I Cant Do It Again Im Not Strong Enough

• Research
• Open up Access
• Published: xiii November 2017

"I'm non stiff enough; I'chiliad not skilful enough. I can't practise this, I'grand failing": a qualitative written report of depression-socioeconomic status smokers' experiences with accessing cessation support and the part for culling engineering-based support

International Journal for Equity in Health volume 16, Commodity number:196 (2017) Cite this article

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Abstruse

Groundwork

The social gradient in smoking rates persist with an overrepresentation of smoking and its associated harms concentrated within lower socioeconomic status (SES) populations. Low-SES smokers are motivated to quit merely face multiple barriers when engaging a quit endeavour. An understanding of the current handling service model from the perspectives of handling-seeking low-SES smokers is needed to inform the design of alternative smoking cessation back up services tailored to the needs of low-SES populations. This qualitative report aimed to: i) explore low-SES smokers' recent quitting experiences; ii) assess factors that touch treatment engagement; and iii) determine the acceptability and feasibility of alternative approaches to smoking cessation.

Method

Low-SES participants (n = 24) previously enrolled in a smoking abeyance RCT participated in either a semi-structured focus group or in-depth phone interview. Information was obtained and analysed using thematic assay from October 2015 to June 2016. Assay was deductive from the interview guide and supplemented inductively.

Results

Participants expressed feelings of guilt and shame around their smoking behaviour and experienced stigmatisation for their smoking. Guilt, shame, and stigmatisation negatively impacted treatment seeking behaviours with most avoiding current quit services. Costs of pharmacotherapy and treatment adherence were normally cited barriers to treatment success. Electronic-cigarettes were perceived to be unsafe due to doubt on their legal status and regulatory restrictions. Engineering-based text-messaging quit support was endorsed as a more than favourable alternative compared to existing behavioural treatment services.

Conclusion

Stigmatisation was commonly endorsed and acted as an impediment to current treatment utilisation. Electronic-cigarettes may present a viable harm reduction alternative, just their likely uptake in socioeconomically disadvantaged groups in Australia is limited past smokers' doubtfulness about their regulation and legality. Mobile telephone based cessation support may provide an culling to phone counselling and overcome the stigmatisation low-SES smokers face up while trying to quit.

Background

Smoking prevalence in Australia (i.e. daily smokers aged fourteen years and older) is currently below 13% and has declined from 24.3% in 1991 [i]. The reduction in the Australian smoking rate has largely emanated from Authorities policy [2], in particular strong enforcement of measures outlined in the World Wellness System's (WHO) Framework Convention on Tobacco Control (FCTC) [3]. Despite this decrease, smoking rates remain disproportionately high amid smokers from low socioeconomic status (SES) backgrounds; 19.9% in the everyman-SES bracket compared to 6.7% in the highest-SES bracket [i]. Low-SES can exist characterised past depression educational attainment, low incomes, unemployment and include the long-term unemployed, homeless, mentally ill, ethnic minorities, prisoners, at-adventure-youth and single parents [4].

While Australian tobacco control policies such equally increasing the price of tobacco and banning smoking in public areas has led to an overall turn down in smoking rates, such policies may have had unintended consequences among disadvantaged groups who continue to smoke at high rates. Depression-SES smokers often have college levels of nicotine dependence [v] are just every bit motivated and try to quit as their loftier-SES counterparts simply are less likely to succeed during a quit endeavour [6]. Factors that may contribute to this reduced success is the social context of smoking where smoking behaviours are entrenched and normalised [7, 8] and stigmatisation of this health adventure behaviour [9]. Smoker-related stigma encourages secrecy and social withdrawal from non-smokers [ten] and further exacerbates health inequalities since smoking prevalence is highest among socioeconomically disadvantaged smokers [11, 12]. Among other population groups with health hazard behaviours or chronic diseases including persons with a mental health disorder, hepatitis C, HIV, sexual practice workers, and injecting drug users' stigmatisation functions as a bulwark to help-seeking behaviours [13,14,15,16,17]. Nevertheless, the subjective experience of smoker-related stigma among depression-SES smokers is non well understood and needs further attention.

