University of Birmingham A qualitative exploration of smokers' views regarding aspects of a community-based mobile stop smoking service in the United Kingdom

Background: Developing more accessible stop smoking services (SSS) is important, particularly for reaching smokers from socio-economically deprived groups who are more likely to smoke and less likely to quit in comparison to their more affluent counterparts. A drop-in mobile SSS (MSSS) was piloted across 13 locations in socio-economically deprived areas of Nottingham. Methods: Semi-structured telephone interviews were conducted to explore the views of 40 smokers who registered with the MSSS. Results: The MSSS appeared to trigger quit attempts. For some of the participants the attempt was totally unplanned; for others, it built on pre-existing thoughts about quitting which had not yet been acted upon. Smokers interested in quitting were comfortable about approaching the MSSS, whilst acknowledging that they did not feel pressured to register with the service. The drop-in format of the MSSS was found to be more appealing than making an appointment. In addition, several participants articulated that they may not have utilised other SSS had they not come across the MSSS. Conclusions: A MSSS may be an effective way to prompt quit attempts for smokers not planning to quit and also reach smokers who would not engage with SSS. Background In the United Kingdom (UK), the association between smoking prevalence and social disadvantage is well documented. Adults from socio-economically deprived groups and/or areas, as determined by level of education, housing tenure, social class and income level, are more likely to smoke and less likely to quit when compared to their more affluent counterparts [1]. Smoking prevalence has declined between 1980 and 1996 in the general population from 39% [2] to 28% respectively [3]. In recent years however, the decline has slowed down and prevalence was reported as being 22% in 2008/09 [3]. In contrast, differences according to socio-economic factors remain marked and unchanged [4], with 32% of men and 27% of women estimated to smoke in routine and manual occupations compared with 17% of men and 14% of women in managerial and professional groups [3]. Smoking therefore remains a significant contributor to health inequalities; for example, it is the main factor associated with higher death rates in the manual as compared with the non-manual occupation group [5]. Therefore, smoking is an important factor when attempting to understand reasons for those from less affluent groups experiencing poorer health outcomes and decreased life expectancy when compared with those from more affluent groups [6]. Hence, efforts to increase engagement of smokers from less affluent socio-economic groups are a priority for Public Health [7,8]. Whilst the provision and uptake of National Health Service (NHS) stop smoking services (SSS) has improved in recent years [9], only 8% of all smokers utilise them [3]. Typically, SSS involve smokers booking an appointment at clinics often held in health or community centres, where they meet with a trained advisor for one-toone or group behavioural support and receive * Correspondence: [email protected] UK Centre for Tobacco Control Studies, Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK Bains et al. BMC Public Health 2011, 11:873 http://www.biomedcentral.com/1471-2458/11/873 © 2011 2011 Bains et at; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. pharmacotherapy treatment [10,11]. The success of these services is undisputed [12], with chances of quitting increased by four-fold when compared with willpower alone [11]. A review of NHS SSS in general, summarises that some have been successful in attracting smokers from deprived areas and thus have worked towards addressing health inequalities [13]. However, similar to other health screening initiatives [14-16], the uptake of SSS by smokers from poorer socio-economic groups remains a challenge [13,17], due to barriers such as fear of being judged, fear of failure, lack of knowledge about the existence and nature of SSS and availability of pharmacotherapy [5]. Novel approaches to engage, recruit and support smokers from these groups are required [18-22]. For example, when considering breast cancer screening, services located at non-health facilities were perceived as more accessible than those at health facilities; however, reasons for this requires further research [14]. At present, strategies to recruit smokers from disadvantaged groups are limited, although there is some evidence that providing SSS in alternative settings such as workplaces could improve access [17]. The Roy Castle Fag Ends SSS in Liverpool (UK) is an example of a client-led approach that is flexible offering both oneto-one or group support where there is no waiting list, clients choose whether to make an appointment or drop-in, and they decide when to stop attending [23]. Considerable success has been attributed to the accessibility of the service with self-referral by drop-in accounting for 41% of total clients seen in 2005, an increase from 19% in 2001. In addition, 57% of clients were abstinent from smoking at 4 weeks (annual average over the period 2001 to 2005 [23]). The need for more dynamic and flexible SSS is further supported by research suggesting that a notable proportion of quit attempts are unplanned and spontaneous [24,25]. The PRIME (plans, responses, impulses, motives, evaluations) theory of motivation [26] argues that smokers can be prompted to quit, without prior thought or planning [24,27]. Research also indicates that it is possible to support smokers with varying levels of motivation to quit [27]; thus questioning the usefulness of behaviour change models such as stages of change in the tobacco domain [28]. Making unsupported unplanned quit attempts does not appear to differ according to socio-economic groups and are often triggered by advice from a health care professional [29]. However, efforts to further understand spontaneous quit attempts have found that, for some, an element of planning was inherent [30,31]. This study explores the views of smokers who registered with a mobile, communitybased SSS (MSSS) taken to socio-economically disadvantaged areas in Nottingham, over 4 weeks (September to October 2010); this formed part of a pilot study that was conducted prior to a main study of the MSSS’s effectiveness.