More than quit rates - our smoking research was about complexity, trust, and real voices

Posted by Angela Rodrigues, Associate Professor at Northumbria University, and co-lead of the Fuse Behaviour Change Cluster, and Team

By the time we wrapped up our final interviews, we felt a mix of pride, exhaustion, and curiosity. Pride because we’d managed to complete a complex mixed-methods evaluation across four pilot sites. Exhaustion because, well, public health research never seems to run smoothly, and we had a few recruitment bumps along the way. And curiosity because we still weren’t sure how all the pieces would fit together. This was a mixed-methods evaluation of a 20-week smoking cessation service in the North East & North Cumbria.

The context: why this service mattered

When we first got involved, the idea was simple: evaluate an enhanced stop smoking service designed specifically for people living with severe mental illness (SMI). People with SMI experience stark health inequalities. On average, they die 15-20 years earlier than the general population, largely due to chronic physical health conditions rather than psychiatric causes. Smoking is a major reason for this health gap, and it is something that can be changed. Yet many tobacco dependence services do not adequately meet their needs.

The service offered more support than the standard provided by the local council, combining behavioural support with medication-assisted treatment over 20 weeks. It followed a ‘cut down to quit’ model, and aimed to be person-centred, flexible, and responsive.

Our approach: mixed methods and lived experience

We used a mixed-methods approach, including quantitative analysis of recruitment and outcomes, surveys with service providers, qualitative interviews with both staff and service users, and a review of Smokefree Taskforce documents. We started with a well-defined plan, but the process taught us to embrace flexibility. Recruitment was slow. Referral pathways shifted. Data systems didn’t always talk to each other. And finding service users willing to be interviewed was harder than we expected.

One of the most rewarding aspects was working with our Lived Experience Advisory Panel (LEAP). They helped shape our protocol, refine our interview questions, and interpret findings. Their input reminded us why we do this work. It’s easy to get lost in methodological frameworks, but the real insight often comes from lived experience. One LEAP member words stuck with us:

“You need to understand what it’s like to be told to quit smoking when smoking is the only thing that gets you through the day.”

What we found: complexity at every level

The Behaviour Change Wheel framework (figure 1) helped us make sense of what was happening on the ground. Service providers used a range of strategies, including medication, leaflets, nicotine e-cigarettes, planning, and social support. Most felt capable and motivated to deliver the service, but some found it more harder than expected. Complexity was a recurring theme, as illustrated in one advisor words:

“It’s not just about smoking, it’s about everything else going on in their lives.”

Figure 1: Visual map of key themes identified in our study

We also saw how broader systems shaped delivery. Some sites had strong links with primary care; others struggled. Data recording was patchy. Staff wanted more training, not just in smoking cessation, but in understanding mental health complexity more broadly. And while the service was designed to be flexible, that flexibility sometimes created confusion. Who was eligible? How long should support last? What counted as a successful quit?

For service users, the benefits were clear: 

• better physical and mental health
• financial savings
• fewer unpleasant smells
• and fewer side effects than expected.

But staying engaged was tough. Motivation fluctuated. Life got in the way. Participants reminded us regularly that behaviour change doesn’t happen in a vacuum:

“I wanted to quit, but then my meds changed and everything fell apart.”

The challenge and value of qualitative work

Personally, we found the qualitative interviews both the most challenging and the most illuminating part of the process. Some participants were open and reflective; others were more reserved and required extra support and reassurance to feel comfortable speaking openly, particularly service users. We learned to be flexible in our approach, arranging a casual phone call with service users to build a rapport prior to the interview.

Despite the difficulties recruiting service users, once they were engaged in the interviews, all were eager and willing to share their experiences. We learned that it is important to develop a level of trust with service users, and that patience and empathy can encourage openness and in-depth understanding.

There were challenges too. We had hoped for more interviews with service users, more consistent data, and deeper engagement with those delivering the service. In particular, connecting with service deliverers proved difficult, largely due to the time lag between service implementation and the research evaluation. By the time we began our research, staff had moved on, memories had faded, and priorities had shifted, making it harder to capture a full and accurate picture of delivery. But public health research rarely hands you a neatly packaged story. What it does offer is insight into systems, into people, and into the messy, unpredictable reality of trying to improve lives.

Why it worked: partnership and collaboration

Looking back, we think the study worked because it was grounded in genuine partnership. The Smokefree NHS strategic team were incredible, collaborative, responsive, and deeply committed to making the service work.

We built relationships with service providers who shared their experiences openly, with LEAP members who challenged our assumptions, and with service users who trusted us enough to talk. Within our research team, we supported each other through the inevitable ups and downs. That collective effort, across roles, organisations, and lived experiences, is what made the project feel meaningful.

This experience has already shaped how we’re approaching future projects. Next time, we’ll go in with clearer expectations, more flexible timelines, and a deeper appreciation for the emotional labour involved, not just for us as researchers, but for the people we’re working with.

Researching smoking cessation in people living with severe mental illness isn’t just about measuring quit rates or evaluating service models. It’s about recognising the complexity of their lives, earning trust, and ensuring their voices shape the research process. More than anything, this project reminded us that we, as researchers, must be more attuned, more patient, and more willing to adapt.

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About the authors:

Dr Angela Rodrigues, Associate Professor, Northumbria University, and co-lead of the Fuse Behaviour Change Cluster

Dr Lauren Hoult, Associate Lecturer, Researcher in Behaviour Change & Public Health, Northumbria University

Prof Katie Haighton, Professor in Public Health and Wellbeing, Northumbria University

What is the best way to reduce the amount of meat we eat?

Posted by Jack Hughes, PhD Candidate in Behavioural Science; Mario Weick, Professor of Behavioural Science; and Fuse Associate Milica Vasiljevic, Associate Professor of Behavioural Science, from Durham University

The science is clear that eating meat can be bad for our health; eating meat has been linked to an increase in cardiovascular risks, diabetes, stroke, cancers, and even dementia. Meat is also bad for the planet, with the livestock industry being estimated to be responsible for up to 15% of greenhouse gas emissions. Eating meat is also surprisingly closely connected to the risk of pandemics, with zoonotic diseases (caused by harmful germs that spread between animals and people) much more easily spread from eating animals.

