Barriers, Facilitators and Future Directions for Smoking Cessation Among
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“I'm not strong enough, I'm not good enough, I can't do this, I'm failing”: Barriers, facilitators and future directions for smoking cessation among low-socioeconomic status Australian smokers Veronica Clare Boland BA (Psychology & English) / PostGradDipPsych A thesis in fulfilment of the requirements for the degree of Doctor of Philosophy National Drug and Alcohol Research Centre School of Public Health and Community Medicine Faculty of Medicine University of New South Wales November 2018 THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname/Family Name: Boland Given Name/s: Veronica Clare Abbreviation for degree as give in the University calendar: PhD Faculty: Medicine School: School of Public Health and Community Medicine Thesis Title: “I'm not strong enough, I'm not good enough, I can't do this, I'm failing”: Barriers, facilitators and future directions for smoking cessation among low-socioeconomic status Australian smokers Abstract 350 words maximum: Australia did not meet its National Tobacco Strategy (NTS) target of a 10% smoking rate by 2018. Low-socioeconomic status (low-SES) smokers are not quitting at the same rate as other smokers and the disparity in smoking prevalence between the most and least advantaged Australians contributes to health inequalities. National guidelines recommend a focus on these smokers, and reduced smoking in low-SES groups is a priority for Australia’s NTS. The overarching aim of this thesis was to evaluate effective approaches to smoking cessation, and to examine quantitatively and qualitatively the factors associated with the utilisation of smoking cessation treatment and smoking abstinence among low-SES smokers. This thesis addressed this aim through a series of five studies that were designed to examine and determine among low-SES smokers: 1) the methodological quality and effectiveness of alternative and novel technology-based smoking cessation interventions; 2) the factors associated with self-reported behavioural and pharmacological smoking cessation treatment; 3) the factors associated with verified smoking abstinence; 4) the qualitative factors that impacted treatment engagement and the acceptability and feasibility of alternative approaches to smoking cessation support; and 5) the motivational influences of quitting behaviours as experienced by smokers and ex- smokers. Several important findings were identified. Firstly, a paucity of high-quality technology-based smoking cessation interventions were identified. The pooled estimates suggest some technology-based platforms are more effective for increasing abstinence than standard care. Secondly, reporting a mental health disorder, alcohol consumption at hazardous levels, and self-efficacy to quit were factors associated with prior smoking cessation treatment utilisation. Logistic regression suggested that independent factors associated with reduced likelihood of achieving verified abstinence were having a mental health disorder or reporting prior treatment utilisation at study enrolment. Finally, the experience of smoker-related stigma and positive smoker identity undermined quit attempts, and mobile phone text messaging for quit support was endorsed as an alternative to existing Quitline services. Providing cost-effective, easily accessible and tailored cessation support is required to lift treatment engagement, quit attempts, and quit rates among low-SES smokers. Future research aimed at developing tailored technology-based quit support that can be upscaled and incorporated into existing services is warranted. Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only). 30th August 2018 ……………………………………… …………………………..…………… …………...…….… Signature Witness Signature Date The University recognises that there may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years must be made in writing. Requests for a longer period of restriction may be considered in exceptional circumstances and require the approval of the Dean of Graduate Research. FOR OFFICE USE Date of completion of requirements for ONLY Award: ii ABSTRACT Australia did not meet its National Tobacco Strategy (NTS) target of a 10% smoking rate by 2018. The National Drug Strategy Household Survey reported no significant decrease in Australia’s daily smoking rate from 2013 to 2016 – the first plateau since 1991. Low-socioeconomic status (low-SES) smokers are not quitting at the same rate as other smokers; the disparity in smoking prevalence between the most and least advantaged Australians contributes to health inequalities. There is a lack of evidence on effective smoking cessation interventions for low-SES groups. National guidelines recommend a focus on these smokers and reducing smoking in low-SES groups is a priority for Australia’s NTS. Evidence-based cessation treatments are available in developed countries, including behavioural and pharmacotherapy support, for example, nicotine replacement therapy (NRT), varenicline and bupropion, and more recently electronic nicotine delivery systems. Cochrane review evidence suggests that the most effective treatment approach for smoking cessation is a combination of pharmacotherapy and behavioural support, either provided face-to-face or – as is typical in Australia – via telephone (Quitline). Despite the availability of evidence-based treatments, low-SES smokers quit at a lower rate than the general population. Innovative cost-effective cessation methods with high reach, increased user acceptability and likelihood of adherence are needed to improve health and reduce healthcare costs for low-SES smokers. Australia is “not on track to reach the Council of Australian Governments (COAGs) benchmarks” and healthcare agencies recognise the high priority for “Commonwealth, state and territory governments to jointly investigate the merits of alternative modes of Quitline delivery iii and coordination and to examine better strategies to reach the most disadvantaged smokers”. This thesis aimed to address these gaps by using a mixed methods approach including: a systematic review and meta-analysis; and using data from the Financial Intervention for Smoking Cessation Among Low-income Smokers (FISCALS) study quantitative and qualitative methodologies were used. The studies that comprise the chapters of this thesis were designed to examine and determine: 1) the methodological quality and effectiveness of alternative and novel technology-based smoking cessation interventions in low-SES groups; 2) the factors associated with self-reported behavioural and pharmacological smoking cessation treatment amongst a large sample of low-SES smokers; 3) the factors associated with abstinence in a large sample of treatment-seeking low-SES smokers; 4) qualitatively, among low-SES smokers post- intervention, the factors that impacted treatment engagement and the acceptability and feasibility of alternative approaches to smoking cessation support; and 5) the motivational influences of quitting behaviours as experienced by low-SES smokers and ex-smokers. This thesis identified several important findings. Firstly, the systematic review identified a lack of methodologically rigorous technology-based smoking cessation interventions tailored to low-SES smokers. However, meta-analysis results indicated that mobile phone text messaging, computer and internet platforms are effective at increasing abstinence among low-SES smokers for up to 18-months post-intervention. Secondly, in the FISCALS cohort, underutilisation of Quitline support was reported and factors associated with prior treatment utilisation included having a mental health diagnosis, alcohol use, and self-efficacy to quit. Logistic regression suggested that independent factors associated with reduced likelihood of achieving verified iv abstinence were having a mental health disorder or reporting prior smoking cessation treatment utilisation at study enrolment. Finally, the experience of smoker-related stigma and positive smoker identity undermine quit attempts and mobile phone text messaging is perceived as more favourable than conventional treatment approaches. Providing cost-effective, easily accessible and tailored cessation support is required to lift treatment engagement, quit attempts, and quit rates among low-SES smokers. Future research aimed at developing tailored technology-based quit support that can be upscaled and incorporated into existing services is warranted. v Table of Contents ABSTRACT ................................................................................................................ iii Originality statement ................................................................................................ x Inclusion of publications statement ......................................................................... xi Supervisor statement ............................................................................................