A factor contributing to the high smoking rates amid disadvantaged groups is the overall scarcity of inquiry output targeting disadvantaged smokers [eighteen] and the widespread paucity of evidence for effective smoking cessation interventions for disadvantaged smokers [nineteen]. Engaging with low-SES smokers to discuss alternative cessation support is needed if smoking rates are to decline for this group. Providing tailored support to meet the needs of depression-SES is urgently needed and requires consumer engagement at all stages of intervention evolution.

Potential alternatives include the use of electronic cigarettes (ECs) and technology-based behavioural support. A contempo Cochrane review plant ECs to be an effective cessation device compared to placebo, and that ECs were constructive at reducing cigarette consumption in smokers unable to quit [20], an approach that may be underutilised. Since mobile telephone engineering science penetration and accessibility is loftier amongst disadvantaged groups [21] behavioural support delivered via mobile phones could be a viable alternative. The WHO Tobacco Free Initiative identified mHealth as a cost-constructive, scalable, and sustainable platform for tobacco control interventions [22], still, it is not known qualitatively if abeyance support delivered via mobile-phone engineering science is acceptable amongst disadvantaged smokers.

Although engaging low-SES smokers subsequently they have attempted to quit smoking provides an opportune time to explore the personal experiences of a quit attempt in guild to gain feedback for hereafter research, this approach is lacking. Gaining feedback on alternative quit support may serve to benefit futurity intervention designs aimed at increasing cessation among low-SES smokers. This qualitative study served to fill this enquiry gap and aimed to: i) explore low-SES smokers' recent quitting experiences; two) assess the factors that impacted treatment engagement and quit success immediately following participation in a big-calibration randomised controlled trial (RCT) [23]; and three) make up one's mind the acceptability and feasibility of alternative approaches to cessation including electronic cigarettes and applied science-based support.

Method

Design

Participants who had previously participated in a smoking cessation RCT aimed at improving smoking cessation outcomes in depression-SES smokers by providing financial pedagogy and support to reduce financial stress [23] betwixt 2013 to 2015, were invited to participate in this qualitative study. Further details on the RCT are available elsewhere [23]. A combination of focus groups (FGs) and in-depth interviews were used to provide a comprehensive exploration of the complexities of quitting faced past this disadvantaged group. FGs let for participant interactions as a mode to stimulate discussions and gain multiple perspectives and the sharing of ideas and experiences that may not exist explored in individual interviews [24] while individual phone interviews sought to enhance information richness by drawing on personal in-depth accounts that might not be disclosed in a group setting [25].

Iii focus groups (FGs) were conducted at the University of New South Wales (UNSW) campus (n = two) or at a customs library (due north = 1), and vii in-depth interviews were conducted over the telephone in UNSW interview rooms in Metropolitan Sydney, Australia. All participants were reimbursed $50 for their time. The study received ethics approval from the UNSW Human Research Ethics Committee (HC15523), and was funded by the Cancer Institute New South Wales (CINSW), Australia.

Participant eligibility

Participants who had participated in a previous RCT [23] and consented to existence contacted for future research were eligible to participate in this study. Inclusion criteria for the previous RCT was: aged eighteen years or over; currently smoking at least ten cigarettes per day; currently in receipt of a government pension or allowance (proxy for low-SES); motivated to quit; willing to brand a quit endeavor in the side by side month; not currently taking whatever smoking cessation medications; willing to receive telephone-based support to aid quit smoking; able to read and understand English linguistic communication; and accept a home or mobile telephone. All participants in the previous RCT were mailed an 8-week supply of combination NRT comprising 21 mg/24-h nicotine patches plus either 2 mg gum or lozenges.

