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Background Physical activity can support smoking cessation for smokers wanting to quit, but there have been no studies on supporting smokers wanting only to reduce. More broadly, the effect of motivational support for such smokers is unclear. Objectives The objectives were to determine if motivational support to increase physical activity and reduce smoking for smokers not wanting to immediately quit helps reduce smoking and increase abstinence and physical activity, and to determine if this intervention is cost-effective. Design This was a multicentred, two-arm, parallel-group, randomised (1 : 1) controlled superiority trial with accompanying trial-based and model-based economic evaluations, and a process evaluation. Setting and participants Participants from health and other community settings in four English cities received either the intervention (n = 457) or usual support (n = 458). Intervention The intervention consisted of up to eight face-to-face or telephone behavioural support sessions to reduce smoking and increase physical activity. Main outcome measures The main outcome measures were carbon monoxide-verified 6- and 12-month floating prolonged abstinence (primary outcome), self-reported number of cigarettes smoked per day, number of quit attempts and carbon monoxide-verified abstinence at 3 and 9 months. Furthermore, self-reported (3 and 9 months) and accelerometer-recorded (3 months) physical activity data were gathered. Process items, intervention costs and cost-effectiveness were also assessed. Results The average age of the sample was 49.8 years, and participants were predominantly from areas with socioeconomic deprivation and were moderately heavy smokers. The intervention was delivered with good fidelity. Few participants achieved carbon monoxide-verified 6-month prolonged abstinence [nine (2.0%) in the intervention group and four (0.9%) in the control group; adjusted odds ratio 2.30 (95% confidence interval 0.70 to 7.56)] or 12-month prolonged abstinence [six (1.3%) in the intervention group and one (0.2%) in the control group; adjusted odds ratio 6.33 (95% confidence interval 0.76 to 53.10)]. At 3 months, the intervention participants smoked fewer cigarettes than the control participants (21.1 vs. 26.8 per day). Intervention participants were more likely to reduce cigarettes by ≥ 50% by 3 months [18.9% vs. 10.5%; adjusted odds ratio 1.98 (95% confidence interval 1.35 to 2.90] and 9 months [14.4% vs. 10.0%; adjusted odds ratio 1.52 (95% confidence interval 1.01 to 2.29)], and reported more moderate-to-vigorous physical activity at 3 months [adjusted weekly mean difference of 81.61 minutes (95% confidence interval 28.75 to 134.47 minutes)], but not at 9 months. Increased physical activity did not mediate intervention effects on smoking. The intervention positively influenced most smoking and physical activity beliefs, with some intervention effects mediating changes in smoking and physical activity outcomes. The average intervention cost was estimated to be £239.18 per person, with an overall additional cost of £173.50 (95% confidence interval −£353.82 to £513.77) when considering intervention and health-care costs. The 1.1% absolute between-group difference in carbon monoxide-verified 6-month prolonged abstinence provided a small gain in lifetime quality-adjusted life-years (0.006), and a minimal saving in lifetime health-care costs (net saving £236). Conclusions There was no evidence that behavioural support for smoking reduction and increased physical activity led to meaningful increases in prolonged abstinence among smokers with no immediate plans to quit smoking. The intervention is not cost-effective. Limitations Prolonged abstinence rates were much lower than expected, meaning that the trial was underpowered to provide confidence that the intervention doubled prolonged abstinence. Future work Further research should explore the effects of the present intervention to support smokers who want to reduce prior to quitting, and/or extend the support available for prolonged reduction and abstinence. Trial registration This trial is registered as ISRCTN47776579. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 4. See the NIHR Journals Library website for further project information.

IntroductionIncorporating spirometry into low-dose CT (LDCT) screening for lung cancer may help identify people with undiagnosed chronic obstructive pulmonary disease (COPD), although the downstream impacts are not well described.MethodsParticipants attending a Lung Health Check (LHC) as part of the Yorkshire Lung Screening Trial were offered spirometry alongside LDCT screening. Results were communicated to the general practitioner (GP), and those with unexplained symptomatic airflow obstruction (AO) fulfilling agreed criteria were referred to the Leeds Community Respiratory Team (CRT) for assessment and treatment. Primary care records were reviewed to determine changes to diagnostic coding and pharmacotherapy.ResultsOf 2391 LHC participants undergoing prebronchodilator spirometry, 201 (8.4%) fulfilled the CRT referral criteria of which 151 were invited for further assessment. Ninety seven participants were subsequently reviewed by the CRT, 46 declined assessment and 8 had already been seen by their GP at the time of CRT contact. Overall 70 participants had postbronchodilator spirometry checked, of whom 20 (29%) did not have AO. Considering the whole cohort referred to the CRT (but excluding those without AO postbronchodilation), 59 had a new GP COPD code, 56 commenced new pharmacotherapy and 5 were underwent pulmonary rehabilitation (comprising 2.5%, 2.3% and 0.2% of the 2391 participants undergoing LHC spirometry).ConclusionsDelivering spirometry alongside lung cancer screening may facilitate earlier diagnosis of COPD. However, this study highlights the importance of confirming AO by postbronchodilator spirometry prior to diagnosing and treating patients with COPD and illustrates some downstream challenges in acting on spirometry collected during an LHC.

