NICE Coronary heart disease


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NICE Coronary heart disease

  1. 1. Coronary Heart Disease Guidance for implementing the preventive aspects of the National Service Framework
  2. 2. The Health Development Agency The Health Development Agency (HDA) is a special health authority with a remit to improve the health of people in England and in particular, to reduce inequalities in health. It achieves this by: • Working with key statutory and non-statutory organisations at national, regional and local level • Finding out what works and maintaining this evidence base • Turning the evidence into action by building up the skills and capacity of those working to improve the public’s health • Advising on the setting of standards for public health planning and practice.
  3. 3. Contents iii INTRODUCTION Methods used to develop the guidance 1 Focusing on coronary risk factors 3 PREVENTION OF CHD THROUGH PROMOTING HEALTHIER LIFESTYLES 5 Chapter 1: REDUCING SMOKING PREVALENCE 7 1.1 Introduction 7 1.1.1 The National Service Framework for coronary heart disease 7 1.1.2 Benefits of smoking cessation for CHD 8 1.1.3 Trends in smoking 8 1.2 Objectives of interventions to reduce smoking 9 1.3 Features of effective interventions 9 1.4 Components of a local strategy 10 1.4.1 Develop smoking cessation services 10 1.4.2 Reduce smoking in public places including workplaces 12 1.4.3 Support national media campaigns 13 1.4.4 Use media advocacy 13 1.4.5 Monitor the voluntary advertising ban 14 1.4.6 Reduce sales of cigarettes to children under 16 years old 14 1.4.7 Encourage the introduction of smoking policies in schools 14 1.5 Reducing inequity 15 1.5.1 Black and minority ethnic groups 15 1.6 Tables of suggested activities to support local action Intervention, Evidence, Outcome, Who could be involved?, Skills and resources, Points to consider, Further information 17 1.7 References 21 Contents
  4. 4. Coronary heart disease: guidance for implementing the preventive aspects of the NSF iv Chapter 2: IMPROVING DIET AND NUTRITION 25 2.1 Introduction 25 2.2 Objectives of nutritional interventions 25 2.2.1 Professional knowledge and expertise 26 2.3 Features of effective interventions 27 2.4 Components of a local strategy 27 2.4.1 Schools 27 2.4.2 Local/community projects 28 2.4.3 Workplace 28 2.4.4. Healthcare 29 2.5 Reducing inequity 29 2.5.1 Black and minority ethnic groups 30 2.5.2 Children 30 2.6 Tables of suggested activities to support local action Intervention, Evidence, Outcome, Who could be involved?, Skills and resources, Points to consider, Further information 31 2.7 References 40 Chapter 3: INCREASING PHYSICAL ACTIVITY 43 3.1 Introduction 43 3.2 Objectives of physical activity interventions 43 3.3 Features of effective interventions 44 3.4 Components of a local strategy 44 3.4.1 Healthcare interventions 44 3.4.2 Exercise referral schemes 44 3.4.3 Workplaces 44 3.4.4 Mass media 45 3.4.5 Schools 45 3.4.6 Older people 45 3.4.7. Physically active transport 46 3.5 Reducing inequity 46 3.6 Useful sources of information about community based programmes 47 3.7 Tables of suggested activities to support local action Intervention, Evidence, Outcome, Who could be involved?, Skills and resources, Points to consider, Further information 48 3.8 References 54
  5. 5. Contents v Chapter 4: REDUCING OVERWEIGHT AND OBESITY 57 4.1 Introduction 57 4.2 Objectives of weight management 58 4.2.1 Definitions of ‘lifestyle’ weight management interventions 58 4.3 Features of effective interventions 59 4.3.1 Skills 60 4.4 Reducing inequity 60 4.5 Further information 61 4.6 Tables of suggested activities to support local action Intervention, Evidence, Outcome, Who could be involved?, Skills and resources, Points to consider, Further information 63 4.7 References 68 STRATEGY DEVELOPMENT 71 Chapter 5: DEVELOPING A LOCAL STRATEGY 73 5.1 Establishing a local CHD implementation team 73 5.1.1 Milestones and goals 73 5.2 Developing local delivery plans 73 5.3 Building effective partnerships 74 5.3.1 New freedoms to promote and support joint working 74 5.3.2 Making the partnership effective 75 5.4 Involving local communities 75 5.4.1 Consulting local communities 76 5.4.2 Developing capacity 77 5.4.3 Engaging ‘excluded’ groups 77 5.5 Health needs assessment 77 5.6 Community profiling 77 5.7 Equity profiling 78 5.7.1 Audit of current provision 78 5.7.2 Personal and professional development audit 78 5.8 Monitoring progress 79 5.8.1 Developing local targets 80 5.8.2 Monitoring frameworks 82 5.9 Illustrative monitoring frameworks 5.10 Further sources of information 87 5.11 References 90 Appendix 91 Contributors 91 Glossary 93
  6. 6. Coronary heart disease is the biggest killer of men and women in this country. More than 111,000 people die from this condition, and about 300,000 have heart attacks every year. The national service framework for coronary heart disease (NSF CHD), which the government published in March 2000, is our blueprint for tackling this chronic disease. This document is a key component of that blueprint. The framework and The NHS plan describe a range of strategies to diagnose, treat and care for people who suffer from heart disease, and also how to prevent it occurring in the first place. The health service must give people who want to make changes to their lifestyles, the support and advice that they need. Effective interventions at an early stage will not only reduce the immediate risks, but also slow down the progression of the disease, identify the early symptoms and limit the incidence of death and long term incapacity. This document explains how this is possible at local level. It provides evidence-based examples of effective interventions for dealing with all the primary risk factors for heart disease – smoking, poor nutrition, physical inactivity, overweight and obesity. It is, in effect, an early warning system for tackling heart disease. I am confident that the document will help to transform prevention services throughout the NHS. Alan Milburn Secretary of State for Health Foreword by the Secretary of State for Health i
  7. 7. The prevention of coronary heart disease (CHD) is a government priority. The white paper Saving lives: our healthier nation [Department of Health (DH) 1999] set a target of reducing the death rate from heart disease, stroke and related conditions by 40% in those aged under 75 years by the year 2010. CHD is common, frequently fatal and largely preventable. The burden of heart disease is higher, and has fallen less in the UK than many other countries. It is the leading cause of death, killing over 110,000 people in England in 1998, including more than 41,000 under the age of 75 years (DH 2000a). The recently published NHS plan reinforces CHD as a clinical priority and focuses on preventive aspects of the disease. The Plan emphasises the importance of the NHS role of working in partnership with others to address health inequalities (DH 2000b). The plan highlights the importance of the NSF CHD which, for the first time, sets out national quality standards for preventive and clinical services. The HDA, at the request of the DH, has developed this guidance. It is intended to assist local implementation teams [health authorities (HAs), primary care groups (PCGs) and primary care trusts (PCTs), local authorities (LAs) and other local stakeholders] in developing their approaches to addressing the preventive aspects of the NSF CHD. It therefore relates to Standards 1, 2, 3, 4 and 12 (see Box on the next page). The guidance should be read in conjunction with the NSF CHD main report (DH 2000c), Chapter 1 of the NSF (DH 2000a) and relevant sections of Chapter 2 (DH 2000d) and Chapter 12 (DH 2000e). The HDA’s Health update: coronary heart disease and stroke provides useful information on trends and risk factors (HDA 2000). The guidance covers strategy development and interventions to promote CHD-related healthier lifestyles (smoking, nutrition, physical activity and weight management). In the strategy section, approaches that should underpin all health improvement work are covered briefly and further information is signposted where available. In the sections on risk factors, key objectives are presented that will contribute to CHD prevention together with an overview of effective approaches that will promote healthier lifestyles. In addition to CHD, the risk factors and the strategies listed in this resource will also have a significant impact on other initiatives in public health, such as The cancer plan, the forthcoming NSF for older people and the NSF on diabetes. A range of interventions to be developed locally is suggested, involving a range of players in a variety of settings, which could link with other local initiatives. This work is evolving and represents the first stage of support for those working on preventive aspects of the NSF CHD at a local level (see box on next page). The HDA welcomes comment on this document and suggestions on how to improve the guidance. Please contact Karen Ford ( or Hilary Whent ( at the HDA. Methods used to develop the guidance A range of research and expert opinion has been drawn upon in preparing this report. Systematic reviews and literature reviews have been scanned, and literature searches and consultation with expert informants have been carried out. Some 65 critical readers were sent a first draft of this document and amendments were made in the light of their comments. Introduction Introduction 1
  8. 8. The HDA takes a broad approach to evidence, valuing a range of research methods, which contribute to the multidisciplinary nature of health improvement work. Implications from the research evidence have been drawn out and recommendations for local action are made. Gaps in the evidence base have been highlighted. A broad front approach: upstream and downstream The government recognises the socio-economic influences on population health. In its strategy to improve public health, it identifies the complex interaction of causes of poor health, and recommends action right across government to reduce social inequalities in health (DH 1999). The government’s strategy is informed by the evidence from the Independent Inquiry into Inequalities in Health, chaired by Sir Donald Acheson (Acheson 1998). This recommended that a broad front approach be taken to tackle the underlying, root causes of inequalities in health. The inquiry reported that policies to improve health are needed both ‘upstream’ and ‘downstream’. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 2 Preventive aspects of the National Service Framework Reducing heart disease in the population Standard 1 The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease. Standard 2 The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the general population. Milestones: pages 20–21 of NSF CHD (DH 2000c) Prevention of coronary heart disease in high risk patients in primary care Standard 3 GPs and primary care teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks. Standard 4 GPs and primary care teams should identify all people at significant risk of cardiovascular disease but who have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks. Milestones: pages 25–26 of NSF CHD (DH 2000c) Cardiac rehabilitation Standard 12 NHS trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to hospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of subsequent cardiac problems and to promote their return to a full and normal life. Milestones: pages 54–55 of NSF CHD (DH 2000c)