Due to geographical constraints and travel requirements merely participants residing within the Sydney region were invited to participate in FGs. Sydney region was divers past suburb and postcode based on the Australian Regime's Section of Social Services statistical division postcode reference listing (https://www.dss.gov.au/our-responsibilities/settlement-and-multicultural-affairs/programs-policy/settlement-services/settlement-grants-program/assist-from-the-section/publications/statistical-divisionpostcode-reference-list). In-depth interviews were restricted to participants who had completed terminal follow-up in the previous RCT inside a year of this qualitative interview being conducted.

Focus groups

A total of 133 prospective participants resided within the Sydney region and were sent an invitation letter. Of the 133 participants, 64 (48%) were unable to be contacted, 35 (26%) were not interested in participating, and 12 (nine%) were unable to travel to the specified locations. A total of 22 accepted the invitation to participate, only 5 did not attend leaving a full of 17 participants. Reasons were not provided for not-attendance. All FG participants provided written informed consent and each FG was audio recorded. FGs included betwixt four to viii participants, and ran for 90 min.

In-depth telephone interviews

Individual interviews were conducted after the FGs were completed. Invitation telephone calls were conducted to outline the study and participation requirements. If the invitation was accepted, information sheets were mailed to participants, and exact consent was obtained at the beginning of the interview. A total of 12 invitation telephone calls were made, of which five were non-contactable, and 7 were accepted. All 60-min in-depth interviews (north = 7) were audio-recorded. Four of the seven participants were biochemically verified abstinent merely at the time of the interview one participant had relapsed.

Procedure

FGs and in-depth interviews were conducted in 2015 and facilitated by two members (VCB and RJC) of the research team, one researcher (VCB) was trained in qualitative research methods. Both researchers were involved in the previous RCT. A semi-structured interview guide was used to facilitate discussions and ensure the aforementioned topics were covered in FGs and in-depth interviews but were non followed prescriptively. Questions were designed to explore participants quitting experiences, cartoon on their engagement with quit support treatment and services, the factors that influence their treatment engagement, and to open up discussion about the type of support they want and recommendations they accept for a hereafter research project.

Measures

Socio-demographic, smoking characteristics, and quitting behaviours including age, sex, marital status, education, number of cigarettes smoked pre and postal service RCT, number of years smoked and percent of life smoked, e'er tried to quit and utilize pharmacotherapy, and always spoken to the Quitline was obtained from the data collection in the previous RCT [23]. The previous RCT used the Russell Standard criteria [26] using cotinine urine analysis to verify prolonged forbearance. Current smoking status was obtained via self-study (i.e. Are you currently smoking? yeah/no). Participants were as well asked if they owned a mobile telephone and used the text-messaging role at to the lowest degree one time a week.

Information assay

Audio-recordings were transcribed verbatim and checked confronting audio recordings to ensure accuracy and overview of the text. FG and in-depth interviews were analysed together using Braun and Clarke's six stage method for thematic analysis [27]. VCB read all transcripts several times to familiarize with the content. Analysis was deductive from the interview guide and supplemented inductively. Initial codes were generated based on interview guide headings and patterns observed in the information with first guild concepts or codes including "strategies/approaches to quitting" identified. Smoker and ex-smoker experiences were grouped separately by these codes. Codes were then grouped into overarching themes, and sub-themes were identified within these themes. Some sub-themes also had key concepts. Formatted transcripts were imported into the computer software NVivo 10 (QSR International, Melbourne, Australia). Thematic maps were generated to assist in understanding relationships of themes [28, 29] and were developed using the scissor-and-sort technique [30]. Data assay was performed by VCB who met regularly with RJC throughout the coding procedure to hash out and refine themes and sub-themes. VCB and RJC were researchers on the previous RCT which provided contextual information while analysing the data. Participant quotations were chosen to illustrate themes, sub-themes and key concepts with participant identifiers being sex (F: female person or Yard: male), and smoking status (smoker or ex-smoker). Descriptive analysis of demographic data was performed using statistical software package STATA, version 11.

