Delivering smoking cessation support to disadvantaged groups: a qualitative study of the potential of community welfare organizations

Reaching disadvantaged groups for smoking cessation represents a significant challenge. Not-for-profit community service organizations (CSOs) represent a promising setting for the delivery of quit smoking support to disadvantaged smokers. However, their potential has not yet been explored. This qualitative study examined the acceptability of community service-delivered smoking cessation care. In-depth interviews and focus groups were conducted with 8 managers, 35 staff and 32 clients of CSOs between December 2008 and March 2009 in New South Wales, Australia. Discussions were audiotaped, transcribed and analysed using thematic analysis techniques. Quantitative surveys were also conducted to explore preferences for cessation support. Results showed that the acceptability of providing and receiving cessation support in the community service setting was high. Staff perceived the provision of quit support to be compatible with their role but reported barriers to providing care including competing priorities, insufficient resources and inadequate staff training. Brief intervention approaches were preferred by managers and staff, while financial incentives and access to free or subsidized nicotine replacement therapy (NRT) were desired by clients. The community service setting represents a promising access point for engaging disadvantaged smokers for cessation and further research exploring the effectiveness of support delivered in this setting is clearly warranted.     

Factors influencing the willingness of community service organisation staff to provide smoking cessation support: a qualitative study

Objective : This study aimed to explore factors influencing community service organisation (CSO) staff members’ willingness to provide tobacco cessation support to clients experiencing disadvantage. Methods : Face‐to‐face semi‐structured interviews were conducted with 29 staff members from seven services in the alcohol and other drugs, homelessness, and mental health sectors in Western Australia. Results : The primary barriers to providing cessation support were believing that addressing smoking was not a priority relative to other issues, being a current smoker, and the lack of a formal tobacco cessation program within the organisation. Factors that appeared to be most influential in enabling the delivery of cessation support were organisational processes requiring staff to routinely ask clients about tobacco use, confidence to provide support, and being a past smoker. Conclusions : The introduction of organisational procedures that include routine cessation care should be of high priority in CSOs to help reduce smoking rates among clients. Staff may also benefit from receiving training in the provision of cessation support and education about the importance and feasibility of addressing smoking concurrently with other issues. Implications for public health : The results may inform future efforts to increase the delivery of cessation care to groups of people experiencing disadvantage and comorbidity.     

Identifying perceived needs among nurses in providing their patients with smoking cessation support in a Japanese hospital results from focus group interviews

OBJECTIVE: To identify perceived needs among nurses in providing their patients with smoking cessation support in a Japanese hospital. SUBJECTS: Thirty-three female nurses who were interested in providing their patients with smoking cessation support in the hospital setting participated in focus group interviews. They conducted six focus group interviews segmented by age, working conditions (e.g., outpatient or inpatient sections) and occupational class (e.g., administrative post or not). DESIGN: An experienced researcher moderated two focus groups and another researcher who received training moderated four focus groups. At least two observers hand-recorded participants' conversations in each group and all groups were also tape-recorded. Moderators and observers analyzed the focus group data together. RESULTS: We found that smoking cessation counseling or health education on effects of smoking to be rarely conducted in the hospital. The study participants ordinarily just told patients to stop smoking. They mentioned several barriers to conducting smoking cessation support and suggested a number of ideas to promote this aim in the hospital. CONCLUSIONS: The focus group interview is an effective means to determine the needs and interests of Japanese health professionals. Nurses have many opinions and insights for supporting smoking patients. To introduce a smoking cessation program into hospitals, there are various problems that should be solved. First, nurses and other health professionals should have accurate knowledge, positive attitudes and appropriate skills for smoking cessation support. Second, smoking cessation support should be programmed as part of treatment or nursing. Third, healthcare professionals, especially doctors, should collaborate in supporting patients to stop smoking. Fourth, the hospital environment should be modified to promote smoking cessation. Finally, hospitals should develop a consensus among all staff about the importance of smoking cessation support and smoking control activities. As the result, multidimensional strategies are needed to effectively promote smoking cessation support in the hospital setting.     

