Summary of the impact

Smoking is the single most important preventable cause of mortality and inequalities in health in the UK. Tobacco use causes over 100,000 deaths each year in the UK, with around 10,000 of these due to non-smokers' exposure to secondhand smoke. The total cost of smoking to society is estimated to be over £13 billion. The UoE Tobacco Control Research Group's (TCRG) research and knowledge exchange activities have significantly influenced tobacco control policy and practice in the UK (http://www.cphs.mvm.ed.ac.uk/groups/tcrg or http://tinyurl.com/nwxcpnh). More specifically, their research on smoking and non-smoking by young people has influenced smoking prevention and cessation policy at the national level in Scotland and England and at regional/local levels. Their evaluation studies of the national smoke-free legislation in Scotland and England provided important evidence on the legislation's positive public health impact, thereby undermining the case for repealing or diluting the legislation. Their research on reducing smoking in the home has influenced national policy and practice on this issue in Scotland including national mass media campaigns.

Underpinning research

Background

TCRG members (listed below) have undertaken a range of research projects focusing on improving understanding of the processes involved in smoking uptake and cessation, and exposure to secondhand smoke in children and disadvantaged smokers. These studies, which mostly take a multi-disciplinary mixed methods approach, have advanced understanding of determinants of smoking uptake, barriers to cessation, reducing exposure to secondhand smoke and the effectiveness of innovative new approaches to tackling these issues.

Amanda Amos, Professor of Health Promotion (1985 - present), Stephen Platt, Professor of Health Policy Research (2005 - present), Sarah Cunningham-Burley, Professor of Medical and Family Sociology (1990 - present), Dr Deborah Ritchie, Senior Lecturer in Health Promotion and Mental Health (1999 - present), Dr Catriona Rooke, Research Fellow (2011- present), Dr Heide Weishaar, Research Fellow (2013 - present), Dr Gill Highet, Research Fellow (2007-09), Dr Wendy Gnich, Research Fellow (2002-06), Dr Richard Phillips, Research Fellow (2006-07).

Young people and smoking

Very few UK studies have assessed the effectiveness of smoking cessation services or support for young people. TCRG members undertook the first national study of innovative cessation approaches for young people (2002-06) (Gnich et al 2008). Qualitative and quantitative methods were used to evaluate a national programme of eight innovative pilot smoking cessation projects in Scotland. The evaluation concluded that, while some approaches had developed constructive ways of engaging with young smokers, none had been effective in increasing quit rates.

TCRG members subsequently undertook several studies, mostly using qualitative methods, which have made important contributions to understanding the determinants of youth smoking. Amos was commissioned by the Department of Health in 2008 to lead a review on young people and smoking in England, which was to inform the development of the Government's tobacco control white paper. This review developed a model which summarised key determinants of smoking uptake and made evidence-based recommendations on the most effective policy and practice interventions in smoking prevention (Amos et al 2009).

Smokefree public places and homes (2002-12)

Scotland introduced comprehensive smokefree legislation banning smoking in public places in 2006; the following year a similar ban was introduced in England. These initiatives were described by Ministers as the most important public health legislation in a generation. TCRG members undertook three studies as part of the separate national evaluation programmes in Scotland and England. These evaluations were internationally unique in using qualitative longitudinal designs to explore the legislation's impact on disadvantaged groups and in affluent compared to deprived communities. As part of the Scottish evaluation programme (CLEAN), they also undertook a qualitative study of the legislation's impact on smoking in the home. These studies showed that the smokefree legislation had an important influence on smokers' attitudes and behaviour within and outside the home. TCRG members are involved in the REFRESH study which comprises several components, including testing a novel intervention to help disadvantaged mothers who smoke reduce their child's exposure to secondhand smoke in the home. 2700 `How to Guides' based upon the REFRESH findings have been distributed to Health Boards across Scotland.

References to the research

Grants

Amos A, `A Review of Young People and Smoking in England'. Department of Health (England). 2008-09, £45k.

Platt S, Amos A, et al, `Evaluation of HEBS Young People's Smoking Cessation Pilots'. Health Education Board for Scotland. 2002-06, £250k.