  9. 9. 3 ‘For instance, a policy which reduces inequalities in income and improves the income of the less well off, and one which provides pre-school education for all four year olds are examples of “upstream” policies which are likely to have a wide range of consequences, including benefits to health. Policies such as providing nicotine replacement therapy on prescription, or making better facilities for taking physical exercise, are “downstream” interventions which have a narrower range of benefits’ (Acheson 1998). This guidance document fully endorses this approach to improving health. Where evidence is available on the impact of upstream policies, it is reported. However, for the most part, there is greater evidence of the impact of downstream policies. There are more reported studies of interventions aimed at individuals (lifestyle and health related behaviours) than there are of policies that seek to influence the broader determinants of CHD. This preponderance of research aimed at assessing the effectiveness of downstream policies should not be seen as evidence that downstream policies are more effective than upstream policies. It simply reflects the fact that downstream policies tend to be more amenable to research efforts that seek to assess the effectiveness of interventions. Focusing on coronary risk factors ‘... by April 2001 all NHS bodies, working closely with local authorities will have agreed and be contributing to the delivery of local programmes of effective policies on: a) reducing smoking b) promoting healthy eating c) increasing physical activity d) reducing overweight and obesity’ (DH 2000c, page 57; DH 2000a, page 18) The NSF CHD focuses on three main lifestyle behaviours that are associated with risk of CHD: smoking, physical activity and diet. It also focuses on obesity, which is associated with both these last two factors, and is also independently associated with some increase in CHD risk. In addition, there is now strong evidence that a moderate intake of alcohol reduces the risk of CHD, but an excessive alcohol intake increases the risk. Quantifying the impact of risk factors on CHD It is hard to give figures for the proportion of CHD that could be prevented if lack of physical activity, poor diet (high fat, low fruit and vegetables) and smoking were successfully eliminated. This is because many people with heart disease have multiple risk factors, and it is hard to disentangle the separate effects. The American Public Health Association did make an attempt at such an estimate (Smith and Pratt 1993) and the results are shown in the box below. A similar modelling exercise in the UK would be expected to produce slightly different findings because more of the UK population are smokers, while fewer are obese. However, the information is useful in giving some indication of the relative importance of these risk factors in terms of the potential for making an impact on CHD rates. In the following sections, information is presented about effective interventions, which aim to bring about change in these risk factors. Implications are drawn from the evidence and suggestions are made for local action at a number of levels, involving a range of players and linking to other local initiatives. Further information sources are also signposted. The gaps have been identified in the evidence base. There is an urgent need for more and better designed evaluations of interventions aiming to improve health and well being and the dissemination of results. Evaluation is Introduction Proportion of CHD attributable to various modifiable risk factors in the USA Risk factor Best estimate Range % % Cholesterol >200 mg/dl 43 39–47 Physical inactivity 35 23–46 Cigarette smoking 22 17–25 Obesity 17 7–32 Source: Smith and Pratt (1993)
  10. 10. a planned set of activities, which helps people to see how work is progressing and whether or not it is effective. It should be seen as an integral part of projects and programmes. Evaluation requires relevant skills and it is worth considering making links with local researchers (within the NHS, LAs and academic institutions). There are many approaches to evaluation and sources of support are listed on p89. References Acheson, D., 1998. Independent inquiry into inequalities in health. London: The Stationery Office. DH, 1999. Saving lives: our healthier nation. London: The Stationery Office. DH, 2000a. National service framework for coronary heart disease: Chapter 1. Reducing heart disease in the population. London: DH. DH, 2000b. The NHS plan. A plan for investment. A plan for reform. London: The Stationery Office. DH, 2000c. National service framework for coronary heart disease: main report. London: DH. DH, 2000d. National service framework for coronary heart disease, Chapter 2. Preventing coronary heart disease in high risk patients. London: DH. DH, 2000e. National service framework for coronary heart disease: Chapter 12. Cardiac rehabilitation. London: DH. HDA, 2000. Health update: coronary heart disease and stroke. London: HDA. Smith, C. and Pratt, M., 1993. Cardiovascular disease. In: R. Brownson, P. Remington and J. Davis, eds. Chronic disease epidemiology and control. Washington: American Public Health Association. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 4
  11. 11. 1.1 Introduction Smoking is the cause of one out of every seven deaths from heart disease (nearly one in four deaths among men and one in 10 among women). Nine in 10 deaths from lung cancer among men and nearly three in four among women are estimated to have been caused by smoking – 84% of all lung cancer deaths. Among those aged under 65 years, two in five deaths from stroke were caused by smoking. Smoking is also linked to many other serious conditions, including asthma and other respiratory illnesses, cataracts, peripheral vascular disease, periodontal disease and brittle bone disease (Callum 1998). Treating the illnesses and diseases caused by smoking is estimated to cost the NHS up to £1.7 billion every year (Raw et al. 1998). Passive smoking – breathing in other people’s tobacco smoke – is also a major cause of mortality and morbidity. It contributes to death from heart disease and a range of other health problems (Royal College of Physicians 1992). In December 1998, the Government’s first-ever white paper on tobacco, Smoking kills, set three targets, for adults smoking, smoking during pregnancy and children smoking (DH 1998a). • To reduce adult smoking in all social classes so that the overall rate falls from 28% to 24% or less by 2010, with a fall to 26% by the year 2005. In terms of today’s population, this would mean 1.5 million fewer smokers in England. • To reduce the percentage of women who smoke during pregnancy from 23% to 15% by the year 2010, with a fall to 18% by the year 2005. This will mean approximately 55,000 fewer women in England who smoke during pregnancy. • To reduce smoking among children from 13% to 9% or less by the year 2010, with a fall to 11% by the year 2005. This will mean approximately 110,000 fewer children smoking in England by the year 2010. The cancer plan published in September 2000 introduces new national and local targets to address inequalities in smoking rates between socio-economic groups. At a national level the target is: • To reduce smoking rates among manual groups from 32% in 1998 to 26% by 2010 (DH 2000a). 1.1.1 The National Service Framework for coronary heart disease The NSF CHD (DH 2000b) states that ‘by October 2000 HAs, LAs, PCGs/PCTs and NHS trusts will have set up, or have firm plans in place [for a range of NHS smoking cessation services which will enable national and regional targets for the numbers of smokers quitting to be met]. By April 2001, HAs, LAs, PCGs/PCTs and NHS trusts will have agreed and be contributing to the delivery of the local programme of effective policies on reducing smoking; as an employer, have implemented a policy on smoking and be able to refer clients/service users to specialist smoking cessation services, including clinics …’ The immediate priorities for implementing the smoking cessation area of the NSF CHD are: • By April 2001, health authorities will introduce specialist smoking cessation clinics, helping 150,000 people Chapter 1 Reducing smoking prevalence Reducing smoking prevalence 7
  12. 12. • Delivering the early milestones set out in Chapter 1 of NSF CHD: Reducing heart disease in the population (DH 2000b). The requirements of smoking cessation are detailed in Appendix A, Chapter 1 of NSF CHD: Reducing heart disease in the population (DH 2000b). 1.1.2 Benefits of smoking cessation for CHD The costs and benefits of smoking cessation are well established (Raw et al. 1998). • Reductions in smoking prevalence are guaranteed to bring population health gains (Raw et al. 1998; US Department of Health and Human Services 1990). • Smoking cessation reduces the risk of dying from smoking related diseases. Smokers have about twice the risk of dying from CHD compared with lifetime non-smokers. This excess risk is reduced by about half among ex- smokers after only one year of abstinence and declines gradually thereafter. After 15 years of abstinence, the risk of CHD is similar to that of people who have never smoked (Tang et al. 1992). Smoking cessation is particularly important in the secondary prevention of CHD. In smokers with existing CHD, the risk of premature CHD mortality can be reduced by 50% or more on giving up (US Department of Health and Human Services 1990). • Reductions in smoking prevalence will produce sizeable reductions in common hospitalised events and costs (Naidoo et al. 1999). • The cost savings that can be made through moderate success in smoking cessation programmes are significant and cumulative (Naidoo et al. 1999). 1.1.3 Trends in smoking Adults The prevalence of smoking in the UK over the past 20 years or so has fallen. In 1998, 27% of adults aged 16 years and over smoked cigarettes compared with 40% in 1978. However, most of this decline occurred in the 1970s and 1980s. In the 1990s, the decline in smoking prevalence among adults levelled off (DH 2000c). The prevalence of smoking is higher among people in manual than non-manual social classes (32% compared with 21% in 1998). The widening of this gap over the past 20 years reflects a steeper decline in smoking prevalence among non-manual classes compared with manual classes (DH 2000c). The social class differentials in smoking are reflected in the social gradients of deaths caused by smoking. The percentage of deaths from ischaemic heart disease caused by smoking ranges from 39% for men aged 35–64 years in social classes I–II to 49% of those in classes IV–V. For women aged 35–64 years the figures range between 35% for classes I–II to 46% for classes IV–V (Callum 1998). Pregnant women The proportion of women who smoke during pregnancy has fluctuated over the past eight years (Owen et al. 1998; Owen and Penn 1999). In 1999 nearly a third of women (30%) smoked during pregnancy compared with 27% in 1992. Among young pregnant women (aged 16–24 years) from social groups C2DE (similar to manual and unemployed classes), the percentage is even higher, with 51% smoking during pregnancy in 1999 (Owen and Penn 1999). Teenagers In 1999, an estimated 9% of children aged 11–15 years smoked cigarettes (DH 2000c). This figure has varied considerably over time, showing a low of 8% in 1988 and a high of 13% in 1996 (DH 2000b). As the majority of smokers take up the habit in their teens, any increases in the rates of young smokers will eventually feed through into adult smoking rates. Black and minority ethnic groups Cigarette smoking among minority ethnic groups is generally less than among the UK population as a whole (28%1). However, a more detailed examination reveals important differences between and within groups. The smoking rate among Bangladeshi men is very high (49%). Coronary heart disease: guidance for implementing the preventive aspects of the NSF 8 1Differences between the HEA (1999a) and DH (2000c) surveys in timing and methodology most likely account for the 1% difference in the estimates of the percentage of adults who smoke.