The objective of this review was to identify, appraise, and synthesize the evidence related to experiences and views of parents, children, and professionals on the prevention of second-hand smoke exposure to women and children in Middle Eastern countries.Second-hand smoke exposure is a major health concern. It is problematic during pregnancy because of potential adverse reproductive effects and poor fetal outcomes. Childhood second-hand smoke exposure is linked to increased morbidity and mortality. Smoking prevalence is high among men in Middle Eastern countries and, as a result, large numbers of non-smoking men, women, and children are exposed to second-hand smoke daily.Studies were considered for inclusion if they explored experiences and views on the prevention of second-hand smoke exposure among women and children in homes, workplaces, schools, personal vehicles, and public places in 17 Middle Eastern countries. This review included studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative descriptive, and feminist research.MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus databases were searched to identify published studies from inception to January 2021. The search for unpublished studies included EThOS, OpenGrey, and ProQuest Dissertations and Theses. No language restrictions were applied. The JBI guidelines for qualitative systematic reviews were followed in conducting the review. The JBI process of meta-aggregation was used to identify categories and synthesize findings.Of 5229 records identified, two qualitative studies (in three publications) met the eligibility criteria and were included in the review. One study was conducted in Turkey and the other study (reported in two papers) was conducted in Israel. The methodological quality of the studies was high. The participants in the included studies were parents (n = 118 participants) aged between 18 and 42 years. The methods used for data collection were interviews analyzed using thematic content analysis. A total of 50 findings were extracted and aggregated into eight categories, based on the similarity of meaning. Three synthesized finding were generated (all with moderate confidence): i) Parents were aware of second-hand smoke and that exposure to second-hand smoke is harmful, although the health dangers of second-hand smoke exposure were not commonly discussed with parents during pregnancy;ii) Smoking is a socially and culturally accepted norm, with parents reporting cultural beliefs about traditional values as a barrier to reducing second-hand smoke exposure in the home and personal psychological factors to quitting smoking; iii) Parents implemented different physical restrictions on smoking, such as having rules about where smoking can take place, with psychological motivators reported as drivers to decrease second-hand smoke exposure among children in the home, but tended to lack certainty or confidence regarding whether such protective measures were needed or would be effective.The findings of this study offer an insight into parents' views on second-hand smoke exposure and its prevention in Middle Eastern countries. Parents have conflicting views on second-hand smoke exposure and techniques to minimize it. Interventions are needed to increase parents' knowledge about the harms of second-hand smoke to reduce women's and children's exposure to second-hand smoke.PROSPERO CRD42019137006.

The concept of cure from cancer is important to patients, but can be difficult to communicate in terms that are meaningful. This is because there are a number of definitions of cure that are applied by clinicians, patients and the public, and by policymakers that have a different meaning and significance. In this article, we provide a narrative review of the evidence concerning cure in lung cancer and show how the different definitions may apply in different settings. A better understanding of the various concepts of cure will improve communication with patients on this important topic. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Rationale: The American Thoracic Society (ATS) developed a clinical practice guideline on initiating pharmacologic treatment in tobacco-dependent adults. Controller pharmacotherapies treat tobacco dependence effectively when taken as prescribed, but relapse after pharmacologic discontinuation is common. Objectives: To evaluate the effectiveness and safety of initiating controller for an extended (.12 wk) versus a standard duration (6-12 wk) in tobacco-dependent adults. Methods: We systematically searched PubMed, ExcerptaMedica Database, Cumulative Index toNursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials fromdatabase inception toDecember 2021 to identify randomized controlled trials comparing extended versus standard duration of controllers for tobacco-dependent adults. We conductedmeta-analyses using the Mantel-Haenszelmethod with random effectsmodel.Outcomes of interest include point-prevalent abstinence at 1-year follow-up or longer, relapse, adverse events, quality of life, and withdrawal symptoms. Subgroup analyses were conducted according to types of treatment and duration of extended therapy when feasible.We assessed the certainty of the estimate following the grading of recommendations, assessment, development and evaluationmethodology. Results: We included 13 randomized controlled trials including 8,695 participants that directly compared extended- (.12 wk) versus standard-duration controller therapy with varenicline, bupropion, or nicotine replacement therapy. Compared with standard-duration controller therapy, extendedduration controller therapy probably increased abstinence at 1-year follow-up, measured as 7-day point-prevalence abstinence (relative risk, 1.18; 95% confidence interval [CI], 1.05-1.33; moderate certainty). Extended-duration controller therapy probably reduced relapse compared with standardduration controller therapy, assessed at 12-18 months after initiation of therapy (hazard ratio, 0.43; 95% CI, 0.29-0.64; moderate certainty). Moderate certainty evidence also suggested that extended-duration controller therapy probably did not increase risk of serious adverse events (relative risk, 1.37; 95% CI, 0.79-2.36). Conclusions: This systematic review supported the recommendation for extended-duration therapy with controllers. Further studies on optimal extended duration are warranted.

Smoking cessation services have rapidly transformed during the COVID-19 pandemic. Changes include pivoting from face-to-face to telephone and video call support, remote provision of stop smoking aids and more flexible appointments. This study reports an evaluation of a charity-led smoking cessation service rapidly conceived and launched in this context. The pilot service accepted self-referrals in Yorkshire, England from 20 May 2020 to 5 June 2020. A dedicated smoking cessation practitioner provided 12 weeks of weekly behavioural support over telephone or video call. NRT and/or medication and/or e-cigarettes were posted to the participant bi-weekly for up to 12 weeks. Written and telephone evaluation questionnaires were administered post-programme. Of 79 participants, 57 (72.2%) self-reported a 4-week quit and 51 (64.6%) self-reported a 12-week quit. Those concurrently using e-cigarettes and NRT had an 84.1% 12-week quit rate. The majority of participants chose to use e-cigarettes and NRT in combination (55.7%). 39 participants completed an evaluation form, with at least 90% recording they were “very satisfied” with each service component. 27 participants completed a telephone interview, reporting a relationship with practitioners, as well as convenience, and organisational reputation as service strengths. Virtual services can be set up quickly and effectively in response to demand. Quit rates were highest for those concurrently using e-cigarettes and NRT. Service users value flexibility and convenience of remote support and posting of quit aids.

Background Exposure to alcohol, tobacco and high fat, sugar and salt (HFSS) food imagery is a significant risk factor for the uptake and regular use of these products in young people, and imagery are more frequently portrayed in video-on-demand (VOD) than in terrestrial television programmes. This study compared alcohol, tobacco and HFSS imagery in original films on Amazon Prime Instant Video and Netflix. Methods Content analysis of 11 original films released by Amazon Prime and Netflix in 2017 using 5-minute interval coding of alcohol, tobacco and HFSS content. Proportions of intervals containing alcohol, tobacco and HFSS imagery were compared between services using the chi-square test. Results Alcohol content appeared in 200 (41.7%) out of the total of 479 intervals coded, whereas tobacco and HFSS appeared in 129 (26.9%) and 169 (35.24%), respectively. Proportions were similar between Amazon Prime Instant Video and Netflix original films and were unrelated to film age classification. Conclusions Alcohol, tobacco and HFSS content likely to promote consumption among young people occurs frequently in original films shown by VOD services in the UK. Further studies are needed to investigate effective regulatory frameworks for VOD services to protect viewers from harmful or unwanted contents.

