Evidence Summary:
Public health interventions
to support smoking cessation
and prevention of uptake
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Debbie Sigerson, Public Health Adviser – Local Government and Young People,
NHS Health Scotland, Fiona Moore, Public Health Adviser – Tobacco, NHS
Health Scotland, Dr Eileen Scott, Public Health Adviser – Children, Families
and Communities, NHS Health Scotland and Dr Kate Woodman, Public Health
Adviser – Early Years, NHS Health Scotland.
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Evidence Summary:
Public health interventions to support
smoking cessation and prevention of uptake
CONTENTS
Page no.
Introduction
3
The rationale and process for identifying and summarising evidence of effectiveness
Context – specific to topic
Summaries
5
1. Smoking in pregnancy and following childbirth
- Identifying pregnant women who smoke and referring them to Smoking
Cessation Services
- Smoking Cessation Services – initial and ongoing support
- Use of NRT and other pharmacological support
Economic evidence
5
2. Smoke free homes
- Interventions to promote smoke free homes
Economic evidence
8
3. Brief interventions
- Brief interventions from nurses and doctors
- Brief interventions by type
- Brief interventions for special populations
Economic evidence
9
4. School based interventions
- Organisation-wide or ‘whole-school’ approaches
- Adult-led interventions
- Peer-led interventions
- Differential effects of interventions according to use of biomedical
validation, type of outcome measures and presentation of results
- Differences in effectiveness by age, sex, ethnicity and socioeconomic
status
- Interventions delaying rather than preventing onset?
Economic evidence
10
References
13
1. Smoking in pregnancy and following childbirth
2. Interventions to promote smoke free homes
3. Brief interventions
4. School based interventions to prevent the uptake of smoking in children
Evidence statements
17
1. Smoking in pregnancy and following childbirth
2. Interventions to promote smoke free homes
3. Brief interventions
4. School based interventions
2
Introduction
The rationale and process for identifying and summarising evidence of
effectiveness
Evidence of effectiveness from research studies helps us to identify areas for
effective action. While the outcomes of individual primary outcome studies are
important, these may be atypical, and potentially biased. Such issues may only
become apparent when studies are repeated or interventions rolled out on a wider
scale. Evidence and evidence informed recommendations from systematic reviews
and reviews of reviews seek to reduce bias by providing an overview of the findings
of a number of studies. These form the basis of ‘highly processed evidence’, for
example practice guidelines, produced by organisations such as the National Institute
for Health and Clinical Excellence (NICE). While we acknowledge that other sources
of evidence may be available, because of time constraints and in the interests of
quality assurance, the evidence presented here is primarily ‘highly-processed
evidence’ as opposed to primary outcome studies. There may also be instances
where the outcomes of a Scottish evaluation are considered important in assessing
what action is required. An indication of the evidence around cost effectiveness is
included.
When considering the included evidence, the following points should be noted:
• The evidence provides an overview of what is currently known from these
selected highly processed sources. However, it is apparent that the evidence
base identified and included within some reviews has limitations, such as there is
a lack of robust, relevant primary outcome studies in several areas of intervention
e.g. for key vulnerable groups.
• Throughout the evidence summaries, issues pertinent to the interpretation of the
evidence are highlighted. For instance, attention is drawn to methodological
issues relating to the evidence, such as much of the included studies being
undertaken in the USA, and so the extent to which the findings are
transferable/generalisable to Scotland is open to question. We also highlight
when it has not been possible to reach definitive conclusions as to what
constitutes an effective intervention, because of the lack of evidence of
effectiveness. By highlighting these issues, our intention is not to detract from
the quality of the included reviews, but rather to support full consideration of the
evidence and its appropriate use by the intended audience.
• It must be recognised that much of the NICE evidence is only part of the material
that they consider to inform recommendations for action as part of the NICE
Public Health Guidance. Expert opinion is central as to how evidence informs
decisions about new action to be taken.
Due to inevitable gaps in strong scientific evidence, the feasibility and desirability of
adopting a purely evidence-based approach to health improvement and reducing
health inequalities are limited. Activities that lack a strong evidence base may have
important contributions to make to overall impact as part of a package of interacting
activities. In judging whether to include certain possible activities it may be useful to
draw on the NHS Health Scotland approach whereby plausible theory and ethical
principles are used to guide decision-making, in addition to available evidence (see
Tannahill, A. ‘Beyond evidence – to ethics: a decision-making framework for health
promotion, public health and health improvement.’ Health Promotion International
2008;23:380-90 at heapro.oxfordjournals.org/cgi/reprint/23/4/380.
3
Context (specific to topic)
This evidence summary presents a summary of highly processed evidence related to
public health interventions to support smoking cessation and smoking prevention.
Interventions are targeted at pregnant women and their partners, brief intervention
support targeted at all age groups, and children of school age 5-18 years.
The evidence presented here has been extracted from the following key sources:
•
•
Eleven reviews of effectiveness evidence/expert reports informing the
development of NICE public health guidance:
o Brief interventions and referral for smoking cessation in primary care and
other settings (PH1)
o Quitting smoking in pregnancy and following childbirth (PH26)
o School based interventions to prevent the uptake of smoking in children
(PH23)
Three reviews of cost effectiveness evidence
The evidence is grouped by sub headings taken from the evidence reviews or from
themes from the related NICE guidance. The evidence statements cited here should
not be considered in isolation of previous evidence presented in national guidelines
for smoking cessation which are still considered valid. The evidence statements
included have been copied from the full review and in most instances, to ensure the
integrity of the information presented, the text included in the summary statements
have been copied verbatim from the corresponding Executive Summary of the full
review. In some cases the text in the main body of full review has been accessed to
obtain a deeper understanding of the evidence, and has been incorporated into the
summary as appropriate to form part of the conclusions.
Other key sources of information and guidance which contextualise the evidence
include:
• NHS Health Scotland and ASH Scotland (2010) A guide to smoking cessation in
Scotland
2010.
NHS
Health
Scotland,
Edinburgh.
www.healthscotland.com/documents/4661.aspx.
The Guide synthesises the
evidence and recommendations from each of the sets of NICE Public Health
Guidance (intervention and programme guidance) relating to smoking cessation,
and from the former Smoking Cessation Guidelines for Scotland, in the context of
current Scottish policy, smoking cessation services and current practice, and
presents them in a compendium format.
• Scottish Briefings on NICE Public Health Guidance
www.healthscotland.com/scotlands-health/evidence/NICE.aspx
• Scottish Executive (2008). Scotland’s Future is Smoke-Free: A Smoking
Prevention Action Plan. www.scotland.gov.uk/Publications/2008/05/19144342/0
• Scottish Executive (2006). Towards A Future Without Tobacco: The Report of the
Smoking Prevention Working Group. Scottish Executive, Edinburgh.
www.scotland.gov.uk/Publications/2006/11/21155256/0
While NICE Guidance does examine evaluations/observations studies of UK smoking
cessation services, the rapidly advancing field means that widespread practice is
often ahead of the evidence. It is not a static landscape. Much research is underway
to address gaps in the evidence base e.g. via the UK Centre for Tobacco Control
Studies.
4
Evidence Summaries
1. QUITTING SMOKING IN PREGNANCY AND FOLLOWING CHILDBIRTH
Context:
Smoking cessation services for pregnant women have developed in line with the
evidence presented in national guidelines for smoking cessation, supplemented by
national pilot interventions (for which national funding was dedicated for their design,
development and evaluation), and separately, a mapping exercise to identify and
disseminate good practice (NHS Health Scotland, 2005). Services have also
developed in line with Medicines and Healthcare products Regulatory Agency
guidance on prescribing (Medicines and Healthcare products Regulatory Agency,
2005), and changes in licensing of NRT to enable its prescription for pregnant
women (BMA, 2003).
The evidence statements cited here should not be considered in isolation of
previous evidence presented in national guidelines for smoking cessation
which are still considered valid.
Identifying pregnant women who smoke and referring them to Smoking
Cessation Services
There are mixed quality survey and qualitative studies that provide evidence that the
information and advice currently provided by health professionals is perceived as
insufficient or inadequate by some women and by professionals themselves. There
is variance in practice between midwives and GPs, with regard to the type of
intervention offered, record keeping, referral and follow up. The international
evidence also suggests that staff perceive that they have limited skills and time
available to implement smoking cessation interventions, with limited knowledge and
use of guidelines and protocols.
There is good evidence that women in the UK under-report smoking during
pregnancy and that CO monitoring can aid in the identification of pregnant smokers.
It is unclear from the evidence as to what constitutes the best cut-off point for
determining smoking status with a carbon monoxide test. So when trying to identify
pregnant women who smoke, it is best to use a low cut-off point to avoid missing
someone who may need help to quit.
[See corresponding evidence statements: R2.1 – R2.11 (Baxter et al, 2009), ER1.6,
1.10, 1.11 (Bauld & Coleman, 2009].
Smoking Cessation Services – initial and ongoing support
The following smoking cessation interventions have been proven to be effective with
the general population: brief interventions; individual behavioural support; group
behavioural support; pharmacotherapies; telephone support. More intensive support
such as face-to-face (where feasible) individual or group support in conjunction with
pharmacotherapy provides the best cessation outcomes.
In addition, studies have shown that the following interventions are effective in
helping women who are pregnant to quit smoking:
•
cognitive behaviour therapy
•
motivational interviewing
5
•
structured self-help and support from NHS Smoking Cessation Services.
In addition, in other countries the provision of incentives to quit has been shown to be
effective with this group (research is required to see whether it would work in the
UK). Interventions using a ‘stages of change’ approach have had mixed success. (In
some studies the approach was effective; in others it was no better than the control.)
Giving pregnant women feedback on the effects of smoking on the unborn child and
on their own health (such as reports of urinary cotinine levels) is not effective.
Evidence from qualitative studies also highlights the barriers to accessing services,
including the length of sessions, lack of transport/childcare, feeling unable to quit and
fearing failing, lack of knowledge about services and concerns about being
stigmatised.
There is very limited evidence of interventions to prevent relapse in pregnant exsmokers. There is a lack of evidence available on stop-smoking interventions for
those planning a pregnancy or who have recently given birth.