  13. 13. This same group of men also has high rates of chewing tobacco products. Smoking rates are even higher among middle-aged and older Bangladeshi men (54% and 70% for men aged between 30–49 and 50–74 years, respectively). Smoking rates among African-Caribbean men and women resemble, and sometimes exceed, the rates for the UK population as a whole. Smoking rates among African-Caribbean women are higher for younger women [Health Education Authority (HEA) 1999a]. Poverty and smoking Traditional measures of social class tend to underplay the extent to which smoking has become concentrated in the poorest sections of society. Recent studies have shown that smoking levels have remained virtually unchanged among those in the poorest groups, and among lone mothers smoking levels have risen (Marsh and McKay 1994; Dorsett and Marsh 1998; Jarvis 1998). In a detailed study, lone parents living in rented accommodation and relying on social security benefits were found to have smoking levels in excess of 75% (Dorsett and Marsh 1998). 1.2 Objectives of interventions to reduce smoking The importance of a comprehensive approach has long been recognised (WHO 1979). As well as approaches aimed at the individual, there has been a recognition of the need for policy and legislative measures and social and environmental initiatives as essential components of any strategy to reduce tobacco use (WHO 1998). Ideally, each component of such a comprehensive strategy would encompass the following objectives: • Promote quitting (not cutting down) among adults and young people • Reduce exposure to environmental tobacco smoke • Create a social environment that is supportive of non-smoking and cessation. In the context of reducing smoking among adults, a secondary objective could include strategies to prevent the uptake of smoking among young people. However, it is important to note that there is little evidence that teenage strategies, especially in the absence of adult strategies, have any impact on the uptake of smoking among children (Reid 1996; Hill 1999). Local strategies to reduce smoking prevalence should reflect the policies and population groups set out in the white paper on tobacco Smoking kills (DH 1998a), The NHS plan (DH 2000d, Chapter 13), NSF CHD (DH 2000b) and The cancer plan (DH 2000a). Local strategies should also include an alliance of NHS, local government, education and commercial interests, as well as voluntary agencies, to help reduce smoking and to provide information on smoking by using local media, creating local activities and promoting debate to generate interest. Some areas of the country already have smoking alliances. These cover about 60% of the population of England and are supported by the DH. 1.3 Features of effective interventions A comprehensive approach – combining community wide approaches with economic and regulatory measures – was identified by the US Surgeon General as the strategy most likely to have the greatest long-term, population impact (US Department of Health and Human Services 2000). Educational and clinical approaches were considered to be of greater importance in helping individuals resist or abandon the use of tobacco. Community wide approaches typically involve a range of agencies including health services, voluntary agencies, the media (paid and unpaid), as well as government and local authorities (see 5.3, Building effective partnerships, p74). Together, they undertake a range of activities such as direct smoking cessation, helplines, training and resources for health professionals, development of policies to reduce smoking in public places, media campaigns and advocacy, reducing sales to minors and work in schools. Overall, community interventions seek to influence both individual behaviour and the environmental, social and cultural conditions that affect tobacco use (Lantz et al. 2000). The impact of a comprehensive approach is difficult to evaluate, especially given the potential for individual components to work synergistically to produce combined effects (Chapman 1993; US Department of Health and Human Services 2000). For example, the effectiveness of school based programmes appears to be enhanced when they are included in broad based community interventions (Lantz et al. 2000). Nevertheless, Reducing smoking prevalence 9
  14. 14. studies that have sought to measure the effects of a comprehensive approach have yielded encouraging results (US Department of Health and Human Services 2000; Lantz et al. 2000; Sowden and Arblaster, 2000a,b; Wakefield and Chaloupka 2000). It is accepted that population-wide approaches should aim to reduce both adult and teenage smoking. But where should the emphasis lie? Experts agree that teenage smoking rates are unlikely to decline in the absence of a fall in adult rates. The view that smoking among adults should therefore be tackled ahead of teenagers was discussed by Hill (1999) in a recent article. His argument is fivefold: • First, reducing smoking among adults will lead to a quicker and bigger reduction of tobacco related harm, because there is a higher level of smoking related mortality and morbidity among adults than teenagers • Second, reducing smoking among adults will provide protection to the unborn and recently born against exposure to direct and indirect tobacco smoke • Third, quitting by adults (especially by parents) reduces the likelihood of children taking up smoking • Fourth, while there are clear ethical reasons for educating children about what is the largest preventable cause of death, beyond this, the methods of delivering interventions are fraught with practical problems and the evidence of effectiveness of interventions aimed at young people is poor • Finally, the fact that the tobacco industry itself supports antismoking campaigns targeted at teenagers should be taken as a warning signal: ‘Even Phillip Morris was confident that [antismoking] youth campaigns could do them little damage’ (Hill 1999). 1.4 Components of a local strategy 1.4.1 Develop smoking cessation services • The health improvement programme (HImP) should emphasise the importance of an integrated service including primary care advice, specialist smoking cessation clinics, one-to-one cessation advice [Health Service Circular (HSC) 1998, 1999; Action on Smoking and Health (ASH) 2000a,b]. The requirements for smoking cessation are detailed in Appendix A, Chapter 1 of NSF CHD: Reducing heart disease in the population (DH 2000b). • Build upon and develop these guidelines for local cessation services. • Provide special services for pregnant women. The NHS plan (DH 2000d) states that ’the specialist smoking cessation services will focus on heavily dependent smokers needing intensive support, and on pregnant smokers as part of antenatal care. Primary care groups will take the lead in commissioning – and where appropriate providing – these services’. In support of the smoking cessation treatments bupropion is now available on prescription and The NHS plan recommends that nicotine replacement therapy (NRT) should also be made available on prescription. These services followed evidence based guidelines for smoking cessation published in December 1998 (Raw et al. 1998). These guidelines have been updated and will be available in December 2000. The Committee on Safety of Medicines will consider whether NRT can be made available for general sale. An evaluation of the first year of the development of the national cessation services has recently been published (Adams et al. 2000). At a meeting of smoking cessation experts held in July 2000, it was agreed that the smoking cessation services should offer support to all people who request it. The focus on particular groups could be achieved through recruitment to the services – for example by engaging midwives or promoting the services at antenatal classes (ASH 2000a,b; The meeting, with representation from the DH, identified a model approach to smoking cessation services in primary care, which also sought to provide clarification on the role of intermediate cessation services. Discrepancies in the guidelines concerning intermediate services had caused confusion in some health action zones (HAZs) (Adams et al. 2000). Both intermediate services and specialist clinics have been subsumed in the model by the term ‘qualifying specialist services’ for which a minimum standard of service to the smoker has been set and for which the centrally provided smoking cessation budget may be used. The model of the service is set out in Figure 1 on facing page. For full details and further guidance see: Coronary heart disease: guidance for implementing the preventive aspects of the NSF 10
  15. 15. Model of the service to the smoker Each smoker contacting the NHS should be offered a package of both pharmaceutical aids and behavioural support that meets their particular needs and circumstances. Given restrictions on who can prescribe drugs, and limitations on the extent to which those who may prescribe are able to offer support, it will not always be possible to provide a ‘one-stop shop’. The aim must be to make access to drugs and support as straightforward as possible. The elements of the support package include: • Influences on smokers’ motivations to quit, including advice from primary care professionals, national campaigns, No Smoking Day and manufacturers’ advertising • Brief opportunistic interventions by the GP and other primary care professionals • Prescribing pharmacotherapies: NRT and bupropion (Zyban) • Behavioural support. This will need to be tailored to match the circumstances of the smoker, but the range of options includes: Referral to a ‘qualifying’ specialist service – these would qualify for funding from the smoking cessation budgets if they offered a certain minimum service standard Discussion of other support options (eg telephone, self-help) that the smoker could consider, if he/she chose not to attend a qualifying specialist service. Reducing smoking during pregnancy For pregnant women, pregnancy specific materials are more cost effective than less specific, cheaper, standard information because of their greater effectiveness (Buck and Godfrey 1994). The intensity of the intervention also affects outcome. While there is some evidence of the effectiveness of advice when literature is coupled with follow up, more intensive interventions (eg a structured Reducing smoking prevalence 11 Figure 1. Configuration of smoking cessation support services.
  16. 16. cessation course based on self-help booklets) provide stronger evidence (Raw et al. 1998). Public education campaigns may be effective in shifting pregnant women’s attitudes and behaviour (Campion et al. 1994). The difficulties of advising outright cessation in pregnancy has led some health professionals to suggest cutting down as an alternative. However, there is little evidence to show that cutting down is of any health benefit (Raw et al. 1998). Thus quitting as opposed to cutting down needs to be emphasised. Many women who do stop smoking in pregnancy go back to smoking after the birth of the baby. In one American study over half (56%) of women who stopped during pregnancy were smoking within one month of the birth (Secker-Walker et al. 1995). Relapse prevention interventions with pregnant women and women who have recently given birth are needed. • All those responsible for providing antenatal care should ensure that relapse prevention is included as a component in the smoking cessation service. The lower rate of cessation associated with mothers from lower socio-economic groups, led the Scientific Advisory Group on Inequalities to conclude that ‘interventions that target the individual behaviour alone may not be sufficient ... broader policies to combat inequality are also required’ (Acheson 1998). Further information on smoking and pregnancy can be obtained in the following reports: • Smoking and pregnancy: a survey of knowledge, attitudes and behaviour 1992–1999 (Owen and Penn 1999) • Smoking and pregnancy: guidance for purchasers and providers (HEA 1994a) • Helping pregnant smokers quit: training for health professionals (HEA 1994b) • Smoking and pregnancy: developing a communications strategy for cessation (Owen and Bolling 1996) • Smoking and pregnancy: a growing problem (HEA 1996a). Mechanisms for delivering cessation services for young people are outlined in the document Smoking cessation in young people: should we do more to help young people quit? (HDA 2000a). 1.4.2 Reduce smoking in public places including workplaces Restricting smoking is important not only for limiting the public’s exposure to toxins in sidestream smoke, but also for broader policy reasons. First, it puts smoking in a broader context than one of personal choice and personal risk and legitimises it as a social problem; second, it may be the source of litigation against employers or businesses; and third, the spread of smoking restrictions reduces the opportunities to smoke and thus reduces consumption (Borland et al. 1991; Brenner and Mielck 1992; Marcus et al. 1992; Wakefield et al. 1992; Jeffery et al. 1994; Glasgow et al. 1997; Brauer and Mannetje 1998). The Health and Safety Executive (HSE) has been examining current practice on restricting smoking at work with a view to issuing an Approved Code of Practice (ACoP). There are potential legal liabilities for employers who do not address passive smoking in the workplace. Employees have recourse to civil law, contract and employment law and the general provisions of the Health and Safety at Work Act (1974). The ACoP will clarify the legal position for both employers and employees, and enable LA environmental health officers (EHOs) to intervene. Local plans should include objectives to: • Ensure that all local hospitals have smoking policies (DH 1998a; HEA 1999b), and that these are fully implemented • Implement policies to restrict smoking in public places [Scientific Committee on Tobacco and Health (SCOTH) 1998] • Encourage restaurants, bars and other leisure facilities to provide smoke free areas. Many employers now find an advantage in smoking restrictions through savings on sickness absences, increased productivity, lower insurance and cleaning costs. The checklist in Box 1.1 will help managers of workplaces to develop an effective strategy on smoking. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 12
