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Aim and objectives of the research
The aim of the review was to gain independent insight into the effectiveness of the tobacco control action plan (TCAP), TCDP1 and TCDP2 and to establish how the work associated with the delivery plans may have contributed to the decline in smoking prevalence rates among both adults and young people in Wales during the period 2012 to 2020. The findings will help to inform the approach taken by Welsh Government to direct future action in tobacco control.
The specific objectives of the research were:
- to explore the extent to which the TCAP, TCDP1, and TCDP2 are likely to have contributed to the changes in smoking behaviour among adults with a particular focus on young adult smokers (aged 18 to 25) since their introduction in 2012.
- to examine the views of key stakeholders on the following issues:
- the extent to which it is thought the action areas/themes within the TCAP were the most appropriate in tackling the issues identified when it was introduced;
- which action areas/themes within the TCAP are likely to have been most (and least) effective in achieving progress;
- which specific actions are likely to have been most (and least) influential in contributing towards the TCAP’s overall aims, including the goal of reducing health inequalities (specified as an overall outcome in the TCAP).
- the degree to which the implementation of the TCAP reflects the ways of working outlined in the Well-being of Future Generations legislation; and
- the role that Welsh language provision has played in contributing to changes in smoking behaviour.
- To examine the views of young smokers around quitting, smoke free spaces, awareness of Help Me Quit, smoking and the pandemic and solutions for quitting smoking.
A mixed methodology was adopted consisting of secondary desk-based research and primary semi-structured interviews with both a sample of key stakeholders and a sample of young, current smokers. These methods enabled the examination of how the work associated with the TCAP may have contributed to the decline in smoking prevalence rates in Wales during the period 2012-2020. A brief netnographic study was also conducted to more widely explore the success of the TCAP and TCDP.
Desk-based research entails investigating and synthesizing existing evidence such as reports, online data, news articles and governmental policy documents on the subject matter. To closely align the method with the TCAP and TCDP, the desk-based research reviewed evidence focussed specifically on the four action areas: Promoting leadership in tobacco control, preventing the uptake of smoking, reducing smoking prevalence levels and reducing exposure to secondhand smoke.
A total of 16 stakeholders were interviewed and included representatives with responsibility for tobacco control policy and/or delivery from a range of organisations including Public Health Wales, ASH Wales, Cancer Research UK and there was representation from four out of the seven Welsh health boards. The stakeholders provided their views about the strengths and weaknesses of the TCAP, the impact of the pandemic on the TCAP and smoking behaviours more generally, the progress of the TCAP towards reducing health inequalities, their views on e-cigarettes, Well-being of Future Generations and the role of the Welsh Language in relation to the TCAP and priorities for the new tobacco control strategy for Wales.
A total of 16 young smokers aged 18 to 25 years and living in Wales were interviewed about their smoking behaviours, quit attempts and attitudes towards quitting and how the pandemic had affected their smoking behaviours. They were also asked for their views regarding TCAP initiatives such as Help Me Quit and Choose Smokefree, their attitudes towards smoke free spaces regulations and their proposed solutions for quitting smoking.
To gather a wider understanding of the success of the TCAP, a netnographic study was conducted. Netnography is an online marketing research technique that can be used to provide insight into people’s opinions and behaviour and can also be referred to as Social Media Observation. In this project, the netnography focussed on Help Me Quit, Choose Smokefree and ASH Wales in order to ascertain the usefulness, and popularity of each of their websites and social media channels.
Conclusions and recommendations
Both the desk research and interviews with stakeholders confirmed that the TCAP has achieved its primary target, which was to reduce the smoking rate in Wales to 16 per cent. The TCAP actions that are likely to have contributed to this change include the uptake of the integrated of the highly praised integrated Help Me Quit service and the work of the smoking cessation sub-group. Other successes of the TCAP include the various smoke free spaces regulations that have been enacted which has likely contributed to the denormalization of smoking and reduced visibility of the behaviour. Additionally, the various campaigns by ASH Wales have played a supportive role to the work of the Welsh Government. A continuation in the reduced rate of smoking depends on deterring the younger generation from the behaviour.