Governmental policy and legislative choices play an important role in our excessive meat consumption. The Committee on Climate Change has recommended a 20% reduction in UK meat consumption by 2030 if we want to hit our net zero targets. Additionally, the Department of Health and Social Care recommends eating no more than 70g of meat a day, but average meat consumption in the UK is closer to 90g. So, what is the best approach? Do we advocate for a ‘nanny state’ that bans meat or imposes hefty taxes? Or do we advocate for a removal of all subsidies for meat farming and just let the market and people decide how much meat we consume under the hopes that awareness of the dangers of meat will drive down consumption?

There are of course significant problems with both approaches, but maybe there is a third option. One that can be applied not just to meat but to all society’s destructive large-scale behaviours, from alcohol to tobacco to ultra-processed foods to sedentary lifestyles.

In 2003 Richard Thaler and Cass Sunstein coined the phrase Libertarian Paternalism. Essentially arguing that the best way to produce policy is to design interventions that change behaviour without affecting people’s right to choose. So, you can still eat as many steaks as you like but policy will build an environment that unconsciously discourages eating an excessive amount. This idea could be argued to balance individual and government responsibilities, the government is nudging people to healthier choices, but the individual still gets to make the final decision.

For example, in a recent study of ours we found that sticking a graphic warning label (similar to those you see on cigarettes) onto meals could reduce the amount of meat chosen. Not only were the labels effective, leading to between a seven and 10 percent reduction in meat meals chosen, but the idea of introducing them as policy received fairly neutral responses. Which, let’s be honest, makes it more popular than most policy proposals!

When we look at recent research we can see that a variety of interventions have shown promising effectiveness on reducing meat consumption. Whether changing the ratio of meat to non-meat meals on offer, making meat meals less appealing by using less flattering descriptions, changing which meals appear at the top of the menu, or adding eco and warning labels to discourage the selection of meat meals, there are many ways of changing the environment without reducing the freedom of choice consumers ask for.

The question is though: is this approach the best or the worst of both arguments? Does Libertarian Paternalism thread the needle between governmental and personal responsibility? Others might say the approach is too hands off, or too hands on. If we accept that as a society we would benefit from eating less meat, which policy strategy do you support? The ‘nanny state’, the free market, or the libertarian paternalist approach?

The paper described in this blog-post can be accessed here:

Hughes, J. P., Weick, M., & Vasiljevic, M. (2023). Impact of pictorial warning labels on meat meal selection: A randomised experimental study with UK meat consumers. Appetite, 190, 107026. https://www.sciencedirect.com/science/article/pii/S0195666323024881

Are we really aware of the harm Big Tobacco causes our planet?

Posted by Ailsa Rutter OBE, Director of Fresh and Balance on World No Tobacco Day

The annual World Health Organization (WHO) campaign highlights the many harms of tobacco. This year’s theme explores the growing threat to our environment.

We know that smoking is the worst thing that we can do for our health – 8 million people around the world lose their lives from it each year.

Many of us are already taking action to do our bit in tackling climate change. But do we ever think about how tobacco is polluting our world globally, nationally and here in North East England?

As we face a climate emergency, our fragile ecosystems are being put under even more pressure by the tobacco industry. Tobacco damages the environment, from growing and production, distribution to waste.

Reflecting on my 24 plus years in tobacco control, I’ve seen many appalling tactics from Big Tobacco (the largest global tobacco companies who make billions in profit from killing people and destroying the planet) – including ploys to get kids hooked on a life-long addiction.

It takes a lot to shock me these days, but even I am shocked to read the things that the tobacco industry is doing to our environment.

What we see on the surface is just the tip of the iceberg. Some of the mind-blowing statistics every year:

• 600 million trees chopped down for tobacco.
• 84 million tonnes of C02 released into the air, raising global temperatures.
• 22 billion tonnes of water used to make cigarettes.
• 4.5 trillion cigarette butts not disposed of properly across the globe, generating 1.69 billion pounds of toxic waste and releasing thousands of chemicals into the environment.

Big Tobacco ‘greenwashes’ its impact on the environment through sustainability corporate social responsibility and marketing initiatives, designed to make people and investors think it cares.

Every day we see its impact on our streets and beaches. Cigarettes are the most commonly littered item in the world.

Cigarette butts are made of cellulose acetate, a man-made plastic material, which takes years to degrade and dump a toxic mix of nicotine, arsenic and heavy metals into our water, soil and oceans before turning into microplastic pollution. It makes me so sad to think what this toxic waste is doing to our marine and river wildlife.

Eight out of 10 (81%) North Easterners in a YouGov poll commissioned by Action on Smoking and Health (ASH) want to see plastic in cigarette butts banned. As part of our World No Tobacco Day activity, we’re joining forces with environmental campaigners to protect the region’s beaches from plastic cigarette butts.

Beyond our region, in the developing world, deforestation for tobacco plantations is happening on a vast scale. Around 3.5 million hectares of land are destroyed for tobacco growing each year. That’s the equivalent of over 1.4 million football fields!

The environmental burden is falling on the countries which are the least able to cope with it. Farmers in low- and middle-income countries are left in debt, with widespread poverty and illness among farm workers. Meanwhile the global tobacco companies continue to make billions in profit.

I reflect on when I attended a world conference in 2006 and heard about young children being exploited for child labour by tobacco companies; picking tobacco leaves and exposed to toxic pesticides and hazardous working conditions. The consequences are life-long and this is happening around the world, as shown in the devastating 2016 Human Right Watch report “Harvest is in my Blood”.

As a mother, with children and grandchildren, I am extremely concerned about the future impact.

The question I think we should ask ourselves is – are we really aware of the harm that the tobacco industry is causing to the environment? If the answer is no, then let’s pledge to read some of the fantastic resources on the issue, including those on the WHO website. Talk to people about it, call for action. Learn more about the tobacco industry; the harm it causes.

 

We are supporting national colleagues Action on Smoking and Health in calling for a levy on Big Tobacco, to clean up the harm and to further reduce smoking to reach the Government’s target of a Smokefree 2030 (5% by 2030).