Results

Sample

Table 1 reports the participant characteristics by smoking condition and full sample. A total of 24 participants, 12 males and 12 females, took office in either a mixed gender FG or in-depth interview. The average age of the total sample was 48 years (SD = xiv.1), 45.eight% had completed high school or less, and 87.5% were single and lived alone. At the time of interviewing, a total of five (twenty.8%) participants cocky-reported quit status and 22 (92%) participants endemic a mobile phone with xix (79.2%) participants sending text-messages at to the lowest degree once a week.

Table 1 Sample characteristics (n = 24)

Full size table

Themes, sub-themes, and key concepts

Two wide themes (treatment acceptance barriers and alternative cessation support), four sub-themes, and 13 fundamental concepts were identified. A summary of the themes, sub-themes, key concepts, and sample quotes are shown in Table two.

Table ii Alphabetize of themes, sub-themes, and key concepts

Total size table

Treatment credence barriers

Stigmatisation

Shame

Participants expressed feelings of guilt and shame around their smoking behaviours and club's perceptions of them as smokers. The disapproval they have of their own smoking behaviours combined with the perceived disapproval they experience when accessing handling was expressed by the shame they felt when having to acknowledge their smoking habit to someone else: "Exactly, exactly. Because [if Quitline calls] they're like, oh I'yard smoking. This is just shameful." (F, ex-smoker).

Shame was linked to previous failed quit attempts, the belief that they have failed to control their addiction and were a slave to nicotine, failure at needing external back up to combat this addiction, and the futility of trying to quit when they considered smoking as entrenched in their social networks. Also, failing to quit while using pharmacotherapies was likewise expressed and about cited that nicotine was harder to quit than heroin and therefore quitting smoking was perceived every bit impossible: "It's a joke, because it'southward like treating a drug dependency for heroin with pocket-sized doses of heroin. That's exactly what it is. All the smokers that tried to quit that I know, almost fifteen people, all of them tried patches and chewing gum. None of them quit." (One thousand, smoker).

Factors that reinforced the shame and stigma they experienced included by interactions with Quitline telephone counselling. Quitline was perceived to be counter-productive and condescending. Not calling Quitline or telling friends and family they were trying to quit was a shame-saving strategy: "Because if you're calling Quitline then you're accepting defeat of some grade. People just don't like doing that stuff." (G, ex-smoker); "I never tell people that I have quit smoking. I have at times… the longest I've gone without smoking would be almost ii years and during that two years people say, 'I heard y'all've quit smoking,' and I'd say, 'No, no. I'm only not smoking at the moment,' because I cannot bear the matter, that shame of them and so seeing me once again smoking, yous know what I mean. Oh I failed again!" (F, smoker). The master reasons for not liking Quitline were: they felt like they were beingness monitored or judged; they felt the service reinforced the pressure to succeed and increased the chances of feeling shame if they failed or guilty if they slipped upwardly; and they simply did not similar the strategies and feedback they received from Quitline counsellors: "The beginning fourth dimension I rang Quitline the young lady told me to have a carrot!... And that's why I dropped off and I went back to smoking." (M, smoker); "I just didn't like it [Quitline] considering information technology made me feel guilty…..It made me feel guilty, then I hated it." (F, ex-smoker).

Tobacco control policies

Tobacco command policies and reforms such equally banning smoking in public spaces, increased tobacco taxes, and the societal changes in attitudes towards smoking directly impacted participant's everyday lives and quit attempts. Issues discussed focussed on: personal experiences of beingness vilified or abused in public: "I was walking effectually near where I live and at that place is an outside dining area, and I was walking along with a cigarette talking on my phone and someone at the table screamed out, 'You lot tin't fume four metres from nutrient being served.'" (One thousand, smoker); the internalisation of the stigma associated with beingness a smoker: "Fifty-fifty when I started smoking – that was xx years ago – it was… in that location were more than provisions for smokers than there were non-smokers; there were never any non-smoking areas…[the societal change in how we treat smokers]… That's where the stigma comes from." (M, smoker); and the negative impact of increased tobacco taxes preventing spontaneous quit attempts: "The economics of smoking. If you buy a pack and you take a quit date set, if you lot've still got three or four left at the end of the pack y'all don't want to throw them out [equivalent to throwing coin away]." (M, smoker).