Background Exposure to alcohol, tobacco and foods high in fat, sugar or salt (HFSS) content in media is a risk factor for smoking, alcohol use and HFSS consumption in young people. We report an analysis of tobacco, alcohol and HFSS content in a sample of reality TV programmes broadcast on TV and video-on-demand services throughout a 1-year period. Methods We used 1-min interval coding to quantify content in all episodes of 20 different reality TV programmes between August 2019 and August 2020 and estimated population exposure to a sample of these programmes using viewing data and UK population estimates. Results We coded 13 244 intervals from 264 episodes. Tobacco content appeared in 227 intervals (2%) across 43 episodes (2%), alcohol in 5167 intervals (39%) across 258 episodes (98%) and HFSS in 1752 intervals (13%) across 234 episodes (88%). A sample of 15 series delivered ~157.4 million tobacco, 3.5 billion alcohol and 1.9 billion HFSS gross impressions to the UK population, including 24 000, 12.6 million and 21.4 million, to children, respectively. Conclusion Tobacco, alcohol and HFSS content are common in reality TV programmes. These programmes deliver exposure to tobacco, alcohol and HFSS imagery, which are a potential driver of tobacco use, alcohol use and HFSS consumption in young people.

Prevention of smoking uptake in young people is an essential public health target. We have previously reported a systematic review and meta-analysis of the effect of exposure to smoking imagery in films on the risk of smoking uptake in young people. This study updates that review, and includes studies of the effects of exposure to media vaping imagery on vaping uptake. Four electronic databases (MEDLINE, EMBASE, PsycINFO, and IBSS) were searched to August 2020 for studies reporting the association between exposure to smoking/vaping in films and smoking/vaping uptake in adolescents. Two authors independently screened papers, extracted data, and assessed quality. This review included 26 studies. Exposure to high levels of smoking imagery in films was associated with an increased likelihood of having ever smoked in nine cross-sectional studies and of smoking uptake in 11 longitudinal studies. Vaping imagery in films was associated with increased likelihood of ever vaping in two cross-sectional studies and vaping uptake in five longitudinal studies. This review concluded that exposure to smoking imagery in films increases the risk of smoking among young people. It is likely that a similar association exists between exposure to vaping imagery and vaping uptake. Therefore, this review recommends introduction of new policies to minimize the impact of this in films which contain smoking or vaping and are likely to be viewed by children and adolescents.

Objective: This systematic review aims to identify and explore the experiences and views regarding secondhand smoke (SHS) exposure among women and children in the home, workplace, school, personal vehicles, and public places from the perspectives of (i) women, (ii) children and (iii) professionals in Middle Eastern countries. Introduction: Exposure to SHS is a significant public health problem globally, particularly Middle Eastern countries. Whilst many Middle Eastern countries have implemented tobacco control programs and have legislation that bans smoking in public places, the legislation is not always comprehensively implemented or enforced. Therefore, women and children continue to be exposed to SHS in public and private settings. Inclusion criteria: This review will consider studies that include the views and experiences of any of the following three groups: (i) women (including pregnant women and mothers), (ii) children (primary and secondary school age), and (iii) professionals (including health professionals and policy makers), regarding the prevention of SHS exposure in women and children in Middle Eastern countries. Methods: Six databases (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science and Scopus) and three sources of grey literature will be searched for eligible studies. Databases will be searched from their inception dates and no language restrictions will be applied. Two reviewers will independently screen studies, extract data and assess methodological quality of included studies, following JBI systematic review guidelines. The JBI process of meta-aggregation will be used to identify categories and synthesize findings. The ConQual approach will be used to assess confidence in the findings.

Background Conflict in Nigeria displaced millions of people, and some settled in camp-like locations within the country. Evidence on the association between living conditions and health outcomes among these populations are limited. This study investigated the risk factors associated with illnesses among camp-dwelling internally displaced persons (IDPs) in northern Nigeria. Methods A cross-sectional study was conducted in nine camps in 2016. Self-reported data on socio-demography, resource utilization and disease outcomes were collected. Association between health conditions and various factors, including sanitation and healthcare access, was investigated. Results Data from 2253 IDPs showed 81.1% (CI = 79.5–82.7) experienced one or more health conditions; however, over 20% did not access healthcare services. Most common diseases were malaria, fever, typhoid and diarrhoea. Multivariable logistic regression presented as adjusted odds ratios(aOR) and 95% confidence intervals(CIs) showed factors significantly associated with increased likelihood of illnesses included being female (aOR = 1.53;CI = 1.19–1.96), overcrowding (aOR = 1.07;CI = 1.00–1.36), long-term conditions (aOR = 2.72;CI = 1.88–3.94), outdoor defecation (aOR = 2.37;CI = 1.14–4.94) and presence of disease-causing vectors (aOR = 3.71;CI = 1.60–8.60). Conclusion Most diseases in the camps were communicable. Modifiable risk factors such as overcrowding and poor toilet facilities were associated with increased poor health outcomes. This evidence highlights areas of high priority when planning humanitarian public health interventions.

Background: Conflict and violent crises have resulted in over 40 million of internally displaced persons (IDPs). Most affected regions lack access to basic health resources and generally rely on humanitarian support. The objective of this review was to appraise primary health service interventions among conflict-induced internally displaced populations in low and middle income countries between 2000 and 2019. Methods: A systematic review of literature in the following databases: Embase, MEDLINE, PsyArticles, PsycINFO, Scopus, Web of Science, LILAC and CAB Articles, was performed to identify interventions implemented in conflict IDP settings. Results: Initial searches yielded 4578 papers and 30 studies met the inclusion criteria. Descriptivesynthesis analysis was used, and the final selections were assessed using a customized CriticalAppraisal Skills Programme (CASP) checklist. Included papers were from Sub-Saharan Africa, South Asia and the Middle East regions. Most studies were on prevention interventions, especially water treatment and maternal health. Treatment interventions mostly focused on onmalaria and mental health. Only one food and nutrition study with outcome data was identified, indicating limitations in IDP health-related intervention publications. Reported interventions were conducted between one week to five years, and the study qualities were moderate. The most effective interventions were integrated programmes and common challenges were weakstudy methodology and data reporting. Conclusion: Regardless of the intervention types and durations, the services offered were beneficial to the IDPs. More intervention evidence are, however required as shown in gaps around food and nutrition, health education and disease surveillance.