In the North East we’ve seen smoking rates fall faster than anywhere else in the country, thanks to the hard work and dedication of colleagues in the region.

But as the major threat of climate change looms, it’s vital that we go further and faster than ever to reduce the tobacco industry’s destructive impact and make smoking history for the next generation.



Ailsa Rutter OBE, is Director of Fresh and Balance, the North East’s combined alcohol and tobacco programme, working to reduce the harm, the death and disease caused by smoking and alcohol.

Tobacco is still the biggest cause of premature death in the UK, with an estimated 74,000 deaths each year in England and over 113,000 deaths from smoking in the North East since the year 2000.

Now that's what I call blogging 2021

Posted by Mark Welford, Fuse Communications Manager, Teesside University

Let’s all channel British novelist E.M. Forster and play a little game of Only Connect. What connects the things below?

“Yes of course, they can all be a type of list” (said in the friendly yet ever so slightly patronising manner of host Victoria Coren Mitchell)

I think it's fair to say that we all love a list. I mean, the premise of another very popular BBC gameshow is basically to list pointless stuff.

So here again (a little later than advertised) is our annual list of the most-viewed Fuse blog posts of 2021!

You'd be forgiven for thinking that this would be dominated by Covid and the pandemic as we saw in the 2020 list.

Obviously, we had our fair share of pandemic related posts. Blogs about misinformation, food insecurity, malnutrition, obesity and what children made of it all. How it impacted on work and engagement with public partners, parents, decisionmakers, practitioners, policy-makers and commissioners. How it affected our mental health, our liberties and even inspired a song and a cat-scale of wellbeing!

But as you can see from the list below it didn't dominate the top 5 chart-toppers of 2021. Perhaps a little escapism goes along way...

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Katsushika Hokusai: The Great Wave off Kanagawa

5. The other third wave: a mass epidemic of very individual pain

Posted by Jack Nicholls, Lecturer in Social Work at Northumbria University

Lockdown restrictions were beginning to ease in the UK. But after the jubilation, what if you don't feel the way you think you should?

A very personal post by Jack Nicholls on the long-term mental health consequences of the pandemic, of lockdown and social restrictions, and of its easing. 

*Content/trigger warning: mental health, depression, suicidal feelings.

Page views: 938

Published: 16 April 2021.

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4. Patient and Public involvement with Parents during a Pandemic: the four ‘P’ challenge

Posted by Hannah Batten, Food and Human Nutrition undergraduate student at Newcastle University. Hannah was on a placement year with the Population Health Sciences Institute, as part of the MapMe study aiming to help parents assess child weight.

Body image scales on the MapMe website are being updated for MapMe2

"Most importantly, is to say to our participants that we are extremely grateful for their time and input, particularly during these uncertain times."

Hannah tells us how she and the MapMe study team met the challenges involved in recruiting and running an online Parent Involvement Panel (PIP) to help review documents and study materials, when parents were already dealing with a global pandemic. 

Page views: 1,029

Published: 5 March 2021.

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3. Should pregnancy 'be incentive enough' to quit smoking?

Posted by Susan Jones, Research Associate at Teesside University

In this blog post on #NoSmokingDay, Dr Jones explored deprivation, guilt, shame, stigma and the complex web of reasons behind smoking behaviour.

Just searched #smoking #pregnancy #incentives - struck by many tweets that say 'pregnancy should be incentive enough' to quit smoking. Clearly the stats tell a different story for a significant minority - the question surely is why and what can be done? @ASH_LDN @FreshSmokeFree

— Dr Susan Jones (@Susan_E_Jones) December 10, 2020

Page views: 1,155
Published: 10 March 2021.

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2. Things I wish I’d known when I started my PhD… (part 1)

Posted by members of the Population Health Interventions Programme at the MRC Epidemiology Unit

Research doesn't happen overnight, avoid comparison and channel your inner Arsène Wenger ("Le Professeur"). In our second most popular blog post, the early, mid and senior career researchers at University of Cambridge share their tips for PhD survival.

Here is part 2 which interestingly received only half as many views despite including a High School Musical reference.

Page views: 1,347

Published: 4 June 2021.

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1. Can Forest School inspire the next generation to be happy & healthy?

Posted by Katie Beresford, undergraduate student at Durham University

With more than 2,700 views this is our most read post of 2021 by some distance!

In it Katie explores growing up in the Lake District, embracing nature, finding school restrictive and struggling academically in her early years.

Nearly two decades later she is completing a Fuse summer internship with the NIHR School for Public Health Research and is tasked to review literature discussing the effectiveness of Forest School as a public health intervention.

Why not grab a coffee and take a walk with Katie into the woods to find out what she discovered...

Page views: 2,746

Published: 8 October 2021.

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So there you have it, the top five Fuse blog posts of 2021. Congratulations to Katie who wins a rare and coveted Fuse paperweight!  

Fantastically both Katie and Hannah's blog posts were part of our Fuse blog Student Series which we launched last year! This showcases posts by students who have been challenged to write a blog as part of their studies. The authors may be new to blogging and we hope to provide a 'safe space' for the students to explore their subject and find their voice in the world of public health research. Hopefully this will encourage other students to take the plunge!

As always, many thanks to our loyal readers and fantastic contributors.

Can we do any better in 2022? If you fancy giving it a go, please find out what we are looking for and how to take part here. All contributors receive a much sought-after Fuse badge.

Images:

2. Image: Katsushika Hokusai, (CC0 1.0), via Wikimedia Commons

4. Mr. Alexander Ottesen, CC BY-SA 2.5, via Wikimedia Commons

Is it ethical to promote quitting smoking to patients with mental health issues?

Posted by Susan Jones, Research Associate, Teesside University

Smoking rates and levels of dependency are high in people with psychiatric problems and, it has been argued, that smoking helps people with mental health disorders to cope with the struggles in their lives (Malone et al., 2018). On the other hand, the National Institute for Health and Care Excellence (NICE, 2013) argues that introducing a smokefree culture into NHS Trusts offers an opportunity for patients and staff to benefit in terms of physical and mental health and is achievable with appropriate support. Certainly this viewpoint was supported in our research:

"I think for some of our patients because it’s actually a learning disabilities hospital but obviously a lot of them have mental health issues as well, it increased their confidence and self-esteem. A lot of our patients had poor self-esteem and they actually achieved something by stopping smoking, they achieved something that was extremely difficult and I think it made them think, if we can do that we can do other things as well." 

