and control had
monthly income of less than 250 US dollars, respectively. The percentage reporting quitting
smoking was 24.3%, 13% and 0.8% of the child intervention, mother intervention and
control at six months respectively, and the three groups were statistically significantly
different from each other. When the rates of smoking cessation were controlled for monthly
family income there were statistically significant differences for both income levels. The
percentage reporting quitting smoking was 25%, 8.1% and 1.5% of the child intervention,
mother intervention and control at six months respectively for ‘low income’ and 23.6%,
17.4% and 0% of the child intervention, mother intervention and control at six months
respectively for ‘high income’.
Family income was an independent factor significantly influencing smoking location change
and post-intervention knowledge, but not smoking cessation. Location change was not
defined within the paper. Higher income families had less location change than lower
income families but greater improvement in knowledge scores at six months follow-up.
In summary, this study of a brief counselling intervention provided by nurses to mothers that
focussed on either risk to the child or risk to the mother produced significantly higher rates
of smoking cessation compared to control. The intervention focusing on risk of smoking to
the child produced the greatest rates of smoking cessation. Income level did not appear to
influence smoking cessation (neutral equity impact).
3.6 Mass media – Quitlines and Quit & Win campaigns
Two observational cohort studies which had an element of mass media were included: one
study of a telephone quitline and one study of a Quit & Win campaign. It was unclear how
representative either of the study samples was and so it was also unclear how generalisable
the study results are. Both studies had high levels of attrition and in the case of the Quit &
Win intervention results from seven years post campaign might not be attributable to the
actual campaign.
An English study37 evaluated the impact of a telephone helpline (Quitline) with additional
support (written information) on callers who used the service during a mass media campaign
which consisted of a 3-month TV and advertising campaign supported by advertorials
(adverts that look like editorial) in women's magazines. The television advertisements were
targeted at young smokers (aged 16-24 years) and aimed to challenge their reasons for
38
smoking and provide them with reasons to quit. In contrast to previous campaigns, the TV
adverts adopted a hard hitting testimonial approach. The radio and magazine adverts were
aimed at a slightly wider audience and were intended to provide support and encouragement
to those who want to quit. All adverts included the free phone Quitline number.
Three thousand and nineteen of 18,873 log sheets were randomly selected and compared
with all smokers in the general population in England. Quitline callers were more likely to be
women, in the age groups 25-34 or 35-44 years, to come from households with children
under the age of 16 years, and to be heavy smokers (smoke 20 or more cigarettes a day). Of
6038 callers who had left telephone numbers to be contacted, 730 were follow-up at one year
(12%) which represented a relatively small number of the initial sample.
Compared with callers at baseline, women, those aged 35 and over, those with moderate
consumption levels (10-19 cigarettes a day), and more long-term smokers were over-
represented in the one year recall sample. Quitline received around half a million calls in the
course of one year, representing 4.2% of the total population of adult smokers in England.
At one year the social class profile of callers to the helpline reflected the social class profile
of all adult smokers; 63% of the sample were of manual occupations or unemployed
compared with 61% of the adult smoker population. At one year 22% (95% CI; 18.4% to
25.6%) of smokers reported that they had stopped smoking. Assuming that those who
refused to take part in the one year follow up were continuing smokers and a further 20% of
reported successes would fail biochemical validation, this yielded an adjusted quit rate of
15.6% (95% CI 12.7% to 18.9%) at one year. Twenty-five percent (95% CI: 17.05 to 32.95)
of social classes ABC1 and 21% (95% CI: 13.52 to 28.48) social classes C2DE had stopped
smoking at one year but this difference was not significant. Thus, the equity impact in
relation to quit rates was neutral.
A Polish study38 aimed to determine the factors ‘allowing non-smoking’ during the two years
following a 5-year period of no smoking, in former participants of a Quit & Win contest. In
1996 the 2nd International Anti nicotine Campaign “Quit & Win” took place in Poland in the
region of Łódź (large cities) and Kalisz (small towns/rural). The paper describes the results
of a questionnaire conducted in 2003 with participants who self-reported in 1998 and 2001
that they were non-smokers since they participated in the Quit & Win contest in 1996.
The 2003 questionnaire was returned by 296 respondents (65.9%). In 2003, 284 of 296
respondents (92.6%) reported that they were still abstinent, during the two years following a
five year period of abstinence (seven years after the Quit & Win competition). There was a 39
significantly greater percentage of non-smoking adults with ‘other’ levels of education
(94.8%) compared with non-smoking adults with elementary education (84.2%) (p=0.004).
The questionnaires from 1998 and 2001 are not referenced within the paper and it is unclear
how representative the 2003 study was of the original study sample, with the potential for
selection bias (respondents to all/some of the surveys may have been more likely to be non-
smokers). The study showed that the maintenance of nicotine abstinence was associated with
having a higher than elementary education level and the equity impact was negative.
In summary, two observational cohorts were included of mass media to promote a quitline in
England and a Quit & Win campaign in Poland. One study was associated with a neutral
equity impact and the other study with a negative equity impact. Neither study reported on
reach although the differences in relapse/abstinence suggest that in the long-term, both
quitline and Quit & Win campaign were less effective in lower SES participants in the
longer-term.
A study39 investigated how seven smoking cessation quitlines across Europe were matched
to callers characteristics, including educational level. Between February 2005 and April
2006, 3,585 callers to seven European quitlines responded to the survey; the distribution of
educational level was: 29.3 percent low, 40.7 percent medium, and 30.0 percent high. While
the study was ineligible for inclusion in the systematic review because it did not report quit
rates, it is being described here as it gives some useful insights into why low SES smokers
might have lower quit rates using this type of support.
The findings for education level were not consistent across the seven quitlines and so results
were stratified by quitline. The only two significant findings were that in the Dutch quitline
low educated callers were more likely to receive information on pharmacotherapy (OR =
2.27; 95% CI = 1.46-3.51) while counsellors in the UK quitline were more likely to refer low
educated smokers to a health professional (most likely community smoking cessation
services) (OR = 2.68; 95% CI = 1.40-5.12). An additional finding was that, on average, the
duration of the call was longer with more highly educated callers (17.11 minutes) than with
callers who had a medium (14.72 minutes) or a low (14.38 minutes) education (F = 22.45; df
= 2; p < .001). There was no significant association between any other type of service and
the educational level of caller.
The survey found that the lower the education of the smoker, the shorter the call to the
quitline. Low educated callers were not receiving the more intense counselling support. The
study authors state that ‘quitline representatives justified the lengthier calls because it was
40
their impression that highly educated smokers requested more specific and detailed guidance
compared to the lower educated. Furthermore, it was their experience that higher educated
callers are more willing to expressing fears and ask more questions, making it easier for
them to be counselled.’ The study authors recommended tailoring of quitline service to
include less-educated smokers.
3.7 Text-based interventions
One RCT of a text-based intervention was included. A UK study examined predictors of use
of a text message system by analysing data collected prospectively from participants in the
intervention arm of ‘txt2stop’, an RCT of an automated, mobile phone text message-based
smoking cessation intervention to prevent smoking relapse.40 The text-based intervention
included motivational messages and behaviour change support; the messages also promoted
the use of the QUIT smoking cessation telephone helpline and NRT. There were 5,800
participants randomized in txt2stop (men and women aged 16 to 78 years, recruited from
London, UK from 2009 to 2010).
A previous paper41 of the main trial results reported that biochemically verified continuous
abstinence at 6 months was significantly increased in the txt2stop group (10·7% txt2stop vs
4·9% control, RR; 2·20, 95% CI: 1·80 to 2·68; p<0·0001). Similar results were obtained
when participants that were lost to follow-up were treated as smokers and when they were
excluded. There was no significant difference in abstinence between manual and nonmanual
participants.41
There were 2,915 participants randomised to the intervention group and this paper includes
only these intervention participants. Participants could text “crave” or “lapse” when they
experienced either; an automated system registered the time of the text message to the
nearest second. Participants in the intervention group could send and/or receive text
messages from a central automated system. Participants in the intervention group were asked
to set a quit date and received a series of text messages around the quit date and beyond to
support their quit attempt.
Following a quit attempt, women were more likely to relapse, but education or occupation
levels were not significantly different between those who relapsed (male and female) and
those who did not. Among those who relapsed, those who used the text lapse function were
41
statistically significantly more likely to be female, but education or occupation levels were
not significantly different versus those who relapsed but did not text.
One thousand one hundred and twenty one (38.5%) participants sent a lapse or crave
message to request support. In unadjusted analyses, those employed in a non-manual job and
those with more than 11 years of education were likely to have a shorter time to first lapse
text. In the fully adjusted model, having a non-manual occupation remained significant, but
education was no longer significant after accounting for other variables. Intervention
participants who had more than 11 years of education had a shorter time to first crave text in
both adjusted and unadjusted analyses.
In order to evaluate the relevance of time to first lapse and time to first crave text message as
outcomes, the relationship between these outcomes and smoking outcomes needs to be
assessed. Texting lapse within 3 days was strongly associated with texting crave within 3
days; similarly, texting lapse before 4 weeks was associated with texting crave before 4
weeks and self-reported quit at 4 weeks, and texting lapse at any point over the 6 months of
the trial was associated with texting crave and with self-report continuous abstinence or
biochemically verified cessation at 6 months. Those who texted crave before 4 weeks were
more likely to report being quit at 4 weeks, while those who texted lapse before 4 weeks
were more likely to report smoking at 4 weeks. However, those who reported texting crave
at any point over the trial were no more or less likely to self-report continuous abstinence or
biochemically verified cessation at 6 months.
In summary, the ‘txt2stop’intervention was associated with a neutral equity impact in
relation to quitting. Both education and occupation did not predict relapse following a quit
attempt. The paper only reports on the intervention group, of which 61.5% did not send any
text messages. The representativeness of this study sample is unclear and thus the
generalisability of the results to the general population is uncertain.
3.8 Internet-based interventions
Two internet-based interventions were included, both set in the UK: an uncontrolled before
and after study and an RCT. Recruitment rates to both studies were low and it is therefore
unlikely that the study samples were representative of the study populations with results that
could be generalisable on a national scale. Attrition rates were also high in the RCT.
A UK pilot study of StopAdvisor: an internet-based interactive smoking cessation
intervention, evaluated whether outcomes were affected by SES.42 Two hundred and four
42
adult daily smokers willing to make a serious quit attempt were included. ‘StopAdvisor’
recommends a structured quit plan and a variety of behaviour change techniques for smoking
cessation. A series of ‘tunnelled’ exposure to key messages (where the user has little
navigational control) and a variety of interactive menus provide tailored support for up to
one month before quitting through until one-month post-quit.