  17. 17. Further information For examples of case studies of effective practice within the NHS see Tobacco control policies within the NHS: case studies of effective practice (HDA 2000b). For further information on developing, reviewing and amending tobacco control policies, see Been there, done that: revisiting tobacco control policies in the NHS (HEA 1999b). Sample policies and consultation questionnaires can be found in Smoking policy for the workplace: an update (HEA 1999c) and Towards tobacco-free environments: guidelines for local authorities (HEA 1999d). Also see the ASH website: 1.4.3 Support national media campaigns Mass media campaigns can influence smoking behaviour (DH 1998a; Lantz et al. 2000; Sowden and Arblaster 2000a,b) and may be especially appropriate for reaching those who are less educated (Mackaskill et al. 1992) and those in poor communities (Jenkins et al. 1997). Message content and the intensity and duration over which the messages are delivered appear to be important factors in determining the impact of mass media campaigns (Grey et al. 2000; Lantz et al. 2000). Media campaigns should focus predominantly on adults, since the majority of cigarettes (>95%) are consumed by adults and adult smokers are a major factor influencing the uptake of smoking by minors. Local media may be used to raise the profile of national campaigns (No Smoking Day). For ideas in planning local media campaigns see: Tel: 020 7916 8070. • Local plans should include links to the network of local smoking control alliances in England. 1.4.4 Use media advocacy There is some evidence that the use of media advocacy (see Box 1.2) may affect tobacco consumption (Buck and Godfrey 1994), but its major role is in social marketing. This involves shaping the media agenda, prompting policy changes and influencing the social norms around smoking (Reid et al. 1992). Media advocacy techniques Reducing smoking prevalence Box 1.1 Management checklist for a smoking policy • Review current situation. • Assess need, capacity to change. • Make sure you consult with everyone. • Seek feedback, not permission. • Decide on the policy details. • Decide on a total or partial ban. • Decide what restrictions to impose if a total ban is not possible. • Communicate final decisions clearly to all staff. • Label smoking and smoke-free areas. • Monitor and review the policy. Source: HEA (1999c) Box 1.2 Checklist for setting up local media advocacy work First think about the following points: • What you hope to achieve • Who your campaign is aimed at • How much you think it will cost • How it will be supported by local activity and action • How you plan to evaluate it (have you achieved what you hoped?). Create a media plan: • What stories or angles will attract the media? • What information is needed for a newsworthy press release? • Draw up a media list – names and contact numbers of relevant journalists • Find out the deadlines for media you are targeting • Find out how media contacts want you to communicate with them (press release, direct contact) • Decide who will act as spokespersons • Coordinate media schedules with partners who may also be using the media • If the campaign is a long one, create a media calendar to ensure a constant supply of news items. 13
  18. 18. may be especially effective with poor communities (Jernigan and Wright 1993) since low income groups, including smokers, are high consumers of TV. For further guidance on media advocacy and factors that influence its effectiveness, see An investigation into the potential of media advocacy as a health promotion strategy (HDA in press). 1.4.5 Monitor the voluntary advertising ban Indirect marketing of cigarette brands is the growing and preferred marketing strategy of the tobacco industry, perhaps in response to threats of advertising restrictions. Until legislation is introduced, the existing ‘voluntary agreements’ on tobacco promotion should continue to be monitored locally, not so much because these restrictions have been found to be effective in preventing uptake of smoking, but because infringement of the rules offers opportunities for media advocacy. Those provisions include, for example, banning advertising on billboards near schools and promotions in magazines for young people. People working locally should be vigilant in monitoring any new marketing strategies, for example, using events at discos, student functions and the Internet to promote brands. 1.4.6 Reduce sales of cigarettes to children under 16 years old Combining regular test purchasing with a high profile media approach has been found to be successful in reducing the incidents of reported sales of cigarettes to people under 16 years of age. Overall, the evidence of effectiveness of sales restrictions suggests that vigorous local enforcement of the law forbidding sale of tobacco to under-16s can reduce sales (Stead and Lancaster 2000). This strategy has also been shown to have a small delaying effect on the uptake of smoking among children. There is little evidence, however, to suggest that it has any effect on the uptake of smoking among children. Considerable resources are required, both in terms of trading standards officers’ and court time. The existing law is not being applied effectively (DH 1998a). The Local Government Association and Local Authorities Co-ordinating Body on Food and Trading are developing a new enforcement protocol to address this. Features of the protocol are listed in Box 1.3. Proof-of-age card schemes have been developed, but the government recommends that a single system be agreed. The vending machine trade association, the National Association of Cigarette Machine Operators, has produced a new, stricter code for its members to clarify siting arrangements and monitoring for vending machines (DH 1998a). 1.4.7 Encourage the introduction of smoking policies in schools A formal, well publicised school policy on smoking reinforces non-smoking as the norm in society, supports health messages in the curriculum and may have positive effects on smoking levels among pupils, staff and all adult users of the premises (see Box 1.4). Additional potential benefits include reduced absenteeism, reduced costs and elimination of the harmful effects of passive smoking. • Provide support to schools to introduce no smoking policies. The National Curriculum Science Order recommends that teaching the harmful effects of tobacco, alcohol and other drugs should begin at Key Stage 2 (age 7–11 years). The Office of Fair Standards and Training in Education (OFSTED) 1999 report Drug education in schools and the Department for Education and Employment (DfEE 1998) report Protecting young people: good practice in drug education in schools and the youth Coronary heart disease: guidance for implementing the preventive aspects of the NSF Box 1.3 Enforcement protocol • Local authorities should publish a clear statement on underage tobacco sales. • Ensure that all shops and vending machines display notices stating the law. • Use test purchases to assess local compliance by retailers. Gather information about premises likely to be breaching the law. • Use media advocacy to raise the profile locally. • Educate to increase compliance. • Detail enforcement action taken, prosecutions and fines, to act as a deterrent. 14
  19. 19. service recommend teaching young people from the age of five years upwards about the risks and consequences of tobacco, alcohol and drug use, together with teaching the life skills needed to resist the pressure to misuse these substances. Teaching should clearly cover issues relevant to the child’s age and experience. This frequently entails tackling smoking and alcohol-related issues first, as these are the substances that young people will generally be exposed to first. 1.5 Reducing inequity With little or no decline in the lowest income groups, smoking has become concentrated in Britain’s poorest households. For example, among lone parents on benefits and living in council housing, more than three-quarters smoke (Dorsett and Marsh 1998). Moreover, recent research suggests that nicotine dependence is higher in people experiencing disadvantage (Jarvis and Wardle 1999). In keeping with these findings, the Independent Inquiry into Inequalities in Health recommended a short- term strategy to reduce nicotine dependence, which is likely to be stronger in disadvantaged smokers, through the provision of free NRT. A complementary, longer-term strategy aims at removing the cultural and environmental barriers that disadvantaged people face. Community based interventions, brief advice from a GP and specialised smoking clinics are also recommended as effective settings in which to provide NRT (Acheson 1998). Attempts to set up community based projects to promote smoking cessation have met with mixed success. In a report of initiatives set up in low income communities in Scotland, the authors concluded that: ‘small grant funding for time limited projects can promote work on smoking amongst women living or working in low income communities. Although reducing smoking was a long term goal for the majority of the initiatives most did not perceive themselves as a cessation group. As a result they did not measure success by the numbers quitting. Changes in individual smoking behaviours were noted and these ranged from extending the period of smoke free time, to restricting smoking to a specific room or location and trying nicotine replacement therapy’ (ASH Scotland and HEBS 1999). Examples of other community based projects funded through small grants schemes can be found in Empowering smokers to quit: success principles for community stop-smoking projects (HEA 1996b). The use of mass media, especially TV, may be particularly appropriate for reaching less educated and/or disadvantaged smokers. This reflects the tendency for the less educated to receive information from TV more often than those who are more educated (Buck and Godfrey 1994). Indeed, research has shown that mass media antismoking campaigns can have a significant impact on low income and low educational groups (Macaskill et al. 1992; Jenkins et al. 1997). 1.5.1 Black and minority ethnic groups Little has been published on the impact of smoking cessation interventions in reducing tobacco use among black and minority ethnic groups in England. However, studies from the USA suggest that they can be effective Reducing smoking prevalence 15 Box 1.4 Checklist for a school’s smoking policy • Put the development of a smoking policy on the agenda. • Review the current situation. • Identify staff with sufficient skill and seniority to take responsibility for developing a new policy if necessary. • Form a working party involving key people from the school and community, if appropriate. • Establish a rationale for the policy. • Identify educational, health and economic reasons for introducing a policy or improving existing conditions. • Draft the policy. • Evaluate the draft policy by consulting with all relevant parties, identify potential constraints and problems. • Inform everyone about the policy before it is implemented. • Allow sufficient time for implementation of the new policy – three to six months is considered a reasonable time between initiating and implementing the policy. • Monitor the operation of the new policy.