Frontline Staff, Trust B

Nevertheless, by taking this position, NICE have highlighted a contentious issue. In our research we found that the patients and healthcare community were still divided about introducing smokefree policies and supporting patients and staff to quit smoking (Jones et al., 2020). There was a lot of passion on both sides! In some wards (mostly those with non-acute patients, such as those with learning difficulties or associated with forensics) staff and patients took on the challenge to change their environment and behaviours and embrace a smokefree way of life. They were creative in how they prepared for quitting and even made it fun, with games and decorations.

In other areas e.g. acute services, the challenges were different and there was much more scepticism about the ethics and value of offering support to quit smoking. Although awareness raising and training in smoking cessation was available, the role of choice and a pro-smoking narrative was widespread. 

Normalisation of smokefree policies

In mental health, smoking is an established cultural norm both in the community and in healthcare settings. We found that it is seen as an acceptable, even beneficial, coping mechanism for people who suffer from mental health disorders.

Research evidence would argue the converse; that the physical and mental benefits are far greater than continuing to smoke (Harker & Cheeseman, 2016). People with psychiatric problems tend to be highly addicted and there is a definite need to push through the initial stages of withdrawal from nicotine, which can be harder due to greater dependency, and more complicated due to interactions with psychiatric medication. Nevertheless, the evidence shows that people still want to be physically healthier, free from the downsides of addiction and supported to achieve these goals (Harker & Cheeseman, 2016).

Promoting normalisation through collective action

Perseverance is required to change any norm; old habits and perspectives die hard and continual reinforcement of new patterns are needed for success (Jones et al., 2020). This applies at an individual level but also at the organisational level.

Role of context

Our environment is so important in enabling or blocking behaviour; or even ‘nudging’ it in a certain direction (Ratschen et al, 2011). If a hospital is smokefree, then patients who don’t smoke will be able to maintain their status as non-smokers more easily. Alternatively, a smoking environment legitimises and encourages continued smoking. 

Sustainability

Maintaining changed behaviours, like smoking, is known to be challenging; however there is an inherent contradiction in implementing smokefree policies on-site only. Patients and staff move between hospital and community and it is all too easy for this to be seen as abstaining while in hospital, rather than quitting for good.

What we found 

Two mental health trusts in North East England - Northumberland Tyne and Wear NHS Foundation Trust and Tees, Esk and Wear Valleys NHS Foundation Trust - went smokefree in March 2016. In our research to evaluate the implementation of smokefree policies within the trusts, we found that:

• Inroads had been made in changing an entrenched, smoking culture into one that was smokefree on Trust sites. However, there remained variations across specialities and challenges to full implementation.
• Once there was sufficient ‘buy-in’ to a non-smoking culture it was anticipated that the issues relating to enforcement and perceived risk would diminish.
• Long-term perseverance is required to establish smokefree sites in participating mental health trusts, supported by robust, routine, data collection.
• Normalisation Process Theory and logic modelling are helpful in increasing understanding of the dynamic implementation process. 

Policy relevance and implications

• Careful use of language is needed to encourage smokefree policies to be seen positively.
• When interpretation of the term ‘patient leave’ was left open for leave to be used for smoking, it led to inconsistent practice.
• Consistency of enforcement is key to success.
• There were many details that needed to be worked out following the introduction of the policies; suggesting a requirement for ongoing review and response in a timely manner.

Read more about Sue's research in this Fuse research brief: Introducing smokefree policies into hospital mental health services.

References:

Harker K, Cheeseman H. The mental health and smoking action report: the

stolen years. 2016 [Available from: https://ash.org.uk/information-and-resources/reports-submissions/reports/the-stolen-years] 

Jones, Susan E; Billett, A; Mulrine, S; Clements, H; Hamilton S. (2020) Supporting mental health service users to stop smoking: findings from a mixed method evaluation of the implementation of nicotine management policies into two mental health trusts. BMC Public Health, 20:1619

https://doi.org/10.1186/s12889-020-09673-7

Malone V, Harrison R, Daker-White G. Mental health service user and staff

perspectives on tobacco addiction and smoking cessation: a meta-synthesis

of published qualitative studies. J Psychiatr Ment Hlt. 2018;25(4):270–82. https://doi.org/10.1111/jpm.12458

National Institute for Health and Care Excellence. Public health guidance 48:

smoking: acute, maternity and mental health services. London: NICE; 2013. https://www.nice.org.uk/guidance/ph48

Ratschen E, Britton J, McNeill A. The smoking culture in psychiatry: time for

change. Brit J Psychiat. 2011;198(1):6–7. https://doi.org/10.1192/bjp.bp.110.081372

Images:

1. “Smoke-Free Bench” by Michael Coghlan via Flickr.com, copyright © 2011: https://www.flickr.com/photos/mikecogh/5645977385/in/photostream/ (CC BY-SA 2.0)

2. Copyright © South Tees Hospitals NHS Foundation Trust: https://www.southtees.nhs.uk/news/services/trust-to-go-completely-smokefree/ (2019)

The views expressed here are those of the authors and do not necessarily reflect those of the author's employer or organisation.

Should pregnancy 'be incentive enough' to quit smoking?

Guest post by Susan Jones, Research Associate, Teesside University

I have seen many people on twitter express the view that thinking about their baby should make pregnant women automatically quit smoking. Indeed many women when they decide to try for a baby or find out they are pregnant do quit smoking. However, it does seem illogical - and shocking - to many that this is not always the case.