The sample was recruited via an advert placed on the UK Department of Health's smoking
cessation portal for 4 days in June 2011. The advert generated 1310 hits from which 228
people signed up, 217 completed baseline measures and a total of 204 smokers were
included. The study design was an uncontrolled pre and post intervention design with 8-
week follow-up. The effect on efficacy and satisfaction by SES was assessed by logistic
regression. The effect on website usage was assessed using t-tests. Self-reported data about
abstinence at follow-up was available for 169 (83%) participants of which 48 (24%)
participants self-reporting being abstinent, and 41 (20%) also provided samples for
biochemical verification. Eighty one (40%) participants completed satisfaction ratings.
At 8 weeks post-enrolment, 19.6% (95% CI: 14.1 to 25.1) of participants (40/204) were
abstinent as measured by self-report of at least 1 month of continuous abstinence collected at
2 months post enrolment and verified by saliva cotinine or anabasine. Participants viewed a
mean of 133.5 pages (median=71.5) during 6.4 log-ins (median=3). A majority of
respondents rated the website positively on each of the four satisfaction ratings measured by
helpfulness, personal relevance, recommendation and use in future. There was no evidence
of an effect of SES on cessation (OR=0.99, CI: 0.48–2.02), usage or satisfaction, using both
an occupational and an educational measure of SES (neutral equity impact).
An internet-based RCT43 compared tailored cessation advice report (based on social
cognitive theory and the perspectives on change model) with a non-tailored standardised
advice report. Tailoring was based on smoking-related beliefs, personal characteristics and
smoking patterns, self-efficacy and outcome expectations. Participants (n = 1758; 59.1% of
interested registrants) were visitors to the QUIT website between November 2008 and May
2010, who were based in the UK, aged 18 years or over and who smoked cigarettes or hand-
rolled tobacco. Smokers planning a quit attempt within the next 6 months and recent ex-
smokers were included.
The primary purpose of the tailored advice report was to encourage smokers who wished to
quit on their own. However, participants were reminded that they could obtain support from
the Quitline or from other local health professionals. Intervention group participants were
43
invited by e-mail to return to the website 4 weeks after receiving the tailored advice report to
complete a progress assessment questionnaire. Intervention participants received a tailored
progress report which encouraged and prevented relapse in quitters, reassessed the
expectations in non-quitters and analysed the relapse situation if applicable.
Due to slow recruitment the target sample size had 70% power to detect a difference in quit
rate of 8% versus 5%. Intention to treat analyses were carried out with those lost to follow-
up assumed to be smoking. Mean age was 38 years and 64% were female, smoking 18
cigarettes a day, and strongly motivated to quit. Ex-smokers comprised 15.6% of the sample.
Nicotine dependence was significantly higher in the control group at baseline. Follow-up
response rate at 6 months was 40.0% (351 of 877) in the intervention group and 42.1% (371
of 881) in the control group, and these did not differ significantly.
The intervention group did not differ from the control group on self-reported three month
prolonged abstinence (9.1% versus 9.3%; OR = 1.02, 95% CI: 0.73 to 1.42) or on any of the
secondary outcomes (one month prolonged abstinence, 7-day and 24-hour point prevalence
abstinence all collected at six months). There were no significant moderating effects of
baseline smoking status or deprivation on the intervention effect for any of these four
outcomes. The tailored internet-based intervention was not more effective than the non-
tailored intervention and was associated with a neutral equity impact.
In summary, two UK internet-based smoking cessation interventions in samples of motivated
smokers with three-months or less follow-up, were associated with a neutral equity impact.
One study did not have a comparison control group and the results of the RCT showed that
the tailored intervention was no more effective than the non-tailored control intervention. It
was unclear how representative or generalisable the interventions were.
44
4 DISCUSSION
The review presented in this report has systematically assessed the available evidence on the
impact of individual cessation support interventions on socioeconomic inequalities in adult
smoking. Twenty-seven studies were included which have evaluated the impact of individual
cessation support interventions on quit rates in adults by SES, measured by a range of
indicators including income, occupation, education and area deprivation. Before presenting
the main review findings it is important to consider the strengths and limitations of both the
review and the available evidence.
4.1 Strengths and limitations of the review
Considerable attempts were made to include published and ‘in press’ studies as well as ‘grey
literature’. The search included searching key reviews, handsearching to identify ‘in press’
articles from four key journals, and contacting European tobacco control experts and asking
them to provide any other relevant peer reviewed articles (non-English language) or grey
literature. However, it is possible that some relevant studies might have been missed which
had not been published in the peer reviewed literature and/or which were not published in
English. In addition a pragmatic decision was taken to exclude studies published prior to
1995.
The inclusion criteria for this systematic review were intentionally wide in order to gather
the broadest possible range of evidence that could inform equity-orientated policies. Any
type of individual level smoking cessation intervention, of any length of follow-up was
included as long as the study took place in a European country. Studies were included which
did or did not have a specific equity focus. A further inclusion criterion was that a measure
of SES had to be reported within the abstract of a paper. It is possible that papers which
undertook analyses by SES were not included because these analyses were not mentioned in
their abstract. Socioeconomic variables included income, education, occupational social
class, area-level socio-economic deprivation and subjective social status. These SES
variables do not encompass all disadvantaged people, who might have been captured by
including other measures of SES, such as ethnicity. In addition, the socioeconomic
conditions captured by SES measures, such as income, education and occupation, can vary
widely between countries across Europe.
Studies targeted at low SES sub-populations that did not report differential smoking-related
outcomes for at least two socio-economic groups were excluded because, although they can
45
potentially provide useful information about uptake and impact within specific lower SES
groups, they cannot provide information about any equity impact.
We developed a new quality assessment tool, an adapted version of previously used tools,
which was designed to enable us to assess the quality of the diverse range of types of
interventions and study designs encompassed in the included studies. Given the variations in
study methodologies, intervention types and outcome measures, the results were presented in
the form of a narrative synthesis and according to intervention type. In order to provide a
simple basis for comparing the methodology of each study, a typology of study designs was
devised.
We also adapted a model to assess the equity impact of each intervention/policy. A study
was classed as associated with a positive equity impact when low SES groups, such as lower
occupational groups, those with a lower level of educational attainment, the less affluent or
those living in more deprived areas, had relatively higher quit rates. A study was classed as
associated with a neutral equity impact when there was no social gradient in the quit rates by
SES. This could mean that both lower and higher SES groups benefitted equally from the
cessation intervention or that the intervention was not effective in any SES group. A study
was classed as associated with a negative equity impact when high SES groups had relatively
higher quit rates.
46
4.2 Strengths and limitations of the available evidence
A relatively small number of studies (27) were identified and included within this systematic
review. The majority of the evidence concerns the effectiveness of combined behavioural
plus pharmacological interventions (15). A relatively small number of studies were included
for other types of interventions including behavioural only (5); pharmacological only (1);
brief interventions (1); mass media campaigns (2); text based interventions (1) and internet
based interventions (2).
There was considerable variation in the type of designs and quality of the studies: fourteen
studies were population-based observational studies, seven studies were intervention-based
observational studies and eight studies were intervention-based experimental studies. The
majority (16) of the studies were based in the UK and these were mainly evaluating the UK
NHS SSS. Two studies each were from Denmark, France, the Netherlands and Poland. One
study each was from Israel, Spain and Turkey. The majority of study samples were derived
from the general population, two studies were in pregnant women, one in mothers, one in
participants with Crohn’s disease and one in men at high risk for CHD. Some of the study
populations were motivated to quit and some were smokers with a history of relapse.
Settings included hospitals, community, pharmacies, and general practices. Two of the 27
interventions included smoking cessation advice as part of lifestyle counselling.
The summary of the equity impact of policies/interventions was based only on quit rates.
Other smoking-related outcome measures were not considered. In addition several of the UK
NHS SSS studies also looked at the relative reach of services. Thus, the overall equity effect
which combined reach with quit rates may be different and this is addressed in our
population-level intervention review. In one case it was not possible to assess the equity
impact and the equity impact of this study was classed as ‘unclear’.
4.3 Main findings and conclusions
There were 27 studies which reported quitting by SES included in the review. The initial
electronic search produced 12,605 references, of which 20 studies met the inclusion criteria.
A further five studies were identified through hand-searching, searching of grey literature,
key reviews and contacting experts. An update of the electronic searches and journal
handsearching was carried out in January 2013 which identified a further two relevant
studies.
47
All the literature was European due to the inclusion criteria, with the majority of studies
being carried out in the UK. Most of the British studies assessed the impact of the NHS stop
smoking services. The majority of the evidence concerns the effectiveness of combined
behavioural plus pharmacological interventions (15). The other types of
interventions/policies included were: behavioural only (5); pharmacological only (1); brief
interventions (1); mass media campaigns (2); text based interventions (1) and internet based
interventions (2).
4.4 Equity impact
Out of the 27 included interventions the equity impact was: 10 ‘neutral’ interventions, 16
‘negative’ interventions and 1 ‘unclear’ intervention (Appendices G and H). It is important
to point out that the 10 ‘neutral’ studies indicate that these interventions/policies have
benefits for adults across all SES groups.
The bulk of the evidence is of behavioural and pharmacological interventions (15) which
showed mostly negative results for equity (10), with 4 ‘neutral’ studies and 1‘unclear’ study.
Eleven of these fifteen studies were of the UK NHS SSS. There were too few studies in the
other types of intervention categories to draw any conclusions regarding the equity impact.
Although there were five behavioural interventions the study populations were too disparate
to permit merging of results or produce any meaningful summary.
5 CONCLUSIONS
Twenty-seven studies were included in this systematic review of the effectiveness of
individual cessation support interventions to reduce socio-economic inequalities in smoking
among adults. The majority of the studies assessed interventions which combined
behavioural and pharmacological elements.
Among the included interventions most (59%) had a negative equity impact and just over a
third (37%) had a neutral equity impact. It is important to point out that most of the
interventions associated with a neutral equity effect had equal benefits for all SES groups. It
is also important to point out that the equity impact in this review related only to the impact
on quit rates. There was evidence from several of the UK NHS SSS studies that when
cessation services, which use a combination of behavioural and pharmacological support, are
targeted at low SES smokers that a higher relative uptake (reach) of services can more than
48
compensate for the relatively lower quit rate in low SES groups. Thus, the overall equity
impact in terms of reduced smoking prevalence by SES can be positive. However, it is clear
from the studies included in this review that untargeted smoking cessation interventions and
support in Europe may contribute to reducing smoking but are, on balance, likely to increase
inequalities smoking.