Pharmacotherapy treatment

Cost

The cost associated with buying cigarettes and over-the-counter (OTC) NRT was considered to exist comparable. The lack of conviction expressed in using pharmacotherapy treatment meant that participants would rather spend their money on cigarettes, which they enjoyed, than pay full price for a medication that may or may non work. Therefore, the cost of purchasing NRT was considered in the event they relapsed prohibitively expensive due to the combined cost of NRT and a packet of cigarettes: "You're buying the same amount [of NRT] as a bundle of cigarettes so what's the use if yous're not smoking [you're even so spending the same amount]." (F, smoker).

Subsidised medication

Accessing Australian Regime subsidised smoking cessation medication through the pharmaceutical benefits scheme (PBS) is restricted to one course of handling every 12-months. Due to the entitlement restrictions, some participants expressed planning their quit attempts around their yearly PBS prescription and did not consider unplanned or unassisted quitting every bit a feasible option for them: "The cost of different products. Like, non everyone can afford to, like, either accept it privately or under PBS, not everyone can do it on PBS. And the price of information technology, sometimes information technology costs more than to quit than it does to actually smoke." (F, smoker).

Adherence

Not-adherence to medications presented as a barrier to cessation and was viewed equally a contributing factor for relapse. Most participants indicated they had ceased treatment early considering they forgot to take their medication, stopped due to side-effects, or they believed they did not need it anymore either because of relapse or cessation: "Yep, I just forgot to take it [varenicline]. Considering I'm not really large on taking tablets, and then my retentivity for taking tablets – information technology only goes out the door." (F, ex-smoker). Frequently participants did not apply smoking cessation medication at the recommended dose, despite acknowledging that the treatment was effective when used correctly: "Information technology would practise if I used it correctly. I mean, I practice use the patches and I still smoke while I've got patches on ." (F, smoker).

Withdrawal

A common belief was that NRT was delaying the inevitable nicotine withdrawal and was creating another addiction to overcome. Participants expressed cessation every bit eliminating all nicotine. For some participants NRT presented a barrier to quit success since information technology nonetheless meant they were dependent on nicotine: "I found that I'thousand merely postponing the inevitable. The nicotine withdrawal'south going to come up as soon as you take that last patch off, well it was for me. Even weaning down a chip, when I jumped off that final bit information technology felt the same every bit just putting cigarettes down." (Yard, ex-smoker).

Side-effects

Most participants cited side-effects as the crusade for non-adherence to medications (i.e. NRT or varenicline). Side-effects ranged in severity from pare rashes to psychological disturbance: "Like subsequently four days of taking it [vareniclicne] I had to telephone call my GP and say, 'Is this supposed to happen?' And he said, 'Ok, immediately stop using it. Come up in and see me.'" (M, smoker). Theyalso cited smoking concurrently while using NRT or varenicline. It appeared that pharmacotherapies were effective at reducing cigarette consumption simply non consummate cessation for some: "While I was on the nicotine patches I used to also fume at the aforementioned time." (Chiliad, smoker).

Alternative cessation back up

Electronic cigarettes (ECs)

Knowledge

Well-nigh participants knew of ECs simply wanted more information about them: "I have heard of them. That's the electronic one that actually feels like yous're smoking but it'due south got cypher in it or something." (F, smoker).

Purpose/role

Some participants had tried ECs but it was not articulate if the device they had used contained nicotine or not. In that location were differing views regarding the purpose and use of ECs with some participants viewing them as equivalent to smoking or as a potential cessation aid like NRT: "I was similar, wow, this is stupid. This is more work for people that want to give up." (F, ex-smoker).