The main causes of non-communicable diseases (NCDs), health inequalities and health inequity include consumption of unhealthy commodities such as tobacco, alcohol and/or foods high in fat, salt and/or sugar. These exposures are preventable, but the commodities involved are highly profitable. The economic interests of ‘Unhealthy Commodity Producers’ (UCPs) often conflict with health goals but their role in determining health has received insufficient attention. In order to address this gap, a new research consortium has been established. This open letter introduces the SPECTRUM (Shaping Public hEalth poliCies To Reduce ineqUalities and harM) Consortium: a multi-disciplinary group comprising researchers from 10 United Kingdom (UK) universities and overseas, and partner organisations including three national public health agencies in Great Britain (GB), five multi-agency alliances and two companies providing data and analytic support. Through eight integrated work packages, the Consortium seeks to provide an understanding of the nature of the complex systems underlying the consumption of unhealthy commodities, the role of UCPs in shaping these systems and influencing health and policy, the role of systems-level interventions, and the effectiveness of existing and emerging policies. Co-production is central to the Consortium’s approach to advance research and achieve meaningful impact and we will involve the public in the design and delivery of our research. We will also establish and sustain mutually beneficial relationships with policy makers, alongside our partners, to increase the visibility, credibility and impact of our evidence. The Consortium’s ultimate aim is to achieve meaningful health benefits for the UK population by reducing harm and inequalities from the consumption of unhealthy commodities over the next five years and beyond.

Background More than 50% of non-smoking women and children are exposed to second-hand smoke (SHS) in Middle Eastern countries. This review aims to synthesize the evidence on experiences and views of parents, children, and professionals towards SHS exposure prevention in Middle Eastern countries. Methods We included qualitative studies exploring experiences and views on prevention of SHS exposure among women and children in all settings in Middle Eastern countries. A systematic review was undertaken according to the Joanna Briggs Institute (JBI) guidelines for qualitative systematic reviews. Nine databases were searched from inception to January 2021. Meta-aggregation was used to synthesize the findings. Results Out of 5229 records identified, two qualitative studies reported in three publications met the eligibility criteria and were included. Using the JBI checklist for qualitative research, the critical appraisal scores of all papers were high. One study was conducted in Turkey and the other one in Israel, and study participants were parents of children. A total of 49 findings were extracted and aggregated into 8 categories, based on the similarity of meaning. Parents were aware that SHS is harmful, although the hazards of SHS exposure were not commonly discussed during pregnancy. However, there were conflicting views on ways of SHS exposure and approaches to minimise it. Parents implemented rules to decrease SHS exposure among children. While some parents were uncertain about the effectiveness of protective measures. Most common perceived barriers to reducing SHS exposure were beliefs about traditional values and personal psychological factors. Conclusions Parents in Middle Eastern countries knew that children's SHS exposure is harmful, though knowledge was not comprehensive and did not translate into actions to protect children. Health education program is essential to improve parental knowledge on hazards of SHS and effective preventive measures. Key messages Parents’ risk-awareness of SHS exposure is inadequate. Health education program is essential to improve parental knowledge on hazards of SHS and effective preventive measures in Middle Eastern countries.

Background Exposure to tobacco and alcohol content in media is a risk factor for smoking and alcohol use in young people. Our previous research suggested that tobacco and alcohol imagery is common in soap operas. We now report an analysis of tobacco and alcohol content in a sample of soap operas broadcast in the UK. Methods We used 1-minute interval coding to quantify tobacco and alcohol content in all episodes (including advertisement breaks) of six soap operas broadcast on UK television during three separate weeks in November and December 2018 and January 2019. Results We coded 2222 intervals from 87 episodes and 360 intervals from 77 advertisement breaks. Tobacco content was rare, occurring in 4% of all intervals across 30% of episodes, the only tobacco appearances in adverts appeared in anti-smoking advertising. Alcohol occurred in 24% of intervals across 95% of episodes and in 13% of advertisement intervals. The programmes delivered ~381.28 million tobacco and 2.1 billion alcohol gross impressions to the UK population, including 18.91 million tobacco and 113 million alcohol gross impressions to children. Conclusion Whilst tobacco was rare, alcohol content was common, resulting in billions of viewer impressions. Soap operas represent a potential driver of alcohol consumption in young people.

Aims To quantify Guinness-related branding in the 2019 Guinness Six Nations Championship. Methods Content analysis of Guinness-related branding (‘Guinness’ and the alibi brand ‘Greatness’) was shown during active play throughout all 15 games of the 2019 Guinness Six Nations Championship. The duration of each appearance was timed to the nearest second to provide information on the amount of time that Guinness-related branding was shown on screen. Census data and viewing figures were used to estimate gross and per capita alcohol impressions. Results Our coding identified a total of 3719 appearances of two logos of which 3415 (92%) were for ‘Guinness’ and 304 (8%) were for ‘Greatness’. ‘Guinness’ imagery was present for 13,640 s (227.3 min or 3.8 h, 16% of total active play time), ‘Greatness’ was present for 944 s (15.7 min, 1% of total active play time), with a combined total of 14,584 s across all games (243 min or 4.05 h, 17% of active play time). The 15 games delivered an estimated 122.4 billion Guinness-related branded impressions to the UK population, including 758 million to children aged under 16. Conclusions Alcohol marketing was highly prevalent during the 2019 Guinness Six Nations Championship and was a significant source of exposure to alcohol marketing and advertising for children, likely influencing youth alcohol experimentation and uptake.