49
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54
7 APPENDICES7.1 APPENDIX A Search strategies: electronic searches,
handsearching and searching for grey literatureElectronic searches Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1946 to May 04 2012, search date 09/05/2012; also Ovid MEDLINE(R) 1946 to January week 3, 2013, search date 23/01/2013
1. smoking/2. smoking cessation/3. tobacco/4. "Tobacco Use Disorder"/5. nicotine/6. tobacco, smokeless/7. tobacco use, cessation/8. (smokers or smoker).ti,ab.9. cigar$.mp.10. smoking.ti,ab.11. or/1-1012. smoking cessation/13. tobacco use, cessation/14. tobacco use, cessation products/15. smoking/pc16. smoking/dt17. smoking/th18. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (ban or bans or prohibit$ or restrict$ or discourage$)).ti,ab.19. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (workplace or work place or work site or worksite)).ti,ab.20. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (public place$ or public space$ or public area$ or office$ or school$ or institution$)).ti,ab.21. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (legislat$ or government$ or authorit$ or law or laws or bylaw$ or byelaw$ or bye law$ or regulation$)).ti,ab.22. ((tobacco free or smoke free) adj3 (hospital or inpatient or outpatient or institution$)).ti,ab.23. ((tobacco-free or smoke-free) adj3 (facilit$ or zone$ or area$ or site$ or place$ or environment$ or air)).ti,ab.24. ((tobacco or smok$ or cigarette$) adj3 (campaign$ or advertis$ or advertiz$)).ti,ab.25. ((billboard$ or advertis$ or advertiz$ or sale or sales or sponsor$) adj3 (restrict$ or limit$ or ban or bans or prohibit$)).ti,ab.26. (tobacco control adj3 (program$ or initiative$ or policy or policies or intervention$ or activity or activities or framework)).ti,ab.27. ((smok$ or tobacco) adj (policy or policies or program$)).ti,ab.28. ((retailer$ or vendor$) adj3 (educat$ or surveillance$ or prosecut$ or legislat$)).ti,ab.29. test purchas$.ti,ab.30. voluntary agreement$.ti,ab.31. health warning$.ti,ab.32. ((tobacco or cigarette$) adj3 (tax or taxes or taxation or excise or duty free or duty paid or customs)).ti,ab.33. ((cigarette$ or tobacco) adj3 (packaging or packet$)).ti,ab.34. ((cigarette$ or tobacco) adj3 (marketing or marketed)).ti,ab.35. ((cigarette$ or tobacco) adj3 (price$ or pricing)).ti,ab.36. point of sale.ti,ab.
55
37. vending machine$.ti,ab.38. (trade adj (restrict$ or agreement$)).ti,ab.39. (contraband$ or smuggl$ or bootleg$ or cross border shopping).ti,ab.40. (tobacco control act or clean air or clean indoor air).ti,ab.41. ((reduce$ or prevent$) adj3 (environmental tobacco smoke or passive smok$ or secondhand smok$ or second hand smok$ or SHS)).ti,ab.42. ((population level or population based or population orientated or population oriented) adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.43. (community adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.44. ((sale or sales or retail$ or purchas$) adj3 (minors or teenage$ or underage$ or under-age$ or child$)).ti,ab.45. (youth access adj3 restrict$).ti,ab.46. (smoking cessation or cessation support).ti,ab.47. (smokefree or smoke-free or smoke free).ti,ab.48. ((stop$ or quit$ or reduc$ or give up or giving up) adj3 (cigarette$ or tobacco or smoking)).ti,ab.49. quit attempt$.ti,ab.50. tobacco quit.ti,ab.51. quit rate$.ti,ab.52. (quitline$ or quit line$ or quit-line$).ti,ab.53. ((smok$ or tobacco or nicotine or cigarette$) adj2 (abstinence or cessation)).ti,ab.54. or/12-5355. (socioeconomic or socio economic or socio-economic).ti,ab.56. inequalit$.ti,ab.57. depriv$.ti,ab.58. disadvantage$.ti,ab.59. educat$.ti,ab.60. (social adj (class$ or group$ or grade$ or context$ or status)).ti,ab.61. (employ$ or unemploy$).ti,ab.62. income.ti,ab.63. poverty.ti,ab.64. SES.ti,ab.65. demographic$.ti,ab.66. (uninsur$ or insur$).ti,ab.67. minorit$.ti,ab.68. poor.ti,ab.69. affluen$.ti,ab.70. equity.ti,ab.71. (underserved or under served or under-served).ti,ab.72. occupation$.ti,ab.73. (work site or worksite or work-site).ti,ab.74. (work place or workplace or work-place).ti,ab.75. (work force or workforce or work-force).ti,ab.76. (high risk or high-risk or at risk).ti,ab.77. (marginalised or marginalized).ti,ab.78. (social$ adj (disadvant$ or exclusion or excluded or depriv$)).ti,ab.79. exp socioeconomic factors/80. exp public assistance/81. exp social welfare/82. vulnerable populations/83. or/55-8284. 11 and 5485. 83 and 8486. limit 85 to (abstracts and english language and yr="1990 -Current")
56
Embase; Excerpta Medica Database Guide, 1980 to 2012 Week 18, search date 09/05/2012; also 1980 to 2013 week 3, search date 23/01/2013
1. smoking/2. smoking cessation/3. tobacco/4. nicotine/5. tobacco, smokeless/6. "smoking and smoking related phenomena"/7. cigarette smoking/8. cigarette smoke/9. tobacco smoke/10. (smokers or smoker).ti,ab.11. cigar$.mp.12. smoking.ti,ab.13. or/1-1214. smoking cessation program/15. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (ban or bans or prohibit$ or restrict$ or discourage$)).ti,ab.16. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (workplace or work place or work site or worksite)).ti,ab.17. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (public place$ or public space$ or public area$ or office$ or school$ or institution$)).ti,ab.18. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (legislat$ or government$ or authorit$ or law or laws or bylaw$ or byelaw$ or bye law$ or regulation$)).ti,ab.19. ((tobacco free or smoke free) adj3 (hospital or inpatient or outpatient or institution$)).ti,ab.20. ((tobacco-free or smoke-free) adj3 (facilit$ or zone$ or area$ or site$ or place$ or environment$ or air)).ti,ab.21. ((tobacco or smok$ or cigarette$) adj3 (campaign$ or advertis$ or advertiz$)).ti,ab.22. ((billboard$ or advertis$ or advertiz$ or sale or sales or sponsor$) adj3 (restrict$ or limit$ or ban or bans or prohibit$)).ti,ab.23. (tobacco control adj3 (program$ or initiative$ or policy or policies or intervention$ or activity or activities or framework)).ti,ab.24. ((smok$ or tobacco) adj (policy or policies or program$)).ti,ab.25. ((retailer$ or vendor$) adj3 (educat$ or surveillance$ or prosecut$ or legislat$)).ti,ab.26. test purchas$.ti,ab.27. voluntary agreement$.ti,ab.28. health warning$.ti,ab.29. ((tobacco or cigarette$) adj3 (tax or taxes or taxation or excise or duty free or duty paid or customs)).ti,ab.30. ((cigarette$ or tobacco) adj3 (packaging or packet$)).ti,ab.31. ((cigarette$ or tobacco) adj3 (marketing or marketed)).ti,ab.32. ((cigarette$ or tobacco) adj3 (price$ or pricing)).ti,ab.33. point of sale.ti,ab.34. vending machine$.ti,ab.35. (trade adj (restrict$ or agreement$)).ti,ab.36. (contraband$ or smuggl$ or bootleg$ or cross border shopping).ti,ab.37. (tobacco control act or clean air or clean indoor air).ti,ab.38. ((reduce$ or prevent$) adj3 (environmental tobacco smoke or passive smok$ or secondhand smok$ or second hand smok$ or SHS)).ti,ab.39. ((population level or population based or population orientated or population oriented) adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.40. (community adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.
57
41. ((sale or sales or retail$ or purchas$) adj3 (minors or teenage$ or underage$ or under-age$ or child$)).ti,ab.42. (youth access adj3 restrict$).ti,ab.43. (smoking cessation or cessation support).ti,ab.44. (smokefree or smoke-free or smoke free).ti,ab.45. ((stop$ or quit$ or reduc$ or give up or giving up) adj2 (cigarette$ or tobacco or smoking)).ti,ab.46. tobacco quit.ti,ab.47. quit attempt$.ti,ab.48. quit rate$.ti,ab.49. (quit line$ or quitline$ or quit-line$).ti,ab.50. ((smok$ or tobacco or nicotine or cigarette$) adj2 (abstinence or cessation)).ti,ab.51. or/14-5052. (socioeconomic or socio economic or socio-economic).ti,ab.53. inequalit$.ti,ab.54. depriv$.ti,ab.55. disadvantage$.ti,ab.56. educat$.ti,ab.57. (social adj (class$ or group$ or grade$ or context$ or status)).ti,ab.58. (employ$ or unemploy$).ti,ab.59. income.ti,ab.60. poverty.ti,ab.61. SES.ti,ab.62. demographic$.ti,ab.63. (uninsur$ or insur$).ti,ab.64. minorit$.ti,ab.65. poor.ti,ab.66. affluen$.ti,ab.67. equity.ti,ab.68. (underserved or under served or under-served).ti,ab.69. occupation$.ti,ab.70. (work site or worksite or work-site).ti,ab.71. (work place or workplace or work-place).ti,ab.72. (work force or workforce or work-force).ti,ab.73. (high risk or high-risk or at risk).ti,ab.74. (marginalised or marginalized).ti,ab.75. (social$ adj (disadvant$ or exclusion or excluded or depriv$)).ti,ab.76. exp socioeconomics/77. public assistance/78. welfare, social/79. exp social status/80. social security/81. vulnerable population/82. or/52-8183. 13 and 5184. 82 and 8385. limit 84 to (abstracts and english language and yr="1990 -Current")
58
PsycInfo (OVID) 1987 to May Week 1 2012, search date 10/05/2012; also 1987 to January week 3 2013, search date 23/01/2013
1. exp tobacco smoking/2. exp smoking cessation/3. nicotine/4. tobacco, smokeless/5. (smokers or smoker).ti,ab.6. tobacco.ti,ab.7. nicotine.ti,ab.8. cigar$.mp.9. smoking.ti,ab.10. or/1-911. exp smoking cessation/12. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (ban or bans or prohibit$ or restrict$ or discourage$)).ti,ab.13. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (workplace or work place or work site or worksite)).ti,ab.14. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (public place$ or public space$ or public area$ or office$ or school$ or institution$)).ti,ab.15. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (legislat$ or government$ or authorit$ or law or laws or bylaw$ or byelaw$ or bye law$ or regulation$)).ti,ab.16. ((tobacco free or smoke free) adj3 (hospital or inpatient or outpatient or institution$)).ti,ab.17. ((tobacco-free or smoke-free) adj3 (facilit$ or zone$ or area$ or site$ or place$ or environment$ or air)).ti,ab.18. ((tobacco or smok$ or cigarette$) adj3 (campaign$ or advertis$ or advertiz$)).ti,ab.19. ((billboard$ or advertis$ or advertiz$ or sale or sales or sponsor$) adj3 (restrict$ or limit$ or ban or bans or prohibit$)).ti,ab.20. (tobacco control adj3 (program$ or initiative$ or policy or policies or intervention$ or activity or activities or framework)).ti,ab.21. ((smok$ or tobacco) adj (policy or policies or program$)).ti,ab.22. ((retailer$ or vendor$) adj3 (educat$ or surveillance$ or prosecut$ or legislat$)).ti,ab.23. test purchas$.ti,ab.24. voluntary agreement$.ti,ab.25. health warning$.ti,ab.26. ((tobacco or cigarette$) adj3 (tax or taxes or taxation or excise or duty free or duty paid or customs)).ti,ab.27. ((cigarette$ or tobacco) adj3 (packaging or packet$)).ti,ab.28. ((cigarette$ or tobacco) adj3 (marketing or marketed)).ti,ab.29. ((cigarette$ or tobacco) adj3 (price$ or pricing)).ti,ab.30. point of sale.ti,ab.31. vending machine$.ti,ab.32. (trade adj (restrict$ or agreement$)).ti,ab.33. (contraband$ or smuggl$ or bootleg$ or cross border shopping).ti,ab.34. (tobacco control act or clean air or clean indoor air).ti,ab.35. ((reduce$ or prevent$) adj3 (environmental tobacco smoke or passive smok$ or secondhand smok$ or second hand smok$ or SHS)).ti,ab.36. ((population level or population based or population orientated or population oriented) adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.37. (community adj3 (intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.38. ((sale or sales or retail$ or purchas$) adj3 (minors or teenage$ or underage$ or under-age$ or child$)).ti,ab.39. (youth access adj3 restrict$).ti,ab.40. (smoking cessation or cessation support).ti,ab.