 

Just searched #smoking #pregnancy #incentives - struck by many tweets that say 'pregnancy should be incentive enough' to quit smoking. Clearly the stats tell a different story for a significant minority - the question surely is why and what can be done? @ASH_LDN @FreshSmokeFree

— Dr Susan Jones (@Susan_E_Jones) December 10, 2020

For those who do continue to smoke, it is perhaps more of a hint of a complex web of reasons behind their smoking behaviour, rather than any greater willingness to harm their baby. Smoking throughout pregnancy is often associated with environmental and social deprivation, which gives us a clue. Hilary Graham’s seminal work into women’s smoking and its association with family health, published in 1987, opened the door to a new understanding of what some of the reasons might be for this apparently illogical and paradoxical behaviour on the part of pregnant women from deprived communities. Graham concluded that:

"The study suggests that, for a significant minority of mothers, poverty and caring combine with low levels of physical and emotional energy, with sleep problems and with feelings of social isolation. In this context, smoking appeared to provide a way of coping with caring-in-poverty: a way of coping alone with the demands of full-time caring and with the struggle of making ends meet."

This work revealed that there were other, stronger reasons to continue smoking, which counteracted any impulse to quit.

Guilt and shame

An earlier study of ours heard pregnant smokers confess to feeling guilty and ashamed of smoking in pregnancy and how they are very aware of the stigma associated with their behaviour:

“But then once I lit it up and had half of it I felt guilty. But it took that edge away, but I still felt guilty. So if I felt even more guilty I probably mebbees wouldn’t have touched it, but I feel weak because I have had to do it.”

“I think the kids always make it like, they have more effect on you than what anyone else does, because they're, well you feel guilty if you're letting them down and doing something they don't want you to do.”

We also found that sometimes it can be a distrust of public health messages combined with a real lack of knowledge about the mechanics of how smoking affects the developing baby. Nevertheless, it must be acknowledged that, for whatever reason, not everyone says they want to quit; but of those who do want to quit, some say they do not feel able to. For the sceptics out there, this may seem only subtly different to choosing to smoke, alternatively it may be a real barrier to quitting. Graham’s work would suggest the latter. More recent research has built on her findings and investigated what methods of support may work for these pregnant women, who do not quit, and for whom the health outcomes are comparatively worse for themselves and their babies.

What can be done?

Research over several decades has shown that there are ways to support pregnant women to quit smoking, focusing on:

• Referring to stop smoking support services
• Offering support to change behaviour
• Support through medication.

It is clear now that opt-out approaches to referral and carbon monoxide monitoring and much more personalised support are also helpful to women (see our short video below).

   

Work has been undertaken to implement these supports more fully; e.g. the Local Maternity Systems (LMS) in North East England designed the Maternity Pathway and have led the work across the organisational systems to integrate these mechanisms. Becca Scott, the North East Local Maternity Systems Public Health Prevention Lead says:

"The LMS have led North East organisations and service users to contribute to the target of 5% or less women smoking in pregnancy by 2025. That would mean 2723 fewer women smoking at time of delivery across the North East since 2018. It does this by offering all expectant mothers, and their partners, a multiagency-developed, smoke-free pregnancy pathway and minimum service standards (as detailed in each of the Maternity providers bespoke plans). The impact of the engagement with the work has seen prioritisation throughout all Local Authority Health and Wellbeing boards, as well as consistency in the way smoking in pregnancy is identified and supported, which is demonstrated in significant improvement in adherence to NICE Guidance."

What more can be done?

The results of this partnership work are encouraging. Is there anything else that can be done? The evidence for the effectiveness and cost-effectiveness of financial incentives to support pregnant women to quit has been building. Trials have been conducted which have found that there is "substantial evidence for the efficacy of incentives for smoking cessation in pregnancy" – however this idea has encountered significant public scepticism and opposition.

ash. Smoking in Pregnancy Challenge Group Webinar - Incentive schemes

Although there has been more balanced reporting too and more recently, the headline below suggests the idea has become more acceptable.

Capture from The Sun online (09/03/21)

Modelling financial incentives in smoking in pregnancy

A team of us (details below*) have been awarded funding from the NIHR Applied Research Collaboration (ARC) North East & North Cumbria Open Funding Competition to look into an alternative way to take into account the views and responses from all stakeholders, including staff, pregnant women, and the public. We will also be building a mathematical model based on Evolutionary Game Theory (EGT). EGT is a mathematical framework of contests, strategies and analytics into which Darwinian evolution can be modelled. It is designed to capture the strategic interactions between stakeholders, because ultimately these interactions will drive health behaviour. Incentivisation will be modelled to see how it affects some behaviours and in what contexts. We hope the model will be able to guide commissioning and provision, so that any intervention is as effective and cost-effective as possible, without having to conduct further lengthy and expensive trials beforehand. Watch this space!

*Associate Professor Emma Giles (Teesside University), Professor Falko Sniehotta (Newcastle University and University of Twente), Dr Jean Adams (University of Cambridge) and other partners working in NHS Trusts and local authorities. Colleagues in the School of Computing, Design and Digital Technologies, Associate Professor The Anh Han and Tedy Cimpeanu from Teesside University.

If you are going to give up smoking, this is a very good moment to do it

In today’s Fuse blog Rachel McIlvenna, from Public Health South Tees, writes about managing a local specialist stop smoking service during the COVID-19 pandemic.

Casting my mind back to when the news started reporting increasing numbers of confirmed cases of COVID-19 in the UK feels like a lifetime ago. Chief on my mind pre-lockdown, was to re-emphasise the need for adhering to our robust infection control procedures, but also given the new threat to health, ensure we had sufficient stock of disposable gloves for clinic venues where there were no hand washing facilities. Looking back now, those days feel like a different era and my team, I and perhaps most people in the UK were unaware that our world was going to be turned upside down. 

In the weeks that followed things changed at a dizzying pace resulting in me activating our continuity arrangements earlier than anticipated, largely dictated by the shifting landscape that depended in part on what we heard from the Government’s daily press briefings but also from our strategy and plans as a Local Authority.

As the rates of infections started to increase exponentially, many services scurried to shut down for the foreseeable future and rightly so; everyone had to do their part to flatten the curve. We, as a service, didn’t have such a luxury by virtue of the fact that stopping support midway through a treatment pathway was not an option. The chances of a client successfully quitting smoking increase with regular behavioral support and uninterrupted access to treatments, like Nicotine Replacement Therapy (NRT) and Champix tablets.