There is moderate evidence that multi-component interventions that include free
nicotine replacement therapies, delivered by highly trained staff, are effective in
encouraging partners who smoke to stop smoking. There is strong evidence that
effectiveness of an intervention for partners may be influenced by the socioeconomic
status of the target audience. Lack of follow up in an intervention is also a barrier to
effectiveness.
[See corresponding evidence statements: R2.12 (Baxter et al, 2009), ER 1.1, 1.2,
1.5, 1.8, 1.9, 1.12 (Bauld & Coleman, 2009), R3.1, 3.2 (Baxter et al, 2009), ER3.1,
3.2 (Myers et al, 2009), ER2.1 – 2.8 (Hemsing et al, 2009].
Use of NRT and other pharmacological support
Earlier NICE guidance on NRT and bupropion, endorsed as valid for Scotland by the
Health Technology Board for Scotland (now part of Quality Improvement Scotland),
advised that the use of NRT in pregnancy was appropriate, providing a discussion of
the risks/benefits had taken place with the woman concerned. One of the key risk
factors to assess is the likelihood of the woman continuing to smoke without the use
of NRT (NHS Health Scotland & ASH Scotland, 2005). In 2005, the Medicines and
Healthcare Regulatory Authority undertook a review of the licensing arrangements for
nicotine replacement therapy (NRT) and, on the basis of the evidence, advised that
NRT could be used by pregnant and breastfeeding smokers (Medicines and
Healthcare products Regulatory Agency and Committee on Safety of Medicines,
2005).
There is mixed evidence on the effectiveness of nicotine replacement therapy (NRT)
for promoting smoking cessation in pregnancy. There is no evidence that NRT either
increases or decreases child birthweight, and insufficient data to form judgements
about any impact of NRT on stillbirth or special care admissions.
[See corresponding evidence statements: ER 1.3, 1.4 (Bauld & Coleman, 2009],
Economic evidence
Effective smoking cessation aids and services are highly cost effective. There were
not sufficient data to estimate the cost effectiveness of services for pregnant women
who smoke. Specifically, it was not possible to determine which of the following
would be more cost effective:
• encourage pregnant women to use NHS Smoking Cessation Services or other
publicly-funded smoking cessation services
• train midwives to a standard that would allow them to act as smoking cessation
6
advisors
•
send members of a dedicated team from the NHS or another publicly-funded
smoking cessation service to the women’s homes.
Overall, brief advice, individual behavioural counselling, group behaviour therapy,
pharmacotherapies, self-help materials, telephone counselling and quitlines were
cost effective compared with no intervention. Methods of assisting pregnant women
to quit smoking are cost effective if the women do not return to smoking after the birth
of the baby. Insufficient evidence was available to determine whether home visits by
specialist stop smoking professionals were cost effective compared with attending
stop smoking clinics, using NRT or attempting to quit without assistance. (NHS
Health Scotland, 2010).
Economic analysis of interventions for smoking cessation aimed at pregnant women
determined the net benefit, or ‘value’ of a range of interventions to promote smoking
cessation in pregnant women. All interventions (cognitive behaviour strategies,
stages of change, feedback, rewards, pharmacotherapies) were shown to reduce
costs and increase quality-adjusted life years (QALYs), for both the mother and the
child. Furthermore, at a societal level, the net benefit (i.e. accounting for money and
health gains), could be in excess of £500 million. Detailed costing of each
intervention should be undertaken, which would allow the decision-maker to
determine the relative cost-effectiveness of each intervention (Taylor, 2009).
The cost-effectiveness model showed that interventions to encourage women who
are pregnant to quit smoking were cost effective (in the main, they were more
effective and less costly than not intervening). However, due to insufficient data, not
all the effects of smoking during pregnancy were modelled. For instance, the model
did not include the impact on subsequent infant morbidity and quality of life or
healthcare costs for children aged over 5 years. If these factors had been included in
the analysis, the NICE Public Health Interventions Advisory Committee believes the
interventions would have probably been even more cost effective (NICE, 2010).
7
2. INTERVENTIONS TO PROMOTE SMOKE FREE HOMES
Context
Reducing children’s exposure to tobacco smoke requires a co-ordinated approach
focused on reducing smoking rates among parents, reducing children’s exposure to
second hand smoke (SHS) and reducing smoking rates among young people. A
Cochrane review from 2002 found that there was insufficient evidence about which
interventions aimed at parents would reduce children’s exposure to SHS (BMA,
2007). The authors noted that, while interventions appeared to change participants’
knowledge of the effects of SHS, they did not necessarily result in changes in
smoking behaviour of reductions in children’s exposure to SHS. Increases in the
numbers of smoke-free homes are a response to reduced prevalence of smoke-free
environments in the population at large, and to the wider policy context and
increasing information about the health risks of SHS. The single most effective
intervention to reduce children’s exposure to SHS is for parents and carers to stop
smoking. Effective stop smoking interventions for young smokers would also
improve their individual health outcomes, and break the intergenerational cycle of
tobacco use.
Summary
There is mixed evidence for the effectiveness of interventions to reduce parental
environmental tobacco smoke in early infancy. Interventions were categorized in
terms of those based on counselling, counselling plus additional elements,
individually adapted programmes and motivational interviewing. The findings suggest
inconclusive evidence relating to these intervention types, with a range of outcome
measures reported. (Baxter et al, 2011).
At present, there is insufficient evidence from which to develop recommendations for
action to promote smoke free homes, since this remains a small area of development
and it is in its infancy in terms of learning internationally. NICE were unable to
generate recommendations for action from the evidence review (Baxter et al, 2009)
due to the limitations of the evidence.
[See corresponding evidence statements R.1.1 - R1.5 (Baxter et al, 2009].
Economic evidence
No evidence was identified on the cost effectiveness of the interventions. (Baxter et
al, 2009).
8
3. BRIEF INTERVENTIONS AND REFERRAL FOR SMOKING CESSATION IN
PRIMARY CARE AND OTHER SETTINGS
Context
The following smoking cessation interventions have been proven to be effective: brief
interventions; individual behavioural support; group behavioural support;
pharmacotherapies; self-help materials; telephone support and quitlines; mass
media. Previous UK guidance has emphasised the importance of offering two forms
of smoking cessation support to achieve the greatest population health benefit
through wider population reach and through lower reach but higher success rates
respectively: opportunistic, brief advice to encourage all smokers to quit and to point
them to effective treatments that can help; smoking cessation services for those who
would like or need help to stop. Most of the research for the development of NICE
Public Health Intervention Guidance 1 (2006) on brief interventions preceded the
development of specialist smoking cessation services. Referral is now a key
component of brief interventions delivered across the NHS – recommendations
include all smokers being advised to quit and being asked how interested they are in
quitting and being referred on to smoking cessation services.
Brief interventions from nurses and doctors
There is evidence of efficacy for physician advice as a brief intervention for smoking
cessation and for nurse structured advice as a brief intervention for smoking
cessation in primary care and community settings. There is insufficient evidence yet
to determine the efficacy of brief interventions from other health professions.
However, all health professionals can play a role in encouraging smokers to stop
and, more importantly, in promoting the use of the NHS SCSs.
[See corresponding evidence statements ‘Brief interventions from nurses and
doctors’].
Brief interventions by type
Evidence supports the efficacy of NRT as part of a brief intervention for smokers
wishing to make a quit attempt, whilst there is mixed evidence on the effectiveness of
NRT for promoting smoking cessation in pregnancy. Evidence also supports the
limited efficacy of standard self-help materials as a brief intervention, and the efficacy
of individually (but not population) tailored materials. There is some evidence to
support the efficacy of telephone helplines. There is mixed evidence to support using
a Stages of Change based approach and insufficient evidence to determine the
efficacy of brief multicomponent interventions or the use of biological measures of
risk or exposure. There is evidence that extending the time spent in providing a brief
intervention may slightly augment the effect on quitting.
[See corresponding evidence statements ‘Brief interventions by type’].
Brief interventions for special populations
There is no evidence for efficacy of brief behavioural interventions delivered as part
of routine care for pregnant smokers, or for brief family and carer interventions to
decrease children’s exposure to environmental tobacco smoke. There is insufficient
evidence to determine the efficacy of brief interventions for adolescents/students and
for smokeless tobacco users.
9
[See corresponding evidence statements ‘Brief interventions for special populations’].
Economic evidence
A systematic review of original studies with economic data on the comparison of brief
interventions with usual care included 24 studies, seven from the UK. These studies
suggest that for a very small financial outlay, significant health improvements can be
made by a programme of brief interventions. Overall, the evidence is insufficient to
satisfactorily quantify these gains or make comparisons between types of brief
intervention in different settings and directed at different population groups. The
review found no evidence by which to assess the cost-effectiveness of brief
interventions with referral. A model based analysis, incorporating quality of life data
is recommended to enable the estimation of the cost-effectiveness of brief advice
and referral to specialist smoking cessation services (Parrott and Godfrey, 2006).
4. SCHOOL BASED INTERVENTIONS TO PREVENT THE UPTAKE OF SMOKING
IN CHILDREN
Context:
Prior to the development of NICE Public Health Intervention Guidance 23 (2010)
recommending school based interventions to prevent the uptake of smoking in
children, smoking prevention activity has developed in line with the Towards A Future
Without Tobacco report (Scottish Executive, 2006) which presented the evidence
around smoking prevention and subsequently the Scottish Prevention Action Plan
(Scottish Executive, 2008).
Organisation-wide or ‘whole-school’ approaches
Qualitative evidence of mixed quality suggests the main facilitators for effective whole
school interventions are good timing, reinforcement of messages across the
curriculum, incorporation into a tobacco control strategy and smoke free policies
applying to staff as well as pupils.
[See corresponding evidence statements: QR1, 5 (Bauld, Brandling & Templeton,
2009), ES24 (Olalekan et al, 2009].
Adult-led interventions
There is evidence from twenty seven randomised controlled trials that adult led
interventions may be effective, and that the addition of booster sessions enhanced
effectiveness of main programmes. There is however, moderate evidence indicating
that multi-component interventions incorporating both school and community
components are ineffective in preventing the uptake of smoking compared to usual
education. There is inconclusive evidence as to the effectiveness of interventions
incorporating both school and specific family components in preventing the uptake of
smoking compared to usual education.