59
41. (smokefree or smoke-free or smoke free).ti,ab.42. ((stop$ or quit$ or reduc$ or give up or giving up) adj3 (cigarette$ or tobacco or smoking)).ti,ab.43. quit attempt$.ti,ab.44. tobacco quit.ti,ab.45. quit rate$.ti,ab.46. (quitline$ or quit line$ or quit-line$).ti,ab.47. ((smok$ or tobacco or nicotine or cigarette$) adj2 (abstinence or cessation)).ti,ab.48. or/11-4749. (socioeconomic or socio economic or socio-economic).ti,ab.50. inequalit$.ti,ab.51. depriv$.ti,ab.52. disadvantage$.ti,ab.53. educat$.ti,ab.54. (social adj (class$ or group$ or grade$ or context$ or status)).ti,ab.55. (employ$ or unemploy$).ti,ab.56. income.ti,ab.57. poverty.ti,ab.58. SES.ti,ab.59. demographic$.ti,ab.60. (uninsur$ or insur$).ti,ab.61. minorit$.ti,ab.62. poor.ti,ab.63. affluen$.ti,ab.64. equity.ti,ab.65. (underserved or under served or under-served).ti,ab.66. occupation$.ti,ab.67. (work site or worksite or work-site).ti,ab.68. (work place or workplace or work-place).ti,ab.69. (work force or workforce or work-force).ti,ab.70. (high risk or high-risk or at risk).ti,ab.71. (marginalised or marginalized).ti,ab.72. (social$ adj (disadvant$ or exclusion or excluded or depriv$)).ti,ab.73. exp socioeconomic status/74. poverty/75. disadvantaged/76. or/49-7577. 10 and 4878. 76 and 7779. limit 78 to (english language and abstracts and yr="1990 - 2012")
60
Cochrane Library 2012 (Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects; Cochrane Central Register of Controlled Trials; Health Technology Assessment Database), search date 10/05/12; also January 2012 to December 2012, search date 29/04/13.
#1 MeSH descriptor Smoking, this term only#2 MeSH descriptor Tobacco Use Cessation explode all trees#3 MeSH descriptor Tobacco explode all trees#4 MeSH descriptor Tobacco Use Disorder, this term only#5 MeSH descriptor Nicotine, this term only#6 (smoking or smokers or smoker or tobacco or cigar* or nicotine)#7 (#1 OR #2 OR #3 OR #4 OR #5 OR #6)#8 (smok* or anti-smok* or tobacco or cigarette*) near3 (ban or bans or prohibit* or restrict* or discourage*)#9 (smok* or anti-smok* or tobacco or cigarette*) near3 (workplace or work place or worksite)#10 (smok* or anti-smok* or tobacco or cigarette*) near3 (public next place*)#11 (smok* or anti-smok* or tobacco or cigarette*) near3 (public next space)#12 (smok* or anti-smok* or tobacco or cigarette*) near3 (public next area*)#13 (smok* or anti-smok* or tobacco or cigarette*) near3 (office* or school* or institution*)#14 (smok* or anti-smok* or tobacco or cigarette*) near3 (legislat* or government* or authorit* or law or laws or bylaw* or byelaw* or bye-law* or regulation*)#15 (tobacco-free or smoke-free) near3 (hospital* or inpatient* or outpatient* or institution*)#16 (tobacco-free or smoke-free) near3 (facility* or zone* or area* or site* or place* or environment* or air)#17 (tobacco or smok* or cigarette*) near3 (campaign* or advertis* or advertiz*)#18 (billboard* or advertis* or advertiz* or sale or sales or sponsor*) near3 (restrict* or limit* or ban or bans or prohibit*)#19 (tobacco next control) near3 (program* or initiative* or policy or policies or intervention* or activity or activities or framework)#20 (smok* or tobacco) next (policy or policies or program*)#21 (retailer* or vendor*) near3 (educat* or surveillance or prosecut* or legslat*)#22 test next purchas* in All Fields or (voluntary next agreement*)#23 (sale or sales or retail* or purchas*) near3 (minors or teenage* or underage* or under-age* or child*)#24 (youth near3 access) near3 restrict*#25 health next warning*#26 (tobacco or cigarette*) near3 (tax or taxes or taxation or excise or duty-free or duty-paid or customs)#27 (cigarette* or tobacco) near3 (packaging or packet*)#28 (cigarette* or tobacco) near3 (marketing or marketed)#29 (cigarette* or tobacco) near3 (price* or pricing)#30 "point of sale"#31 vending next machine*#32 trade near3 (restrict* or agreement*)#33 contraband* or smuggl* or bootleg* or (cross-border next shopping)#34 "tobacco control act" or "clean air" or "clean indoor air"#35 reduce* near3 "environmental tobacco smoke" or (passive next smok*) or (secondhand next smok*) or (second next hand next smok*) or SHS#36 prevent* near3 "environmental tobacco smoke" or (passive next smok*) or (secondhand next smok*) or (second next hand next smok*) or SHS#37 (population next level) near3 (intervention* or prevention or policy or policies or program* or project*)#38 (population next based) near3 (intervention* or prevention or policy or policies or program* or project*)#39 (population next orientated) near3 (intervention* or prevention or policy or policies or program* or project*)
61
#40 (community next level) near3 (intervention* or prevention or policy or policies or program* or project*)#41 (community next based) near3 (intervention* or prevention or policy or policies or program* or project*)#42 (community next orientated) near3 (intervention* or prevention or policy or policies or program* or project*)#43 (community next oriented) near3 (intervention* or prevention or policy or policies or program* or project*)#44 smoking next cessation or cessation next support#45 smokefree or smoke-free or smoke next free#46 (stop* or quit* or reduc* or give next up or giving next up) near3 (cigarette* or tobacco or smoking)#47 quit next attempt*#48 tobacco next quit#49 quit next rate*#50 quitline* or quit-line* or quit next line*#51 (smok* or tobacco or nicotine or cigarette*) near2 (abstinence or cessation)#52 (#8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51)#53 socioeconomic or socio next economic or socio-economic#54 inequalit*#55 depriv*#56 disadvantage*#57 educat*#58 social next (class* or group* or grade* or context* or status)#59 employ* or unemploy*#60 income#61 poverty#62 SES#63 demographic*#64 insur* or uninsur*#65 minorit*#66 poor#67 affluen*#68 equity#69 underserved or under next served or under-served#70 occupation*#71 work next site or worksite or work-site#72 work next place or workplace or work-place#73 work next force or workforce or work-force#74 high next risk or high-risk or at next risk#75 marginalised or marginalized#76 social* next (disadvant* or exclusion or excluded or depriv*)#77 MeSH descriptor Socioeconomic Factors explode all trees#78 MeSH descriptor Public Assistance, this term only#79 MeSH descriptor Social Welfare, this term only#80 MeSH descriptor Vulnerable Populations, this term only#81 (#53 OR #54 OR #55 OR #56 OR #57 OR #58 OR #59 OR #60 OR #61 OR #62 OR #63 OR #64 OR #65 OR #66 OR #67 OR #68 OR #69 OR #70 OR #71 OR #72 OR #73 OR #74 OR #75 OR #76 OR #77 OR #78 OR #79 OR #80)#82 (#7 AND #52)#83 (#81 and #82), from 1990 to 2012
62
Science Citation Index Expanded, Social Sciences Citation Index, Conference Proceedings Citation Index (Science, and Social Science & Humanities), in Web of Science hosted on ISI Web of Knowledge, search date 10/05/12; also 1st May 2012 to 31st December 2012, search date 29/04/13.
(TS=(smoking or smokers or smoker or tobacco or cigar* or nicotine) AND TS=(abstinence or cessation or quit*) AND TS=(socioeconomic or socio economic or socio-economic)) AND Language=(English), Timespan=1990-2012
BIOSIS Previews hosted on ISI Web of Knowledge, search date 10/05/12
(TS=(smoking or smokers or smoker or tobacco or cigar* or nicotine) AND TS=(abstinence or cessation or quit*) AND TS=(socioeconomic or socio economic or socio-economic)) AND Language=(English), Timespan=1990-2012; also January 2012 to December 2012, search date 29/04/13.
CINAHL Plus (EBSCO host) search date 10/05/12; also 1st May 2012 to 31st December 2012, search date 29/04/13.
