Tackling tobacco: an exploration of social and community service organisations as a way of reaching the socially disadvantaged for smoking cessation

This thesis by publication is composed of an introduction, six papers, and a final chapter providing conclusions. All papers relate to exploring the potential of a novel setting- social and community service organisations- for addressing smoking among severely disadvantaged, low socioeconomic status groups in Australia. At the time of submission, all six papers have been accepted for publication in peer reviewed journals. The Introduction provides an overview of the global smoking epidemic, including the well documented socio-economic gradient in smoking prevalence. It provides a discussion of the social determinants of health framework, a summary of smoking prevalence in socially disadvantaged and severely disadvantaged groups, and a rationale for why social and community service organisations hold potential for being a highly valuable setting in increasing the reach of smoking cessation support to disadvantaged smokers. This chapter gives focus to smoking prevalence in Australia and other western developed countries (particularly the United States, Canada, the United Kingdom and New Zealand) who have similar smoking prevalence rates and socioeconomic gradients in tobacco use. Paper one, “A survey of smoking prevalence and interest in quitting among social and community service organisation clients: a unique opportunity for reaching the highly disadvantaged”, reports the results of a touch-screen computer survey of 383 clients accessing three community service organisations in New South Wales, Australia, over a nine-month period. More than 61% of participants surveyed were daily or occasional smokers. Most (77%)had tried to quit smoking in the past and a substantial proportion (53%) wanted to receive support from the community service organisation. These results provide evidence of the potential uptake of smoking cessation support delivered in the community service setting. This paper has been published in BMC Public Health. Paper two, “Developing cessation interventions for the social and community service setting: A qualitative study of barriers to quitting among disadvantaged Australian smokers” is a qualitative paper exploring the barriers to quitting smoking in the Australian context. Focus groups were conducted with thirty-two clients of social and community service organisations in New South Wales, Australia. Findings show that disadvantaged smokers in Australia, like those in other countries, find quitting difficult for a number of reasons, including poor self-efficacy,poor knowledge of available support, limited provision of support, the high cost of nicotine replacement therapy, and pro-smoking community norms. The paper concludes that multi-component interventions providing information about the availability of quit support, practical strategies for engaging disadvantaged smokers with available quit support, and access to free or subsidized nicotine replacement therapy are needed to overcome barriers to quitting among disadvantaged smokers. This paper has been published in BMC Public Health. Paper three, “Delivering smoking cessation support to disadvantaged groups: A qualitative study of the potential of community welfare organisations” is a qualitative paper examining the feasibility and acceptability of the community service sector for providing individuals with smoking cessation support from the perspectives of both clients and staff. Results showed the acceptability of providing and receiving cessation support in the community service setting was high from both staff and clients. Staff perceived the provision of quit support to be compatible with their role but reported barriers to providing care including competing priorities, insufficient resources, and inadequate staff training. Brief intervention approaches were preferred by managers and staff, while financial incentives and access to free or subsidised nicotine replacement therapy were desired by clients. This paper has been published in Health Education Research. Paper four “A systematic review and meta-analysis of the effectiveness of behavioural smoking cessation interventions in selected disadvantaged groups” presents the results of a systematic review and meta-analysis of behavioural cessation interventions targeted at six severely disadvantaged groups: the homeless, prisoners, indigenous populations, at-risk youth, individuals with low socio-economic status, and individuals with a mental illness. The review shows that while few high-quality trials of the effectiveness of smoking cessation interventions for disadvantaged groups have been published, behavioural interventions do hold promise of effectiveness. No studies were conducted in the social and community service organisation setting, indicating a gap in knowledge requiring some attention. This paper has been published in Addiction. Paper five, “Assessing smoking status in disadvantaged populations: is computer administered self-report an accurate and acceptable measure” examined the validity and acceptability of touch-screen computer administered self-report of smoking status among clients attending community service organisations for welfare support. It finds that self-report of smoking status in the community service sector is accurate, with less than 7% of participants misreporting their smoking status. The study also found good acceptability for the use of touch-screen computers for assessing the health of low income individuals in a community welfare setting, with high consent rates (69%) and most participants reporting that the touch screen survey was both enjoyable (79%) and easy (88%) to complete. This paper has been published in BMC Medical Research Methodology. Paper six is the final paper of the thesis “Implementing a smoking cessation program in social and community service organisations: A feasibility and acceptability trial”. It reports the results of a pilot trial examining the acceptability and feasibility of integrating the delivery of quit smoking support into a community service organisation providing support to individuals with a mental illness. The study found that community service organisations are both willing to and capable of providing smoking cessation support to clients. The intervention increased mean time spent addressing client smoking from 3.8 minutes per visit at baseline (SD=2.6, range 0-7.5 minutes) to 15.5 minutes per visit at six months follow-up (SD=8.7, range 7.5-30 minutes). Receiving support was acceptable to clients and resulted in a significant reduction in the number of cigarettes smoked by participants from 20.5 cigarettes per day (SD=9.9, range 8-45)at baseline to 15 cigarettes per day (SD=9.3, range 4-40) at six months follow-up (t= 2.26, p=0.04). This paper has been accepted for publication in Drug and Alcohol Review. In conclusion, this program of research provided formative assessment of the potential of social and community service organisations for addressing smoking among disadvantaged groups within Australia. It has provided information about the prevalence of smoking and interest in quitting among clients of social and community service organisations, as well as the acceptability and feasibility of integrating the provision of support into the social and community service setting. A methodologically rigorous trial of the effectiveness and cost of this approach is now needed.

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