There is evidence from six qualitative studies of variable quality that specific
elements of the intervention can act as facilitators namely: delivery by a trusted
external professional, delivery by non-smoking teacher and the involvement of
parents. Barriers indentified included delivery of the intervention by teachers who are
reluctant to discuss parental smoking and by teachers who use outdated methods to
10
communicate prevention messages.
[See corresponding evidence statements: ES1, 6-8, 13, 25, 26 (Olalekan et al, 2009),
QR 4, 6 (Bauld, Brandling & Templeton, 2009].
Peer-led interventions
It is not clear whether effectiveness of school-based smoking prevention
programmes depend on the status of the person delivering it. There is conflicting
evidence whether peer-led programmes produced most effective intervention effects
on smoking initiation. It is important to note that a peer-led programme may be
differentially effective based on how leaders are selected and how groups are
formed, and may be curriculum-dependent. There is some evidence that teacher-led,
health educator-led, and peer-led programmes tend to be equally effective. Much of
the evidence is from the USA and it is not clear if their findings are applicable to the
UK.
Some of the main facilitators to the delivery of peer interventions include
nomination of peer supporters by fellow students and training for peer supporters
delivered away from school and by external professionals.
[See corresponding evidence statements: ES11: (Olalekan et al, 2009), and QR3
(Bauld, Brandling & Templeton, 2009].
Differential effects of interventions according to use of biomedical validation,
type of outcome measures and presentation of results
There is no evidence of the intervention having a differential effect according to
whether a study used biochemical validation or not. There is good evidence of the
intervention having a differential effect according to type of outcome measures used
(prevalence of regular or experimental smoking) and according to the way the results
were presented.
[See corresponding evidence statements: ES 2-5 (Olalekan et al, 2009].
Differences in effectiveness by age, sex, ethnicity and socioeconomic status
There is conflicting evidence of differential effects of interventions according to the
age and sex of the children. Regarding ethnicity, four studies from the USA indicate
that ethnicity is an important predictor of smoking behaviour, such that white students
were less likely to be smoker, yet there is moderate evidence that the observed
association between race and smoking behaviour depended on how the outcome
was measured. There is no conclusive evidence about the variability of programme
effectiveness in high risk individuals or by socioeconomic status.
[See corresponding evidence statements: ES14-19, 21, 22, 23 (Olalekan et al, 2009)
and QR2 (Bauld, Brandling & Templeton, 2009].
Interventions delaying rather than preventing onset?
There is conflicting evidence whether school-based smoking prevention programmes
are delaying rather than preventing smoking uptake in children, and no robust
evidence indicating that any school-based intervention has long-lasting effects
beyond school leaving age.
[See corresponding evidence statements: ES 9, ES 10 (Olalekan et al, 2009].
11
Economic evidence
A review of the economic literature revealed no published economic evaluations of
school-based smoking prevention programmes in the UK. Studies based in other
countries are of limited relevance to the UK because of differences in both the
populations being studied and the methodological framework used. A further
limitation with the existing literature is that most published studies assume that
school-based smoking prevention programmes can achieve a lasting reduction in
smoking prevalence beyond school-age which is not supported by evidence in the
effectiveness literature. Economic modelling analyses (using ‘age of initiation’ and
‘effect’ models) suggested that a school-based smoking prevention programme,
delivered at the age of 11 years, may be cost-effective at a willingness-to-pay
threshold of £20,000 per quality-adjusted life years (QALY) gained (Jit el al, 2009)
12
References
1. QUITTING SMOKING IN PREGNANCY AND FOLLOWING CHILDBIRTH
Details of Studies
Bell, K., McCullough, L. and Greaves, L., et al, on behalf of the British Columbia
Centre of Excellence for Women’s Health, Vancouver (2006, updated 2007). Rapid
Review: The Effectiveness of National Health Service Intensive Treatments for
Smoking Cessation in England.
http://www.nice.org.uk/nicemedia/live/11925/43886/43886.pdf
Baxter, S., Blank, L., Guillaume, L., et al on behalf of The University of Sheffield:
School of Health and Related Research (ScHARR) (2009). Systematic review of how
to stop smoking in pregnancy and following childbirth. Review 1 (R1). Which
interventions are effective and cost effective in encouraging the establishment of
smoke free homes? Review 2 (R2). Factors aiding delivery of effective interventions.
Review 3: The health consequences of pregnant women cutting down as opposed to
quitting (R3). http://www.nice.org.uk/nicemedia/live/13023/49420/49420.pdf
Expert Report 1: (ER1)
Bauld, L. and Coleman, T., on behalf of University of Bath, the University of
Nottingham, and the UK Centre for Tobacco Control Studies (2009). The
Effectiveness of Smoking Cessation Interventions during Pregnancy: A Briefing
Paper. http://www.nice.org.uk/nicemedia/live/13023/49422/49422.pdf
Expert Report 2: (ER2)
Hemsing N, O’Leary R, Chan K, Okoli C and Greaves L (2009) Interventions to
improve partner support and partner cessation during pregnancy. Centre of
Excellence
for
Women's
Health,
British
Columbia.
http://www.nice.org.uk/nicemedia/live/13023/49423/49423.pdf
Expert report 3: (ER3)
Myers K, West O and Hajek P (2009) Rapid review of interventions to prevent
relapse in pregnant ex-smokers. Queen Mary University of London, Barts & The
London School of Medicine and Dentistry, Wolfson Institute of Preventive Medicine.
http://www.nice.org.uk/nicemedia/live/13023/49424/49424.pdf
Economic evidence
Taylor M (2009) Economic Analysis of Interventions for Smoking Cessation Aimed at
Pregnant Women.
York Health Economics Consortium, University of York.
http://www.nice.org.uk/nicemedia/live/13023/49421/49421.pdf
Other references
NHS Health Scotland (2010) A guide to smoking cessation in Scotland 2010. NHS
Health Scotland. Edinburgh. http://www.healthscotland.com/documents/4661.aspx
NHS Health Scotland (2008). Smoking cessation support in pregnancy in Scotland.
NHS Health Scotland. Edinburgh. www.healthscotland.com/documents/2665.aspx
NHS Health Scotland and ASH Scotland (2005). Smoking Cessation Guidelines for
Scotland: 2004 Update. NHS Health Scotland: Edinburgh.
13
Medicines and Healthcare products Regulatory Agency and Committee on Safety of
Medicines (2005). Report of the Committee on Safety of Medicines Working Group
on
Nicotine
Replacement
Therapy.
http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/Safetywar
ningsandmessagesformedicines/CON2022933.
Up-to-date information on pharmacotherapy prescribing for smoking cessation
is available through www.mhra.gov.uk
British Medical Association and Royal Pharmaceutical Society of Great Britain
(2003). British National Formulary Number 46. London: The Pharmaceutical Press.
www.bnf.org, volume 46. Up-to-date information on licensing and
pharmacotherapy prescribing for smoking cessation is available through
www.bnf.org
National Institute for Health and Clinical Excellence (2010): Quitting smoking in
pregnancy and following childbirth. Public Health Intervention Guidance 26. NICE,
London; http://www.nice.org.uk/PH26
2. SMOKE FREE HOMES
Details of Studies
Baxter, S., Blank, L., Guillaume, L., et al on behalf of The University of Sheffield:
School of Health and Related Research (ScHARR) (2009). Systematic review of how
to stop smoking in pregnancy and following childbirth. Review 1: Which interventions
are effective and cost effective in encouraging the establishment of smoke free
homes? For NICE http://www.nice.org.uk/nicemedia/live/13023/49420/49420.pdf
Data also published in:
Baxter S, Blank L, Everson-Hock ES, Burrows J, Messina J, GuillaUme L, Goyder E.
(2011) The effectiveness of interventions to establish smoke-free homes in
pregnancy and in the neonatal period: a systematic review. Health Education
Research 10.1093/her/cyq092
http://her.oxfordjournals.org/citmgr?gca=her;cyq092v1.
Other references
BMA Board of Science (2007). Breaking the Cycle of Children’s Exposure to Tobacco
Smoke. BMA, London.
3. BRIEF INTERVENTIONS – REFERENCES
Details of Studies
Stead, L; McNeill A; Shahab L, West R (2005) Rapid Review Of Brief Interventions
And Referral For Smoking Cessation. Academic & Public Health Consortium,
commissioned for NICEPHIG1
http://www.nice.org.uk/nicemedia/live/11375/43949/43949.pdf
Economic evidence
Parrott, S, Godfrey C, (2006) Rapid Review of the cost-effectiveness of brief
14
interventions for smoking cessation. Centre for Health Economics, University of York
http://www.nice.org.uk/nicemedia/live/11375/43950/43950.pdf
Other references
NHS Health Scotland (2007) NHS Health Scotland Commentary on NICE Public
Health Guidance on brief interventions and referral for smoking cessation in
primary care and other settings. NHS Health Scotland: Edinburgh.
http://www.healthscotland.com/documents/2372.aspx
NICE (2006) Public Health Guidance PH1: Brief interventions and referral for
smoking cessation in primary care and other settings. NICE: London.
http://www.nice.org.uk/nicemedia/live/11375/31864/31864.pdf (Reviewed in March
2010 – no update required.)
NHS Health Scotland (2006) External evaluation of the NHS / ASH Scotland Young
People and Smoking Cessation Pilot Programme. NHS Health Scotland, Edinburgh.
http://www.healthscotland.com/documents/1381.aspx
West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an
update. Thorax 2000; 55: 987-999 doi:10.1136/thorax.55.12.987 http://www.britthoracic.org.uk/Portals/0/Clinical%20Information/Smoking/smokingcessationThorax2
000.pdf
4. SCHOOL BASED INTERVENTIONS - REFERENCES
Details of Studies
Olalekan, U., Yahaya, I., Pennant, M., et al (2009) School-based interventions to
prevent the uptake of smoking among children and young people: effectiveness
review.