S8 S5 AND S9, Limiters - Published Date from: 19900101-20121231S9 S6 OR S7 OR S8 S8 TX social* W1 (disadvantage* or exclusion or excluded or depriv*)S7 TX social W1 (class* or group* or grade* or context* or status)S6 (MH "Socioeconomic Factors") OR "SOCIOECONOMIC" OR (MH "Poverty") OR "POVERTY" OR "EQUITY"S5 S1 OR S2 OR S3 OR S4S4 TX (stop* or quit* or reduc* or give up or giving up) W3 (cigarette* or tobacco or smoking)S3 TX Smoking W1 cessationS2 (MH "Tobacco, Smokeless") OR (MH "Tobacco Abuse Control (Saba CCC)") OR (MH "Risk Control: Tobacco Use (Iowa NOC)") OR (MH "Passive Smoking")S1 (MH "Smoking Cessation Programs") OR (MH "Smoking Cessation") OR (MH "Smoking Cessation Assistance (Iowa NIC)")
ERIC (EBSCO Host) search date 11/05/12; also 1st May 2012 to 31st December 2012, search date 29/04/13.
S10 S8 and S9S9 S4 or S5 or S6 or S7S8 S1 or S2 or S3S7 AB Socioeconomic OR AB Poverty OR AB equityS6 ((DE "Socioeconomic Background" OR DE "Socioeconomic Influences" OR DE "Socioeconomic Status") OR (DE "Poverty")) AND (DE "Disadvantaged Environment" OR DE "Economically Disadvantaged" OR DE "Socioeconomic Influences")S5 TX social* W1 (disadvantage* or exclusion or excluded or depriv*)S4 TX social W1 (class* or group* or grade* or context* or status)S3 TX (stop* or quit* or reduc* or give up or giving up) W3 (cigarette* or tobacco or smoking)S2 TX Smoking W1 cessationS1 DE SMOKING
63
Handsearching:
1. Addiction 2012 volume 107 issues 1 to 8 (August 2012) and Early View, search date 31/7/12; also ‘Accepted Articles’, ‘Early View’, search date 14/2/13 and 2012 volume 107 issues 12 and S2, volume 108 issues 1 to 2 search date 18/2/13.
2. Nicotine and Tobacco Research 2012, volume 14, issues 1 to 6, search date 30/7/12; also 2013 volume 15 issues 1 to 3 and ‘Advance Access’ search date 18/2/13.
3. Social Science and Medicine 2012, volume 74 issues 1 to 12, volume 75 issues 1 to 7, articles ‘in press’ search date 31/7/12; also 2013 volumes 74 to 82 ‘in progress’, and ‘articles in press’, search date 18/2/13.
4. Tobacco Control 2012, volume 21, issues 1 to 4, ‘online first’ search date 31/7/12; also volume 21 issue 6, volume 22 issues 1 to 2 and ‘online first’, search date 18/2/13.
64
Searching for grey literature
23/11/12
Dear All,
As you know, ENSP is an Associated Partner in the SILNE project (http://www.ensp.org/node/738).
In order to support the implementation of Work Package 6: Review & Synthesis by Amanda Amos and Tamara Brown, our colleagues from the University of Edinburgh, and help them to identify any grey literature, we would be grateful if you could inform them of any such literature that they may be able to include in their review, particularly government reports that they may not have identified through their searching.
They are now at the stage where they have a complete list of included studies both for the review of youth policies and the review of adult policies. Please see the attached inclusion/exclusion criteria. Attached are also the reference lists of these studies.
Amanda and Tamara are specifically interested in any reports of the socio-economic impact of policies which are written in non-English and which an English synopsis could be provided.
Please do not hesitate to contact them should you need any further clarification:
Tamara BrownResearch FellowCentre for Population Health SciencesUniversity of EdinburghTeviot PlaceEdinburghEH8 9AGScotland, UKTel: 0131 650 3237Fax: 0131 650 6909Email: [email protected]
It would be great if you could not remain simply silent. So, even if you have no available information, a simple negative reply would be appreciated. The deadline is 31/12/12.
Thanking you in advance,
Best regardsFrancisFrancis GrognaSecretary GeneralENSP - European Network for Smoking and Tobacco Prevention
65
10/12/12
To all members of SILNE,
I am pleased to tell you that the youth report for Work Package 6: Review & Synthesis is nearly complete and the adult policy review is well under way.
Amanda and I look forward to presenting the initial results of these reviews when we all meet in Brussels in January.
Do you know of any grey literature that we may be able to include in our review, particularly government reports that we may not have identified through our searching? We are specifically interested in any reports of the socio-economic impact of policies which are written in non-English and which an English synopsis could be provided.
I attach reference lists of included studies both for the review of youth policies and the review of adult policies. I also attach our inclusion/exclusion criteria.
Our deadline for receiving literature is 31/12/12.
Please let me know if you require any further information and I look forward to some hopeful replies and meeting you again in January.
Very best wishes Tamara
Tamara Brown Research Fellow Centre for Population Health Sciences University of Edinburgh Teviot Place Edinburgh EH8 9AG Scotland, UK Tel: 0131 650 3237 Fax: 0131 650 6909 Email: [email protected]
66
7.2 APPENDIX B WHO European countries Albania AndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIceland
67
IrelandIsraelItalyKazakhstanKyrgyzstanLatviaLithuaniaLuxembourgMaltaMonacoMontenegroNetherlandsNorwayPolandPortugalRepublic of MoldovaRomaniaRussian FederationSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTajikistanThe Former Yugoslav Republic of MacedoniaTurkeyTurkmenistanUkraineUnited Kingdom of Great Britain and Northern IrelandUzbekistan
7.3 APPENDIX C Inclusion/exclusion formRef ID FIRST AUTHOR YEAR
CODE
ANSWER TYPE QUESTION
1 population Is the study population 11 years of age or older?2 Is it based in a WHO European country or non-
European country at stage 4 of the tobacco epidemic?
3 intervention/policy
Is it an intervention or policy to reduce adult smoking or to prevent youth starting to smoke?
4 socio-economic inequalities
Does it report outcomes for high vs. low socio-economic group?*
What type of study design is it? (highlight) Review RCT Non-randomised controlled study
68
Observational cohort Qualitative Other
What type of intervention is it? (highlight) taxation/pricing tobacco advertising and marketing bans smoking cessation support smoke free policies (public places, workplaces, home) school-based interventions mass media campaigns community programmes educational policies social and welfare policies employment policies multifaceted lifestyle interventions/policies (not just smoking cessation) other
What type of SES indicator does it report? (highlight) Income Education Occupational social class Area-level socio-economic deprivation Housing tenure Subjective social class Health insurance Proxy measures for youth, i.e. Free School Meals, Family Affluences Scale (FAS)
What type of outcomes does it report? (highlight) quit rates initiation rates changes in initiation/cessation or abstinence rates uptake and reach use of quitting aids/services smoking status (self-reported/validated) number of quit attempts exposure prevalence changing attitudes passive smoking policy reach/awareness/comprehensiveness attitude/social norms intentions to smoke sources (i.e. vending machines) second hand smoke exposure other
What is the length of follow up? (highlight)<3 months3 months6 months12 monthsOtherIs the interventionYouth or adult or both? (highlight)Individual support or population/policy or both? (highlight)
What is the type of analyses?Population-level or individual level or both? (highlight)
69
*INCLUDE? YES/NO/UNCLEAR (highlight)
*To be included a paper must be rated as YES to 1 + 2 + 3 + 4
REVIEWER COMMENTS
70
7.4 APPENDIX D Included studiesReference SourceBauld L, Chesterman J, Judge K, Pound E, Coleman T, English Evaluation of Smoking Cessation Services (EESCS). Impact of UK National Health Service smoking cessation services: variations in outcomes in England. Tobacco Control 2003; 12(3):296-301.
MEDLINE
Bauld L, Judge K, Platt S. Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study. Tobacco Control 2007; 16(6):400-404.
MEDLINE
Bauld L, Chesterman J, Ferguson J, Judge K. A comparison of the effectiveness of group-based and pharmacy-led smoking cessation treatment in Glasgow. Addiction 2009; 104(2):308-316.
MEDLINE
Bauld L, Ferguson J, McEwen A, Hiscock R. Evaluation of a drop-in rolling-group model of support to stop smoking. Addiction 2012.
HANDSEARCH
Bernard P, Ninot G, Guillaume S, Fond G, Courtet P, Christine PM et al. Physical activity as a protective factor in relapse following smoking cessation in participants with a depressive disorder. American Journal on Addictions 2012; 21(4):348-355.
EMBASE-UPDATE SEARCH
Brown J, Michie S, Geraghty AWA, Miller S, Yardley L, Gardner B et al. A pilot study of StopAdvisor: A theory-based interactive internet-based smoking cessation intervention aimed across the social spectrum. Addictive Behaviors 2012; 37(12):1365-1370.
EMBASE – UPDATE SEARCH
Cosnes J, Beaugerie L, Carbonnel F, Gendre JP. Smoking cessation and the course of Crohn's disease: an intervention study. Gastroenterology 2001; 120(5):1093-1099.
MEDLINE
de Vries H, Bakker M, Mullen PD, van BG. The effects of smoking cessation counseling by midwives on Dutch pregnant women and their partners. Patient Education and Counseling 2006; 63:177-187.
HANDSEARCH
De Vries H, Kenward MG, Free CJ. Preventing Smoking Relapse Using Text Messages: Analysis of Data From the txt2stop Trial. Nicotine and Tobacco Research 2012; Advance Access published April 19, 2012
HANDSEARCH
Edwards R, McElduff P, Jenner D, Heller RF, Langley J. Smoking, smoking cessation, and use of smoking cessation aids and support services in South Derbyshire, England. Public Health 2007; 121(5):321-332.
MEDLINE
Ferguson J, Bauld L, Chesterman J, Judge K. The English smoking treatment services: one-year outcomes. Addiction 2005; 100 (Suppl 2): 59-69.
MEDLINE
Fernandez E, Schiaffino A, Borrell C, Benach J, Ariza C, Ramon JM et al. Social class, education, and smoking cessation: Long-term follow-up of patients treated at a smoking cessation unit. Nicotine and Tobacco Research 2006; 8(1):29-36.
MEDLINE
Hiscock R, Judge K, Bauld L. Social inequalities in quitting smoking: what factors mediate the relationship between socioeconomic position and smoking cessation? Journal of Public Health 2011; 33(1):39-47.
MEDLINE
Johnstone E, Hey K, Drury M, Roberts S, Welch S, Walton R et al. Zyban for smoking cessation in a general practice setting: the response to an invitation to make a quit attempt. Addiction Biology 2004; 9(3-4):227-232.
MEDLINE
Judge K, Bauld L, Chesterman J, Ferguson J. The English smoking treatment services: short-term outcomes. Addiction 2005; 100 (Suppl 2):46-58.