Financial obligations and economic barriers to antiretroviral therapy experienced by HIV-positive women who participated in a job-creation programme in northern Uganda

Economic costs are commonly cited as barriers to women’s use of antiretroviral therapy (ART) in sub-Saharan Africa; however, little is known about how changes in women’s income influence economic barriers to care. We analysed in-depth interviews with 17 HIV-positive women who participated in a job-creation programme in northern Uganda and two key informant interviews with programme staff to examine lingering economic barriers to care experienced after programme enrolment. We found that participants continued to experience economic barriers even after receiving a steady income and improving their economic status. Two themes emerged: first, limited resources in health facilities (e.g. drug and staff shortages) led participants to view ART utilisation as a primarily economic endeavour where clients made informal payments for prompter service or sought treatment in private facilities where ART was readily available; second, increased economic status among participants increased expectations of economic reciprocity among participants’ social networks. Financial obligations often manifested themselves in the form of caring for additional dependents, limiting the resources women could allocate toward their HIV treatment. When paired with limited resources in health facilities, increased financial obligations perpetuated the economic barriers experienced by participants. Job-creation programmes should consider how health institutions interact with participants’ financial obligations to influence women’s access to HIV services.     

Australian nurses' smoking behaviour, knowledge and attitude towards providing smoking cessation care to their patients

This study examined smoking-related knowledge, attitudes andpractices of hospital-based nurses. The specific aims were:to determine the prevalence of self-reported smoking and thecharacteristics of hospital nurses who smoke; to describe nurses'knowledge of the health risks of smoking and strategies whichaid quitting; and to describe their attitudes to smoking andquitting and providing smoking cessation care. The sample wasformed from all direct-care nurses from six large hospitalsin the Hunter region of New South Wales, Australia rosteredon the randomly selected data collection days over 4 monthsin 1991 (n = 388, 98%). Participating nurses completed an interviewmeasuring demographic and smoking history characteristics, andknowledge of smoking-related diseases, quitting strategies andreferral options (open-ended questions). A self-completed questionnairemeasured attitudes about smoking, quitting and nurse provisionof smoking cessation care. Twenty-two percent of nurses reportedbeing current smokers and 21.5% reported being ex-smokers, withhigher smoking rates reported by enrolled nurses compared withregistered nurses. Knowledge about the health effects of smokingwas high, but knowledge of more effective strategies to aidquitting and referral options was poor. Nurses had positiveattitudes towards assisting patients to stop smoking (60%),but restricted this to patients who wanted to quit. Only 21%felt competent to discuss cessation with patients and identifiedskills training as necessary. The findings suggest that smokingrates among nurses may be lower than those reported in pastdecades and lower than rates among women of the same age inthe general population. The findings also suggest that nurses,while perceiving a role in smoking care, require training inthe provision of smoking cessation care to hospital patients,and that hospital policies and nurse education providers needto strongly support the provision of smoking cessation by providingnurses with time, access and incentive to undertake such activities.     

Culturally (In)competent? Dismantling Health Care Barriers for Sexual Minority Women

Lesbian and bisexual (LB) women exhibit elevated rates of a variety of behaviors (i.e., smoking, excessive caloric intake, physical inactivity, heavy alcohol consumption) that put them at risk for adverse health consequences. Furthermore, LB women experience numerous barriers to obtaining culturally competent health care. In this article we review risk behaviors and health care barriers and we discuss the role of stress as an important contributing factor in LB women’s health outcomes. We suggest future research, health care delivery changes, and training improvements that will prepare social workers to effectively address the needs of their LB clients.     

Work stress, smoking habits and competence in supporting clients to cease smoking--a survey among Finnish nurses

This paper describes results of a survey of Finnish nurses (n=882), their views of themselves as employees, their experiences of work stress and their competence to guide clients in smoking cessation. Nurses' skills to guide clients were fairly good but they had a lack of knowledge of smoking cessation centers and nicotine substitutions. The more positive the nurses' views were of themselves as employees, and the less they had experienced work stress related to their clients, the better they evaluated their skills and knowledge to guide clients to cease smoking. The results can be used to develop nurse education by providing a stronger knowledge base of smoking cessation. Nurses' view of themselves as employees could be strengthened by providing them with positive feedback from colleagues and managers.     

Health literacy training for Australian home care workers: Enablers and barriers

The rapidly expanding Australian home care workforce represents an untapped resource for improving health literacy (HL) and health outcomes of their clients. Nine home care workers (HCWs) were interviewed for this study to gain data around their experiences of providing HL support to their clients, key HL needs and priorities, and training that would best these needs. Findings indicate that HCWs are providing HL support, and identify a number of enablers and barriers to providing this support. Core inclusions for a HL training checklist are suggested. Implications for future research are considered.     