Being responsible for the care of over 200 clients during a pandemic needs careful consideration. Our contingency plans made provision to stop face-to-face consultations in March with interim arrangements to supply stop smoking treatments during the pandemic. This challenge was further amplified when we received guidance from the National Centre for Smoking Cessation and Training (NCSCT) about ceasing all face-to-face consultations immediately and further news that the local community hubs, where clinics would normally be held, were shutting down completely to the public. So, without a location where clients could come and pick up their prescriptions regardless of social distance measures in place, we had to adapt our plans. Eventually and after several phone calls, we managed to support most of the clients via telephone and put arrangements in place for collection of scripts.

It didn’t end there though, as we then had the concern of how we would support new clients who wished to stop smoking, particularly pregnant women who were referred from maternity. Constant in my mind was safeguarding my staff and the public, so I knew that a long-term solution needed to be sought to minimise risk. After talking to several colleagues on the pros and cons of electronic vouchers and other options, we settled on posting prescriptions directly to clients (1st Class and with trackable labels) as it was the least restrictive option.

The next challenge was to introduce this very new way of working to my team, by explaining and demonstrating why this approach was best in these circumstances. Thankfully, a close colleague had helped me to draft a Standard Operating Procedure (SOP), which was soon amended and rolled out. This new way of dealing with scripts hasn’t been without its drawbacks. Sometimes the prescriptions have been delayed in the post for up to 10 days, which has meant that the staff have had to think 2-3 weeks ahead to ensure clients don’t run out of medication. But it has meant that we have minimised risk and enabled the team to work remotely from home, without the need to come to a central location to arrange for medication or go out to pharmacies, which have seen an increased demand during the pandemic.

The last few weeks have now been spent amplifying the #Quit4Covid message, learning from areas like Hertfordshire, Sheffield and Newcastle, and putting our own spin on these messages to engage smokers. This has included sending proactive text messages to unsuccessful quitters, bespoke postcards to homes of known smokers (who have given consent) and using social media. To date, we have seen promising results with many smokers engaging, and I am hopeful that there will be more dividends in future weeks.

What has been insightful for me has been the opportunity to lead our fantastic team of nurses during this period and observe their reactions to the unprecedented changes in their way of working and providing support for smokers. As a manager, it has been a privilege to help them navigate and accept the new realities that COVID-19 presents to all of us. Don’t get me wrong, it’s not all been smooth sailing, there have been several minor blips with a fair dose of IT challenges, to name just one. In the last few weeks, I have felt a quiet steadying as my nurses have become more confident about the change in work practices that they were long accustomed to as clinical staff. The challenges of remote consultations have been accepted, as has the notion that for some clients our weekly or fortnightly contact is literally a lifesaving form of communication.

The emerging evidence around adverse outcomes for smokers with COVID has reinforced what I have believed for a long time. Supporting people to stop smoking is one of most important public health interventions and not just for a host of non-communicable diseases associated directly or indirectly with smoking, but now with the threat of a communicable disease like COVID-19. To echo the words of England’s Chief Medical Officer Prof Chris Whitty to the Health Select Committee:

“If you are going to give up smoking, this is a very good moment to do it”

Rachel McIlvenna works as an Advanced Public Health Practitioner for Public Health South Tees and leads on tobacco dependency and long term conditions. Her portfolio also includes managing the in-house specialist stop smoking service, which includes a small team of vibrant nurse prescribers.

For information on stopping smoking in Middlesbrough / Redcar & Cleveland, visit: https://www.stopsmokingsouthtees.co.uk


Image attribution
3: "Dominic Raab Covid-19 Presser 06/04" by Number 10 via Flickr.com, copyright © 2020: https://www.flickr.com/photos/number10gov/49742982126/ (CC BY-NC-ND 2.0)

Now that's what I call blogging 2019

Posted by Mark Welford, Fuse Communications Officer, Teesside University

Happy New Year – can I still say that or have we reached peak-greet when this obligatory salutation is no longer required in email, phone, or awkward fleeting corridor exchange?

This time of year is all about numbers: the 12 days of Christmas, the pounds you’ve gained (lbs) or lost (£), counting steps, units, the 31 days of Dry January, Veganuary, or the point at which you can grant yourself a run free day.

It therefore seems fitting that the Fuse blog has a countdown of its own.  Last year was a fine vintage for blog posts but you may not have had the opportunity to read all 40 of them.  To save you time we have had a look back and created a Top 5 Chart of the ‘bestsellers’.

So without further ado, here’s our chart toppers:

5. The provocatively titled Can cancer ever be a good thing? in which Fiona Menger (@slt_fi) revisits the writing of 'cancer columnist' John Diamond while working on a head-and-neck cancer research study with a focus on a phenomenon called post-traumatic growth.

Page views: 585.  Posted: 31 May 2019 

4. In What old crisp packets dig up Duika Burges Watson (@debedub) gets hands on to unpack the mystery of the humble crisp.  What is their continued value as ‘food’ and can we still enjoy them as a cultural icon without creating so much waste and damaging our health?

Page views: 640.  Posted: 22 February 2019

Still from the animation

3. Why do some women continue to smoke when they are pregnant?  Sue Jones (@Susan_E_Jones) shares research findings on overcoming barriers to implementing NICE guidance on supporting pregnant women to quit smoking.  The blog includes a short animation which was developed based on the findings.

Page views: 663.  Posted: 10 May 2019

2. If at first you don’t succeed, try, try, try & try again...  Suzanne Moffatt (@SuzanneMoffatt) reflects on 58 months of knock backs in her efforts to secure ‘the big grant’ because multiple failures before success is often untold and sometimes persistence pays off.

Page views: 686.  Posted: 15 February 2019

Courtesy of Children's Future Food Inquiry via twitter

1. "It’s time to act!  It’s time this country gave every child the right to food!"  Pamela Graham (@PamLGraham) begins her blog post with this powerful statement from Corey (pictured right), a 15-year-old Young Food Ambassador who sat on a stage in Westminster and bravely told an audience about her experiences of food insecurity.  With more than double the views of its nearest competitor, Young people taking a stand for their #Right2Food takes the crown as most popular blog post in 2019.

Page views: 1474.  Posted: 03 May 2019

So there you have it, the top five Fuse blog posts from 2019. Can we can do any better in 2020? If you fancy giving it a go, please find out what we are looking for and how to take part here.