MEDLINE
Low A, Unsworth L, Low A, Miller I. Avoiding the danger that stop smoking services may exacerbate health inequalities: building equity
MEDLINE
71
into performance assessment. BMC Public Health 2007; 7:198.Lowey H, Lowey HH. Smoking cessation services are reducing inequalities. Journal of Epidemiology and Community Health 2003; 57(8).
PSYCINFO
Mason D, Gilbert H, Sutton S. Effectiveness of web-based tailored smoking cessation advice reports (iQuit): a randomized trial. Addiction 2012;107, 2183-2190.
UPDATE HANDSEARCH
McEwen A, West R. Do implementation issues influence the effectiveness of medications? The case of nicotine replacement therapy and bupropion in UK Stop Smoking Services. BMC Public Health 2009; 9:28.
MEDLINE
Neumann T, Rasmussen M, Ghith N, Heitman BL, Tonnesen H. The Gold Standard Programme: smoking cessation interventions for disadvantaged smokers are effective in a real-life setting. Tobacco Control 2012; TC Online First, published on June 16, 2012 as 10.1136/tobaccocontrol-2011-050194.
HANDSEARCH
Owen L. Impact of a telephone helpline for smokers who called during a mass media campaign. Tobacco Control 2000; 9(2):148-154.
MEDLINE
Pisinger C, Glumer C, Toft U, von Huth SL, Aadahl M, Borch-Johnsen K et al. High risk strategy in smoking cessation is feasible on a population-based level. The Inter99 study. Preventive Medicine 2008; 46(6):579-584.
MEDLINE
Polanska K, Hanke W, Sobala W, Lowe JB. Efficacy and effectiveness of the smoking cessation program for pregnant women. International Journal of Occupational Medicine & Environmental Health 2004; 17(3):369-377.
MEDLINE
Sperber AD, Goren-Lerer M, Peleg A, Friger M. Smoking cessation support groups in Israel: a long-term follow-up. Israel Medical Association Journal: Imaj 2000; 2(5):356-360.
MEDLINE
van der Aalst CM, de Koning HJ, Van den Bergh KAM, Willemsen MC, van Klaveren RJ. The effectiveness of a computer-tailored smoking cessation intervention for participants in lung cancer screening: A randomised controlled trial. Lung Cancer 2012; 76(2):204-210.
EMBASE
Wisniewska M, Kowalska A, Szpak A. Factors influencing the maintenance of nicotine abstinence among the habitants of the region of Lodz and Kalisz in the years 1996-2003. Roczniki Akademii Medycznej W Bialymstoku 2005; 50(Suppl 1):238-240.
MEDLINE
Yilmaz G, Karacan C, Yoney A, Yilmaz T. Brief intervention on maternal smoking: a randomized controlled trial. Child: Care, Health & Development 2006; 32(1):73-79.
MEDLINE
72
7.5 APPENDIX E Excluded studiesReference Reason for
exclusionBrouwer W, Oenema A, Raat H, Crutzen R, de NJ, de Vries NK et al. Characteristics of visitors and revisitors to an Internet-delivered computer-tailored lifestyle intervention implemented for use by the general public. Health Education Research 2010; 25(4):585-595.
Did not report measure of quit
Carlini BH, McDaniel AM, Weaver MT, Kauffman RM, Cerutti B, Stratton RM et al. Reaching out, inviting back: using Interactive voice response (IVR) technology to recycle relapsed smokers back to Quitline treatment--a randomized controlled trial. BMC public health 2012; 12:507.
Cessation delivery
Chin DL, Hong O, Gillen M, Bates MN, Okechukwu CA. Occupational factors and smoking cessation among unionized building trades workers. Workplace Health and Safety 2012; 60(10):445-452.
Does not analyse intervention effect by SES
Gilbert H, Leurent B, Sutton S, Morris R, Alexis-Garsee C, Nazareth I. Factors predicting recruitment to a UK wide primary care smoking cessation study (the ESCAPE trial). Family Practice 2012; 29(1):110-117.
Participants profile only
Gilbert HM, Sutton SR, Leurent B, Alexis-Garsee C, Morris RW, Nazareth I. Characteristics of a population-wide sample of smokers recruited proactively for the ESCAPE trial. Public Health 2012; 126(4):308-316.
Participants profile only
Khan N, Anderson JR, Du J, Tinker D, Bachyrycz AM, Namdar D. Smoking cessation and its predictors: Results from a community-based pharmacy tobacco cessation program in New Mexico. Annals of Pharmacotherapy 2012; 46(9).
US based
Meland E, Maeland JG, Laerum E. The importance of self-efficacy in cardiovascular risk factor change. Scandinavian Journal of Public Health 1999; 27(1):11-17.
Combined control and intervention arms in analysis
Murray RL, Szatkowski L, Ussher M. Evaluation of a Refined, Nationally Disseminated Self-Help Intervention for Smoking Cessation ("Quit Kit-2"). Nicotine & Tobacco Research Advance Access . 2013.
Does not analyse intervention effect by SES
Parrish DE, von SK, Velasquez MM, Cochran J, Sampson M, Mullen PD. Characteristics and factors associated with the risk of a nicotine exposed pregnancy: expanding the CHOICES preconception counseling model to tobacco. Maternal & Child Health Journal 2012; 16(6):1224-1231.
Baseline data for alcohol intervention
Smit ES, Hoving C, Cox VC, de vH. Influence of recruitment strategy on the reach and effect of a web-based multiple tailored smoking cessation intervention among Dutch adult smokers. Health Education Research 2012; 27(2):191-199.
Education level as predictor of quit attempts but not quit by SES
Wasserfallen J-B, Digon P, Cornuz J. Medical and pharmacological direct costs of a 9-week smoking cessation programme. European Journal of Preventive Cardiology 2012; 19(3):565.
Separates completers and quitters
Whembolua G-L, Davis JT, Reitzel LR, Guo H, Thomas JL, Goldade KR et al. Subjective social status predicts smoking abstinence among light smokers. American Journal of Health Behavior 2012; 36(5):639-646.
US based
Wiggers LCW, Stalmeier PFM, Oort FJ, Smets EMA, Legemate DA, De Haes JCJM. Do patients' preferences predict smoking
Did not report outcomes for SES
73
cessation? Preventive Medicine 2005; 41(2):667-675. by each study arm
74
7.6 APPENDIX F Quality assessment Study study
design+Quality of execution
Gen
eral
isab
ility
+
Rep
rese
ntat
iven
ess*
Ran
dom
isat
ion*
*
Com
para
bilit
y***
Cre
dibi
lity
of d
ata
colle
ctio
n in
stru
men
ts†
Att
ritio
n ra
te††
Att
ribu
tabi
lity
to
inte
rven
tion†
††
Behavioural & pharmacologicalBauld 2003 1.1 Yes n/a n/a yes n/a yes nationalBauld 2007 1.2 yes n/a n/a yes yes yes national
Bauld 2009 1.1 yes n/a n/a yes n/a yes nationalBauld 2012 1.3 n/a n/a yes yes
Bernard 2012 2.1 n/a n/a yes yesEdwards 2007 1.1 n/a n/a yes n/a yes
Ferguson 2005 1.1 yes n/a n/a yes n/a yes nationalHiscock 2011 1.1 n/a n/a yes n/a
Johnstone 2004 2.1 n/a n/a yes yesJudge 2005 1.1 yes n/a n/a yes n/a yes national
Low 2007 1.2 n/a n/a yes yesLowey 2003 1.1 n/a n/a yes n/a yes
McEwen 2009 2.2 yes n/a n/a yes yes yes nationalNeumann 2012 1.3 n/a n/a yes yes yes
Sperber 2000 2.1 n/a n/a yes yes yesBehaviouralCosnes 2001 2.2 yes n/a yes yes yes nationalDe Vries 2006 3.1 yes yes yes yes yes
Pisinger 2008 3.1 yes yes yes yes nationalPolanska 2004 3.3 yes yes yes yes yes national
Van der Aalst 2012 3.1 yes yes yesPharmacologicalFernandez 2006 2.1 n/a n/a yes yesBrief interventionsYilmaz 2006 3.1 yes yes yes yes yes yes regionalMass media – Quitlines and Quit & Win campaignsOwen 2000 1.3 n/a n/a yes yesWisniewska 2005 1.3 n/a n/a
Text-basedDevries 2012 3.1 yes yes
Internet-basedBrown 2012 2.1 n/a n/a yes yes yes
Mason 2012 3.1 yes yes yes yes
75
# Typology of study designs
Code Study design
1.0 Population-based observational1.1 Cross-sectional1.2 Repeat cross-sectional1.3 Cohort longitudinal1.4 Econometric analyses (cross-sectional data)2.0 Intervention-based observational2.1 Single intervention (before and after, same participants)2.2 Single intervention with internal comparison2.3 Comparison between different types of intervention3.0 Intervention-based experimental3.1 Randomised controlled trial (individual or cluster)3.2 Non-randomised controlled trial3.3 Quasi-experimental trial4.0 Qualitative4.1 Cross-sectional4.2 Repeat cross-sectional4.3 Longitudinal
76
## Quality of execution
*Representativeness: Were the study samples randomly recruited from the study population with a
response rate of at least 60% or were they otherwise shown to be representative of the study
population?
**Randomisation: Were participants, groups or areas randomly allocated to receive the intervention
or control condition?
***Comparability: Were the baseline characteristics of the comparison groups comparable or if there
were important differences in potential confounders were these appropriately adjusted for in the
analysis? If there is no comparison group this criterion cannot be met.
†Credibility of data collection instruments: Were data collection tools shown to be credible, e.g.
shown to be valid and reliable in published research or in a pilot study, or taken from a published
national survey, or recognized as an acceptable measure (such as biochemical measures of smoking).
††Attrition Rate: Were outcomes studied in a panel of respondents with an attrition rate of less than
30% or were results based on a cross-sectional design with at least 200 participants included in
analysis in each wave?
†††Attributability to intervention: Is it reasonably likely that the observed effects were attributable to
the intervention under investigation? This criterion cannot be met if there is evidence of
contamination of a control group in a controlled study. Equally, in all types of study, if there is
evidence of a concurrent intervention that could also have explained the observed effects and was not
adjusted for in analysis, this criterion cannot be met.
+ Generalisability: Is the study generalisable at National, State/Regional, or Local level? A study
cannot be generalisable if not representative or representativeness is unclear.
Randomisation is not applicable (N/A) for all study designs except trials coded 3.1. Attrition rate is
N/A to cross-sectional studies coded 1.1.