West
Midlands
Health
Technology
Assessment
Collaboration
http://www.nice.org.uk/nicemedia/live/12827/47624/47624.pdf
Bauld, L., Brandling, J., Templeton, L., (2009). Facilitators and barriers to the delivery
of school-based interventions to prevent the uptake of smoking among children: A
systematic review of qualitative research. University of Bath & UK Centre for tobacco
Control
http://www.nice.org.uk/nicemedia/live/12827/47627/47627.pdf
Naidoo B et al. (2004). Smoking and public health: a review of reviews of
interventions to increase smoking cessation, reduce smoking initiation and prevent
further uptake of smoking. Evidence briefing. 1st edition. NHS Health Development
Agency
http://www.nice.org.uk/nicemedia/documents/smoking_evidence_briefing.pdf
Economic evidence
Jit M, Barton P, Chen YF, Uthman O, Aveyard P, Meads C (2009) Evidence review:
School-based interventions to prevent the uptake of smoking among children and
young people: cost-effectiveness model.
West Midlands Health Technology
15
Assessment Collaboration, University of Birmingham
http://www.nice.org.uk/nicemedia/live/12827/47628/47628.pdf
Other references
National Institute for Health and Clinical Excellence (2010): Public Health Intervention
Guidance 23. NICE, London http://guidance.nice.org.uk/PH23
NHS Health Scotland (2010) A guide to smoking cessation in Scotland 2010. NHS
Health Scotland, Edinburgh. http://www.healthscotland.com/documents/4661.aspx
Scottish Executive (2008). Scotland’s Future is Smoke-Free: A Smoking
Prevention Action Plan. www.scotland.gov.uk/Publications/2008/05/19144342/0
Scottish Executive (2006) Towards A Future Without Tobacco. Scottish Executive,
Edinburgh. http://www.scotland.gov.uk/Publications/2006/11/21155256/12
16
Evidence statements
1. QUITTING SMOKING IN PREGNANCY AND FOLLOWING CHILDBIRTH
Evidence statements
Identifying pregnant women who smoke and referring them smoking cessation
services
R2.1: Whether or not the subject of smoking is broached when pregnant
women are seen by health professionals
Two qualitative studies (one [+] Northern Ireland and one [-] USA) and five survey
studies (France, UK, Australia, New Zealand and South Africa) provide evidence that
not all staff ask all pregnant women about their smoking status during consultations.
One (-) study reports data from a lower income/educated population. Three studies
(one [++], one [+], one [-] and one narrative provide evidence that staff may not ask
about smoking status because of concerns regarding damaging the relationship
between themselves and a pregnant woman.
R2.2: The advice/recommendations given by health professionals
Five qualitative studies (one [-] USA and four [+] from South Africa, Sweden,
Northern Ireland and USA) and three surveys (France, Australia and GB) provide
evidence that the information and advice currently provided by health professionals is
perceived as insufficient or inadequate by some women and by professionals
themselves. There is the suggestion that advice could be more detailed and explicit,
and that professionals find discussion of individual smoking behaviours challenging.
Three of the studies (one [-] and two [+]) report data from a lower income/lower
educated/deprived area.
R2.3: The way that information and advice is communicated
Five qualitative papers (three [+] from Sweden, South Africa and GB and two [-] from
GB and USA) describe how the style or way that information/advice is communicated
to pregnant women smokers can impact on how the advice or information is
received. Concerns regarding advice being construed as nagging or preaching are
reported, together with the recommendation that a more caring, empathetic approach
may be helpful.
R2.4: The intervention provided during and after a consultation
One qualitative study ([+] Northern Ireland) and four surveys (Australia, France, New
Zealand and USA) provide evidence that there is variance in practice among staff in
regard to the type of intervention offered during and following a consultation, such as
whether a leaflet is offered, whether there is referral on to a specialist programme, or
whether ongoing personal support is offered.
R2.5: Whether or not policies/procedures/protocols are in place
There is evidence from one qualitative study ([+] South Africa) and two surveys (GB
and USA) that there is limited knowledge/availability/use of guidelines or protocols in
practice. There is evidence from one survey (Australia) that having
guidelines/protocols in place may be associated with an increase in the number of
17
smoking interventions offered.
R2.6: Record keeping and follow up
Evidence from four qualitative studies (one [++] New Zealand and three [+] from
Sweden, South Africa and USA) three surveys (GB, France and New Zealand) and a
narrative report (USA) suggests that record-keeping practices and follow-up
enquiries may be inconsistent among practitioners. Pregnant women smokers and
recent mothers differed in their views regarding the frequency with which they should
be asked about their smoking.
R2.7: The knowledge and skill base of staff
Three qualitative studies (one [++] New Zealand and two [+] from South Africa and
Sweden), seven surveys (four from Australia, two from USA and one GB) and one
narrative report (USA) suggest that staff perceive that they have limited skills and
knowledge to implement successful smoking cessation interventions.
R2.8: Time constraints
Two qualitative studies (one [+] South Africa and one [-] Australia), seven surveys
(three from Australia, two from USA, one New Zealand and one GB) and one
narrative report (USA) provide evidence that staff perceive that lack of time is a
significant barrier to the implementation of smoking cessation interventions.
R2.9: Resource constraints
One qualitative study ([+] South Africa), six surveys (four from Australia and two from
USA) and narrative from one study (USA) suggest that staff perceive that limited
resources, in the form of either staff or patient education materials, impact on the
delivery of interventions. These papers report findings from Australia and the USA –
their applicability to the UK may need to be considered.
R2.10: Staff perceptions of ineffectiveness
Two qualitative studies (one [+] Sweden and one [+] South Africa) and seven surveys
(three from Australia, two from USA, one New Zealand and one GB) suggest that
staff perceptions regarding the limited effectiveness of interventions may impact on
their delivery of services. One paper (USA) describes a lack of firm reasons for nonattendance given by women who did not attend a smoking intervention programme.
R2.11: Differences between professional groups
Four surveys (two from Australia, one New Zealand and one GB) provide evidence
that typical practice in regard to smoking cessation advice and management of care
can vary between doctors and midwives. It is reported that GPs are more likely to
advise women to quit smoking completely, whereas midwives are more likely to
advise gradual reduction. Also, the evidence suggests that midwives are more likely
to refer on to other agencies and record smoking status. GPs may be more likely
than midwives to raise the subject of smoking at subsequent consultations.
Evidence statement ER1.6
There is evidence from four UK studies (all [+]) that NHS Smoking Cessation
Services are effective in supporting pregnant women to stop smoking. The NHS Stop
Smoking Service interventions for pregnant women described in these articles
consist of a combination of behavioural support (delivered in a range of settings and
formats) and NRT (for most but not all women). They report varied outcomes but
those that included 4-week post-quit date outcomes reported quit rates of between
32% and 48%. However, evidence from a national study of smoking cessation
services for pregnant women in Scotland found that the reach and effectiveness of
services varied significantly between health boards. Some areas offered no tailored
18
(specialist) smoking cessation interventions for pregnant women.
Evidence statement ER1.10
There is good evidence that women in the UK under-report smoking during
pregnancy and that CO monitoring can aid in the identification of pregnant smokers.
Two studies (one [++] and one [+]) found that around one in four pregnant women in
the west of Scotland do not accurately disclose their smoking status when asked
during the booking visit with a midwife. One of these studies described how routine
CO monitoring in antenatal clinics, if implemented consistently, can improve the
accurate identification of pregnant smokers and facilitate referral to smoking
cessation services.
Evidence statement ER1.11
There is very preliminary evidence from two observational studies that opt-out
referral pathways can increase the number of women who engage with NHS
Smoking Cessation Services and result in larger numbers of women quitting
smoking, when compared with opt-in referral pathways.
Smoking Cessation Services – initial and ongoing support
Evidence statement R2.12
One qualitative study ([+] GB) and two narrative reports (both USA) describe
obstacles to pregnant women smokers accessing services as including: the length of
sessions; difficulty making telephone contact; and a lack of transport or child care. It
is suggested that domiciliary or very local services, the provision of crèche facilities,
appointment systems or telephone counselling could be suitable service delivery
options. One study (USA) suggests, however, that telephone support services may
have poor success in terms of contact rates.
Evidence statement ER1.5
There is good evidence from one recent systematic review (++) on the effectiveness
of self-help interventions for smoking cessation in pregnancy, although the extent of
UK evidence is limited. Fifteen trials were included in the review and 12 in the
primary meta-analysis which found that self-help interventions were effective (Odds
ratio [OR] 1.83, 95% CI 1.23-2.73). A further meta-analysis failed to find evidence
that more intensive self-help interventions had greater impact than less intensive
ones.
Evidence statement ER1.8
There is limited evidence about whether the form of delivery can affect the
effectiveness of smoking cessation interventions for pregnant women.
One trial ([++] UK) found some evidence that stage-matched interventions for
smoking cessation in pregnancy were more effective, particularly in improving
women’s readiness to quit, but concluded that it was difficult to interpret this finding
as the stage-based interventions were also more intensive. Another qualitative study
([+] UK) summarised the delivery characteristics of Smoking Cessation Services for
pregnant women that were perceived to be successful by key stakeholders. These
characteristics included: training of midwives in how to refer pregnant smokers to
specialist services, offering NRT to almost all clients, having an efficient system of
providing prescriptions, offering home visits, and providing intensive multi-session
behavioural support delivered by specialist staff.
Evidence statement ER1.9
19
There is limited evidence that the site or setting of the intervention influences the
effectiveness of smoking cessation interventions for pregnant women in the UK. One
study ([+] UK) found that most Smoking Cessation Services in Scotland offered home
visits by trained advisers to pregnant women. An analysis of routine service data
suggested that, for those home-based services for which data on engagement
(whether a woman attended the first appointment with a specialist adviser) were
available, about 50% of those referred engaged compared with 20% for clinic-based
services.
Evidence statement ER1.12
Two studies (one [+] UK and one [-] UK) explored pregnant women’s views about
smoking cessation services. Barriers to accessing services included, among others,
feeling unable to quit, lack of knowledge about services, difficulty of accessing
services, fear of failing and concerns about being stigmatised.
Evidence statement ER1.1
There is good evidence from one recently updated systematic review (++) on the
effectiveness of interventions for promoting smoking cessation in pregnancy.