  20. 20. (Botvin et al. 1992; Elder et al. 1993; Lillington et al. 1995; Elder et al. 1996). In the absence of UK studies, patterns of tobacco use (HEA 1999a) and research into the role of tobacco within and between black and minority ethnic groups (Maltby et al. 2000) can provide some pointers for the way forward. Examples of these are highlighted below (HEA 1999a; Maltby et al. 2000). • The high rates of tobacco chewing, especially among Bangladeshis, suggests that this practice should be included in interventions aimed at reducing tobacco use. • Sensitivity to gender issues is vital. • Literature should be multi-lingual and in a style that is culturally familiar (eg use of vignettes to highlight health risks associated with tobacco use). • Information campaigns should be developed to redress misperceptions about tobacco use (eg belief that tobacco use can relieve indigestion; belief that healthy practice in other areas such as diet and exercise will offset the detrimental effects of smoking). • Ethnic differences in attitudes and beliefs about cigarette smoking should be incorporated into smoking cessation interventions. Thus, to be successful, a tobacco cessation campaign must take account of the culture, tradition and religion of the particular target group. In so doing it will need to involve community groups, religious groups, smoking cessation coordinators, local tobacco alliances, primary health care (PHC) teams, culturally relevant local and national media as well as key individuals within different ethnic groups. In response to ethnic health inequalities, the government has announced that £1,000,000 will be made available to help reduce the high rates of smoking among certain ethnic groups. Further information on black and minority ethnic groups DH, 1996. Directory of ethnic minority initiatives, G60/008 3934 1P 5K May 96 (23). London: DH. Gervais, M. and Jovchelovitch, S., 1998. The health beliefs of the Chinese community in England: a qualitative research study. London: HEA. HEA, 1999. Black and minority ethnic groups and tobacco use in England: a practical resource for health professionals. London: HEA. HEA, 2000. Black and minority ethnic groups in England: the second health and lifestyles survey. London: HEA. McKeigue, P. and Sevak, L. 1994. Coronary heart disease in South Asian communities. London: HEA. Sproston, K., Pitson, L., Whitfield, G. and Walker E., 1999. Health and Lifestyles of the Chinese population in England. London: HEA. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 16
  21. 21. Reducing smoking prevalence 17 Dependsontheparticular interventionunder consideration(seebelow). Candoubletheeffectiveness ofanintervention,beitbrief advicefromaGPorintensive supportthroughaspecialist clinicorwill-poweralone. Intervention Smokingcessation Nicotine replacement therapy Bupropion(Zyban) Evidence Effectivenessandcosteffectiveness arewellestablished(Fioreetal. 1996;Rawetal.1998).Updated guidelines(Dec2000). Doubleschanceofsuccessof smokerswishingtostop(Fioreetal. 1996;Rawetal.1998). JustlaunchedintheUK.An effectivepharmacotherapy(Hurtet al.1997;Jorenbyetal.1999),itwill beavailableonprescription. Whocouldbe involved? Healthprofessionals, LAs,specialist smokingcessation coordinators, voluntarysector, HAZs,localsmoking alliance. PHC,pharmacists, healthpromotion specialists. GPsandthose approvedfor prescribingthrough thePatientGroup Directive, PHC,pharmacists, healthpromotion specialists. Skillsandresources Smokingcessationskills, carbonmonoxidemonitor, leaflets.Althoughtraining schemesareavailable nationally,accreditedcourses shouldbeestablished. Demonstratecultural sensitivity. Smokingcessationskills, accesstoNRTproducts. Smokingcessationskills. Pointstoconsider Majorcomponentof governmentstrategyto reducesmokinginEngland. HSC(1999)hassetout guidelinesonmonitoringfor thenewservices. Theavailabilityand accessibilityofservicesshould takeaccountofcultural differences. Currently,someareavailable onprescriptionaswellas beingavailableoverthe counter(OTC).Nasalsprayis OTCand2mggumisalso availableonthegeneralsales list(GSL). Prescriptiononly. Furtherinformation HSC(1998,1999),DH (1998a),Acheson(1998). CochraneLibrarywebsite: http://www.update- clib.htm Evaluationofyearoneof nationalcessationstrategy (Adamsetal.2000).ASH (2000a). Seeabove. Outcome Table1.6Suggestedactivitiestosupportlocalaction
  22. 22. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 18 BriefadviceinNHS andprimarycare Verybriefadvice(three minutes)canresultina2% increaseinnumberof smokersabstinentforsix monthsorlongercompared withnoadvice.Briefadvice (10minutes)canresultina 3%increase.AddingNRTto briefadvicecanresultina 6%increase. Comparedwithno interventionintensivesupport canresultinan8%increase inthenumberofsmokers abstinentforsixmonthsor longer. Resultina5%increaseinthe numberofsmokersabstinent forsixmonthsorlonger. Resultina7%increaseinthe numberofsmokersabstinent forsixmonthsorlonger. Quitrateof15.6%(adjusted) reportedinEnglandwith massmediacampaign(Owen 2000). Intensivesupport (egsmokers’clinics) Cessationadvice andsupportfor hospitalpatients Cessationadvice andsupportfor pregnantsmokers Telephone helplines Fioreetal.1996;Rawetal.1998; updatedguidelines(Dec2000). Fioreetal.1996;Rawetal.1998; updatedguidelines(Dec2000). Rawetal.1998;Fioreetal.1996; updatedguidelines(Dec2000). Evidencebaseforeffectivenessis growingandThoraxguidelines indicatethattheymayprovidean effectiveservice(Rawetal.1998). Ameta-analysisreportsasignificant effect(Fioreetal.1996). Seeabove. Providersof(national andlocal)helplines, workplace,public places,NHS, communitygroups, cessationservices. InterventionEvidence Fioreetal.1996;Rawetal.1998; updatedguidelines(December 2000). Whocouldbe involved? PHCteam,linkwith othersupport servicesif appropriate [eghealthyliving centres(HLCs), hospitalstaff, doctors,nurses, midwives]. Skillsandresources Smokingcessationskills. Smokingcessationskills. Smokingcessationskills. Smokingcessationskills. Smokingcessationskills, trainedstaffrequired. Pointstoconsider Reachlowerthanthatfor briefadvice,butassociated withahighersuccessrate; resourceintensive;easeof access(egconvenience,safe location,timing)andcost (ifany)areimportant considerations. Massreach,easyand convenientforsmoker. Guidelinesareavailablefor thosewantingtosetuplocal helplines.Alternatively, activitiesandliteraturecould beundertakentoraisepublic awarenessofanduseof existinghelplines.Canbe usedtopromoteother cessationsupportservicesin locality. Furtherinformation Asabove. Asabove.TheMaudsley smokers’clinicisanexample ofgoodpracticehighlighted inthetobaccowhitepaper (DH1998a). Lichtensteinetal.(1996), NHSDirectHelpline 08001690169, Quit(Charity) 02073885775, Quitline0800002200. Outcome
  23. 23. Reducing smoking prevalence 19 Likelyimpactuncertain. AUSstudyofemployees reportedareductionof5% insmokingprevalenceand 10%inconsumptionafter theintroductionofworkplace bans.Otherbenefitsinclude recognitionofnon-smoking asnorm,protectionofnon- smokers,increasedpublic awarenessandacceptanceof healthrisks.Mayencourage adolescentsnottostart. Quitrange0–5%foradult interventions(Reid1996), directinfluenceonclimateof publicopinion. Reducesmokingin publicandwork places Massmedia campaigns Associatedwithreduced consumption,possiblereductionsin prevalenceinthelongerterm (BrennerandMielck1992;Buck andGodfrey1994;Reid1996). Canenhancenaturalquitrateand mayreducerelapse(Reid1996; McVeyandStapletoninpress);may alsoreduceuptakeofsmokingin youngpeople(Sowdenand Arblaster2000a). BritishHospitality Association,The Restaurant Association,British Instituteof Innkeeping,Brewers andLicensed RetailersAssociation, Associationof LicensedMultiple Retailers,employers andemployees,NHS. Nationalandlocal media,community settingsand activities,workplaces andpublicplaces. Intervention Othertreatments Evidence Insufficientevidenceofeffectiveness forhypnotherapyandacupuncture, etc.(Abbotetal.2000;Whiteetal. 2000). Whocouldbe involved? Privatesector,links withothersmoking cessationproviders. Inviewoflackof evidencebase, considercontacting recognised professional associationsfor trainedindividuals. Skillsandresources Costly;requiresminimallevel ofexposureanddevelopment ofnewmessagestoavoid consumerburn-out. Pointstoconsider Smokersshouldbegiven informationaboutother treatmentstoenablethemto makeaninformedchoice withoutdiscouraging attemptstostop.Levelof traininglikelytovaryfrom nonetosufficienttojustify membershipofaprofessional body(Rawetal.1998). Charteragreedbetween governmentandlicensed hospitalitytrade.TheHSEis producinganewACoPon smokingintheworkplace, whichwillprovidepractical adviceonhowtocomply withthelaw. Highreach;workswellwith otherinterventionssuchas taxincreases;cansupport localcessationservices;focus shouldbeonadults. Furtherinformation BritishHypnotherapy Association(BHA),1 WythburnPlace,London W1H5WLTel:0207723 4443,email: BritishSocietyof Hypnotherapists(BSH),37 OrbainRoad,LondonSW6 7JZTel:02073851166 AssociationofGeneral PractitionersofNatural Medicine(AGPNM),38Nigel House,PortpoolLane, LondonEC1N7UR Tel:02074052781. InstituteofComplementary Medicine(ICM),POBox194, LondonSE161QZ Tel:02072375165. DH(1998a),HEA(1999c,d). TheNationalHSE(NHSE)is developingatoolkittohelp withtheimplementationof itspolicies. DHsmokingpolicyteam, DHcommunicationsteam, reviewofuseofmassmedia campaignsinEngland availablefromHDA(Greyet al.2000).CochraneLibrary websitehttp://www.update- Outcome