77
7.7 APPENDIX G Equity Impact
78
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Behavioural & PharmacologicalBauld 2003
1.1 England Health action zones (HAZ)Index of Multiple deprivation
NHS Smoking Cessation Services
Reach,Number quit at 4 weeks,Cessation rate,Loss to follow-up
Cessation services based in health action zones (HAZ, areas of high deprivation) reached 140% more smokers compared to other more affluent areas, and the number of people who reported quitting at four weeks was 90% greater in HAZ areas. However, there was an inverse relationship between reach and cessation rates (the number of smokers who reported quitting at four weeks as a percentage of those setting a quit date). Cessation rates were lower in deprived areas compared with more advantaged areas. Typically the cessation rate in an area with an upper quartile deprivation score was 6% lower than that in an area in the lower quartile. Services operating in deprived areas were more likely to lose clients between setting a quit date and reporting outcomes at four weeks. The study did not assess the overall equity impact of the services (ie whether the higher reach in deprived areas compensated for lower quit rates).
Negative
Bauld 2007
1.2 England Index of Multiple Deprivation
NHS Smoking Cessation Services
Quit rates (self-reported at 4 weeks and
Although disadvantaged groups had proportionately lower quitting success rates than their more affluent neighbours,
Negative
79
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
estimated at one year)
services were treating many more clients in disadvantaged communities. Overall, therefore, the net effect of service intervention was to achieve a greater proportion of quitters among smokers living in the most disadvantaged areas and a slight narrowing effect on inequalities in smoking prevalence. In terms of quit rates the services had a negative equity impact.
80
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Bauld 2009
1.1 Scotland Scottish Index of Multiple Deprivation,Socio-economic group score (summary measure based on whether education finished by 16, single parent, rented housing, unemployed or permanently sick/disabled, whether eligible for free prescriptions and aged under 60, lowest Scottish deprivation decile: range 1 (least deprived) to 6 (most deprived)).
NHS Smoking Cessation Services – pharmacy based vs group-based community service
Carbon monoxide validated 4-week quit rates, number of service users in each type of service
A high proportion of clients in both groups were from disadvantaged areas, with 58.0% of pharmacy-based clients in the bottom Scottish deprivation quintile, compared with 45.5% in group-based community support.
Users who accessed the group-based services were almost twice as likely (OR 1.980; CI 1.50 to 2.62) as those who used pharmacy-based support to have quit smoking at 4-week follow-up.
The quit rates were measured by a number of socioeconomic indicators, and all showed lower cessation rates in low SES groups, but the difference was only significant for smokers using pharmacy services.
In multivariate analysis low SES was significantly associated with lower 4 week quit rates (OR 0.677, p=0.015). In terms of quit rates the services had a negative equity impact.
Negative
81
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Bauld 2012
1.3 England Composite indicator: home ownership; managerial, professional or intermediate occupation; and resident in the most affluent half of Liverpool postcode area neighbourhoods
NHS Smoking Cessation Services – drop-in rolling group service ‘Fag Ends’
52-week CO validated quit rate
In a region of high economic and social disadvantage the service reached a significant proportion of the smoking population however long-term CO-validated quit rates were significantly associated with SES: Higher SES was a predictor of quitting using a composite measure of SES. Group interventions might help to equalize outcomes, and thus have more potential to reduce inequalities than one-to-one support.
Negative
Bernard 2012
2.1 France Education Brief counselling and pharmacotherapy based in hospital setting
Smoking abstinence and relapse rates up to 3 years
Level of education was significantly associated with relapse (relapse rate=0.80, 95% CI: 0.64 to 0.99, p = 0.04).
Negative
82
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Edwards 2007
1.1 England Area-level: ‘disadvantaged areas’ included three ‘Neighbourhood Renewal Areas’ and a small ‘New Deal for Communities’ area in Derby City, and areas within the rural PCTs, which had been designated as ‘Communities in Need’.
Individual-level: low SES was defined as having one or more of the following: no access to a car; leaving school before their 17th
birthday (not used for 65–74-year age group); living in Local Authority or Housing Association rented accommodation; receiving one mean tested benefit or
NHS Smoking Cessation Services ‘Fresh Start’ in Derbyshire
Self-reported motivation to quit,
Quitting in the last year,
Awareness and use of NHS SSS
Motivation to quit did not vary by SES. Awareness varied little by SES but accessing services was generally higher among smokers of lower SES. Quit rates were generally lower among smokers of lower SES, but only significantly so for men aged 25–44 years.
In summary, reach and use of the NHS SSS was associated with a positive equity impact but quit rates were lower among smokers of lower SES but the numbers were small (n=79) and differences were not significant.
Neutral
83
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
more; or being currently unemployed (not used for 65–74-year age group).
84
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Ferguson 2005
1.1 England Summary measure based on whether education finished by 16, single parent, rented housing, unemployed or permanently sick/disabled, whether eligible for free prescriptions and aged under 60, lowest deprivation decile.
NHS SSS 52-week CO-validated quit rate
14.6% CO-validated quit rate at 52-weeks. This rose to 17.7% when self-report cases were included. Relapse rates between 4 and 52 weeks were about 75% in both study areas and were most likely to occur in the first 6 months following treatment.
Service users with lower SES were less likely to be quitters at 52-weeks (OR 0.86; CI 0.78–0.96). 52-week cessation rate ranged from 17.4% for group 1 (relatively advantaged) to just 8.7% for group 6 (relatively disadvantaged).
Negative
85
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Hiscock 2011
1.1 England and Scotland
Summary measure based on whether education finished by 16, single parent, rented housing, unemployed or permanently sick/disabled, whether eligible for free prescriptions and aged under 60, lowest deprivation decile.
NHS SSS 52-week CO-validated quit rate
Continuous abstinence rates at 1 year were higher in England (average 14%) than Glasgow (average 3%). At 52-week follow-up, 14.3% of the most affluent smokers remained quit compared with only 5.1% of the most disadvantaged. After adjustment for demographic factors, the most advantaged clients at the North Cumbria and Nottingham sites and the Glasgow one-to-one programme (but not the group intervention) were significantly more likely to have remained abstinent than those who were most disadvantaged (OR 2.5, 95% CI 1.4 to 4.7; and OR 7.5, 95% CI 1.4 to 40.3 respectively). During the study period relatively few smokers from disadvantaged backgrounds attended the group service.
Negative
86
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Johnstone 2004
2.1 England Deprivation score (no further details),
Social class - % manual work
Zyban plus behavioural support from nurse in general practice setting
Point prevalence and continuous abstinence from smoking at 6 and 12 months
54 of the 239 (23%) made an attempt to stop smoking on the agreed quit date. At 6 months, 21/54 (39%) claimed to be abstinent, and 16/54 (30%) had biochemically verified abstinence. At 12 months, 14/54 (26%) claimed to be abstinent and 12/54 (22%) were biochemically-validated continuously abstinent at 12 months.
When those who attempted to quit were stratified by deprivation score (low, medium, high; less deprivation higher social class), females had significantly less deprivation than males (p = 0.03). This difference in deprivation score persisted among the successful quitters (mean deprivation score at 12 months in females =6.7, in males= 12.1).
There were no significant differences between those who accepted the invitation to participate and those who did not in terms of SES. 42.4% of adults invited to join the study were in manual work and 44% of those who accepted were in manual work. There were slightly higher numbers of manual workers among the successful quitters (55.6% at six months and 46.2% at 12
Neutral
87
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
months), than among the quit attempters (42.6%). However these differences were not statistically significant and the numbers were relatively small.
88
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Judge 2005
1.1 England Summary measure based on whether education finished by 16, single parent, rented housing, unemployed or permanently sick/disabled, whether eligible for free prescriptions and aged under 60, lowest deprivation decile.
NHS SSS 4-week self-report and also CO-validated quit rate
More than one-half of clients (53%) were CO-validated as quitters at 4 weeks, rising to 60.7% when self-reported cases not receiving a CO validation test, were included. Users with lower SES were less likely to quit at four weeks (OR 0.92; CI 0.88–0.95). The CO-validated rate ranging from 59.8% for group 1 (least deprived areas) to 43.1% for group 6 (most deprived areas, P<0.001). The study authors emphasise that the majority of users in this study were relatively disadvantaged.
Negative
89
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Low 2007
1.2 England Index of Multiple Deprivation
NHS SSS Access rates,
Quit rates,
Smoking prevalence rates
The analysis suggests that the Derwentside Stop Smoking Service is operating at a position between equity of access and equity of outcome. Between 2001/02 and 2004/05 there has been some movement towards equity of outcome, but equity of outcome is not yet being achieved ie quit rates remained lower in more deprived wards. The gap in quit rates per adult between affluent and deprived areas is lower than the gap in smoking prevalence means that the Stop Smoking Service in Derwentside is not contributing to a reduction of inequality in smoking prevalence between deprived and affluent areas.
Negative
Lowey 2003
1.1 England Index of Multiple Deprivation 2000
NHS SSS Accessing the services,Setting a quit date,4-week quit rate,
Disproportionately more people living in deprived areas were contacting smoking cessation services. The relative proportion of the total population quitting smoking increased as deprivation increased. In the least deprived quintile, only 0.05% of the total population quit smoking compared with 0.25% in the most deprived areas.
Unclear
90
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
McEwen 2009
2.2 England Education >16 years,Eligibility for free prescriptions
NHS SSS CO-validated 3-4 week abstinence
3–4 week abstinence rate was 41% (865/2129); for clients using bupropion it was 34% (129/377) and for those using NRT it was 42% (736/1752) (χ2 = 7.81, p = .005). There were no differences in abstinence rates according to the level of education of the client nor whether clients were eligible for free prescriptions or not.
Neutral
91
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Neumann 2012
1.3 Denmark Education Six-week ‘Gold Standard Programme’- behaviour change plus NRT
Continuous abstinence, defined as notsmoking at all from the end of the programme to the 6-monthfollow-up
Continuous abstinence of the 16 377 responders was 34% (of all 20 588 smokers: continuous abstinence was 27%, when all non-responders were considered to be smokers).Of the 16 377 responding to follow-up, 27% had a lower level of education compared with 37% in the Danish population. Continuous abstinence was lower in 5738 smokers with a lower educational level (30% of responders, 23% of all) compared with those with a higher education level (35% of responders, 28% of all). The overall difference in continuous abstinence between disadvantaged and non-disadvantaged patients was 5% (with respect to education).
Negative
Sperber 2000
2.1 Israel Years of education Smoking cessation groups based on behaviour modification and peer support
Self-reported and breath text smoking status at 1-3 year follow-up
Thirty-three percent reported that they did not smoke at follow-up and there was 95% agreement rate with carbon monoxide breath tests. There was no difference between quitters and nonquitters in use of NRT and in years of education.