Concerns

The main concerns expressed with using ECs centred on safety and efficacy and whether such devices were legal in Commonwealth of australia. Although some viewed ECs every bit a potential cessation help, overall ECs were perceived every bit comparable to smoking cigarettes with participants not inclined to apply or recommend their use: "Are they legal? If information technology is illegal and I had to do it on the Internet I wouldn't do it. That'south some other matter – cigarettes are still a legal substance. Yep, so if it was illegal I probably wouldn't exercise it." (F, smoker).

Mobile telephone behavioural back up

Effectiveness

Participants expressed the demand for culling support services and were receptive to technology-based quit back up in the class of mobile phone text-messaging with very few suggesting smart-telephone applications: "If I was getting a text bulletin when I was feeling vulnerable, information technology could probably plow me a way [from smoking]." (F, smoker).

Tailored interactive support

Near participants expressed the need for interactive tailored support and suggested intensive text-message support inside the showtime 2 weeks of quitting: "I think someone has to be at that place to bulletin you back at that time, whatsoever time it is. Solar day...." (F, smoker). Text-message quit support was viewed more than positively than traditional phone counselling. This was largely due to the perception that they would have more control over their back up and could decide when and where they engaged with text-quit back up. Text-messaging likewise provided the potential for 24/vii 'existent-time' support and could remain hidden from friends and family: "I hateful, yous don't have to tell anyone who yous're texting or whatever." (F, ex-smoker).

Content

The content of text-messages was focussed on the provision of 'suggestions', positive expectancies, and reminders to take medication: "Knowing the progress you've made as opposed to being constantly reminded that you're a smoker." (M, smoker). Unhelpful texts were seen to focus on the negatives of smoking, either the harms associated with smoking, or the coin lost from smoking. Participants expressed that they already knew the negatives of smoking and that it was counter-productive to exist reminded of all the negative side-effects associated with smoking. The aim of text-back up was to provide back up in a way to permit them to feel like they were quitting on their ain and that they weren't failing themselves e.k. frame support as a 'suggestion' then they can determine how and whether they accept that data on board: "I don't like people telling me what to do. But if they were to in a style where it doesn't sound like they're telling me what to do, even though they actually are, that works. 'This is just a suggestion. Information technology'southward all suggestion; you don't have to practice it." (One thousand, ex-smoker).

Discussion

Summary of main findings

This study engaged a unique sample of handling seeking depression-SES smokers who had recently embarked on a quit effort, and obtained their subjective experiences of this attempt. All of the low-SES smokers and ex-smokers participating in this study had previously tried to quit and several factors preventing engagement with current behavioural and pharmacological cessation treatments were identified. Smoking abeyance treatments received mixed reactions with nigh participants reporting undesirable or unhelpful treatment experiences. Overall, participants were receptive and positive about the potential function of technology-based cessation support in the grade of text-messages and provided feedback nearly its acceptability and possible content. There were mixed views on the use of ECs every bit a potential cessation aid with concerns raised over their safety and efficacy and the legality of their employ inside Australia. Overall, current treatment approaches were perceived as not well-suited to come across the needs of depression-SES smokers. Yet, on a positive note, low-SES smokers and ex-smokers provided insights on culling treatment strategies, and outlined how these treatment approaches can assist in overcoming some of the barriers affecting treatment.