The review included 72 trials, [31 of which used cognitive behavioural approaches to
cessation]. Pooled results show that cessation interventions reduce smoking in late
pregnancy (risk ratio [RR] 0.94, 95% confidence interval [CI] 0.93 to 0.96) and reduce
incidences of low birth weight (RR 0.83, 95% CI 0.73 to 0.95) and pre-term births
(RR 0.86, 95% CI 0.74 to 0.98) while increasing birth weight by a mean of 53.91 g
(95% CI 10.44 g to 95.38 g). The overall finding of the updated review is that
smoking cessation interventions used in early pregnancy can reduce smoking in later
pregnancy by around 6% (or 3% using studies least prone to bias).
Evidence statement ER1.2
There is good evidence from one recently updated systematic review (++) on the
effectiveness of financial incentives for promoting smoking cessation in pregnancy.
Four trials in the review examined financial incentives. A meta-analysis found that
financial incentives paid to pregnant women to promote smoking cessation were
found to be significantly more effective than other intervention strategies (RR 0.76,
95% CI 0.71 to 0.81).
The health consequences of pregnant women cutting down as opposed to
quitting
There is evidence that some health professionals are reluctant to advise outright
cessation rather than cutting down, but cutting down is of little, if any benefit.
Outright cessation should therefore be advised.
Evidence statement R3.1.
There is limited evidence from four good quality studies that quitting versus reducing
cigarette consumption during pregnancy is associated with increased infant birth
weight of between 89 and 254g. Two of the studies provide very little statistical
analysis regarding the significance of these numerical differences between quitters
and reducers. Only one study (+) provides odds ratios, with OR 1.18 for quitters
having a low birth weight infant compared to OR 1.73 for reducers. Baseline
differences between quitters and reducers in all these studies may be significant.
These papers all examine data from studies carried out in the United States of
America which may have implications for applicability to a UK setting.
Evidence statement R3.2.
There is limited evidence from one good quality study (+) that the reduction in
20
cigarette consumption required to make a significant impact on birthweight needs to
be of the magnitude of more than 50% (among women smoking 20 cigarettes per
day) to lead to a statistically significant increase in birth weight . This paper
examines data from studies carried out in the United States of America and may thus
have implications for applicability to a UK population.
Interventions to prevent relapse in pregnant ex-smokers
Evidence statement ER3.1
Two Cochrane Reviews of relapse prevention (RP) interventions with women who
stopped smoking during pregnancy found that the types of interventions examined so
far had no effect on relapse (++). Four evaluative studies were found which did not
qualify for inclusion in the Cochrane Review on RP. One non-randomised cohort
comparison found a significant effect, but three randomised studies produced
negative results.
Evidence statement ER3.2
Overall, the results are consistent with the Cochrane negative verdict (+).
Partner support
Evidence statement ER2.1: Which interventions are effective in encouraging
partners and significant others to support smoking cessation during
pregnancy and following childbirth?
There is limited evidence on which interventions are effective in encouraging
partners to support smoking cessation during pregnancy and postpartum. Seven
of the intervention studies addressed partner support of women‘s cessation.
Studies that reported non-significant outcomes used workbooks (+), counseling
(+ and -), a media education campaign (+), or biofeedback methods (-, +). The
one study that reported significant outcomes was a (+) Dutch randomized control
trial, targeting the partner to encourage smoking cessation during pregnancy. In
this intervention, pregnant women received health counseling along with video
and print resources on smoking cessation, while partners received a booklet
explaining that quitting together is important for the health of the baby. However,
it is unclear what impact the partner-booklet had on pregnant women‘s smoking
cessation, since 76.2% of the women reported delivering the booklet to their
partner, and only 48.5% of partners reported reading the booklet. Applicability:
The one study with significant outcomes took place outside of the UK. Therefore,
findings may not be directly relevant to the UK.
Evidence statement ER2.2: Which interventions are effective in encouraging
partners and significant others who smoke to stop smoking?
There is moderate evidence that multi-component interventions that include free
nicotine replacement therapies are effective in encouraging partners who smoke to
stop smoking. Nine studies (five [+] from USA, the Netherlands, Australia and two
from the UK, one [++] Australia, three [-] from Sweden, China and Norway) examined
whether specific interventions were effective in encouraging partners and ‘significant
others’ who smoke to stop smoking. Interventions that had non-significant outcomes
include: a media education campaign, partner-delivered booklet, counselling,
biofeedback-based interventions, and self-help guidance. Two randomised control
trials from the US and Australia had significant outcomes. These interventions
offered free NRT patches to partners, in conjunction with smoking cessation
resources and multiple telephone counselling sessions which encouraged partner
support, or along with a minimal intervention which included video and print materials
on smoking cessation and multiple contacts to address the male partner’s smoking.
21
However, the effect of treatment on overall quit rates was not sustained at follow-up
periods. Applicability: both studies with significant findings took place outside of the
UK. Therefore, findings may not be directly relevant in the UK.
Evidence statement ER2.3: How does the way the intervention is delivered
influence effectiveness?
There is limited evidence that the method of delivery influences the effectiveness
of interventions targeting partners and significant others in supporting smoking
cessation during pregnancy and following childbirth. Biofeedback approaches,
such as using a demonstration of the health of the fetus with an ultrasound or a
model of fetal heart rate did not show any significant results in two before and
after studies conducted in Australia (+) and Sweden (-). Furthermore, relying on
the woman to provide the intervention materials to her partner also had no
significant effect on smoking outcomes in two RCT studies in the Netherlands (+)
and China (-). Providing free nicotine replacement therapy and having intensive
interventions, showed a significant effect on smoking outcomes in one Australiabased (++) RCT. Applicability: All studies were conducted outside of the UK.
Therefore, findings may not be directly relevant to the UK.
Evidence statement ER2.4: Does effectiveness depend on the status of the
person delivering it?
While no studies specifically examined whether the status of the person
delivering an intervention influences effectiveness, the three studies that
demonstrated significant effects (out of the nine studies reviewed) were delivered
by highly trained medical personnel. Effective interventions in three RCTs [one
++ and two +] conducted in the US, Australia, and the Netherlands utilized highly
trained medical personnel to deliver interventions (including graduate-level
educated counsellors, general practitioners and midwives), but in two of the
studies the there was either no significant effect of the intervention on smoking
cessation outcome or effectiveness was not measured at postpartum.
However, because these studies did not examine the impact of the status of the
person delivering the intervention on its effectiveness, further research is required
and recommended to answer this question. Applicability: All studies were
conducted outside of the UK. Therefore, findings may not be directly relevant to
the UK.
Evidence Statement ER2.5: Does the site/setting influence effectiveness?
While no studies specifically examined the effects of the site/setting of the
intervention, one study provides some relevant evidence related to the site of an
intervention and another intervention took into consideration the setting (context).
In particular, significant results were obtained in one (++) Australian-based RCT
study in which the intervention was performed in participants‘ homes. In addition,
one (-) RCT study based in China included only literate participants, which may
not be applicable to the Chinese context, where illiteracy rates are high.
Applicability: Studies were conducted in Australia and China. Therefore, findings
may not be directly relevant to the UK.
Evidence Statement ER2.6: Does the intensity of the intervention influence
effectiveness or duration of effect?
There is inconsistent evidence whether or not the intensity of the intervention
influences its effectiveness. Direct and repeated contact was a component of
interventions in 3 RCT studies [one ++, two +] conducted in the US, Australia and
22
the Netherlands, which resulted in significant cessation effect with partners and
with pregnant women. However, repeated contacts in one US-based RCT [+] and
one Norwegian before and after study [-] did not result in significant increases in
cessation for pregnant women1 or pregnant women and their partners.
Applicability: Studies were conducted outside of the UK, and therefore may not
be directly relevant to the UK.
ER2.7: How does effectiveness vary according to the age, sex, socio-economic
status or ethnicity of the target audience?
There is strong evidence that effectiveness of an intervention may be influenced by
the socioeconomic status of the target audience. Evidence from two (+) RCT studies,
demonstrates that dropouts are significantly higher among those participants with
lower education and income. One (++) RCT study targeting male partners revealed
that men with a skilled job exhibited a higher quit rate, more quit attempts and (for
those who continue to smoke) smoked their first cigarette of the day later than
unskilled workers. One [+] before and after study described a mass media campaign
targeted to young, low and middle income pregnant women; however, the
intervention yielded no significant changes in smoking prevalence.
There was no available evidence examining the impact of sex or ethnicity.
Applicability: Two studies were conducted in the UK, and therefore the evidence from
these studies is relevant. While the other studies were conducted outside of the UK,
the findings support UK-based evidence.
Evidence Statement ER2.8: What are the facilitators and barriers to
implementation?
An important barrier to consider for treatment implementation may be the
ineffectiveness of one time treatments. In 3 before and after studies [one -, two +]
and 2 RCTs [one +, one -] employing one time treatments the interventions were
ineffective. There is moderate evidence that another barrier to the implementation
of interventions during pregnancy on smoking cessation of partners or pregnant
smokers is the lack of a sustained effect of the interventions in the postpartum
period. In the 3 RCTs where effectiveness was demonstrated, impact was either
not measured or not effective at postpartum [one ++, two +] with significant
results. There is moderate evidence that the use of videos and NRTs in interventions
may enhance the effectiveness of interventions. In RCT studies, interventions which
included videos [one ++, one +] and/or NRT for partners [both +] reported significant
effects. Applicability: One study was conducted in the UK, and therefore the evidence
from this study is relevant. The other studies were conducted outside of the UK, and
therefore may not be directly applicable to the UK-context.
Use of NRT and other pharmacological support
The benefits of NRT outweigh the risks of smoking for pregnant smokers. The use of
NRT by pregnant smokers may benefit the mother and fetus if it leads to cessation of
smoking. There is some evidence that nicotine may be implicated in some of the
damage to the fetus from smoking in pregnancy, but the harm from NRT would be
expected to be less than from smoking. Thus, although there are some concerns
about the safety of nicotine in pregnancy, the risks of smoking in pregnancy can be
expected to outweigh the risks of NRT in pregnancy, so NRT should be considered
for use if it can improve a pregnant smoker’s chances of stopping (NHS Health
Scotland, 2010).
