The Implications of Smoke-Free Legislation for NHS Stop Smoking Services

  • Lucy Hackshaw

Student thesis: Doctoral ThesisPhD


Background Although smoking prevalence in the UK has dropped considerably in recent decades, around one in five adults continue to smoke and prevalence rates are considerably higher in more disadvantaged groups. Smoking remains the single largest preventable cause of death, accounting for over 80,000 deaths in England in 2008. One in two smokers who do not quit will eventually die prematurely from a smoking related disease. Smoking not only puts smokers at risk but also those around them due to exposure to second hand smoke (SHS). SHS is carcinogenic to humans and contains a number of toxins. Scientific evidence accumulated over a number of years has shown that exposure to SHS causes death, disease and disability. In order to reduce the risks associated with SHS exposure, the 2006 Health Act prohibited smoking in all enclosed public places and workplaces in England. This smoke-free legislation, implemented in on July 1st 2007, was primarily intended to protect the public and workers from SHS. However, research in other countries has shown that smoke-free legislation can also influence smoking behaviour. It was therefore anticipated that the introduction of smoke-free could encourage more smokers to try and quit, and that in turn some of these might access England’s free at the point of use cessation services – National Health Service (NHS) stop smoking services (SSSs). This research aimed to explore the implications of the smoke-free legislation in England for NHS SSSs. It explored the capacity of SSSs to respond to any change in service uptake that resulted from the new legislation, to understand the impact of the legislation on smoking behaviour, and to highlight implications for policy and practice. Methods Five inter-related pieces of research were conducted. Two national surveys of English SSS co-ordinators were carried out pre (n=132, 77 %) and post (n=86, 57 %) legislation. These explored the structure and function of the services, their funding and staffing, service delivery and training, preparation for smoke-free and ability to cope with any increase in demand. Comparative analysis of the two surveys was conducted. In-depth semi-structured interviews with 14 service staff and 17 clients allowed for the services and smoke-free legislation to be examined from these two key perspectives. Staff interviews explored career paths, training and the provision of smoking cessation support, whilst clients discussed the experience of attending the service and their smoking behaviour, as well as attitudes towards and experiences of smoke-free for both groups. Finally, data from 10,560 interviews, resulting from collaborative research with colleagues at University College London (UCL), explored intentions to quit smoking and quit attempts in response to smoke-free. Findings Key findings and conclusions are grouped into four main headings: stop smoking structure and development; SSS response to smoke-free; relationships between smoke-free legislation and smoking cessation; and smoke-free and the smoker. Findings on service structure and development highlighted considerable variation in relation to service management and staffing. A shift in service delivery methods (from group-based treatment to one to one interventions) was noted compared with previous research. Services were also increasingly aiming to reach and treat disadvantaged groups. Staff were committed to their role in helping people stop smoking but pointed to a lack of training and promotion opportunities, that pose challenges for the future development of services. In relation to smoke-free legislation, most services actively prepared for the introduction of the new law and almost all anticipated that their client numbers would increase as a result. Comparisons between the pre and post legislation surveys showed that more clients did access the services, although this increase was smaller than anticipated. Few services received additional funding to cope with higher client numbers. Analysis of a large survey dataset of smokers in England showed that a significantly higher percentage of smokers reported making a quit attempt in July and August 2007 compared with the same period the following year. This increase in quit attempts coincided with the implementation of the legislation and was equivalent to over 300,000 smokers trying to quit in response to the introduction of smoke-free. This increase in quit attempts was not, however, sustained beyond the initial period following smoke-free and important questions remain about the longer term impact of the law on smoking rates in England. Qualitative interviews with smokers who were trying to make a quit attempt with the support of the SSS provide further information about how the legislation affected smoking behaviour and attitudes. There were initially mixed attitudes towards the new law before it was introduced but following the legislation most smokers were positive about the change, a finding that is reflected in other recent research in England. Smokers did, however, demonstrate feelings of cognitive dissonance which resulted in their changing attitudes. Some reported a change in cigarette consumption and others did quit. Recommendations for policy and practice emerge from the research. These include the importance of early and substantial preparation for smoke-free, maximising the potential for more smokers to quit during implementation of the policy, investment in SSSs to secure their future and maintaining and further developing the relationship between available support to help smokers quit and other wider tobacco control policies.
Date of Award1 Jul 2010
Original languageEnglish
Awarding Institution
  • University of Bath
SupervisorSuzanne Skevington (Supervisor) & Linda Bauld (Supervisor)

Cite this