Amos A, Martin C, Ritchie D, `Qualitative Study of Changes in Smoking (and Drinking) Behaviour following Implementation of the Prohibition of Smoking in Enclosed Public Places'. NHS Health Scotland. 2002-08, £145k.

Amos A, Martin C, Ritchie D, Cunningham-Burley S, `Qualitative Study of Smoking in the Home'. NHS Health Scotland. 2006-07, £100k.

Platt S, Amos A, Ritchie D et al., `Impact of Smokefree Legislation in England on Individuals and Communities'. Dept of Health (England) through Public Health Research Consortium. 2007-09, £355k.

ASH Scotland, Semple SE, Ritchie D, Amos A, Turner SW, `Reducing Children's Exposure to Secondhand Smoke in the Home (REFRESH)'. Big Lottery Research Fund. 2010-13, £490k.

Details of the impact

With the introduction of bans on smoking in public places in Scotland (2006) and England (2007), the REF period has seen intensive activity in the field of smoking prevention and cessation, where the underpinning research of the Group and its ongoing policy evaluation activities have had an intensive impact on changing policies and practices.

Young people and smoking

The Department of Health (DH) commissioned Amos to lead a review on young people and smoking in England to inform the development of the Government's tobacco control strategy white paper. The DH Review was quoted and referenced in the UK Government's 2010 white paper `A Smokefree Future — a Comprehensive Tobacco Strategy for England' [5.1] and included a key diagram from the report (p. 26). This diagram also appears in the Scottish Government's 2013 `Tobacco Control Strategy for Scotland' [5.2, p. 12]. The UK Government's 2011 white paper `Healthy Lives, Healthy People: a Tobacco Control Plan for England' also referenced the Review [5.3]. The model developed in the Review underpinned the UK Government's adoption of a broad policy approach. The Review's findings also influenced smoking prevention policy and practice at regional/local levels. Amos presented the findings at several regional/local tobacco control seminars and has received feedback that this directly impacted on local plans and priorities. This can be confirmed by regional tobacco control leads [5.4]. The Review's findings form part of the teaching on the only national CPD course on tobacco control
(http://www.ukctcs.org/ukctcs/teaching/index.aspx or http://tinyurl.com/puaswep).

Several of Amos's research publications on young people were referenced in the Scottish Smoking Prevention Working Group's report `Towards a Future Without Tobacco' [5.5]. This report had a major influence on the Scottish Government's Smoking Prevention Action Plan `Scotland's Future is Smoke Free' (2008) [5.6]. In the Foreword, the Minister for Public Health states that the Action Plan "builds upon and responds to the excellent report, `Towards a Future without Tobacco',... the Expert Group's recommendations also provide a clear mandate for the action proposed". This is highlighted throughout the Action Plan. Amos was a member of the expert Prevention Working Group and played an active role, including making presentations to the Group on her research.

Young people and smoking cessation

In Scotland the evaluation of the young people's cessation pilots led to the recommendation in the Scottish Government's 2008 Smoking Prevention Action Plan that youth smoking cessation services should not be established; rather, young people should be supported through standard NHS cessation services. The Action Plan states that "in the light of the recent poor outcome of the pilot smoking cessation services for young people we recommend active consideration is given to developing other approaches" [5.6, p. 37]. This is reiterated in the national guidelines for smoking cessation [5.7], with the study cited as the evidence base. The DH Review (see above) is also cited in these guidelines.

Legislation banning smoking in enclosed public spaces

TCRG members were involved in the national evaluations of the English and Scottish smokefree legislation. In Scotland, in response to a Parliamentary Question on 12/11/08, the Public Health Minister referred to the evidence from the national evaluation programme, which included two TCRG studies, which showed that Scotland was benefiting from the ban [5.8]. The Minister also stated "importantly, there is evidence of a change in the cultural acceptability of smoking", which related to the TCRG qualitative studies' findings. The English evaluation programme was mentioned in the 2010 white paper `Healthy Lives, Healthy People: Our Strategy for Public Health in England' [5.3]. `Healthy Lives, Healthy People: a Tobacco Control Plan for England' [5.3, pp. 37- 8], drawing on an independent academic review of the evidence from the evaluation programme [5.9], concluded that "the Government believes that the aims of the legislation continue to be effectively achieved." This evidence review cites the Final Report and a paper from our English study (Hargreaves et al 2010) and the Final Report of our Scottish study (Martin et al 2008).