Evidence statement ER1.3
There is mixed evidence from one recently updated systematic review (++) and one
23
recent trial ([++] USA) (not included in the review) on the effectiveness of nicotine
replacement therapy (NRT) for promoting smoking cessation in pregnancy.
In the review, meta-analysis of data from five trials found NRT to be effective (RR
0.95 CI 0.92 to 0.98). However, a large, double-blind, placebo-controlled trial,
published after the review searches were completed, found no evidence that NRT
was effective for smoking cessation in pregnancy (RR 0.96, 95% CI 0.85-1.09).
Evidence statement ER1.4
There is no evidence that NRT either increases or decreases low birthweight. There
are insufficient data to form judgements about any impact of NRT on stillbirth or
special care admissions (two [++]).
24
2. INTERVENTIONS TO PROMOTE SMOKE FREE HOMES
Evidence statements
Evidence statement R1.1: Counselling interventions
Mixed evidence from six studies [one - , one + , five ++ ] reported on counselling
interventions to promote smoke free homes. These studies showed only very weak
associations between the counselling interventions and smoke free related outcomes
(such as cotinine measures or self reported smoking). Due to the limited
effectiveness seen, it is not possible to recommend specific types of counselling
approaches or methods of delivery as most beneficial, however the most effective
intervention consisted of behavioural counselling for smoking mothers delivered by
graduate students with 20 hours of training and weekly supervision.
Evidence statement R1.2: Counselling interventions with additional elements
Mixed evidence from two studies [both +] was identified for interventions which
combine counselling with additional elements such as the provision of written
materials or telephone support. However, one study reported only on knowledge
outcomes, rather than behaviour change.
Evidence statement R1.3: Interventions to develop (mostly individualised)
smoke free home policies
Good evidence from four studies [two + , three ++] looked at programmes to
implement individually adapted smoke free home polices or a more generic policy.
These interventions generally had problems with low compliance and loss to follow
up.
Evidence statement R1.4: Motivational interviewing interventions
Good evidence from one study [++] which reported on the use of motivational
interviewing to promote smoke free homes demonstrated a significant decrease in
nicotine levels in intervention households over six months (however, this was not
supported by self-reported smoking rates).
Evidence statement R1.5: Professional training intervention
One study [+] reported on the effect of an educational intervention on the screening
and counselling activities of physicians with regard to passive smoking. This study
did not consider the effect of those who attended the intervention compared to those
who did not so the effectiveness of the intervention is unclear.
25
3. BRIEF INTERVENTIONS
Evidence statements
Brief interventions from nurses and doctors
Brief interventions from doctors
A body of level 1+ evidence directly applicable to UK health care settings supports
the efficacy of physician advice as a brief intervention for smoking cessation but this
evidence preceded the introduction of NHS specialist smoking cessation services in
the UK.
Brief interventions from nurses
A body of level 1+ evidence directly applicable to the UK supports the efficacy of
nurse advice as a brief structured (as opposed to opportunistic during routine care)
intervention for smoking cessation in primary care and community settings. However,
the primary focus of the contact in these studies was smoking, so these interventions
are not brief opportunistic interventions made during routine care. In addition, poor
uptake of invitations to contact nurses for assistance with smoking cessation was
noted in some UK studies. There is insufficient evidence to say whether opportunistic
advice increases quit rates. A moderately sized body of evidence failed to detect any
effect of advice and interventions delivered by nurses as part of a health check. This
evidence preceded the development of specialist smoking cessation services within
the UK.
Does the profession of the practitioner influence effectiveness?
There is insufficient evidence from direct comparisons to draw firm conclusions about
the influence of the profession of a provider delivering a brief smoking cessation
intervention, or the influence of features of the profession, on intervention
effectiveness.
The involvement of health professionals in offering smoking cessation interventions
should be based on factors such as access to smokers, level of training, experience,
and commitment, rather than professional discipline; (West et al, 2000) it remains
possible that such factors are more important than professional discipline. Most of
the research on brief advice has been done with GPs because of their central role
within the NHS. The ACPHR guideline in the USA shows that many professions can
give effective smoking cessation interventions, and the evidence does not strongly
favour one profession over another. There is a need in the UK for more research on
the role of practice nurses, midwives, health visitors, and others, in delivering
smoking cessation interventions because of their wide access to smokers. The
potential for helping smokers in primary care is enormous. The cornerstone of the
NHS smoking cessation strategy should be routine provision of brief advice and
follow up in primary care, including advice on NRT and how to use it (NHS Health
Scotland, 2010).
All smokers should have ready access to, and be strongly encouraged to use,
dedicated SCSs. Behavioural support to aid cessation should not take the form of
brief interventions delivered by non-specialist staff as this has been shown to be
ineffective. However, brief interventions by non-specialist staff (staff who have not
been trained to deliver specialist smoking cessation support and who are not
employed for that purpose) are effective in triggering a quit attempt and encouraging
smokers to use the SCSs but are not a substitute for that service.
26
Brief interventions by type
Adjunct Pharmacotherapy
A body of level 1+ evidence directly applicable to the UK supports the efficacy of
NRT as part of a brief intervention for smokers wishing to make a quit attempt.
There is mixed evidence from one recently updated systematic review (++) and one
recent trial (++, from USA) on the effectiveness of NRT for promoting smoking
cessation in pregnancy. Cessation outcomes are highest when pharmacotherapy
(NRT, bupropion or varenicline) is prescribed in the context of intensive smoking
cessation support such as that provided through NHS specialist smoking cessation
services.
Brief interventions based on self help materials
A body of level 1+ evidence directly applicable to UK settings marginally supports the
efficacy of providing standard self-help materials as a brief intervention (without any
face to face contact) for smoking cessation. A body of level 1+ evidence supports the
efficacy of materials that are tailored for individuals. There is a moderately sized body
of evidence that has failed to detect any benefit for materials tailored for specific
populations compared to standard materials. A body of level 1+ evidence directly
applicable to UK settings does not support any additional benefit of providing selfhelp materials as an adjunct to advice.
Brief telephone based interventions
Support provided by telephone helplines in general has been found to be effective,
but there is insufficient evidence to distil the effectiveness of brief interventions
provided through them.
Brief interventions based on stages of change
A moderately sized body of evidence has not found a benefit of stage matched over
unmatched brief interventions. A moderately sized body of evidence has yielded
conflicting results on the efficacy of stage-matched interventions compared with no
intervention.
Brief multi component interventions
There is insufficient evidence to determine the efficacy of brief multi component
interventions involving assessment of smoking status, advice to quit, and assisting a
quit attempt and offering NRT and counselling.
Other adjuncts to brief interventions
There is insufficient evidence to draw conclusions about the efficacy of adjuncts to
advice such as feedback on CO levels, lung function or other objective markers of
smoking and its effect.
Brief interventions for special populations
Brief interventions for pregnant women
A moderately sized body of level 1+ evidence has not detected any effect of brief
interventions delivered as part of routine care for pregnant smokers. There is
insufficient evidence to determine the efficacy of brief interventions that are not
delivered as part of routine care. Although there is no evidence base to support
midwife delivered advice, it is a basic right of pregnant smokers to be advised of the
specific risks. There is good evidence from one recently updated systematic review
(++) of the effectiveness of interventions for promoting smoking cessation in
27
pregnancy.
Brief interventions for adolescents/students
There is insufficient evidence to determine the efficacy of brief interventions for
adolescents/students. There is little research evidence of effective cessation
programmes with young people to date, but health professionals clearly cannot
ignore their needs. Young people should be offered the same brief interventions as
adults. There are limited trials of NRT with young people but there seems no reason
why they should not use it. This is an area where there is ongoing research – pilot
smoking cessation interventions for young people were being evaluated in Scotland
(NHS Health Scotland, 2006) but general principles suggest that where there is a
demand, it should be offered.
Brief interventions to reduce environmental tobacco exposure in children,
families and carers
A moderately sized body of level 1+ evidence has not detected any effect of brief
family and carer interventions to decrease children’s exposure to environmental
tobacco smoke.
Brief interventions for smokeless tobacco users
There is insufficient evidence to determine the efficacy of brief interventions for
smokeless tobacco users.
4. SCHOOL BASED INTERVENTIONS TO PREVENT THE UPTAKE OF
SMOKING
Evidence statements
Organisation-wide or ‘whole-school’ approaches
Evidence statement QR1: Delivery context
Evidence from two UK (one [++], one [+]), one Canadian (++) and three American (all
[+]) qualitative studies suggests that aspects of the delivery context of school-based
interventions act as barriers or facilitators to effective delivery. The main facilitators
were:
 timing the intervention to suit (that is, not conflict with) school-assessment
schedules
 timing the intervention to include multiple sessions over the course of a school
year
 reinforcing smoking prevention messages in school curricula until school leaving
age
 delivering school-based prevention interventions as part of a wider tobacco control
strategy involving key partner organisations in design and delivery (such as the
school nursing service and universities).
The main barrier was delivering the intervention in a setting where teachers and
28
other school staff are smokers.
Evidence statement QR5: Smoke free schools
There is evidence from one UK (+), one Canadian (++) and one American (-) study
that the extent and enforcement of smokefree school policies can act as a facilitator
or barrier to school-based smoking prevention. Facilitators included:
 smokefree policies that include all internal areas and all school grounds
 smokefree policies that applied to staff as well as pupils.
Barriers included:
 existing designated smoking areas in school grounds or buildings
 poor enforcement of smokefree policies.
Evidence statement ES24
There is limited evidence on adverse or unintentional effect of school based
prevention of smoking uptake. No studies specifically examined adverse or
unintentional effects of school-based smoking prevention programmes. One multicountry study (de Vries et al. 2006 -, EU) in six European countries found that
adolescents in The Netherlands exposed to school-based smoking prevention
programme were more likely to be a regular smoker than those in control condition.
Piper, Moberg, & King 2000 (+, USA) provided evidence that age- appropriate
intervention emerged as marginally harmful over the control condition.
There is review-level evidence to support the effectiveness of community wide
interventions based on social learning theory/social influences approaches in
preventing the uptake of smoking in young people (Naidoo, 2004).