  24. 24. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 20 Oneyearnetquitrates estimated0.3–0.5%(Reidet al.,1992;BuckandGodfrey 1994);influenceonpublic opinion;providesbasisfor otherinitiatives;may contributetoimpactofmass mediacampaign; extendsdebateabout smoking. Impactofmonitoringlocal infringementofvoluntary agreementnotknown,but doesofferopportunitiesfor mediaadvocacy. Localactivitycanreduce sales;usefulformedia advocacy;mayhaveasmall delayingeffectonchildren’s uptake. Implementationvariessothat outcomeisunclear;reinforces non-smokingasthenorm; otherpotentialbenefits includereducedabsenteeism, reducedcostsandelimination ofpassivesmoking. Advertisingban Reduceillegalsales Smokingpoliciesin schools Possibleeffectonadult consumptionandteenage prevalence(Reidetal.1992; SowdenandArblaster,2000a). Localactivitycanreducesales.This mayhaveasmalldelayingeffecton children’suptakeofsmoking. Impactonuptakeofsmoking uncertain. Government,health promotionspecialists, tobaccoadvocates andotherscan monitorexisting voluntary agreements. Magistrates,retailers, localtrading standardsofficers, schools,parents, localgovernment association,LAs, NationalAssociation ofCigaretteMachine Operators. Schoolteachers, governors,heads, parents,pupils,local community(for policiesthatinvolve non-smokingin schoolpremisesfor communityactivities). Intervention Mediaadvocacy andNoSmoking Day Evidence Effectivenesslowerthanmore intensiveinterventionsbuthighly cost-effectivebecausethereachis muchgreater(Reidetal.,1992; BuckandGodfrey1994). Whocouldbe involved? NHS,local government, commercialinterests, voluntaryagencies. Skillsandresources Cheaperthanpaid advertisingbutsubstantial resourcesrequiredfor generatingstories; goodcontactswithlocal mediaandtheleisureand hospitalitytrade.Trainingin mediaadvocacyneeded. Requiressubstantial resources. Pointstoconsider Reliesongoodlinkswith otheragencies(egvoluntary sector,localgovernment, hospitalitytrade)tocreate localactivities. Localactivitycouldinclude monitoringinfringementsto voluntaryagreements(eg advertisingonbillboardsnear schools,promotionsin magazinesaimedatyoung people). Existinglawstatesthatitis illegaltoselltobacco productstounder16s,but enforcementisproblematic. Possiblyaddstoperception thatsmokingisaforbidden fruit(KayScottAssociates 2000). Supportshealthmessagesin thenationalcurriculum. Furtherinformation Exampleofgoodpractice: RoyCastleGoodAirAwards DH(1992).IssuedwithDH circularEL(92)71. NationalAssociationof CigaretteMachineOperators hasproducedacodefor members.LocalGovernment Association(LGA)andLocal AuthoritiesCoordinating BodyonFoodandTrading haveproducedanLA enforcementprotocol. HEA(1993,1999e). Outcome
  25. 25. 1.7 References Abbot, N.C., Stead, L.F., White, A.R., Barnes, J. and Ernst, E., 2000. Hypnotherapy for smoking cessation, Cochrane Review. In: Cochrane Library, Issue 3. Oxford: Update Software. Acheson, D., 1998. Independent inquiry into inequalities in health report. London: The Stationery Office. Adams, C., Bauld, L. and Judge, K., 2000. Baccy to front. Health Service Journal, 110 (5713), 28–31. ASH, 2000a. Smoking cessation in primary care: how to spend NHS money much more effectively. London: ASH. ( ASH, 2000b. Smoking cessation services: Implementing the NHS National Plan. London: ASH. ASH Scotland and HEBS, 1999. Women, low income and smoking: breaking down the barriers. Edinburgh: Action on Smoking and Health Scotland and Health Education Board for Scotland. Borland, R., Owen, N., Hill, D. and Schofield, P., et al., 1991. Predicting attempts and sustained cessation of smoking after the introduction of workplace smoking bans. Health Psychology, 10 (5), 336–342. Botvin, G.J., Dusenbury, L., Baker, E., Ortiz, S., Botvin, E.M. and Kerner, J., 1992. Smoking prevention among urban minority youth: assessing effects on outcome and mediating variables. Health Psychology, 11 (5), 290–299. Brauer, M. and Mannetje, A., 1998. Restaurant smoking restrictions and environmental tobacco smoke exposure. American Journal of Public Health, 88 (12), 1834–1836. Brenner, H. and Mielck, A., 1992. Restrictions to smoking at the workplace and smoking habits: a literature review. Soz Praventivmed, 37 (4), 162–167. Buck, D. and Godfrey, C., 1994. Helping smokers give up: guidance for purchasers on cost effectiveness. London: HEA. Callum, C., 1998. The UK smoking epidemic: deaths in 1995. London: HEA. Campion, P., Owen, L., McNeill, A. and McGuire, C., 1994. Evaluation of a mass media campaign on smoking and pregnancy. Addiction, 89 (10), 1245–1254. Chapman, S., 1993. Unravelling gossamer with boxing gloves: problems in explaining the decline in smoking. British Medical Journal, 307, 429–432. DFEE, 1998. Protecting young people: good practice in drug education in schools and the youth service. Sudbury, Suffolk: DfEE Publications. DH, 1992. Effect of tobacco advertising on tobacco consumption: a discussion document reviewing the evidence (C. Smee, Chair, Department of Health Economics and Operational Research Division). London: DH [issued with DH EL(92)71]. DH, 1998a. Smoking kills, white paper on tobacco. London: The Stationery Office. DH, 1998b. Directory of African Caribbean initiatives. Birmingham: N Films Ltd. DH, 2000a. The cancer plan. London: The Stationery Office. DH, 2000b. National service framework for coronary heart disease. London: DH. DH, 2000c. Statistics on smoking: England, 1978 onwards. London: DH Statistical Bulletin. DH, 2000d. The NHS plan. A plan for investment. A plan for reform. London: The Stationery Office. Dorsett, R. and Marsh, A., 1998. The health trap: poverty, smoking and lone parenthood. London: Policy Studies Institute. Elder, J P., Wildey, M., de Moor, C., Sallis, J.F., Jr., Eckhardt, L., Edwards, C., Erickson, A., Golbeck, A., Hovell, M., Johnston, D., Levitz, M.D., Molgard, C., Young, R., Vito, D. and Woodruff, S.I., 1993. The long-term prevention of tobacco use among junior high school students: classroom and telephone interventions. American Journal of Public Health, 83 (9), 1239–1244. Elder, J.P., Edwards, C.C., Conway, T.L., Kenney, E., Johnson, C.A. and Bennett, E.D., 1996. Independent evaluation of the California Tobacco Education Program. Public Health Report, 111 (4), 353–358. Fiore, M.C., Bailey, W.C., Cohen, S.J., Dorfman, S.F., Goldstein, M.G., Gritz, E.R., Heyman, R.B., Holbrook, J., Jaen, C.R., Kottke, T.E., Lando, H.A., Mecklenburg, R., Mullen, P.D., Nett, L.M., Robinson, L., Stitzer, M.L., Tommasello, A.C., Villejo, L. and Wewers, M.E., 1996. Smoking cessation, Clinical Practice Guideline No. 18. Rockville: Agency for Health Care Policy and Research, US Department of Health and Human Services, Publication No. 96-0692. Glasgow, R.E., Cummings, K.M. and Hyland, A., 1997. Relationship of worksite smoking policy to changes in employee tobacco use: findings from COMMIT. Community Intervention Trial for Smoking Cessation. Tobacco Control, 6 (suppl 2), S44–S48. Reducing smoking prevalence 21
  26. 26. Grey, A., Owen, L. and Bolling, K., 2000. A breath of fresh air: tackling smoking through the media. London: HDA. HDA, 2000a. Smoking cessation in young people: should we do more to help young people quit? London: HDA. HDA, 2000b. Tobacco control policies within the NHS: case studies of effective practice. London: HDA. HDA, in press. An investigation into the potential of media advocacy as a health promotion strategy. London: HDA. HEA, 1993. Smoking policies in schools: guidelines for policy development. London: HEA. HEA, 1994a. Smoking and pregnancy: guidance for purchasers and providers. London: HEA. HEA, 1994b. Helping pregnant smokers quit: training for health professionals. London: HEA. HEA, 1996a. Smoking and pregnancy: a growing problem. London: HEA. HEA, 1996b. Empowering smokers to quit: success principles for community stop-smoking projects. London: HEA. HEA, 1999a. Black and minority ethnic groups in England: health and lifestyles. London: HEA. HEA, 1999b. Been there, done that: revisiting tobacco control policies in the NHS. London: HEA. HEA, 1999c. Smoking policy for the workplace: an update. London: HEA. HEA, 1999d. Towards tobacco-free environments: guidelines for local authorities. London: HEA. HEA, 1999e. Smoke-free schools: seven steps to success. London: HEA. HSC, 1998. Tobacco white paper, HSC 1998/234. London: NHS Executive. HSC, 1999. New NHS smoking cessation services, HSC 1999/087. London: NHS Executive. Hill, D., 1999. Why we should tackle adult smoking first. Tobacco Control, 8, 333–335. Hurt, R.D, Sachs, D.P.L., Glover, E.D., Offord, M.S., Johnston, J.A., Lowell, P.D., Khayrallah, M.A., Schroeder, D.R., Glover, P.N., Sullivan, C.R., Croghan, I.T. and Sullivan, P.M., 1997. A comparison of sustained-release Buproprion and placebo for smoking cessation. New England Journal of Medicine, 337, 1195–1002. Jarvis, M., 1998. Extra analyses of the General Household Survey commissioned by the Health Education Authority. London: HEA. Jarvis, M. and Wardle, J., 1999. Social patterning of health behaviours: the case of cigarette smoking. In: M. Marmott and R. Wilkinson, eds. Social determinants of health. Oxford: Oxford University Press, 1999, 240–255. Jeffery, R.W., Kelder, S.H., Forster, J.L., French, S.A., Lando, H.A., Baxter J.E., 1994. Restrictive smoking policies in the workplace: effects on smoking prevalence and cigarette consumption. Preventive Medicine, 23 (1), 78–82. Jenkins, C.N., McPhee S.J., Le, A., Pham, G.Q., Ha, N.T., Steward, S., 1997. The effectiveness of a media-led intervention to reduce smoking among Vietnamese-American men. American Journal of Public Health, 87 (6), 1031–1034. Jernigan, D. and Wright, P., eds., 1993. Making news: changing policy. Case studies of media advocacy on alcohol and tobacco use. Bethesda, MD: Center for Substance Abuse Prevention. Jorenby, D.E., Leischow, S.J., Nides, M.A., Rennard, S.I., Johnston, J.A., Hughes, A.R., Smith, S.S., Muramoto, M.L., Daughton, D.M., Doan, K., Fiore, M.C. and Baker, T.B., 1999. A controlled trial of sustained-release buproprion, a nicotine patch, or both for smoking cessation. New England Journal of Medicine, 340, 685–691. Kay Scott Associates, 2000. Need a fag, need a fag. Smoking and young people, Report on six qualitative discussion groups. London: ASH. Lantz, P.M., Jacobson, P.D., Warner, K.E., Wasserman, J., Pollack, H.A. and Ahlstrom, A., 2000. Investing in youth tobacco control: a review of smoking prevention and control strategies. Tobacco Control, 9, 47–63. Lichtenstein, E., Glasgow, R.E., Lando, H.A., Ossip-Klein, D.J. and Boles, S.M., 1996. Telephone counselling for smoking cessation: rationales and meta-analytic review of evidence. Health Education Research, 11, 243–257. Lillington, L., Royce, J., Novak, D., Ruvalcaba, M. and Chlebowski, R., 1995. Evaluation of a smoking cessation program for pregnant minority women. Cancer Practice, 3 (3), 157–163. Coronary heart disease: guidance for implementing the preventive aspects of the NSF 22