IntroductionTreating tobacco dependency in patients admitted to hospital is a key priority in the National Health Service long-term plan. This service evaluation assessed the perception, needs and experience of care within an opt-out hospital-based tobacco dependency treatment service (the Conversation, Understand, Replace, Experts and Evidence Base (CURE) team) in North-West England.MethodsA survey was offered to all eligible patients between 1 July 2020 and 30 September 2020. Eligibility criteria were adult patients identified as an active smoker being approached by the CURE team as part of the standard opt-out service model, on a non-covid ward without a high suspicion of COVID-19 infection and able to read and write in English.Results106 completed surveys were evaluated. Participants demonstrated high levels of tobacco dependency with an average of 37 years smoking history and 66% describing the onset of cravings within 30 min of hospital admission. The average number quit attempts in the previous 12 months was 1.3 but only 9% had used the most effective National Institute for Health and Care Excellence (NICE) recommended treatments. 100% felt the opt-out service model was appropriate and 96% stated the treatment and support they had received had prompted them to consider a further quit attempt. 82% of participants rated their experience of care as 9/10 or 10/10. Participants wanted a broad range of support post discharge with the most popular option being with their general practitioner. 66% and 65% of participants would have been interested in a vaping kit as stop smoking intervention and support vaping-friendly hospital grounds respectively.ConclusionThese results suggest this hospital-based, opt-out tobacco dependency treatment service delivers high-quality experience of care and meets the needs of the patients it serves. It also highlights the opportunity to enhance outcomes by providing access to NICE recommended most-effective interventions (varenicline, vaping and combination nicotine replacement therapy) and providing flexible, individualised discharge pathways.

ObjectivesTo identify psychosocial determinants of quit motivation in older deprived smokers. The evidence may be used to optimise smoking cessation interventions for the target population.DesignCross-sectional survey using online recruitment methods including Facebook-targeted advertising.SettingUK, 2019.ParticipantsCurrent smokers aged 50 years or older and from a socioeconomically deprived background.Main outcome measuresMeasures included motivation to stop smoking, smoking history, perceived social support, self-efficacy for quitting, self-exempting beliefs and lung cancer risk perception. Multivariable regression was used to analyse factors associated with quit motivation.ResultsOf a total 578 individuals who consented to take part, 278 (48.1%) did not meet the inclusion criteria. Of the 300 eligible participants, most were recruited using Facebook (94.0%), were aged 50–64 years (83.7%) and women (85.7%). Most participants were renting from a housing association (72.0%) and had low education (61.0%). Higher motivation to quit was statistically significantly associated with a higher intensity of previous quit attempts (p=0.03), higher quit confidence (p=0.01), higher smoking self-efficacy (p=0.01), a lower risk-minimising beliefs score (p=0.01) and using traditional nicotine replacement therapy (NRT) when trying to stop smoking or cut down (pConclusionOlder smokers from deprived backgrounds face complex barriers to quitting smoking. Interventions are needed to increase self-efficacy for quitting, modify risk-minimising beliefs and target elements of previous quit attempts (ie, the use of NRT) that are associated with motivation to stop smoking.

BackgroundScreening with low-dose computed tomography (LDCT) reduces lung cancer mortality; however, the most effective strategy for optimising participation is unknown. Here we present data from the Yorkshire Lung Screening Trial, including response to invitation, screening eligibility and uptake of community-based LDCT screening.MethodsIndividuals aged 55–80 years, identified from primary care records as having ever smoked, were randomised prior to consent to invitation to telephone lung cancer risk assessment or usual care. The invitation strategy included general practitioner endorsement, pre-invitation and two reminder invitations. After telephone triage, those at higher risk were invited to a Lung Health Check (LHC) with immediate access to a mobile CT scanner.ResultsOf 44 943 individuals invited, 50.8% (n=22 815) responded and underwent telephone-based risk assessment (16.7% and 7.3% following first and second reminders, respectively). A lower response rate was associated with current smoking status (adjusted OR 0.44, 95% CI 0.42–0.46) and socioeconomic deprivation (adjusted OR 0.58, 95% CI 0.54–0.62 for the mostversusthe least deprived quintile). Of those responding, 34.4% (n=7853) were potentially eligible for screening and offered a LHC, of whom 86.8% (n=6819) attended. Lower uptake was associated with current smoking status (adjusted OR 0.73, 95% CI 0.62–0.87) and socioeconomic deprivation (adjusted OR 0.78, 95% CI 0.62–0.98). In total, 6650 individuals had a baseline LDCT scan, representing 99.7% of eligible LHC attendees.ConclusionsTelephone risk assessment followed by a community-based LHC is an effective strategy for lung cancer screening implementation. However, lower participation associated with current smoking status and socioeconomic deprivation underlines the importance of research to ensure equitable access to screening.

Introduction Finding effective ways to help pregnant women quit smoking and maintain long-term abstinence is a public health priority. Electronic cigarettes (ie, vaping) could be a suitable cessation tool in pregnancy for those who struggle to quit; however, healthcare professionals (HCP) must be informed about these devices to offer appropriate advice. This study used the Capability, Opportunity, Motivation, and Behavior (COM-B) model and Theoretical Domains Framework (TDF) to explore HCP attitudes towards vaping in pregnancy and postpartum; beliefs about the health risks of vaping; perceived barriers and facilitators of vaping in pregnancy; knowledge of current guidelines and policies; and training needs. Methods Interviews (n = 60) were conducted with midwives (n = 17), health visitors (n = 10), general practitioners (n = 15) and stop smoking specialists (n = 18) across the United Kingdom. Interview transcriptions were analyzed thematically using the framework approach and the COM-B. Results Discussing vaping as a tool for quitting smoking in pregnancy was prevented by a lack of capability (limited knowledge of vaping, lack of training in smoking cessation); lack of opportunity (restricted by organizational policies and guidelines, lack of time and financial issues impacting on training), and negative social influences (sensationalist media and stigma associated with vaping in pregnancy); and lack of motivation (fear of future litigation and comebacks should adverse effects from vaping arise). Conclusions Factors related to capability, opportunity, and motivation were identified that influence HCPs attitudes and behaviors towards vaping in pregnancy. Gaps in knowledge and training needs were identified, which could inform the development of targeted vaping training. Implications Vaping could be suitable in pregnancy for those struggling to quit smoking. However, HCPs must be informed about these devices to offer appropriate advice. These data extend our knowledge of factors influencing HCP attitudes and behaviors towards vaping in pregnancy. Generally, vaping was perceived as safer than cigarettes, but a perceived lack of evidence, health and safety risks, dependency, and regulation issues were concerning. Considering our findings, greater efforts are needed to ensure HCPs are sufficiently informed about vaping and guidelines available. More importance should be placed on training for all HCPs who have contact with pregnant women.