Adult-led interventions
Evidence statement ES1
There is evidence from 27 studies that provided usable data for meta-analysis that
interventions may be effective. Meta-analysis of 27 randomised controlled trials
(RCTs) demonstrated a significant intervention effect for school-based intervention
for preventing uptake of smoking among children. There was moderate statistical
heterogeneity between the trial results. Applicability: most of the studies took place
outside of the UK It is not clear if these findings are directly applicable to the UK.
Evidence statement ES6
There is conflicting evidence about the effectiveness of different conceptual models
of school- based prevention programmes (social influence, social competence,
information giving and combined interventions) and the interventions in many RCTs
were not effective in preventing or delaying uptake of smoking in comparison with no
programmes or in comparison to other forms of prevention programmes. Therefore
there is no clear evidence to suggest that any particular conceptual model
intervention is more effective than any other conceptual model intervention compared
usual education.
There is evidence from 15 RCTs (two ++, Canada; two ++, USA; three +, UK; four +,
USA; one -, Norway; one -, The Netherlands; and two -, USA) that social influence
curricula may be effective in preventing smoking but the size of effect is small. Four
RCTs (three -, The Netherlands and one -, USA) provided evidence that information
giving curricula may be effective with a larger effect size. However, social
competence (one -, UK) and combined (one +, USA and three -, USA) curricula
detected no difference in smoking prevalence between those students in
experimental and control conditions. These results may be confounded by RCT
29
quality.
Evidence statement ES7
There is moderate evidence indicating that multi-component interventions
incorporating both school and community components (with or without an additional
family component) are ineffective in preventing the uptake of smoking compared to
usual education. Five RCTs provided evidence comparing a multi-component
intervention that incorporates both school and community components to usual
education (three [+] USA), one [-] Australia, one [-] UK). Four of the studies (two [+]
USA, one [-] Australia, one [-] UK) found no significant difference between the multicomponent intervention group and the usual education group during a maximum
follow-up between 6 months (one study [-] UK).and 5 years (one study [+] USA). One
study ([+] USA) found no difference at 3-year follow-up and small, marginally
significant positive or negative intervention effects (depending on the school
component) at 4-year follow-up.
Evidence statement ES8
There is inconclusive evidence as to the effectiveness of interventions incorporating
both school and family components in preventing the uptake of smoking compared to
usual education. Thirteen RCTs of mixed quality provided evidence comparing
interventions that incorporate both school and family components to usual education.
Three of the RCTs found a significant positive effect of family and schools
intervention compared to usual education. Nine RCTs showed no significant
difference between family and schools intervention and usual education. One RCT
showed a significant effect in boys but not girls.
Evidence statement ES13
There is clear evidence that the addition of booster sessions enhanced effectiveness
of main programmes. Four studies (one [++] and three [-]) analysed effectiveness of
booster sessions. Evidence from one (++) USA study suggests that addition of
booster sessions significantly enhanced the effectiveness of the main programme
and was more effective than the delayed programme controls. One (-) USA study
found that boosters can be an effective tool for maintaining or increasing the
effectiveness of smoking prevention programmes. One (-) USA study revealed that
addition of booster sessions to cognitive-behavioural approach can reduce tobacco
use. Another (-) USA study showed that continued intervention students reported
significantly less smoking than lapsed intervention and continued control students.
Applicability: all four studies were conducted in the USA. It is not clear if the findings
are directly relevant to the UK.
Evidence Statement ES25
An obvious barrier to interventions may be poor student attendance so that
interventions, regardless of their value, will fail to have positive effects. In one RCT, a
dose-response relationship was observed between programme participation and
changes in smoking status.
Evidence statement ES26
In one RCT, engagement with the intervention (reported programme interesting/very
interesting and useful) was shown to be related to follow-up smoking status; those
engaging being less likely to be smokers at 1 year.
Evidence statement QR4: Delivery mechanisms
Delivery mechanisms: there is evidence from three UK (one [++], one [+] and one [-])
and three American (all [+]) qualitative studies that specific elements of the delivery
30
mechanism for school-based prevention interventions can act as facilitators or
barriers. Facilitators include:
 delivery of the intervention by trusted external professionals (such as doctors)
 delivery of the intervention by non-smoking teachers
 delivery of the intervention by teachers with higher self-efficacy
 involvement of parents in delivery (primarily delivery of supporting materials at
home).
Barriers included:
 delivery of the intervention by teachers who are reluctant to discuss parental
smoking
 delivery of the intervention by teachers who use outdated methods to
communicate prevention messages.
Evidence statement QR6: Programme Content
There is evidence from seven American (all [+]), one Canadian (++) and one UK (-)
qualitative studies that specific elements of programme content can act as facilitators
or barriers to the delivery of school-based prevention interventions. Facilitators
include:
 content that is innovative and interactive
 content that includes role play
 content that includes new material, such as on the cost of smoking
 content that includes correcting misconceptions of high smoking prevalence
among young people
 content that is ethnically and culturally sensitive
 content that is non-judgemental
 content that included de-normalisation approaches (building on the Florida ‘Truth’
campaign approach, exposing the activities of the tobacco industry).
Barriers include:
 content that included fear-based approaches to prevention
 content that is too complex.
Peer-led interventions
Evidence statement ES11
•
It is not clear whether effectiveness of school-based smoking prevention
programmes depend on the status of the person delivering it. There is conflicting
evidence whether peer-led programmes produced most effective intervention
effects on smoking initiation. It is important to note that a peer-led programme
may be differentially effective based on how leaders are selected and how groups
are formed, and may be curriculum-dependent. There is some evidence that
teacher-led, health educator-led, and peer-led programmes tend to be equally
effective.
•
Seven RCTs examined whether effectiveness of school-based smoking
prevention programmes depend on the status of the person delivering it.
• Three other studies provided evidence that peer-led interventions tend to enhance
smoking prevention programmes. For example, results from one (+) USA RCT
31
showed a marked suppression in the onset of both experimental and regular
smoking among those students exposed to the resistance training with peer
involvement. Similarly, one (-) USA RCT found that a cognitive-behavioural
approach when carried out by peer-leaders and when additional boosters are
provided can reduce tobacco use. Yet one (+) USA RCT provided evidence that a
peer-led programme will be differentially effective based on how leaders are
selected and how groups are formed, and this effect may be curriculum
dependent.
• In one RCT ([-] USA), there was no statistically significant difference in regular
smoking rates among students taught by health educators and those taught by
adult teachers assisted by older teens. One (++) UK RCT found that the effect of
ASSIST intervention was much the same for peer supporters and non-peer
supporters. Similarly, one (-) Australia RCT confirmed non-superiority of peer-led
programmes to teacher-led programmes. However, this result was genderspecific.
• Both the teacher-led and peer-led programmes reduced, to about the same
degree, the uptake of smoking by girls while only the teacher-led programme
appeared to be effective in boys. One (++) Canada RCT provided evidence that
teachers and nurses were equally effective providers regardless of delivery
method. While, one (-) USA RCT reported that students exposed to interactive
health educator-led interventions were less likely to use tobacco compared to
those not exposed to health educator-led instruction.
• Applicability: most of the studies were conducted in the USA. It is not clear if these
findings are directly applicable to the UK since the interventions under
investigation are specific to USA. Furthermore, demographics of the participants
are different from those in the UK. Only one (++) UK study is likely to be directly
applicable.
Evidence statement QR3: Peer interventions
There is evidence from three UK (two [++] and one [+]) and one American (+) study
and one systematic review (++) that interventions that directly address peer smoking
norms through involving young people in delivery can facilitate the successful
implementation of school-based prevention interventions. The main facilitators to the
delivery of peer interventions were:
 nomination of peer supporters by fellow students
 training for peer supporters delivered away from school and by external
professionals
 flexibility for peer supporters in how and when they deliver the intervention
 adding ‘value’ to peer intervention by inclusion of other prevention education
materials (such as videos) in schools
 good communication between the external intervention development or research
team and school staff.
Barriers to the delivery of peer interventions were:
 teacher’s concern about ‘suitability’ of some peer supporters selected by fellow
students
 peer norms and peer group structure can influence how much and when
adolescents smoke, and can also influence the extent to which young people are
receptive to prevention messages delivered by peers.
32
There is review level evidence that supports the continued use of school-based ‘peer’
or ‘social-type’ interventions in preventing smoking in children (Naidoo, 2004).
Differential effects of interventions according to use of biomedical validation,
type of outcome measures and presentation of results
Evidence Statement ES2
There is strong evidence from subgroup analysis that interventions show more
pronounced effectiveness in studies with lower quality (as measured by++, + and –
grades).
Evidence Statement ES3
There is no evidence of the intervention having a differential effect according to
whether a study used biochemical validation or not. Evidence from subgroup analysis
shows that the intervention does not have a more pronounced effect when selfreported smoking behaviour was validated using biochemical methods (by saliva
thiocyanate or cotinine or expired air carbon monoxide levels) compared to
questionnaire completion only.
Evidence Statement ES4
There is good evidence about the differential effect according to type of outcome
measures (prevalence of regular or experimental smoking). Results from 16 RCTs
that used prevalence of regular smokers provided evidence that interventions may be
effective in reducing smoking uptake among children. Pooled result from 10 RCTs
that used experimental smoking as the main outcome also found that interventions
could be marginally effective in preventing smoking uptake. Programmes that used
prevalence of regular smoking tended to produce statistically significant results but
the size of combined effect was very similar to that for programmes that used
experimental smoking as an outcome measure. The main difference between the two
was the width of the confidence intervals, giving one as statistically significant but not
the other, so this difference may be a statistical artefact.
Evidence Statement ES5
There is good evidence of the intervention having a differential effect according to the
way the results were presented. It may be that adjusted results tended to produce
more significant programme effectiveness, i.e. when RCTs adjusted for potential
confounders such as baseline smoking rates, sex, and socioeconomic status. Many
of the studies with adjusted results were of low quality.