P.s. perhaps we need to look more closely at what's going on in February and May!?


Image:

1.  'Now That's What I Call Music! 1989' by brett jordan via Flickr. Attribution 2.0 Generic (CC BY 2.0): https://www.flickr.com/photos/x1brett/45056607035/

Perseverance and Public Health: creating a cultural shift takes time

Guest post by Susan Jones, Research Associate, Teesside University

I spoke to a young woman the other day who had moved to North East England recently. She already had a little boy, just coming up 2 years old, and was now well on in her next pregnancy. Because I had been involved in evaluating babyClear© - an intervention to help support expectant mothers to stop smoking - I asked her whether the midwives had enquired if she smoked, (she doesn’t). “Oh yes”, she said, “they’re much more into keeping a close eye on you here”, as compared with the region where she lived before.

This buy-in by maternity staff, and the change to practice, is reflected in our paper, recently published in BMC Health Services Research (Jones et al., 2019)[1], in those Trusts that facilitated the intervention most successfully.

It is crucial, yet difficult, to answer questions about the effectiveness of initiatives like these. It takes time and perseverance t
o identify the questions, conduct the research and bring in the system and practice changes, which in turn support behaviour change in patients.

How do we go about answering questions about effectiveness of interventions designed to support people to change their behaviour and to become healthier?

It was in 2012, that the findings from interviews with midwives were first published (Beenstock et al., 2012)[2] and the search for new ways of embedding National Institute for Health and Clinical Excellence (NICE) Public Health Guidance 26 (2010)[3] more thoroughly, began. As a result, babyClear© was initially implemented across North East England from 2013 to 2015.

Fundamentally, interventions like babyClear© can be shown to be effective in certain circumstances (NICE, 2010; Bell et al., 2018)[4] but our latest paper found that these changes required specific contexts and cultures in the implementing organisation to maximise their effectiveness and potentially their sustainability and transferability.

These changes in staff practice and patient behaviour do not happen in isolation; the external context is important too and, in this case, the national context has become increasingly supportive.

For example, there have been a number of new pieces of legislation, guidance and reports during this time, all pushing in the same direction:

• Saving babies’ lives: reducing stillbirth and neonatal death: a care bundle (NHS England, O'Connor and Gould, 2014)[5]
• Tobacco Control Plan: Delivery Plan 2017 - 2022 (Department of Health and Social Care, 2018)[6]
• Hiding in Plain Sight; treating tobacco dependency in the NHS (Royal College of Physicians and Tobacco Advisory Group, 2018)[7]
• Not to mention ongoing lobbying from the Challenge Group (2018)[8], a coalition of likeminded, stop smoking, activist organisations, with their ‘Review of the Challenge’.

Clearly, there is an appetite to find solutions to the health problems that smoking causes; however, imposing regulation, without understanding and dealing with the causes, is never going to be hugely effective in a democracy like ours.

So what we see is a lot of different ‘scatter gun’ approaches all dedicated to the same aim – typical of lots of health and social interventions – but is this the best approach?

It is being recognised more and more that intervening in complex systems, such as the NHS, is both necessary and – at the same time – problematic. Largely, the problems come from a lack of understanding of the multiple complexities of the contexts and the effect of cultures upon outcomes. New ways of combining research methods are required to investigate these complex systems and find appropriate answers (Moore et al., 2014)[9]. Updated guidance from the Medical Research Council on evaluating complex interventions is being drafted as I write.

Fuse Complex Systems research programme

Only when the links – or active ingredients – between the different elements of an intervention are identified, and proper attention is given to the contexts and cultures surrounding it, will we be able to understand the necessary environment and resources for it to thrive, ensure its sustainability and maximise outcomes.

Our paper is one step in this direction but there is much more to do. Fuse has a Complex Systems research programme, because the researchers know how important it is. They will soon be publishing their plans for the future direction of their research on this topic.

This is an area where research and evaluation are moving fast, as they attempt to get to grips with the way health and public health are changing in the lives of staff and patients.

References: 

1. Jones, S. et al. (2019) What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory. BMC Health Services Research. Available at: https://rdcu.be/bA4fK (Accessed: 20th May 2019).
2. Beenstock, J. et al. (2012) 'What helps and hinders midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of perceived implementation difficulties among midwives in the North East of England', Implementation Science, 7(1), p 1. 
3. National Institute for Health and Care Excellence (2010) Public health guidance 26: Quitting smoking in pregnancy and following childbirth. London: NICE. 
4. Bell, R. et al. (2018) Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation. Tobacco Control. Available at: http://tobaccocontrol.bmj.com/content/early/2017/02/10/tobaccocontrol-2016-053476 (Accessed: 20th May 2019). 
5. NHS England, O'Connor, D. and Gould, D. (2014) Saving Babies Lives: reducing stillbirth and neonatal death: a care bundle. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf (Accessed: 10th April 2019). 
6. Department of Health and Social Care (2018) Tobacco Control Plan: Delivery Plan 2017 - 2022. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/714365/tobacco-control-delivery-plan-2017-to-2022.pdf (Accessed: 20th May 2019). 
7. Royal College of Physicians and Tobacco Advisory Group (2018) Hiding in plain sight: Treating tobacco dependency in the NHS. Available at: https://www.rcplondon.ac.uk/projects/outputs/hiding-plain-sight-treating-tobacco-dependency-nhs (Accessed: 11th April 2019). 
8. Challenge Group (2018) Review of the challenge 2018. Available at: http://ash.org.uk/information-and-resources/reports-submissions/reports/smoking-in-pregnancy-challenge-group-review-of-the-challenge-2018/ (Accessed: 10th April 2019). 
9. Moore, G. et al. (2014) Process evaluation of complex interventions: UK Medical Research Council. Available at: https://mrc.ukri.org/documents/pdf/mrc-phsrn-process-evaluation-guidance-final/ (Accessed: 10th April 2019).

Image:

1. 'Smoking when pregnant' by johndavison883 via Flickr. Public Domain Mark 1.0.

Why do some women continue to smoke when they are pregnant?