IntroductionSmoking reduction can lead to increased success in quitting. This study aims to determine if a client-focused motivational support package for smoking reduction (and quitting) and increasing (or otherwise using) physical activity (PA) can help smokers who do not wish to quit immediately to reduce the amount they smoke, and ultimately quit. This paper reports the study design and methods.Methods and analysisA pragmatic, multicentred, parallel, two group, randomised controlled superiority clinical trial, with embedded process evaluation and economics evaluation. Participants who wished to reduce smoking with no immediate plans to quit were randomised 1:1 to receive either (1) tailored individual health trainer face-to-face and/or telephone support to reduce smoking and increase PA as an aid to smoking reduction (intervention) or (2) brief written/electronic advice to reduce or quit smoking (control). Participants in both arms of the trial were also signposted to usual local support for smoking reduction and quitting. The primary outcome measure is 6-month carbon monoxide-confirmed floating prolonged abstinence following participant self-reported quitting on a mailed questionnaire at 3 and 9 months post-baseline. Participants confirmed as abstinent at 9 months will be followed up at 15 months.Ethics and disseminationApproved by SW Bristol National Health Service Research Committee (17/SW/0223). Dissemination will include publication of findings for the stated outcomes, parallel process evaluation and economic evaluation in peer-reviewed journals. Results will be disseminated to trial participants and healthcare providers.Trial registration numberNCT47776579.

BackgroundExposure to tobacco content in films is a cause of smoking uptake in young people. In an earlier study, we reported that tobacco content occurred in 70% of UK box office films popular between 1989 and 2008. We now report an analysis of tobacco content in a sample of the top grossing UK box office films between 2009 and 2017, and of population exposure resulting from audience exposure to the 2017 films.MethodsOccurrence of tobacco intervals (actual tobacco use, implied use, appearance of smoking paraphernalia or branding) was measured by 5 min interval coding in the 15 most commercially successful films in the UK in each year from 2009 to 2017. A nationally representative survey was used to estimate population exposure to the top 15 films from 2017.ResultsWe coded 3248 intervals from the 135 films. Tobacco content appeared in 245 intervals (8%, 95% CI 7% to 9%) across 56 (41%, 95% CI 33% to 49%) films. Tobacco content occurred in films in all BBFC age ratings, and 36 (64%, 95% CI 51% to 77%) of films containing tobacco imagery were classified as suitable for viewing by people aged under 15 years. Although less prevalent than in our earlier study, there was no evidence of a secular decline in tobacco content during this study period. The top 15 films from 2017 delivered approximately 21.6 (95% CI 21.06–22.14) million tobacco impressions to young people aged 10–18 years in the UK.ConclusionsTobacco content continues to appear in UK Box Office films and is widely seen by young people, representing a major driver of smoking uptake.

Tobacco smoking is a major risk factor for a wide range of diseases, and smoking cessation significantly reduces these risks. Clinical guidelines for diseases associated with smoking should therefore include guidance on smoking cessation. This review updated evidence on the proportion of clinical guidelines that do so. We conducted a systematic review investigating clinical guidelines and recommendations developed by UK national or European transnational medical specialty associations and societies between January 2014 and October 2019 on 16 diseases to be at least twice as common among smokers than non-smokers. Outcomes of interest were the reporting of smoking as a risk factor, and the inclusion either of smoking cessation advice or referral to other cessation guidance. We compared our findings with an earlier review of guidelines published between 2000 and 2013. We identified 159 clinical guidelines/recommendations. Over half (51%) made no mention of smoking, while 43% reported smoking as a risk factor for the development of the disease, 31% recommended smoking cessation and 19% provided detailed information on how to deliver smoking cessation support. These proportions were similar to those in our earlier review. Smoking cessation continues to be neglected in clinical management guidance for diseases caused by smoking.

IntroductionLung cancer is the world’s leading cause of cancer death. Low-dose computed tomography (LDCT) screening reduced lung cancer mortality by 20% in the US National Lung Screening Trial. Here, we present the Yorkshire Lung Screening Trial (YLST), which will address key questions of relevance for screening implementation.Methods and analysisUsing a single-consent Zelen’s design, ever-smokers aged 55–80 years registered with a general practice in Leeds will be randomised (1:1) to invitation to a telephone-based risk-assessment for a Lung Health Check or to usual care. The anticipated number randomised by household is 62 980 individuals. Responders at high risk will be invited for LDCT scanning for lung cancer on a mobile van in the community. There will be two rounds of screening at an interval of 2 years. Primary objectives are (1) measure participation rates, (2) compare the performance of PLCOM2012(threshold ≥1.51%), Liverpool Lung Project (V.2) (threshold ≥5%) and US Preventive Services Task Force eligibility criteria for screening population selection and (3) assess lung cancer outcomes in the intervention and usual care arms. Secondary evaluations include health economics, quality of life, smoking rates according to intervention arm, screening programme performance with ancillary biomarker and smoking cessation studies.Ethics and disseminationThe study has been approved by the Greater Manchester West research ethics committee (18-NW-0012) and the Health Research Authority following review by the Confidentiality Advisory Group. The results will be disseminated through publication in peer-reviewed scientific journals, presentation at conferences and on the YLST website.Trial registration numbersISRCTN42704678andNCT03750110.