Smokefree homes

The REFRESH project piloted an innovative intervention which successfully used personal home air quality feedback with motivational interviews to help smoking mothers reduce their children's exposure to secondhand smoke. REFRESH has influenced policy and practice. REFRESH is mentioned four times in the Scottish Tobacco Control Strategy [5.2, p. 24], including in Action Point 28. Recommendations from REFRESH influenced the inclusion in the Strategy of a commitment to set a target to reduce children's exposure to secondhand smoke. Scotland was the first country in the world to make such a commitment. TCRG members with ASH Scotland used REFRESH findings to develop a `How to' guide for practitioners working with parents. 2700 hard copies have been distributed to 2700 practitioners and it is also available on the study website (http://www.refreshproject.org.uk). It is cited as a recommended resource by the NHS Health Scotland's Maternal and Early Years website and led to a question on smoking in the home being included in the new 24-30 month infant review delivered by public health nurses [5.10]. The Scottish Government's Second Hand Smoke- Social Marketing Steering Group has explicitly drawn on the findings of REFRESH in the commissioning of a national public health campaign to be launched in Spring 2014 (5.10).

Sources to corroborate the impact

PDFs of all web links are available at www.wiki.ed.ac.uk/display/REF2014REF3B/UoA+22

5.1 A Smokefree Future — a Comprehensive Tobacco Strategy for England. 2010. Department of Health, London.
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_d h/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_111789.pdf

5.2. Creating a Tobacco-Free Generation- A Tobacco Control Strategy for Scotland. 2013. Scottish Government, Edinburgh. http://www.scotland.gov.uk/Resource/0041/00417331.pdf

5.3 Healthy Lives, Healthy People: a Tobacco Control Plan for England. 2011. Department of Health, London. https://www.gov.uk/government/publications/the-tobacco-control-plan-for-england

5.4 The following NHS Regional Tobacco Control leads can corroborate that the DH review on young people and smoking, and Professor Amos's presentations on the review at several regional/local tobacco control seminars and conferences, influenced smoking prevention policy and practice at regional/local levels: Director, Fresh- Smoke Free North East; Director, Tobacco Free Futures; Director, Smoke Free South West.

5.5 Towards a Future Without Tobacco: the Report of the Smoking Prevention Working Group. 2006. Scottish Executive, Edinburgh.
http://www.scotland.gov.uk/Publications/2006/11/21155256/4

5.6 Scotland's Future is Smoke Free: A Smoking Prevention Action Plan. 2008. Scottish Government, Edinburgh. http://www.scotland.gov.uk/Resource/Doc/223415/0060163.pdf

5.7 A Guide to Smoking Cessation in Scotland 2010- Planning and Providing Specialist Smoking Cessation Services. 2010. NHS Health Scotland, Edinburgh.
http://www.healthscotland.com/documents/4661.aspx

5.8 The Public Health Minister's response to a Parliamentary Question on 12/11/08 in the Scottish Parliament, which referred to the evidence from the national evaluation programme of the smokefree legislation, which included two TCRG studies, and showed that Scotland was benefiting from the ban can be found on the ASH Scotland website http://www.ashscotland.org.uk

5.9 Bauld L `The Impact of Smokefree Legislation in England: Evidence Review'. University of Bath, 2010. https://www.gov.uk/government/publications/impact-of-smokefree-legislation-evidence-review-march-2011

5.10 NHS Health Scotland Maternal and Early Years website: http://www.maternal-and-early-years.org.uk/topic/0-3-years/smoking-in-the-home. Official at Tobacco Policy, Public Health Division, Scottish Government can corroborate that the REFRESH findings are being used in commissioning the national public health campaign.