Master themes

Prior research has investigated the effects of tobacco control policies on smoking prevalence and tobacco consumption [31,32,33]. Notwithstanding, the electric current study provides insight into how smokers subjective experiences of these policies affect treatment seeking behaviours. Our findings propose that at that place is a circuitous coaction betwixt the changes in tobacco control policies and reform and how participants perceive their smoking behaviour inside the wider social context. The dominant anti-smoking public health soapbox in Australia [2] shapes policies and treatment programmes, and people's experiences with these policies and programmes shape their identity [34]. The internalised view that non-smoking is the norm conceptually positions 'smoking and smokers' as a negatively constructed group. Farther to this, recent tobacco excise increases in Australia has promoted smoking equally unaffordable which may further marginalise low-SES smokers [35]. Consequently, the stigmatisation of being a smoker and the associated feelings of shame, guilt, and failure shaped a relatively negative viewpoint on quitting, and acted as a central barrier to take or engage with quit support and therefore prevented treatment seeking behaviours. Our findings provide insights that may help to serve policy makers both nationally and internationally when developing and implementing new tobacco control policies.

The experience of stigmatisation highlights the connection between treatment services and the experience of disenfranchisement. Rather than Quitline being viewed every bit a back up service, treatment seeking to this service was likened to albeit failure. Accepting help functioned every bit a bulwark because it reinforced the stigma associated with being a smoker. Participants expressed a want to exist left alone during a quit endeavor which could be a reaction to tobacco command policies and societal judgements placed on depression-SES smokers. This finding provides insight into why some low-SES smokers are reluctant to call telephone counselling hotlines and do not perceive such services as helpful. This finding may indicate that the current treatment service model could be reoriented to address the feelings of guilt, shame, and the stigmatisation associated with smoking to encourage wider reach and participation. Treatment engagement is disproportionately low amongst disadvantaged groups [36, 37] and these study findings may help to re-shape current service models to meet the needs of low-SES smokers.

Increasing quit rates is a key challenge for the wider tobacco command field. To date, smoking abeyance randomised controlled trials (RCT) targeting smokers from low-SES populations have found no intervention effect on abeyance outcomes [38,39,xl]. While low-SES smokers are willing and motivated to try to quit [41] the probability of success is low [6]. Despite the majority of participants in this report being treatment failures, they were even so motivated to quit but expressed the need for culling cessation support options. Technology-based quit back up was seen every bit a potential culling that could compliment current treatment approaches. Text-messaging has the potential to exist easily accessible and less judgemental and is supported by the WHO Tobacco Free Initiative [22].

Overall, the office of text-messaging was to provide intensive quit support within the outset 2-weeks of quitting. Adherence support via text-messaging could also be considered since almost participants did not adhere to NRT beyond two-weeks. The importance of personalised and interactive text-messaging was seen as providing your own one-on-one quit buddy which could overcome the stigma and resistance to accept quit support. This report provides preliminary feasibility and acceptability findings of text-messaging quit support for low-SES smokers, which may exist applicable to low-SES smokers in similar countries such as the U.s. and the Britain. Developing interventions inside a community-based participatory research framework [42] is relevant to researchers both nationally and internationally and our findings add to the noesis base of operations for researchers and policy makers.

Participants expressed a desire for text message content that demonstrated progress e.chiliad. number of days quit or money saved, reinforcement of health benefits from quitting, and increased willpower, and medication reminders. Despite low-SES smokers and ex-smokers expressing a willingness and positive attitude towards the use of text-message support, in that location is a lack of methodologically rigorous text-message intervention studies aimed at increasing quit rates amid disadvantaged groups [43, 44]. A recent systematic review and meta-analysis examining engineering based smoking abeyance interventions for disadvantaged smokers found that technology based quit support increased the odds of cessation at 18-months follow-up [44]. Even so, of the 13 included studies, only i report used mobile phone text messaging. Based on this systematic review and the electric current study's findings, in that location is a need for future research to develop mobile phone based cessation support for depression-SES smokers which may overcome social inequalities, increase treatment engagement and adherence. Further enquiry on the effectiveness of text-message abeyance support in combination with or without Quitline support is required for this group.