  27. 27. Macaskill, P., Pierce, J.P., Simpson, J.M. and Lyle, D.M., 1992. Mass media-led antismoking campaign can remove the education gap in quitting behaviour. American Journal of Public Health, 82 (1), 96–98. Maltby, S., Simmons, R., Choudry, S., Warrant, M. and Haggett, C., 2000. Research on tobacco use among black and minority ethnic groups. London: HDA. Marcus, B.H., Emmons, K.M. and Abrams D.B., 1992. Restrictive workplace smoking policies: impact on non-smokers’ tobacco exposure. Journal of Public Health Policy, 13 (1), 42–51. Marsh, A. and McKay, S., 1994. Poor smokers. London: Policy Studies Institute. Naidoo, B., Stevens, W. and McPherson, K., 1999. A report for the Health Education Authority on modelling the short-term consequences of smoking cessation in England on the hospitalisation rates for acute myocardial infarction and stroke. London: London School of Hygiene and Tropical Medicine. OFSTED, 1997. Drug education in schools. London: The Stationery Office. Owen, L., 2000. Impact of a telephone helpline for smokers who called during a mass media campaign. Tobacco Control, 9, 148–154. Owen, L. and Penn, G., 1999. Smoking and pregnancy: a survey of knowledge, attitudes and behaviour 1992–1999. London: HEA. Owen, L., McNeill, A. and Callum, C., 1998. Trends in smoking during pregnancy in England, 1992–7: quota sampling surveys. British Medical Journal, 317, 728. Owen, L. and Bolling, K., 1996. Smoking and pregnancy: developing a communications strategy for cessation. London: HEA. Raw, M., McNeill, A., and West, R., 1998. Smoking cessation guidelines for health professionals. Thorax, 53 (suppl 5). Reid, D., 1996. Tobacco control: overview. British Medical Bulletin, 52 (1), 108–120. Reid, D., Killoran, A., McNeill, A. and Chambers, J., 1992. Choosing the most effective health promotion options for reducing a nation’s smoking prevalence. Tobacco Control, 1, 185–197. Royal College of Physicians, 1992. Smoking and the young. London: Royal College of Physicians. SCOTH, 1998. Report of the Scientific Committee on Tobacco and Health. London: The Stationery Office. Secker-Walker, R.H., Solomon, L.J., Flynn, B.S., Skelly, J.M., 1995. Smoking relapse prevention counselling during prenatal and early postnatal care. American Journal of Preventive Medicine, 11, 86–93. Sowden, A.J. and Arblaster, L., 2000a. Mass media interventions for preventing smoking in young people, Cochrane Review. In: Cochrane Library, Issue 2. Oxford: Update Software. Sowden, A. and Arblaster, L., 2000b. Community interventions for preventing smoking in young people, Cochrane Review. In: Cochrane Library, Issue 2. Oxford: Update Software. Stead, L. and Lancaster, T., 2000. A systematic review of interventions for preventing tobacco sales to minors. Tobacco Control, 9, 169–176. Tang, J.L., Cook, D.G. and Shaper, A.G., 1992. Giving up smoking: how rapidly does the excess risk of ischaemic heart disease disappear? Journal of Smoking-Related Diseases, 3, 203–215. US Department of Health and Human Services, 1990. The health benefits of smoking cessation, a report of the Surgeon General, DHHS Publication No. CDC 90-8416. Rockville, MD: National Centers for Disease Control and Prevention, Office on Smoking and Health. US Department of Health and Human Services, 2000. Reducing tobacco use, a report of the Surgeon General, DHHS Publication No. CDC20402, S/N017-001-00544-4. Rockville, MD: National Centers for Disease Control and Prevention, Office on Smoking and Health. Wakefield, M. and Chaloupka, F., 2000. Effectiveness of comprehensive tobacco control programmes in reducing teenage smoking in the USA. Tobacco Control, 9, 177–186. Wakefield, M.A., Wilson, D., Owen, N., Esterman, A. and Roberts, L., 1992. Workplace smoking restrictions, occupational status, and reduced cigarette consumption. Journal of Occupational Medicine, 34 (7), 693–697. White, A.R., Rampes, H. and Ernst E., 2000. Acupuncture for smoking cessation, Cochrane Review. In: Cochrane Library, Issue 3. Oxford: Update Software. WHO, 1979. Controlling the smoking epidemic, WHO Technical Report Series No. 636. Geneva: WHO. WHO, 1998. Guidelines for controlling and monitoring the tobacco epidemic. Geneva: WHO. Reducing smoking prevalence 23
  28. 28. Box 2.1 Identification of barriers to healthy eating and interventions to address them: an example Chapter 2 Improving diet and nutrition Improving diet and nutrition 25 2.1 Introduction Diet plays a fundamental role in the development of CHD. The type and amount of fat and its relationship to blood cholesterol levels have been recognised for some time as being particularly influential. Salt intake has been implicated in relation to blood pressure and, more recently, an increased intake of fruit and vegetables has been identified as an important factor in reducing the rates of both heart disease and some cancers (DH 1994, 1998). The promotion of healthy eating is important in reducing the risk not only of CHD but also of other chronic conditions, such as obesity and diet related cancers. Effective strategies to promote healthy eating are generally those that work at several levels. It is important to identify the barriers to dietary change in the local population and then select interventions to address them (see Box 2.1). 2.2 Objectives of nutritional interventions Diet is one of the key modifiable risk factors in the prevention of CHD. The government’s Committee on the Medical Aspects of Food and Nutrition Policy (COMA; DH 1994) recommended a reduction in fat (particularly saturated fat), a reduction in salt and an increase in complex carbohydrates. In addition, fruit and vegetable consumption should be increased by at least 50% (to at least five portions per day). The recommendations are summarised in nutrition briefing papers produced by the HEA (1992, 1996). Also, it has been estimated that around one-third of all cancers might be influenced by diet. In 1998, COMA reviewed the evidence on diet and cancer in the UK (DH 1998). The working group recommendations were consistent with other dietary recommendations made for the prevention of obesity, diabetes and cardiovascular disease. Barrier • Belief that the family is already eating enough fruit and vegetables • Dislike of taste of vegetables and lack of confidence in cooking and preparing them; fear of waste and of rejection by the family • Difficulty in finding affordable, good quality fruit and vegetables locally Intervention • Information about five portions a day and portion sizes • Set up cooking skills clubs and tasting sessions, or develop cooking sessions as part of the activities of existing groups (eg women’s groups, youth groups) • Set up community owned retailing and food cooperatives to introduce affordable supplies
  29. 29. 26 In promoting a healthy balanced diet to reduce the risk of cardiovascular disease and diet related cancers in the population, interventions should focus on the following: • Reducing the amount of fat, and in particular, the amount of saturated fat It has been estimated that a 10% reduction in saturated fat intake within the UK population would be associated with a reduction in CHD mortality of between 20% and 30% (Marmot 1994). Therefore, to help achieve a healthy diet, people should be encouraged to use reduced fat spreads and dairy products in place of full fat versions, to replace oils and fats high in saturates with those high in monounsaturates, to reduce the amount of fat used in cooking, to trim fat from meat and to reduce the amount of products such as biscuits, pastries, cakes, and crisps in the diet. • Increasing the amount of fruit and vegetables eaten to at least five portions each day Apart from being rich sources of carbohydrate, dietary fibre, antioxidants and other bioactive factors, fruit and vegetables are also rich sources of potassium, which is associated with lower blood pressure and a lower risk of stroke (Joshipura et al. 1999). For many people, this will mean almost doubling their intake. It will mean having fruit and vegetables at most meals, and as snacks between meals. Access to affordable, good quality supplies of fruit and vegetables must be ensured and skills and confidence to prepare and cook fruit and vegetables should be developed [National Heart Forum (NHF) 1997]. • Increasing the intake of fibre rich, starchy foods, such as bread, potatoes, pasta and rice, by half as much again Make these foods the main part of most meals, and replace fattier snacks. • Reducing the average salt intake by around a third There is now a consensus that dietary sodium is a factor in the development of high blood pressure (DH 1994). People should be encouraged to gradually reduce the salt they add to food, both in cooking and at the table. Also, people should be more aware of low-salt alternatives to processed foods if available and should recognise the salt content of processed foods by reading food labels. • Increasing the amount of fish eaten to at least two portions each week, one of which should be an oily fish Encourage people to eat fish more often: this may mean working with communities to develop their cooking skills and confidence to cook fish. A useful tool to support health promoters in promoting a balanced diet is The balance of good health [HEA, DH and Ministry of Agriculture, Fisheries and Foods (MAFF) 1994]. It shows what proportion of the diet should come from the different food groups and could provide a consistent and easily understood message about a balanced diet1. The balance of good health has also been modified for use with black and minority ethnic groups. The British Dietetic Association and Sainsburys have developed an African-Caribbean version and the British Nutrition Foundation has produced a model suitable for use with the Chinese community. Dietitians at Wandsworth Community Health Trust, with support from Spillers Milling, formed a healthy alliance and produced a version suitable for use with South Asian groups. 2.2.1 Professional knowledge and expertise Identifying the barriers and developing an integrated programme of complementary activities will require the input of staff with a range of skills. While most areas have access to a community dietitian, it is quite common for clinical duties to interfere with the dietitian’s ability to spend time in the community. In planning the resources needed to implement the strategy, it may be worth considering ring fencing a block of dietitian time to devote to community work. Public health nutritionists can provide the expertise to develop and implement a public health nutrition strategy and to work on other nutrition issues at a population level. In recent years, the Nutrition Society has introduced a registration system for public health nutritionists (RPH Nutr). In addition, the Nutrition Society has recently developed an associate registration Coronary heart disease: guidance for implementing the preventive aspects of the NSF 1The balance of good health does not apply to children under two years of age, who need a diet that is higher in fat and lower in fibre rich, starchy foods, to children aged between two and five years (a gradual transition towards a diet consistent with The balance of good health is needed here) or to people with special dietary requirements or those under medical supervision.