Guest post by Susan Jones, Research Associate, Teesside University

"I was 12 years old when I started to smoke. I wasn’t thinking long-term, about my future, about the adult world I would one day join … I just wanted to look cool among my peers, be accepted and act grown up. Then I really did grow up and I was still smoking. Then I became pregnant … and I was still smoking. I didn’t exactly choose to be a smoker when I was pregnant but here I am ... addicted and not really wanting to give it up, or even if I wanted to, I don’t think I could – even for my baby.

"My mam smoked when she was pregnant with me, and I’ve turned out all right; all my family smokes, all my friends smoke, my partner smokes too; in fact smoking is a part of all my close relationships, especially with my partner, we smoke together, it is part of how our relationship works."

"I feel guilty, oh so guilty, but I can’t, I really can’t give up – I simply do not have the confidence to do it. I know that ‘smoking is bad for my baby’; I care for my baby and don’t want to do anything that would cause harm, and I’m really looking after myself, eating well, not drinking any more. I’ve cut down but I hardly dare think about quitting smoking, how on earth would I cope? And my partner, he’s not willing to change his smoking habits, or at least he’s agreed he’ll just not breathe over me when he’s been smoking, but he’s not even prepared to cut down – all he does is tell me, you must quit for the sake of the baby." 

A composite from interviews with pregnant smokers and maternity staff.

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Smoking is highly addictive and habit forming; many people enjoy the feeling it brings too[1]. Nevertheless the damage from smoking to the developing baby is well documented and the high level of smoking in pregnancy is still a major public health concern[2]. The National Institute for Health and Care Excellence (NICE) Public Health Guidance 26 (2010)[3] sets out all the trial-based evidence relating to the activities health professionals should take to support pregnant women to quit smoking. BabyClear© is a programme that supports health professionals to implement NICE guidance and provides standard training for them in order to carry out the activities in the most effective ways[4].

When we evaluated the implementation of the babyClear© package during its roll-out across North East England, we found that, for healthcare practitioners to challenge smoking behaviour amongst pregnant women, there needs to be a whole support system in place for both the professionals and the women whose behaviour they seek to change[5].

We recently developed an animation, based on our findings, which you can watch here:

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South Tees Hospitals NHS Foundation Trust took part in the evaluation of the implementation of the babyClear© package and works closely with its local stop smoking service. As Joanna Feeney, the Smokefree NHS Strategic Manager, says:

"South Tees is a great example of how Stop Smoking Services and Maternity Services can work together to help support Pregnant women to have Smokefree Pregnancies. 

"Most women who smoke during their pregnancy may know that smoking is bad but they are not aware of all the risks to them or to baby, they are also not aware of the help and support that is available to quit, including treatments such as Nicotine Replacement Therapy. 

"Implementing advice and treatment as part of routine Maternal care that is continued outside of hospital with the Stop Smoking Service helps ensure that babies are given the best start in life. 

"Last year in South Tees there were 334 more babies born Smokefree compared to 2012, and this year following the great work done on the wards at James Cook University Hospital the numbers are continuing to reduce but we recognise that there is still more to be done to ensure that every baby is born smokefree."

The Maternity and Stop Smoking Services reviewed the referral pathway and developed an online referral system that not only makes it easier for midwives but increases the speed with which women are contacted and given an appointment with the Stop Smoking Service.

Image courtesy of South Tees Hospitals NHS Foundation Trust

The Stop Smoking Service provides regular feedback to Maternity on the outcomes of women referred, enabling Maternity to offer bespoke interventions to those women who do not engage with treatment.

A further example of how South Tees Hospitals NHS Foundation Trust has moved towards a whole support system and worked in close partnership with stop smoking services is an initiative they undertook last year to redecorate the entrance to their maternity unit using eye-catching posters with a strong, stop smoking message.

And now, a year on, Kay Branch, Consultant Public Health midwife, South Tees Hospitals NHS Foundation Trust says:

"We are still really proud to have led the way towards a smokefree Trust. Our staff have noticed a reduction in the presence of anyone smoking outside entrances. 

"We continue to work collaboratively with the local stop smoking service to ensure a streamlined service for women and their partners. Nicotine replacement therapy is available to all of our patients and is widely used across maternity. 

"Our smoking at time of delivery reflects our hard work and passion for smokefree families."

Maternity’s lead has inspired the whole Trust to implement a systematic approach to treating tobacco dependency with Maternity being the model ward.

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I would encourage you to take a look at the animation above and publications relating to the roll-out of the babyClear© intervention package across the North East region. Please do share them with commissioners and providers of services, but also your colleagues, family and friends and any pregnant smokers you know.

More information on our evaluation work can be found here on the Fuse website.

References:

1. Chamberlain, C., O'Mara-Eves, A., Porter, J., Coleman, T., Perlen, S. M. et al. (2017) Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database of Systematic Reviews. Accessed on 18/03/19 at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001055.pub5/epdf/full
2. Bauld, L., Graham, H., Sinclair, L., Flemming, K., Naughton, F. et al. (2017) Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study. Health Technology Assessment, 21(36). https://www.journalslibrary.nihr.ac.uk/hta/hta21360#/abstract
3. National Institute for Health and Care Excellence (2010) Quitting smoking in pregnancy and following childbirth: public health guidance 26. NICE: London https://www.nice.org.uk/guidance/ph26/resources/smoking-stopping-in-pregnancy-and-after-childbirth-pdf-1996240366789
4. Bell, R., Glinianaia, S. V., Van der Waal, Z., Close, A., Moloney, E., Jones, S., Araujo-Soares, V., Hamilton, S., Milne, E., Shucksmith, J., Vale, L., Willmore, M., White, M., Rushton, S. (2018) Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation. Tobacco Control, 27: 1. Accessed on 18/03/19 at: http://tobaccocontrol.bmj.com/cgi/content/full/tobaccocontrol-2016-053476
5. Jones, S.E., Hamilton, S., Bell, R. Araújo-Soares, V., Glinianaia, S.V., Milne, E.M.G., White, M., Willmore, M., Shucksmith, J. What helped and hindered implementation of an enhanced package of measures to reduce smoking in pregnancy: process evaluation guided by Normalization Process Theory. BMC Health Services Research [In press]