How place matters for smoking cessation: Barriers to smoking cessation among low-income Black women

African Americans start smoking later in life, yet they are less likely to quit smoking than other racial/ethnic groups. Drawing upon 40 in-depth interviews with former and current Black women smokers in the South Side of Chicago, this study examines external barriers to successful smoking cessation among socioeconomically disadvantaged Black women smokers. Beyond individual factors (e.g., stressors), this study finds interpersonal and structural factors that influence Black women's cessation efforts, including the high prevalence and normality of smoking and access to cheaper, loose cigarettes in their communities. Findings highlight the importance of considering local contexts for future tobacco research and policies.     

Where there is smoke, there is stress: low-income women identify support needs and preferences for smoking reduction

Efforts to assist low-income women with tobacco reduction and cessation have typically not been informed by assessment of their needs and wishes. This multi-site qualitative study focused on assessing 64 low-income women's support needs and intervention preferences. These women were interested in smoking cessation, but identified many barriers and needed appropriate supports. However, available smoking cessation programs did not address underlying conditions, such as income instability and stress. The support recommended was psychosocial (e.g., buddy and group support), included self-care (e.g., nutrition, activity, and personal time), and reflected their social-economic circumstances (e.g., free cessation aids and child care).     

The influence of power,poverty and agency in the negotiation of condom use for female sex workers in mainland China

This paper analyses barriers to consistent condom use in the context of transactional sex among female sex workers in mainland China. It reveals how differences in socioeconomic profile and organisational hierarchies amongst different groups of sex workers create different barriers to condom use. Data was collected by means of field observation of entertainment venues and in‐depth interviews. Findings suggest that, compared with other sex workers, street‐walkers are less likely to use condoms with their clients, hold highly disadvantaged socioeconomic profiles and work in isolation. Major barriers to condom use link to economic deprivation and threats of violence from clients. For the women working in entertainment venues, drunkenness of clients, pricing mechanisms and familiarity with clients pose barriers to condom use. Yet within all these constraints women are not powerless and instead find ways to exercise agency and gain personal protection and economic advantage. In the newly emerging China, both structural hierarchies of work and individual agency inform condom use by female sex workers. Future HIV intervention programmes need to take these factors into account in order to meet the needs of different groups of women sex workers.     

Engaging nurses in smoking cessation: Challenges and opportunities in Turkey

This paper discusses the training of nurses in smoking cessation as part of routine patient care in Turkey. Formative research was carried out prior to training to identify challenges faced by smokers when trying to quit. Site visits to government hospitals and cessation clinics were conducted to observe health care provider-patient interactions involving behavior change.Four culturally sensitive cessation training workshops for nurses (n = 54) were conducted in Istanbul. Following training, nurses were debriefed on their experiences delivering cessation advice. Challenges to cessation counseling included lack of time and incentives for nurse involvement; lack of skills to deliver information about the harm of smoking and benefits of quitting; the medicalization of cessation through the use of pharmaceuticals; and hospital policy which devalues time spent on cessation activities. The pay-for-performance model currently adopted in hospitals has de-incentivized doctor participation in cessation clinics.Nurses play an important role in smoking cessation in many countries. In Turkey, hospital policy will require change so that cessation counseling can become a routine part of nursing practice, incentives for providing cessation are put in place, and task sharing between nurses and doctors is clarified. Nurses and doctors need to receive training in both the systemic harms of smoking and cessation counseling skills. Opportunities, challenges and lessons learned are highlighted.     

Helping hospitalised clients quit smoking: a study of rural nursing practice and barriers

ABSTRACT: Brief interventions have been identified as a useful tool for facilitating smoking cessation, particularly in the acute care setting and in areas where access to specialist staff is limited, such as rural Australia. A self-administered survey was used to determine current rural nursing staff practices in relation to brief intervention for smoking cessation, and to ascertain the perceived level of support, skills, needs and barriers amongst these staff to conducting brief interventions. The major findings include that while the majority of respondents were aware of their patients' smoking status, most were not very confident about assisting smoking patients to quit. Casually employed nurses were much less likely to be aware of patient smoking status than nurses employed full-time or permanent part-time. Only one-quarter to one-third of nurses did not believe assisting patients to quit was part of their role, and the vast majority of nurses reported that they were non-smokers. Future programs incorporating the routine use of brief interventions will need to consider these findings.     

