Public health interventions promoting cessation in populations

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Public health interventions promoting cessation in populations
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Self-help movements
Although clinical and public health interventions have proliferated over the past few
decades, up to 90 per cent of ex-smokers report having stopped without any formal help
(Fiore et al. 1990). Lichtenstein and Glasgow (1992) reviewed the literature on self-help
quitting and reported that success rates tend to be about 10–20 per cent at one-year
follow-up and 3–5 per cent for continued cessation. The literature suggests that lighter
smokers are more likely to be successful at self-quitting than heavy smokers and that
minimal interventions, such as follow-up telephone calls, can improve this success.
Research also suggests that smokers are more likely to quit if they receive support from
their partners and if their partners also stop smoking (Cohen and Lichtenstein 1990)
and that partner support is particularly relevant for women trying to give up smoking
during pregnancy (e.g. Appleton and Pharoah 1998). However, although many exsmokers report that ‘I did it on my own’, it is important not to discount their exposure to
the multitude of health education messages received via television, radio or leaflets.
Public health interventions: promoting cessation
in populations
Public health interventions aim to promote behaviour change in populations and
have become increasingly popular over recent years. Such interventions are aimed at all
individuals, not just those who seek help. For smoking cessation, they take the form
of doctor’s advice, worksite interventions, community-wide approaches, government
interventions. For drinking behaviour, most public health interventions take the form of
government interventions.
1 Doctor’s advice. Approximately 70 per cent of smokers will visit a doctor at some
time each year. Research suggests that the recommendation from a doctor, who is
considered a credible source of information, can be quite successful in promoting
smoking cessation. In a classic study carried out in five general practices in London
(Russell et al. 1979), smokers visiting their GP over a four-week period were allocated
to one of four groups: (1) follow-up only; (2) questionnaire about their smoking
behaviour and follow-up; (3) doctor’s advice to stop smoking, questionnaire about
their smoking behaviour and follow-up; and (4) doctor’s advice to stop smoking,
leaflet giving tips on how to stop and follow-up. All subjects were followed up at
one and twelve months. The results showed at one-year follow-up, 3.3 per cent of
those who had simply been told to stop smoking were still abstinent, and 5.1 per
cent of those who were told to stop and had received a leaflet showed successful
cessation. This was in comparison to 0.3 per cent in the group that had received
follow-up only and 1.6 per cent in the group that had received the questionnaire
and follow-up. Although these changes are quite small, if all GPs recommended
that their smokers stopped smoking, this would produce half a million ex-smokers
within a year in the UK. Research also suggests that the effectiveness of doctor’s
advice may be increased if they are trained in patient-centred counselling techniques
(Wilson et al. 1988). Minimum interventions for smoking cessation by health
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professionals are also illustrated by the results of the OXCHECK and Family
Heart Study results (Muir et al. 1994; Wood et al. 1994), which are described in
Chapter 9.
2 Worksite interventions. Over the past decade there has been an increasing interest
in developing worksite-based smoking cessation interventions. These take the form of
either a company adopting a no-smoking policy and/or establishing work-based
health promotion programmes. Worksite interventions have the benefit of reaching
many individuals who would not consider attending a hospital or a university-based
clinic. In addition, the large number of people involved presents the opportunity for
group motivation and social support. Furthermore, they may have implications for
reducing passive smoking at work, which may be a risk factor for coronary heart
disease (He et al. 1994). Research into the effectiveness of no-smoking policies has
produced conflicting results with some studies reporting an overall reduction in the
number of cigarettes smoked for up to 12 months (e.g. Biener et al. 1989) and others
suggesting that smoking outside work hours compensates for any reduced smoking at
the workplace (e.g. Gomel et al. 1993) (see Focus on research 5.2, page 122). In two
Australian studies, public service workers were surveyed following smoking bans in
44 government office buildings about their attitudes to the ban immediately after the
ban and after six months. The results suggested that although immediately after the
ban many smokers felt inconvenienced, these attitudes improved at six months with
both smokers and non-smokers recognizing the benefits of the ban. However, only
2 per cent stopped smoking during this period (Borland et al. 1990). Although worksite interventions may be a successful means to access many smokers, this potential
does not yet appear to have been fully realized.
3 Community-based programmes. Large community-based programmes have been
established as a means of promoting smoking cessation within large groups of
individuals. Such programmes aim to reach those who would not attend clinics
and to use the group motivation and social support in a similar way to worksite
interventions. Early community-based programmes were part of the drive to reduce
coronary heart disease. In the Stanford Five City Project, the experimental groups
received intensive face-to-face instruction on how to stop smoking and in addition
were exposed to media information regarding smoking cessation. The results showed
a 13 per cent reduction in smoking rates compared with the control group (Farquhar
et al. 1990). In the North Karelia Project, individuals in the target community
received an intensive educational campaign and were compared with those in a
neighbouring community who were not exposed to the campaign. The results
from this programme showed a 10 per cent reduction in smoking in men in North
Karelia compared with men in the control region. In addition, the results also showed
a 24 per cent decline in cardiovascular deaths, a rate twice that of the rest of the
country (Puska et al. 1985). Other community-based programmes include the
Australia North Coast Study, which resulted in a 15 per cent reduction in smoking
over three years, and the Swiss National Research Programme, which resulted in an
8 per cent reduction over three years (Egger et al. 1983; Autorengruppe Nationales
Forschungsprogramm 1984).
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