IntroductionIntegration of smoking cessation (SC) into lung cancer screening is essential to optimise clinical and cost effectiveness. The most effective way to use this ‘teachable moment’ is unclear. The Yorkshire Enhanced Stop Smoking study will measure the effectiveness of an SC service integrated within the Yorkshire Lung Screening Trial (YLST) and will test the efficacy of a personalised SC intervention, incorporating incidental findings detected on the low-dose CT scan performed as part of YLST.Methods and analysisUnless explicitly declined, all smokers enrolled in YLST will see an SC practitioner at baseline and receive SC support over 4 weeks comprising behavioural support, pharmacotherapy and/or a commercially available e-cigarette. Eligible smokers will be randomised (1:1 in permuted blocks of random size up to size 6) to receive either an enhanced, personalised SC support package, including CT scan images, or continued standard best practice. Anticipated recruitment is 1040 smokers (January 2019–December 2020). The primary objective is to measure 7-day point prevalent carbon monoxide (CO) validated SC after 3 months. Secondary outcomes include CO validated cessation at 4 weeks and 12 months, self-reported continuous cessation at 4 weeks, 3 months and 12 months, attempts to quit smoking and changes in psychological variables, including perceived risk of lung cancer, motivation to quit smoking tobacco, confidence and efficacy beliefs (self and response) at all follow-up points. A process evaluation will explore under which circumstances and on which groups the intervention works best, test intervention fidelity and theory test the mechanisms of intervention impact.Ethics and disseminationThis study has been approved by the East Midlands-Derby Research Ethics Committee (18/EM/0199) and the Health Research Authority/Health and Care Research Wales. Results will be disseminated through publication in peer-reviewed scientific journals, presentation at conferences and via the YLST website.Trial registration numbersISRCTN63825779,NCT03750110.

ObjectivesExposure to alcohol imagery is associated with subsequent alcohol use among young people, and UK broadcasting regulations protect young people from advertising alcohol content in UK television. However, alcohol promotion during sporting events, a significant potential medium of advertising to children, is exempt. We report an analysis and estimate the UK population exposure to, alcohol content, including branding, in UK broadcasts of the 2018 Formula 1 (F1) Championship.SettingUK.ParticipantsNone. Content analysis of broadcast footage of 21 2018 F1 Championship races on Channel 4, using 1-minute interval coding of any alcohol content, actual or implied use, other related content or branding. Census data and viewing figures were used to estimate gross and per capita alcohol impressions.ResultsAlcohol content occurred in all races, in 1613 (56%) 1-minute intervals of race footage and 44 (9%) of intervals across 28% of advertisement breaks. The most prominent content was branding, occurring in 51% of race intervals and 7% of advertisement break intervals, appearing predominantly on billboard advertisements around the track, with the Heineken and Johnnie Walker brands being particularly prominent. The 21 races delivered an estimated 3.9 billion alcohol gross impressions (95% CI 3.6 to 4.3) to the UK population, including 154 million (95% CI 124 to 184) to children, and 3.6 billion alcohol gross impressions of alcohol branding, including 141 million impressions to children. Branding was also shown in race footage from countries where alcohol promotion is prohibited.ConclusionsAlcohol content was highly prevalent in the 2018 F1 Championship broadcasts, delivering millions of alcohol impressions to young viewers. This exposure is likely to represent a significant driver of alcohol consumption among young people.

Background: Current tobacco treatment guidelines have established the efficacy of available interventions, but they do not provide detailed guidance for common implementation questions frequently faced in the clinic. An evidence-based guideline was created that addresses several pharmacotherapy-initiation questions that routinely confront treatment teams. Methods: Individuals with diverse expertise related to smoking cessation were empaneled to prioritize questions and outcomes important to clinicians. An evidence-synthesis team conducted systematic reviews, which informed recommendations to answer the questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to rate the certainty in the estimated effects and the strength of recommendations. Results: The guideline panel formulated five strong recommendations and two conditional recommendations regarding pharmacotherapy choices. Strong recommendations include using varenicline rather than a nicotine patch, using varenicline rather than bupropion, using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition, initiating varenicline in adults even if they are unready to quit, and using controller therapy for an extended treatment duration greater than 12 weeks. Conditional recommendations include combining a nicotine patch with varenicline rather than using varenicline alone and using varenicline rather than electronic cigarettes. Conclusions: Seven recommendations are provided, which represent simple practice changes that are likely to increase the effectiveness of tobacco-dependence pharmacotherapy.

Lung cancer screening (LCS) with low-dose computed tomography (LDCT) was demonstrated in the National Lung Screening Trial (NLST) to reduce mortality from the disease. European mortality data has recently become available from the Nelson randomised controlled trial, which confirmed lung cancer mortality reductions by 26% in men and 39–61% in women. Recent studies in Europe and the USA also showed positive results in screening workers exposed to asbestos. All European experts attending the “Initiative for European Lung Screening (IELS)”—a large international group of physicians and other experts concerned with lung cancer—agreed that LDCT-LCS should be implemented in Europe. However, the economic impact of LDCT-LCS and guidelines for its effective and safe implementation still need to be formulated. To this purpose, the IELS was asked to prepare recommendations to implement LCS and examine outstanding issues. A subgroup carried out a comprehensive literature review on LDCT-LCS and presented findings at a meeting held in Milan in November 2018. The present recommendations reflect that consensus was reached.

Aims To 1) estimate the number of Parties to the Framework Convention on Tobacco Control (FCTC) providing tobacco dependence treatment in accordance with the recommendations of Article 14 and its guidelines; 2) assess association between provision and countries’ income level; and 3) assess progress over time. Design Cross sectional study. Setting Online survey from December 2014 to July 2015. Participants Contacts in 172 countries were surveyed, representing 169 of the 180 FCTC Parties at the time of the survey. Measurements A 26 item questionnaire based on the Article 14 recommendations including tobacco treatment infrastructure and cessation support systems. Progress over time was assessed for those countries that also participated in our 2012 survey and did not change country income level classification. Findings We received responses from contacts in 142 countries, an 83% response rate. Overall, 54% of respondents reported their country had an officially identified person responsible for tobacco dependence treatment, 32% an official national treatment strategy, 40% official national treatment guidelines, 25% a clearly identified budget for treatment, 17% text messaging, 23% free national quitlines, and 26% specialised treatment services. Most measures were positively and significantly associated with countries’ income level (p=0.001). Measures not significantly associated with income level included mandatory recording of tobacco use (30% of countries), offering help to healthcare workers (HCW) to stop using tobacco (44%), brief advice integrated into existing services (44%), and training HCW to give brief advice (81%). Reporting having an officially identified person responsible for tobacco cessation was the only measure with a statistically significant improvement over time (p=0.0351). Conclusion Fewer than half of countries that are Parties to the Framework Convention on Tobacco Control have implemented the recommendations of Article 14 and its guidelines, and for most measures, provision was greater the higher the country’s income. There was little improvement in treatment provision between 2012 and 2015 in all countries.

