Impact of the NHS Stop Smoking Services on smoking prevalence in England:A simulation modelling evaluation

Background The English National Health Service NHS Stop Smoking Services (SSS), established in 2001, were the first such services in the world. An appropriate evaluation of the SSS has national and international significance. This modelling study sought to evaluate the impact of the SSS on changes in smoking prevalence in England. Methods A discrete time state-transition model was developed to simulate changes in smoking status among the adult population in England during 2001-2016. Input parameters were based on data from national statistics, population representative surveys and published literature. The main outcome was the percentage point reduction in smoking prevalence attributable to the SSS. Results Smoking prevalence was reduced by 10.8 % in absolute terms during 2001-2016 in England, and 15.3 % of the reduction could be attributable to the SSS. The percentage point reduction in smoking prevalence each year was on average 0.72%, and 0.11 % could be attributable to the SSS. The proportion of SSS supported quit attempts increased from 5.5 % in 2001, to as high as 18.9 % in 2011, and then reduced to 8.2 % in 2016. Quit attempts with SSS support had a higher success rate than those without SSS support (15.1% vs 11.3%). Smoking prevalence in England continued to decline after the SSS was much reduced from 2013 onwards. Conclusions Approximately 15% of the percentage point reduction in smoking prevalence during 2001-2016 in England may be attributable to the NHS SSS, although uncertainty remains regarding the actual impact of the formal smoking cessation services

Factors associated with access to care and healthcare utilisation in the homeless population of England

Introduction: People experiencing homelessness are known to have complex health needs which are often compounded by poor access to healthcare. This study investigates the individual-level factors associated with access to care and healthcare utilisation among homeless people in England. Methods: A cross-sectional sample of 2,505 homeless people from 19 areas of England was used to investigate associations with access to care and healthcare utilisation. Results: Rough sleepers were much less likely to be registered with a GP (OR 0.45, CI 0.30-0.66) than single homeless in accommodation (reference group) or the hidden homeless (OR 1.48 CI 0.88-2.50). Those who had recently been refused registration by a GP or dentist also had lower odds of being admitted to hospital (OR 0.67, CI 0.49-0.91) or using an ambulance (OR 0.73, CI 0.54-0.99). Conclusions: The most vulnerable homeless people appear to face the greatest barriers to utilising healthcare. Rough sleepers have particularly low rates of GP registration and this appears to have a knock-on effect on admission to hospital. Improving primary care access for the homeless population could ensure that some of the most vulnerable people in society are able to access vital services which they are currently missing out on

Socioeconomic position and depression in South African adults with long term health conditions: a longitudinal study of causal pathways

Aims. There is convincing evidence that lower socioeconomic position is associated with increased risk of mental disorders. However, the mechanisms involved are not well understood. This study aims to elucidate the causal pathways between socioeconomic position and depression symptoms in South African adults. Two possible causal theories are examined: social causation, which suggests that poor socioeconomic conditions cause mental ill health; and social drift, which suggests that those with poor mental health are more likely to drift into poor socioeconomic circumstances.Methods. The study used longitudinal and cross-sectional observational data on 3904 adults, from a randomised trial carried out in 38 primary health care clinics between 2011 and 2012. Structural equation models and counterfactual mediation analyses were used to examine causal pathways in two directions. First, we examined social causation pathways, with language (a proxy for racial or ethnic category) being treated as an exposure, while education, unemployment, income and depression were treated as sequential mediators and outcomes. Second, social drift was explored with depression treated as a potential influence on health-related quality of life, job loss and, finally, income.Results. The results suggest that the effects of language on depression at baseline, and on changes in depression during follow-up, were mediated through education and income but not through unemployment. Adverse effects of unemployment and job loss on depression appeared to be mostly mediated through income. The effect of depression on decreasing income appeared to be mediated by job loss.Conclusions. These results suggest that both social causation and social selection processes operate concurrently. This raises the possibility that people could get trapped in a vicious cycle in which poor socioeconomic conditions lead to depression, which, in turn, can cause further damage to their economic prospects. This study also suggests that modifiable factors such as income, employment and treatable depression are suitable targets for intervention in the short to medium term, while in the longer term reducing inequalities in education will be necessary to address the deeply entrenched inequalities in South Africa