Differences in effectiveness by age, sex, ethnicity and socioeconomic status
Evidence statement ES14
It is not clear whether the age of the target audience has any impact on effectiveness
of school-based prevention of smoking. There is inconclusive evidence whether the
effectiveness of interventions depend on the age at which students were recruited
and the age of students at maximum follow-up. There is conflicting evidence that age
is an important predictor of smoking in school-based prevention programmes. Three
studies (Dijkstra et al. 1999 (+, USA); Gatta et al. 1991; (+, Italy) and Ausems et al.
2004; (-,The Netherlands)) found that the risk of smoking increased linearly with
increasing age of the participants. Three studies (Johnson et al. 2005; (+, USA);
Elder et al. 2002; (+, USA); and Chatrou et al. 1999; (-, The Netherlands)) found no
33
significant association between age and prevalence of smoking. One particular study
(Ausems et al. 2004; (-,The Netherlands)), found that this association diminished and
became non-significant with longer duration of follow-up. Contrary to this finding,
another study (Chatrou et al. 1999; (-, The Netherlands)) found that age did not
predict prevalence of smoking regardless of duration of follow-up. We found
inconclusive evidence whether effect of intervention depended on the age at which
students were recruited and age of students at maximum follow-up. There is limited
evidence from subgroup analyses which revealed that intervention may be effective
when students were recruited at 11 or 12 years old, and when students were 14 or
16 years at maximum follow-up.
Evidence statement ES15
There is weak evidence (Kellam 1998, - USA; Storr 2002, - USA) indicating that
school-based interventions that start soon after entry into primary schools and that
target behaviour management in the classroom, poor academic achievement, and
teacher-parent communication regarding behaviour management may be effective in
reducing the uptake of smoking up to age of 14. Evidence for the effectiveness of
such interventions beyond this age is lacking.
Evidence statement ES16
Evidence regarding the effectiveness of school-based interventions starting between
age 7 and 10 is inconclusive. Studies report either no significant effect or significant
effects immediately post-intervention which diminish over time. Two interventions
focusing on smoking prevention demonstrated no significant effects on smoking
(Gatta 1991, + Italy; Peterson 2000, ++ USA). Three interventions focusing on drug
(substance) use prevention reported either no effect (Ringwalt 1991, + USA); nonsignificant reduction in smoking prevalence (Schinke 2000, +USA) or significant
reduction in smoking prevalence immediately after intervention period that was not
sustained at subsequent follow-up (Ennet 1994, -USA). One health promotion
program that included a smoking prevention component found no significant effect
(Elder 1996, +USA).
Evidence statement ES17
Forty-six RCTs investigated the effectiveness of school-based interventions that
started in secondary schools between ages 11 to 14. Quantitative analysis indicated
that whilst the observed effect for individual RCTs did not achieve statistical
significance in most cases, overall the interventions appear to have modest effect in
preventing the uptake of smoking. There is significant heterogeneity in the results
between studies, indicating that the findings may be specific to the context of
individual studies/interventions.
Evidence statement ES18
Evidence from seven studies conducted in North America regarding the effectiveness
of school-based interventions that start from age 14 or later is inconclusive. One RCT
(Sussman et al. 2003 -, USA) reported a significant reduction in the odds of smoking
for an educator-led intervention whilst two RCTs (Dent et al. 2001 +, USA; Sun et al.
2006, +, USA) evaluating different versions of the same curriculum reported no
significant intervention effect. Four other RCTs reported significant effects either for a
specific subgroup (Brown et al. 2000 ++, USA) or for outcomes that may be more
relevant to smoking cessation than prevention (Brown et al. 2001 +, USA; Werch et
al. 2005 +, USA; Winkleby et al. 2004 +, USA).
Evidence statement ES19
There is conflicting evidence of differential effect of intervention according to the sex
of the target audience. There is moderate evidence that sex is an important predictor
34
of post-test smoking, but direction of effect (either in male or female student) is
inconclusive. Furthermore, association of sex with smoking prevalence depends on
how the outcome was measured. One recent study ([+] UK) found no significant
difference in effectiveness of school-based intervention among male and female
students. Another study ([++] USA) provided no evidence of Hutchinson Smoking
Prevention Project impact on the prevalence of daily smoking, either for girls or for
boys. Three studies (one [++] Canada; one [+] Canada and one [-] USA)
demonstrated that the intervention was more effective among male students; while
only one study ([-] Australia) found that both teacher-led and peer-led programmes
reduced the taking up of smoking by girls to about the same degree.
There was also conflicting evidence from nine studies whether sex was an important
predictor of post-test smoking. Only one study ([-] The Netherlands) provided
evidence that sex was not associated with post-test smoking. Two studies (one [+]
USA and one [-] USA) found that female students were more likely than male
students to have reported smoking at follow-up and only one study ([-] Australia)
found that boys were less likely than girls to have reported smoking at follow-up. Yet,
three studies (two [-] USA; and one [-] The Netherlands) revealed that males were
more likely to be a smoker than their female counterparts. Another two studies (one
[+] USA and one [+] Italy), demonstrated that compared to male students, female
students were less likely to have used tobacco.
Applicability: most of the studies were conducted in the USA. It is not clear if these
findings are directly applicable to the UK since the interventions under investigation
are specific to the USA. Furthermore, demographics of the participants are different
from those in the UK. Only one study is likely to be directly applicable.
Evidence Statement ES21
There is moderate evidence that ethnicity is an important predictor of smoking
behaviour, such that white students were less likely to be smokers. Similarly, there is
moderate evidence that the observed association between race and smoking
behaviour depended on how the outcome was measured. Four studies (two [+] USA
and two [-] USA) specifically studied whether ethnicity is an important factor in
predicting post-test smoking among students exposed to school-based smoking
prevention programmes. Only one study ([-] USA) demonstrated no association
between ethnicity and smoking status. However, three studies found that ethnicity
was an important factor in predicting post-test smoking behaviour. For example, one
study ([+] USA) provided evidence that white students were less likely to be classified
as smoker. Two studies (one [+] USA and one [-] USA) revealed that ethnicity affects
smoking prevalence depending on how the outcome was measured. One multicountry study ([-] EU) in six European countries, provided evidence that in The
Netherlands there was differential significant effects for adolescents with a Dutch and
non-Dutch origin. The Dutch ESFA programme was effective for non-native
adolescents with fewer new weekly smokers compared to new weekly smokers in the
control group. An opposite effect was found in native Dutch adolescents with more
new weekly smokers in the experimental compared to new smokers in the control
group.
Applicability: none of the studies were conducted in the UK. It is not clear if the
USA/EU findings are directly applicable to the UK since the school-based prevention
programmes under investigation are specific to USA. Furthermore, demographics of
the participants are different from those in the UK.
Evidence statement ES22
There is no conclusive evidence about the variability of programme effectiveness in
high risk individuals. Josendal et al. 1997 (++, Norway) showed positive effects of a
35
school-based intervention at six months in certain high risk groups. Snow et al. 1992
(-USA) provided evidence that students from single parent households were less
likely to have been positively affected by the intervention than those from two-parent
households. The following factors were also found to be associated with post-test
smoking: Attitudes and smoking habits of family (Armstrong et al. 1990 -, Australia;
Elder 1996 +, USA and Chatrou et al. 1999 , The Netherlands) attitudes and smoking
habits of peers,(Armstrong et al. 1990 -, Australia; Chatrou et al. 1999 -, The
Netherlands; Elder 1996 +, USA and Schofield et al. 2003 -, Australia) tobacco
advertising (Armstrong et al. 1990 -, Australia), availability of cigarettes at home
(Elder 1996 +, USA) involvement of students at school (Schofield et al. 2003 -,
Australia) baseline smoking status (Chatrou et al. 1999 -, The Netherlands and
Schofield et al. 2003 -, Australia) and future smoking intentions (Armstrong et al.
1990 -, Australia).
Evidence statement ES23
One RCT (Campbell et al. 2008; + UK) found no association between the students’
socioeconomic status and programme effect.
Evidence statement QR2: Characteristics of Young People
There is evidence from three UK (one ++, one + and one -) and two American
(two ++) qualitative studies (Audrey et al, 2006, Cole, 2000, D’Emidio-Casten
et al, 1998, Mitschke et al, 2006, Spratt and Shucksmith, 2006) that particular
characteristics of young people receiving the intervention (and their families and
communities) can act as barriers. The main barriers were:
-
The presence of regular smokers amongst young people receiving the
intervention
-
The presence of occasional smokers or those ‘experimenting’ with cigarettes
amongst young people receiving the intervention
-
The presence of young people who come from households with one or more
smokers
-
The presence of young people who come from communities with high
smoking prevalence
-
The age of young people – older teenagers can be more critical of prevention
messages
Interventions delaying rather than preventing onset?
Evidence Statement ES9
There is conflicting evidence whether school-based smoking prevention programmes
are delaying rather than preventing smoking uptake in children. Results from
Campbell et al. 2008 (+, UK) and Bond et al. 2004 (+, Australia) RCTs suggested an
attenuation of programme effect over time. Crone et al. 2003 (-, The Netherlands)
and Sussman et al. 2007 (-, USA) also provided evidence that a smoking prevention
programme may be delaying smoking uptake. Evidence from Klepp et al 1994 (-,
Norway) suggested that school based education could have a positive short-term
impact on smoking behaviour, but that these effects tended to disappear over time.
Dent et al. (-,USA) provided evidence that the intervention may be effective in
preventing smoking uptake, and, Elder et al. 1993 (-, USA) provided evidence that
their school-based education programme tended to have a long-term impact on
smoking behaviour. Nutbeam et al. 1993 (+, UK); Peterson et al. 2000 (++, USA);
36
Eisen et al. 2003 (+, USA); Chatrou et al. 1999 (-, The Netherlands); Ennet et al.
1994 (-, USA) and Schinke et al. 2000 (+, USA) showed that school-based
prevention was not effective in preventing smoking at all follow-up periods.
Evidence Statement ES10
There is no robust evidence indicating that any school-based intervention has longlasting effects beyond school leaving age. One US study (Peterson2000, ++)
demonstrated that a comprehensive smoking prevention programme that adopted a
social influences approach, started at age 8-9 and continued through to age 17-18
was ineffective when smoking prevalence was measured at age 20. Another US drug
prevention programme (Lynam 1999, +) targeting children aged 12-13 also found no
significant effect on smoking at age 20.
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