Neutral
92
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
BehaviouralCosnes 2001
2.2 France Socioeconomic status – no further details:‘Low-moderate, Moderate-high,High’
Behavioural counselling with opportunity to join smoking cessation programme, could include nicotine patches and fluoxetine but no further details
One year biochemically verified abstinence,Disease course and therapy for Crohn’s disease
Risk of flare-up of Crohn’s disease in quitters did not differ from that in non-smokers and was less than in continuing smokers (P <0.001). Need for steroids and for introduction or reinforcement of immunosuppressive therapy, respectively, were similar in quitters and non-smokers and increased in continuing smokers. The risk of surgery was not significantly different in the 3 groups.Fifty-nine (12%) participants remained abstinent for more than one year. Independent factors associated with smoking cessation included high SES (adjusted odds ratio, 2.84; 95% CI, 1.43–5.62).
Negative
93
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
De Vries 2006
3.1 The Netherlands
Education level – no further details
Brief health counselling, self-help materials on smoking cessation during pregnancy and earlypostpartum, and a partner booklet vs routine care, delivered by midwives
Self-reported quit attempts,7-day point prevalence
When all dropouts were included as smokers, 19% of the experimental group reported 7-day abstinence compared to 7% of the control group at 6 weeks post-intervention, and 21% and 12%, respectively, at 6 weeks postpartum. For continuous abstinence (defined as reporting 7-day abstinence at both time points) these percentages were 12% in the experimental group and 3% in the control group. When dropouts were excluded from the analysis these percentages for the experimental group and the control group were not markedly different. The intervention had no effect on the smoking behaviour of the partner as reported by the pregnant women (72% of partners smoked).Having a higher education level was predictive of quit attempts but not 7-day point prevalence abstinence at 6 weeks post-intervention and was predictive of quit attempts and 7-day point prevalence at 6 weeks postpartum using intention-to-treat
Negative
94
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
analysis.
95
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Pisinger 2008
3.1 Denmark Education (vocational training)
Behaviour change – individual face-to-face lifestyle counselling
Self-reported point abstinence at 1, 3 and 5 years
When baseline differences between the groups were adjusted for, the difference in self-reported point abstinence group A (OR: 2.19; 95% CI: 1.7 to 2.8; p=0.001) and group B (OR: 1.71; 95% CI: 1.1 to 2.6; p=0.016) were significant when compared separately with group C. The validated point abstinence rates at 5-year follow-up were 11.6% in group A and 9.2% in group B. Smoking status could not be validated in group C. Logistic analyses, adjusted for baseline differences, showed a significant effect of the intervention, even when compared validated point abstinence in groups AB with the self-reported point abstinence in group C (OR: 1.38; 95% CI: 1.1–1.8; p=0.014). Vocational training predicted abstinence at 5-year follow-up in the combined intervention groups AB: OR 1.77 (95% CI: 1.2 to 2.6, p=0.003).
Negative
Polanska 2004
3.3 Poland Education Behaviour Self-reported The chance of quitting smoking was Neutral
96
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
change delivered by midwives
smoking status shortly after delivery
significantly higher in the intervention group than in the control group when including participants, those lost to follow-up, spontaneous quitters and refusals (OR = 2.5; 95% CI 1.8–3.7). No statistically significant differences were found in the efficacy of the intervention with regard to the level of education whether including just participants and those lost to follow-up or also including spontaneous quitters and refusals.
97
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Van der Aalst
3.1 Netherlands and Belgium
Education, Low educational level indicates primary, lower secondary general or lower vocational education; medium educational level, intermediate vocational education or highersecondary education; high educational level, higher vocational education or university.
Computerised individually tailored smoking cessation advice in sub cohort of current male smokers (with long-term smoking history) who participated in lung cancer screening (NELSON trial)
Self-reported quit attempts,Point prevalent smoking abstinence,Prolonged smoking abstinence, Continued smoking abstinence
47.6% (301/633) of the brochure group and 48.8% (309/633) of the tailored information group – were lower educated (primary, lower secondary general or lower vocational education).Twenty-three percent of the male smokers in the tailored information group returned a completed questionnaire and received the tailored advice. The prolonged smoking abstinence was slightly, but not statistically significant, lower amongst those randomised in the tailored information group (12.5%) compared with the brochure group (15.6%) (OR = 0.77 (95%-CI: 0.56–1.06) as was the continued smoking abstinence (OR=0.78; 95% CI: 0.56 to 1.07).Multivariate analysis showed that those who were higher educated and motivated to quit smoking were more likely to quit smoking at follow-up.
Negative
Pharmacological
98
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Fernandez 2006
2.1 Spain Social class based on occupation (Social class I = managerial/senior technical staff/freelance professionals; social class II = intermediateoccupations/managers in commerce;social class III = skilled non-manual workers; social class IV = skilled and partly skilled manual workers; social class V = unskilled manual workers.Education: University or graduate studies (>16 yearsof education);
Specialised smoking clinic in a university teaching hospital
1 year and 8 year abstinence probabilities and hazard ratios for relapse at 8 years
Both men and women in affluent social classes or with higher educational levels had a higher probability of abstinence at 1 year and 8 years. Overall abstinence probability was 0.412 (95% CI 0.387 to 0.437) at 1-year and 0.277 (95%CI 0.254 to 0.301) at 8 years.Lower SES was associated with a higher rate of relapse. This association persisted after adjustment for confounders and despite motivation to quit being equal among all social groups. Men and women in social classes IV–V had significant hazard ratios of relapse after 8 years follow-up (men: 1.36, 95% CI 1.07 to 1.72; women: 1.60, 95% CI 1.24 to 2.06), as compared with patients in social classes I–II. The same independent effect was observed for education: men and women with primary or less than primary education had higher hazard ratios of relapse (men: 1.75, 95% CI 1.35 to 2.25; women: 1.92, 95% CI 1.51 to 2.46), as compared with patients with
Negative
99
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
secondary education (12–15 years ofeducation); and primary studies (5–11 years ofeducation), including less than primary studies (0–4 years of schooling) and illiterate individuals.
a university degree.
100
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Brief interventions
101
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Yilmaz 2006
3.1 Turkey Monthly income Brief advice from nurse focussed either on health risks of smoking to the child or to the mother compared with control (general personal health information)
Self-reported smoking status at six-months follow-up, change in smoking location and knowledge scores
The percentage reporting quitting smoking was 24.3%, 13% and 0.8% of the child intervention, mother intervention and control at six months, respectively and the three groups were statistically significantly different from each other.When the rates of smoking cessation were controlled for monthly family income there were statistically significant differences for both income levels. The percentage reporting quitting smoking was 25%, 8.1% and 1.5% of the child intervention, mother intervention and control at six months, respectively for ‘low income’ and 23.6%, 17.4% and o% of the child intervention, mother intervention and control at six months, respectively for ‘high income’.Family income was an independent factor significantly influencing smoking location change and post intervention knowledge, but not smoking cessation. Higher income
Neutral
102
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
families had less location change than lower income families but greater improvement in knowledge scores at six months follow-up.
Mass media – Quitlines and Quit & Win campaignsOwen 2000
1.3 England Occupational social class
3-month hard-hitting testimonial TV and advertising (radio/magazine) campaign targeted at young smokers (16-24 years) encouraging calls to free Quitline and included additional support (written information)
Characteristics of helpline callers, smoking status at one year
The social class distribution of callers to the helpline reflected the social class distribution of smoking in the population, with nearly two thirds of callers being in manual occupations or unemployed. However, 25% social classes ABC1 stopped smoking at one year, compared to 21% social class C2DE which was not statistically significant.
Neutral
103
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Wisniewska 2005
1.3 Poland Education Quit & Win campaign
Self-report smoking status two years after 5 years abstinence
In 2003, 284 of 296 respondents (92.6%) reported that they were still abstinent, during the two years following a five year period of abstinence (seven years after the Quit & Win competition). The maintenance of nicotine abstinence was associated with having a higher than elementary education level: there was a greater percentage of non-smoking adults with ‘other’ levels of education (94.8%) compared with non-smoking adults with elementary education (84.2%).
Negative
Text-basedDevries 2012
3.1 England The intervention arm of ‘txt2stop’, an RCT of an automated, mobile phone text message-based smoking cessation
Education, occupation
Both education and occupation did not predict relapse following a quit attempt. Both education and occupation did not predict using the text lapse function amongst those who did lapse. Higher SES participants appeared more likely to text crave or lapse but the relationship between these outcomes and smoking outcomes appears complex.
Neutral
104
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
intervention to prevent smoking relapse.
105
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
Internet-basedBrown 2012
2.1 UK National Statistics Socio-Economic Classification (NS-SEC) self-codingmethod (Routine and Manual or Other occupations).Attainment of post-age 16 educationalqualifications
‘StopAdvisor’ recommends astructured quit plan and a variety of behaviour change techniques for smoking cessation
Self-report of at least 1 month of continuous abstinence verified by saliva cotinine or anabasine. Usage was indexed by log-ins and page views. Satisfactionwas assessed by helpfulness, personal relevance, likelihood of recommendation andfuture use
At 8 weeks post-enrolment, 19.6% (95% CI: 14.1 to 25.1) of participants (40/204) were abstinent. Participants viewed a mean of 133.5 pages (median=71.5) during 6.4 log-ins (median=3). A majority of respondents rated the website positively on each of the four satisfaction ratings measured by helpfulness, personal relevance, recommendation and use in future. There was no evidence of an effect of SES on cessation (OR=0.99, CI: 0.48–2.02), usage or satisfaction, using both an occupational and an educational measure of SES.
Neutral
Mason 2012
3.1 UK Composite measure: one point for each of the
Web-based tailored smoking
Self-report 1 month and 3 month
The intervention group did not differ from the control group on self-reported three month prolonged
Neutral
106
Author, year
Study design
Country SES variable Intervention Outcome Equity impact Summary (negative, neutral, positive, unclear)
following: rented home; no car; no educational qualifications; manual occupation; unemployed or full-time student.
cessationadvice reports: iQuit
prolonged abstinence, 7-day and 24-hour point prevalence – all measured at six months follow-up
abstinence (9.1% versus 9.3%; OR = 1.02, 95% CI: 0.73 to 1.42) or on any of the secondary outcomes. There were no significant moderating effects of deprivation on the intervention effect for any of these four outcomes.
107
7.8 APPENDIX H Summary of Equity Impact
Positive Neutral
Negative Mixed Unclear
Total
Behavioural and pharmacological 4 10 1 15Behavioural 1 4 5Pharmacological 1 1Brief interventions 1 1Mass media campaigns - quitlines and Quit & Win 1 1 2Text based 1 1Internet based 2 2Total 0 10 16 0 1 27
108