AimTo identify barriers to implementing the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) Article 14 guidelines on tobacco dependence treatment (TDT).DesignCross‐sectional survey conducted from December 2014 to July 2015 to assess implementation of Article 14 recommendations.Setting and participantsSurvey respondents (n=127 countries) who completed an open‐ended question on the 26‐item survey.MeasurementsThe open‐ended question asked the following: In your opinion, what are the main barriers or challenges to developing further tobacco dependence treatment in your country? We conducted thematic analysis of the responses.FindingsThe most frequently reported barriers included a lack of health care system infrastructure (n=86) (e.g., treatment not integrated into primary care, lack of health care worker training), low political priority (n=66) and lack of funding (n=51). The absence of strategic plans and national guidelines for Article 14 implementation emerged as subthemes of political priority. Also described as barriers were negative provider attitudes towards offering offer TDT (n=11), policymakers' lack of awareness about the effectiveness and affordability of TDT (n=5), public norms supporting tobacco use (n=11), a lack of health care leadership and expertise in the area of TDT (n=6) and a lack of grassroots and multisector networks supporting policy implementation (n=8). The analysis captured patterns of co‐occurring themes that linked, for example, low levels of political support with a lack of funding necessary to develop health care infrastructure and capacity to implement Article 14.ConclusionImportant barriers to implementing the Framework Convention on Tobacco Control Article 14 guidelines include lack of a healthcare system infrastructure, low political priority and lack of funding.

BACKGROUND AND AIMS The United Kingdom's National Institute for Health and Care Excellence guidance (NICE PH48) recommends that pharmacotherapy combined with behavioural support be provided for all smokers admitted to hospital; however, relapse to smoking after discharge remains common. This study aimed to assess the effect of adding home support for newly abstinent smokers to conventional NICE-recommended support in smokers discharged from hospital. DESIGN Individually randomized parallel group trial. SETTING One UK acute hospital. PARTICIPANTS A total of 404 smokers aged > 18 admitted to acute medical wards between June 2016 and July 2017 were randomized in equal numbers to each treatment group. INTERVENTIONS AND COMPARATORS The intervention provided 12 weeks of at-home cessation support, which included help in maintaining a smoke-free home, help in accessing and using medication, further behavioural support and personalized feedback on home air quality. The comparator was NICE PH48 care as usual. MEASURES The primary outcome was self-reported continuous abstinence from smoking validated by an exhaled carbon monoxide level

ObjectivesHigh levels of particulate pollution due to secondhand smoke (SHS) have previously been recorded in English prisons. As part of an evaluation to ascertain whether a new comprehensive smoke-free policy introduced in the first four prisons in England was successfully implemented, this study compares indoor air quality on prison wing landing locations three months before and three months after going smoke-free.DesignAn indoor air quality monitoring study, comparing SHS levels before and after a comprehensive smoke-free prison policy.SettingThe first four prisons in England to implement a comprehensive smoke-free policy.Primary and secondary measuresWe compared concentrations of airborne particulate matter ResultsAfter discarding data from monitors that had been tampered with we were able to analyse paired data across four prisons from 74 locations, across 29 wing landing locations, for an average sampling time of five hours and eight minutes. When comparing samples taken three months before with the paired samples taken three months after policy implementation (paired for prison, day of the week, time of day, wing location and position of monitor), there was a 66% reduction in mean PM₂.₅ concentrations across the four prisons sampled, from 39 to 13 µg/m³ (difference 26 µg/m³, 95% CI 25 to 26 µg/m³).ConclusionPrison smoke-free policies achieve significant improvements in indoor air quality. A national smoke-free policy would therefore be an effective means of protecting prisoners and staff from harm due to SHS exposure in the prison environment.

Tobacco advertising and sponsorship in Formula 1 (F1) racing, which was banned in Europe by the 2005 EU Tobacco Advertising Directive1 and internationally by the Federation Internationale de l'Automobile since 2006,2 continues to this day through the Philip Morris sponsorship of Ferrari,3 thought to be worth $160 million (£124 million) annually.4 Although Marlboro advertising and related barcode alibis disappeared from Ferrari cars after 2010,5 during the 2018 championship, Philip Morris introduced a new marketing campaign, Mission Winnow, with text and logo branding on Ferrari cars and uniforms. Philip Morris states that Mission Winnow promotes their drive towards alternatives to traditional cigarettes and does not advertise tobacco products.6 However, the branding is strongly reminiscent of the Marlboro Chevron logo,4 and the trademark details for Mission Winnow include tobacco products.7 We argue that Mission Winnow is ‘smokescreen’ marketing, covertly advertising tobacco products,8 with much in common with Philip Morris’s earlier Marlboro barcode livery.5 We have quantified the tobacco content in the 2018 F1 Championship to assess compliance with regulatory restraints and to estimate audience exposure to this smokescreen marketing. We measured all tobacco contents shown …

Objectives Exposure to tobacco and alcohol content in audio-visual media is a risk factor for smoking and alcohol use in young people. Previous UK research has quantified tobacco and alcohol content in films and broadcast television but not that of video-on-demand (VOD) services such as Netflix and Amazon Prime. Furthermore, it is not clear whether regulation by Dutch (Netflix) or UK (Amazon Prime) authorities results in differences in content. We report an analysis of tobacco and alcohol content in a sample of episodes from the most popular programmes from these two VOD providers, and compare findings with earlier studies of UK prime-time television content. Setting UK. Participants None. Content analysis of a sample of 50 episodes from the five highest rated series released on Netflix and Amazon Prime in 2016, using 1 min interval coding of any tobacco or alcohol content, actual or implied use, paraphernalia and branding. Results Of 2704 intervals coded, any tobacco content appeared in 353 (13%) from 37 (74%) episodes. Any alcohol content appeared in 363 (13%) intervals in 47 (94%) episodes. There were no significant differences between the two services, however the proportion of episodes containing tobacco and alcohol was significantly higher in VOD original programmes than those recorded in an earlier study of prime-time UK television. Conclusions Audio-visual tobacco and alcohol content is common in VOD original programmes and represents a further source of exposure to imagery causing smoking uptake and alcohol use in young people. This appears to be equally true of services regulated in the UK and The Netherlands. Given that VOD services are consumed by a global audience, it appears likely that VOD content is an important global driver of tobacco and alcohol consumption.