  30. 30. • Clear goals were set, based on theories of behavioural change, rather than relying on the provision of information alone • There was personal contact with individuals or small groups sustained over time • Participants received personalised feedback on any changes in their behaviour and risk factors • Changes in the local environment were promoted, for example in shops and catering outlets to help people choose a healthy diet. Providing information alone is not a solution. Improving people’s knowledge about diet does not necessarily lead to behaviour change. Improvements in knowledge should be accompanied by the development of skills and provide the opportunity to put the knowledge into practice. For example, there is little point in encouraging people to eat more fish, in particular oily fish, if access to these foods is not available, and if people lack the skills and confidence to prepare and cook fish. Integrated programmes of activity could be more effective if they first identify the barriers to dietary change, and then provide the information, skills and opportunities to put the suggestion into practice (NHF 1999). 2.4 Components of a local strategy 2.4.1 Schools A meta-analysis of 12 intervention studies to promote heart-healthy eating behaviour in schools concluded that they can have a significant effect (McArthur 1998). Two reviews have identified the following features of an effective school intervention (Contento 1995; Roe et al. 1997): • Nutrition education interventions are more likely to be effective when they employ educational strategies that are directly relevant to a particular behaviour (eg diet or physical activity) and are derived from appropriate theory and research • Interventions need adequate time and intensity to be effective Improving diet and nutrition 27 scheme for newly qualified public health nutrition professionals who have not yet accumulated the three years’ experience required for full registration as a public health nutritionist. The Register of Public Health Nutritionists can be found on or contact Jackie Landman at the Nutrition Society (020 7602 0228) for further information on the associate scheme. Local people are an important addition to this skill base. Research suggests that the efficiency and effectiveness of community based interventions can be improved by using local people to complement the work of health professionals. McGlone et al. (1999) suggested that ‘if local food projects are to work, then they must genuinely involve local people’. Services provided by local people are often considered more appropriate and more accessible for the health needs of the community. Such services foster self-reliance, community participation and can help overcome barriers. They also allow access to groups that are typically hard to reach and can be particularly beneficial for black and minority ethnic groups. These benefits are two way, as local people have the opportunity to develop their own skills. Exploratory work with this peer education approach (Hodgson et al. 1995; Kennedy et al. 1999) showed that it was possible to achieve both significant increases in nutrition knowledge and potentially beneficial changes in the dietary practices of low income families. The best approach appears to be one in which guided ‘hands on’ food preparation/cooking sessions allow the participants to acquire knowledge and skills. However, it was noted that this approach was resource intensive, particularly in professional staff time, and there is little evidence of effectiveness in terms of dietary change. This approach may result in potential health, social and economic benefits and therefore warrants further study. 2.3 Features of effective interventions A meta-analysis of randomised controlled trials shows that dietary interventions can be effective in reducing CHD risk factors (Brunner et al. 1997). A systematic review of the effectiveness of interventions to promote healthy eating found that characteristics of a successful intervention had the following features (Roe et al. 1997): • It focused on diet alone, or diet plus physical activity rather than tackled a range of risk factors
  31. 31. • Family involvement enhances the effectiveness of programmes for younger children • Incorporation of a self-evaluation or self-assessment and feedback is effective in interventions for older children • Effective nutrition education includes consideration of the whole school environment and community • Interventions in the larger community can enhance school nutrition education • The most effective interventions focus on diet alone or diet and physical activity. 2.4.2 Local/community projects This section includes a range of interventions from small-scale local projects to well funded community interventions. Little rigorous evaluation of the effectiveness of the small scale projects has been carried out. Roe et al. (1997) concluded that intensive, smaller scale projects generally resulted in positive changes in diet and blood cholesterol, at least in the short term. However, many large community-wide studies failed to show a similar effect because they were conducted in the 1980s, a time when awareness of CHD risk factors had increased in the population. Therefore, in one study, the reduction in blood cholesterol observed in the intervention communities was also found in the comparison community. In addition, there was a diversity of other informational and educational interventions; therefore, the investigators were unable to attribute any change to their specific intervention. Effective community interventions appear to: • Focus on diet or diet plus physical activity • Use a theoretical model • Use diverse multiple interventions at individual, group, community and environmental level • Include small-group interventions (Contento 1995; Roe et al. 1997). McGlone et al. (1999) identified the characteristics of projects that appear to have been ‘successful’ using a range of criteria: • Flexibility needed by agencies to respond to the needs of particular communities • Access to secure, and ongoing, funds • Professionals work in partnership with a community • Projects need to involve local people, and ensure equal respect • Evaluation should not be confined to narrow clinical and behavioural measures. Include food purchasing patterns, structural changes and social outcomes, for example • Strike a balance between partnerships and local ownership • Local and national networks should enable sharing of experiences • Training for professionals and members of the community to acquire skills for a new way of working • Government policies that do not deter volunteers (eg social welfare benefits) • Provide incentives for local projects and small businesses, such as tax relief • Allow time for community projects to develop, on the basis that there is no ‘quick fix’ and that local policy should support realistic time frames for community food projects. However, to date, there has been no systematic evaluation of the effectiveness of local projects. 2.4.3 Workplace Three out of four good-quality interventions showed positive effects of nutrition workplace interventions, with decreases in blood cholesterol of between 2.5% and 10% (Roe et al. 1997). An HEA review of the effectiveness of health promotion interventions in the workplace (Peersman et al. 1998) identified four studies Coronary heart disease: guidance for implementing the preventive aspects of the NSF 28
  32. 32. Another systematic review (Roe et al. 1997) included interventions in the primary healthcare setting. Four ‘good quality’ studies were identified in the past 10 years. Modest and sustained effects on both blood cholesterol and dietary fat intake were achieved for dietary interventions only, or for multifactorial interventions. Characteristics of an effective healthcare intervention include: • Small group or one to one counselling sessions • Targeting higher risk groups, which is also more cost- effective (Van der Weidjen 1998; Wood et al. 1998) • Family counselling and education for those at increased risk • Tailoring to the personal characteristics of individuals • Educational and behavioural frameworks which are client centred • Staff training and development (topic based knowledge and counselling skills) • Low intensity interventions, such as mailed, computer generated, personalised, nutrition education material for well-motivated groups (Roe et al. 1997). 2.5 Reducing inequity There are inequalities in diet between those on higher and lower incomes (Acheson 1998). The most striking difference is that people in lower socio-economic groups tend to eat less fruit and vegetables. The 1997 National Food Survey (MAFF 1998) found that consumption of fruit and vegetables by those in the upper socio-economic groups was a third higher than that of those in lower groups. This social class difference has also been reported in children (Gregory et al. 2000). Studies have shown that people on a low income can describe a healthy diet as well as those on higher incomes (Lobstein 1997). Food poverty, affordability and access to a healthy and varied diet have been identified as possible barriers (Lobstein 1997; DH 1996). Improving diet and nutrition 29 on healthy eating with adequate methodologies. Three showed positive effects on fat, fruit and vegetable intake, intention to change the diet and self-efficacy. Characteristics of an effective workplace intervention include: • Visible and enthusiastic support and involvement from management • Involvement by employees at all levels in the planning and implementation phases • A focus on definable and modifiable risk factors rather than multiple risk factor interventions • Screening and/or individual counselling • Changes to the composition of best selling foods provided in canteens and vending machines • Tailoring to the characteristics and needs of the employees • Use of local resources in organisation and implementation of the intervention • Combine population based policy initiatives with intensive individual and group oriented interventions • Built-in sustainability. 2.4.4 Healthcare In a meta-analysis by Brunner et al. (1997), the study participants were well motivated. Most studies were conducted in either a healthcare or an institutional setting. Interventions included dietary advice to reduce fat or sodium and to increase fibre. The authors estimated that, if changes in dietary behaviour were sustained, they could lead to a reduction in the incidence of CHD by 14% and the incidence of stroke by 9%. A meta-analysis by Yu-Poth (1999) reported a 10% reduction in plasma total cholesterol with a low intensity intervention, and a 13% reduction with the high intensity intervention. Tang et al. (1998) reported reductions in blood cholesterol following individual dietary advice to modify fat intake: 8.5% at three months and 5.5% at 12 months.
  33. 33. raised by the recent National Diet and Nutrition Surveys, of children aged 11⁄2 to 41⁄2 years (Gregory et al. 1995) and 4 to 18 years (Gregory et al. 2000). Acheson (1998) concluded that ‘pre-school education or day care may be especially effective in improving the achievement and health of the most disadvantaged children’. A recent review by Tedstone et al. (1998) of the effectiveness of interventions to promote healthy eating in pre-school children aged 1–5 years found that pre-school and day care centres were likely to be appropriate settings for interventions, and that parental involvement may enhance the effectiveness of interventions and should be facilitated. In more detail, the review reported that: • Traditional, video or computer-based teaching methods were successful at increasing nutrition knowledge and the effectiveness was enhanced by the inclusion of parents • Behavioural modification techniques using repeated exposure to initially novel foods were successful in increasing willingness to consume the foods only if tasting was facilitated as part of the exposure • The use of reward to encourage consumption of foods was not successful once the reward had been removed • One to one diet counselling that was ‘needs focused’ was successful at bringing about improvements in UK mothers. Acknowledgement Information in Table 2.6 concerning some of the local community interventions was drawn in part from Making Links – a toolkit for local food projects (Sustain 2000). 30 The Acheson report (Acheson 1998) recommended further development of policies that will ensure adequate retail provision of food to those who are disadvantaged. A report by Policy Action Team (PAT) 13 (1999) confirmed that accessing affordable, good quality fruit and vegetables within some local areas might be difficult. However, access should not be seen purely in terms of physical proximity, and other kinds of access need to be considered, for example, financial access, knowledge and information (HEA 1998a). In areas where a large proportion of the population is unemployed, on low income or in receipt of benefits, interventions to improve people’s access to a healthier diet are likely to be a key priority. 2.5.1 Black and minority ethnic groups Improving the health of minority ethnic groups is also a priority in the government’s drive to reduce social exclusion and inequalities in health. Further impetus was provided by Acheson (1998), who recommended that the needs of black and minority ethnic groups be considered specifically. The HEA (2000) found that among black and minority ethnic groups, understanding of healthy eating messages varied widely across groups and knowledge of foods high in complex carbohydrates, fibre, fat and saturated fat was often poor across all ethnic groups. There is, therefore, a need to raise awareness of the links between diet and CHD among these groups and to promote culturally relevant messages. 2.5.2 Children Early childhood experiences strongly influence dietary preference and good eating habits. While they may not have an immediate effect on the rates of CHD, strategies to promote healthy eating among children will benefit in the longer term. They will help to address the concerns Coronary heart disease: guidance for implementing the preventive aspects of the NSF
  34. 34. Improving diet and nutrition 31 Outcome Compliancewithlegal requirement;givesasound basistoawholeschool approach;willcontributeto achievingtheNational HealthySchoolsStandard (NHSS);clearguidanceand frameworkformonitoring willbeprovided;willensure goodnutritionalstandardsfor freemeals. Intervention Nutritional standardsfor schoollunches FromApril2001, newlegislationwill requireschool lunchestomeet minimumnutritional standards. Evidence Roeetal.(1997)identifiedtwo goodqualitystudiesrelevantto schoolmeals.Ellisonetal.(1989, 1990)showedthatpassive manipulationoffatcontentreduced saturatedfatintakeby2%witha similarincreaseinpolyunsaturated fatintake.Whitakeretal.(1994) showeda3%increaseinlowfat choiceswhenpromoted. Whocouldbe involved? Localeducation authority(LEA),direct serviceorganisation; contractcaterersand in-housedietitians; LocalAuthority Caterers’Association (LACA):http://www. SchoolsNutrition ActionGroup(SNAG) initiativecanhelp schoolsindeveloping aschoolfoodpolicy. Localhealthyschools programme. ChildPovertyAction Group: uk Skillsandresources Supportforcaterersfrom communitydietitianorpublic healthnutritionistintraining inhealthiercateringpractices andinmonitoringcompliance withthestandards. Pointstoconsider Pricingofhealthierchoices– andcaterers’perceptionsof thehigherproductioncosts; introducingaschoolfood policytosupportadoptionof thestandards;opportunityto reviewsnackprovisionsat sametime,aswellas breakfastclubsandvending machines. Meetingandmonitoring standardswillbealegal requirement. Furtherinformation DepartmentforEducation andtheEnvironment(DfEE) http://www.nutritional.stand NationalStandardsfor SchoolLunches,England. Regulations2000.Statutory Instrumentnumber1777. TheStationeryOffice.£1.50. Eatingwellatschool:dietary guidanceforschoolmeal providers(1997).DfEE Publications,POBox5050, Annesley,Nottingham, NG150DJ.Tel:0845 602260.Freeofcharge. SchoolMealsAssessment Pack(SMAP;computer packageassessingthe nutritionalqualityof secondaryschoolmeals) producedbytheNHF. SMAP,POBox7,London W52GQ.£45.00,cheques payabletoBSS. Schoolfoodpolicyguide producedbySNAG. ContactJoeHarvey,Health EducationTrust(tel/fax: 01789773915). Nutritionguidelinesfor schoolmeals(1992)available fromTheCarolineWalker Trust,22KindersleyWay, AbbotsLangley,Herts,WD5 0DQ.Cost£10including postageandpacking(p&p). Whataretoday’schildren eating?TheGardnerMerchant SchoolMealsSurvey2000. GardnerMerchant (tel:01793512112). Table2.6Suggestedactivitiestosupportlocalaction