Smokers aged 65 years and older are a vulnerable group who are likely to have conditions that are caused or complicated by smoking. Older smokers are also likely to die prematurely, losing on average 16 years from their projected life expectancy.
In recent years a growing body of research has demonstrated that older smokers can derive significant health benefits from stopping smoking in later life, despite having smoked for many years. The benefits of cessation are almost immediate for conditions such as heart disease and stroke. Stopping smoking also reduces the risk of developing cancer and stabilises existing conditions such as chronic obstructive pulmonary disease.
Healthcare contacts provide excellent opportunities for smoking-cessation interventions and there is compelling evidence that interventions delivered by health professionals can be effective in triggering and supporting cessation attempts. In the UK, ninety percent of all contacts between members of the public and the NHS take place in the primary care setting, with older adults (≥ 65 years) having contact with members of the primary care team, on average seven times per year. Professionals working in this setting therefore have a crucial role to play in discussing the topic of smoking cessation with older people who smoke.
Unfortunately, despite confirmation of the benefits of smoking cessation in later life and compelling evidence that intervening with older adults can be effective, a number of studies have shown that health professionals, including members of the primary care team, often fail to target this population.
Previous work undertaken by the Research Team has demonstrated that health professionals’ failure to discuss the topic of smoking/smoking cessation can often be the result of limited knowledge of smoking cessation products and services. Professionals have also reported that they do not have the skills required to deliver effective smoking cessation interventions (smoking cessation training is rarely incorporated into undergraduate or post-graduate educational programmes). Finally, pessimistic attitudes towards smoking cessation in later life have been noted, with health professionals often believing that few older people manage to stop smoking successfully.
In light of the above, the current study sought to develop and evaluate specially tailored smoking cessation training for members of the primary care team who work with older people. The aim was to provide professionals with the knowledge and skills required to deliver effective brief interventions.
The study was undertaken in four phases. Phase I involved the development of the tailored smoking cessation training. The training that was developed has been approved by Partnership Action on Tobacco and Health (PATH) and NHS Education for Scotland (NES). PATH is an initiative, funded by the Scottish Executive and managed by ASH Scotland, which aims to support the implementation of Scottish and UK government policies on tobacco and smoking. NES seeks to enhance the quality of the educational provision for nurses, midwives and allied health professionals in Scotland (i.e. NMAHPS).
The second phase of the study focused on the development and testing of the three data collection instruments that would be used to measure the knowledge, attitudes and practice of the study participants before and after the training. This phase of the study was important as it ensured that the instruments used to collect the data were both valid and reliable.
The third phase of the study involved the delivery and quantitative evaluation of the training. This element of the study took the form of a randomised controlled trial. The study participants were 73 nurses and allied health professionals recruited from seven Community Health and Social Care Partnerships. The participants included health visitors, district nurses, practice nurses and nurses and allied health professionals working in Community Older People’s Teams. Following stratification, the study participants were randomly allocated to the intervention group (training) or the control group (no training).
The training was delivered by a professional experienced in the delivery of smoking cessation training, during a seven hour study day.
The data were collected using the validated questionnaire at three time points; just before the training (at baseline), one week after the training and three months after the training. The data collected focused on the knowledge, attitudes and practice of the study participants.
The data were analysed using a two factor repeated measure Analysis of Variance (ANOVA), where the main factors were ‘group’ and ‘time’. This statistical test was used to compare the scores of the two groups (i.e. the intervention and the control group) across the three different time points.
The final phase of the study used a qualitative approach to explore, in some depth, the participants’ views of the training and its impact on their practice. Members of the intervention group participated in a one-to-one semi-structured interview, approximately four months after the training. The audio-recorded interviews were analysed thematically using constant comparative procedures.
The quantitative assessment of the training demonstrated the following:
•A statistically significant improvement in the knowledge of the intervention group that was maintained over time. •A statistically significant improvement in the attitudes of the intervention group that was maintained over time. •A statistically significant improvement in the reported practice of the intervention group that was maintained over time.
The training was therefore found to be effective i.e. it had a demonstrable positive impact on the knowledge, attitudes and practice of the study participants.
The qualitative evaluation of the training confirmed what had been shown in the quantitative results. Prior to the training, members of the intervention group reported limited knowledge and a lack of skills to raise and sustain the subject of smoking/smoking cessation. This often produced a lack of self-efficacy and outcome expectations that focused on failure. Participants’ negative attitudes towards older people stopping smoking also affected their subsequent actions and together these factors strongly influenced their smoking cessation practice. It was evident that the practice of participants who had previous generic smoking cessation training was at a more advanced level when compared to those who had not; however, deficits in knowledge and pessimistic attitudes towards smoking cessation in later life were reported. The qualitative analysis of the participants’ practice after the training clearly demonstrated changes in their practice. These changes were reported as a result of increased knowledge levels, more positive attitudes towards smoking cessation in later life and the skills that had been developed during the training. Enhanced levels of self-efficacy following the training were clearly evident.
This study has developed and tested specially tailored smoking cessation training for members of the primary care team who work with older people. The evaluation of the training has demonstrated that it was effective in enhancing the knowledge, attitudes and practice of those who participated in the study.
Previous research has demonstrated that the delivery of brief opportunistic interventions by health professionals is highly cost-effective.
While the need for generic smoking cessation training has been evident for a number of years, the need to develop tailored training for professionals who have contact with key priority groups such as older adults, has been identified more recently. We believe that we are the first group at a UK-wide level to develop and formally test the efficacy of tailored smoking cessation training for professionals who have contact with older adults. We therefore consider that this study makes an important contribution to the current knowledge base.
Following the positive evaluation of the training we recommend that the training be rolled out at a Scotland-wide level. Further evaluative work will be required.
- smoking cessation,
- brief intervention training,
- mixed methods,
Available at: http://works.bepress.com/susan_kerr/11/