The findings of the stakeholder interviews showed that the third theme of the TCAP (Reducing smoking prevalence levels) had been the most effective in achieving progress. Specifically, the integrated Help Me Quit service and the introduction of various smoke free spaces regulations were highlighted as success factors. The momentum which the TCAP has built as well as the collaborations and involvement of the third sector which it has motivated were also deemed influential. The weaknesses of the TCAP as indicated by the stakeholders included the lack of focus on the remaining three themes and the lack of accountability or monitoring of the remaining actions of the plan. Most of the stakeholders agreed that the goal of reducing health inequalities had not been achieved. All stakeholders agreed that aligning the TCAP with the Well-being of Future Generations Act was beneficial and that work on prevention and denormalisation of smoking as means of deterring children and young people from taking up smoking remains critical. Most stakeholders agreed that the role of the Welsh Language had a minimal impact in contributing to the changes in smoking behaviour.
The findings of the interviews with young smokers showed that most of the young smokers were in favour of the introduction of smoke free spaces regulations, however their awareness of TCAP-related initiatives such as Help Me Quit and Choose Smokefree were low. The campaign which they were more familiar with was Stoptober and some could recall being given leaflets and seeing posters about stopping smoking. They were reluctant to seek support from their GP and instead preferred to use e-cigarettes as a way of cutting down with the aim of quitting. Some of the smokers were confused as to whether e-cigarettes are officially promoted as a way of stopping smoking. A number of young smokers stated that they had seen very little seen on social media about the availability of smoking cessation services. The results of the netnography supported this finding by demonstrating low engagement and low following of some of the key initiatives such as Help Me Quit.
Based on the findings of this report, the recommendations proposed for the new tobacco control strategy for Wales are as follows.
Focus on inequity
Tailored and targeted interventions targeting hard to reach smokers in deprived communities should be prioritised with innovative and flexible means of engagement developed such as working with youth groups, debt advice services and the fire service. Moreover these ‘hard to reach’ groups in lower socio-economic bands should be specifically established i.e. low income families, people with mental health problems, teenage pregnant mothers, and the intervention adapted accordingly to each group.
Contemporary, user-friendly digital solutions should be developed to support existing cessation services for example, a Help Me Quit app and online chat/whatsapp/Facebook messenger alternatives in addition to the HMQ phone number, which should engage younger smokers.
Improved social media marketing of HMQ and better visibility of smoking cessation services on key websites such as PHW and health boards with the aim of increased awareness leading to improved uptake. New messages such as ‘cutting down’ or ‘quit with a friend’ and focussing on the short-term benefits of stopping smoking for young people should be communicated. Other communication tools should be used such as virtual/community support for smokers on social media, success stories and videos of young people who have quit and use of social media influencers to target teenagers. Platforms such as Tiktok and Snapchat should also be explored as means to engage with the younger generation.
Clarification by the Welsh Government on their stance on E-cigarettes should be sought, particularly in light of the policies in England. This should be followed by guidelines for the relevant smoking cessation services e.g. should the new strategy support and promote the transition from cigarettes to e-cigarettes as a way of quitting? What support should be offered to exclusive e-cigarette users who wish to quit?
Accountability and monitoring
Improved accountability, monitoring and evaluation of actions set out in the strategy is imperative moving forward. Suggestions include named individuals/positions or specific departments to be placed against actions and /or any sub-groups and regular reporting of progress by these individuals/positions to the strategic board.
Re-prioritise incomplete actions
An assessment of each incomplete action from the TCAP and whether and how they will be integrated into the new plan should be undertaken for example, tobacco retailers register, the development of a common database to be used by smoking cessation services, review of tobacco education in schools, review of smoke free prison policy.
Denormalisation and preventing the uptake of smoking
The denormalisation agenda should move forward with a focus on the young generation by increasing programmes to engage children and teenagers in schools, including an expansion of JustB (Byw Bywyd) to more schools. The potential of new smoke free spaces where children and young people spend time (for example, skate parks, fairgrounds, tourist attractions) should also be explored, and voluntary smoking bans by influential organisations (as the Football Association of Wales have done) should be encouraged.
Viability of Ottawa model
Examine the viability of developing an Ottawa type model in Welsh secondary care to ensure early identification of smokers, continuity of care and in-hospital support for smokers.
Author: Sara Parry, Edward Shiu, Charlotte Doyle (Bangor University)
Views expressed in this report are those of the researchers and not necessarily those of the Welsh Government.
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Social research number: 37/2022
Digital ISBN 978-1-80364-026-6