A case study of a Canadian homelessness intervention programme for elderly people

The aims of this study were to describe: (1) how the Homelessness Intervention Programme addressed the needs of elderly people who were homeless or at risk of homelessness; and (2) the factors that influenced the ability of the programme to address client needs. The programme was offered by a multi-service non-profit agency serving low-income families and individuals in an urban neighbourhood in Ontario, Canada. Using a case study approach, we conducted 10 individual interviews and three focus groups with programme clients, programme providers, other service providers and programme funders. Programme providers completed intake forms, monthly follow-up forms and exit/housing change forms for each of the 129 clients served by the programme over a 28-month period. Approximately equal proportions of clients were between 54 years old and 65 years old (47%) and over 65 years (53%). There were equal proportions of women and men. In addition to being homeless or marginally housed, clients lived with multiple and complex issues including chronic illness, mental illness and substance abuse. Through the facilitation of continuity of care, the programme was able to meet the needs of this vulnerable group of elderly people. Three types of continuity of care were facilitated: relational, informational and management continuity. The study confirmed the value of a continuous caring relationship with an identified provider and the delivery of a seamless service through coordination, integration and information sharing between different providers. Study findings also highlighted the broader systemic factors that acted as barriers to the programme and its ability to meet the needs of elderly people. These factors included limited housing options available; limited income supports; and lack of coordinated, accessible community health and support services. The central findings stress the importance of continuity of care as a guiding concept for intervention programmes for homeless and marginally housed elderly people.     

Smoking cessation in pregnancy: do effective programmes exist?

Smoking has been described as the most important cause of poorpregnancy outcome in Western countries. None the less, evidenceindicates that health care providers do not routinely providesmoking cessation interventions to pregnant women. The US SurgeonGeneral has recommended that programmes to reduce smoking duringpregnancy should be expanded in the public and private sectors.A review of the literature located 20 controlled evaluationsof smoking cessation interventions in pregnancy. The studieswere rated using the methodological criteria outlined by Windsorand Orleans (1986). Twelve of the studies were judged methodologicallyinadequate and excluded from the review. The remaining studieswere found to support the efficacy of cognitive behaviouralsmoking cessation programmes in pregnancy. There was insufficientevidence to determine whether advice, feedback or nurse home-visitationprogrammes increased smoking cessation rates in pregnancy underideal conditions. None of the methodologically adequate cognitivebehavioural studies fulfilled the criteria necessary for a smokingcessation programme to be incorporated into routine antenatalcare. Importantly, in only two studies were the smoking cessationinterventions delivered by usual care doctors or midwives. Thefindings indicate that it is unsurprising that health care providersdo not routinely deliver smoking cessation programmes to pregnantsmokers. Future research and programme needs are discussed.     

Smoking cessation programs targeted to women: a systematic review

The authors of this systematic review aimed to examine tobacco interventions developed to meet the needs of women, to identify sex- and gender-specific components, and to evaluate their effects on smoking cessation in women. The authors searched electronic databases in the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, EBSCO, PsychINFO, CINHAL, and EMBASE; the search was not restricted by publication date. Data was extracted from published peer-reviewed articles on participants, setting, treatment models, interventions, length of follow-up, and outcomes. The main outcome variable was abstinence from smoking. A total of 39 studies were identified. In efficacy studies, therapists addressed weight concerns and non-pharmacological aspects of smoking, taught mood/stress management strategies, and scheduled the quit date to be timed to the menstrual cycle. In effectiveness studies, therapists were peer counselors, provided telephone counseling, and/or distributed gendered booklets, videos, and posters. Among efficacy studies, interventions addressing weight gain/concerns showed the most promising results. If medication can support smoking cessation in women and how it interacts with non-pharmacological treatment also warrant further research. For effectiveness studies, the available evidence suggests that smoking should be addressed in low-income women accessing public health clinics. Further attention should be devoted to identifying new settings for providing smoking cessation interventions to women from disadvantaged groups. Women-specific tobacco programs help women stop smoking, although they appear to produce similar abstinence rates as non-sex/gender specific programs. Offering interventions for women specifically may reduce barriers to treatment entry and better meet individual preferences of smokers. Developing approaches that fully account for the multiple challenges treatment-seeking women face is still an area of research.