The proliferation and growing popularity of ECs as a impairment-reduction or cessation aid in the The states, UK, and New Zealand [45,46,47] was non reflected among smokers and ex-smokers in this written report. This may be an artefact of Australia'south stringent tobacco command policy on ECs, where selling and the distribution of liquid nicotine is illegal [48]. When faced with purchasing cigarettes or an EC product, participants did not see the advantage in purchasing an illegal device, over legally available tobacco products. The illegality surrounding ECs may foster suspicion effectually their rubber and efficacy and blurs their office every bit a potential cessation aid. Although Australia's strong regulatory framework prohibits the auction of EC containing liquid nicotine, ECs may provide an alternative and less harmful nicotine commitment method [twenty]. However, while Australian Regime policy bans the auction of liquid nicotine vaporising devices, the effectiveness of ECs as a harm reduction or cessation assist amid depression-SES Australians may not be known.

In dissimilarity to ECs, pharmacotherapy treatments were seen as an essential component to a quit attempt. All the same, concerns near the cost of treatment and PBS restrictions were factors impacting quit attempts. PBS restrictions delayed participant's future quit attempts to coincide with their yearly prescription entitlement renewal. Although prior inquiry has identified the cost of NRT as a barrier to treatment [nineteen], participants considered the cost of NRT and cigarettes to be comparable. Nonetheless, NRT was unaffordable when they considered the combined cost of cigarettes and NRT in the issue they lapsed or relapsed.

Lower rates of cessation amid disadvantaged groups take been linked to poor handling adherence [4, 49, 50]. Barriers to pharmacotherapy adherence included side-furnishings, safety concerns, and transferring one addiction for another, and these findings are supported elsewhere [nineteen, 51]. Although about participants had heard of varenicline only a few had used this product with most expressing a willingness to try it in the futurity. Overall, pharmacotherapies were viewed positively and participants expressed a willingness to use these products in time to come quit attempts.

Limitations

This study drew on the experiences of low-SES smokers and ex-smokers who had previously taken part in a smoking cessation trial and most were handling failures. The method of recruitment limited our sample to handling seeking individuals who resided in inner-city areas and were low-SES. Smokers from high-SES background were not included in this study and future research should consider whether the key findings from this report are shared by or differ from high-SES smokers. Such studies may be useful to guide the blueprint and potential tailoring of cessation support services for smokers from all SES backgrounds. The perspectives expressed in this study may differ from opinions of smokers or ex-smokers who do non engage with treatment services and take a preference for unassisted methods. The views expressed may also differ among rural and remote smokers and ex-smokers and among other population groups where loftier smoking rates persist e.g. Ethnic populations, people experiencing homelessness, prisoner populations, and people living with HIV or severe mental affliction. Interview methodology is a farther limitation of the written report. While contiguous interviews can provide rich sources of data they are costly and can be a source of response bias [52], notwithstanding, conducting telephone interviews can also lead to some information beingness lost due to the inability of the researcher to use visual help [53]. Future research may wish to analyse the data by interview type to run across if patterns in the data differ past focus group and in-depth interview. Since participants were recruited from the previous RCT the researchers were involved in, participants were informed that their feedback will help guide a future quit project to overcome a desirability event or social acceptability in reporting. Although every effort was made past the researchers to engage participants in a condom and not-judgemental surroundings, at that place is a possibility that some participants may have felt judged and modified their views to overcome this.

Conclusions

This study drew on the day-to-mean solar day experiences of low-SES smokers and ex-smokers. It is evident that although tobacco control policies are effective at reducing overall smoking rates in Commonwealth of australia, such policies may present unintended consequences including stigmatisation, and farther marginalisation of depression-SES smokers. The provision of culling harm reduction strategies is needed to reduce the disproportionately high rate of smoking in depression-SES groups compared to their peers. Engineering-based abeyance back up requires further investigation since it has the potential to encounter the complex needs of low-SES groups past delivering toll-constructive tailored back up.

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Acknowledgements

The authors wish to thank the enquiry participants.

Funding

The National Drug and Alcohol Enquiry Centre at the UNSW, Australia is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grants Fund and by infrastructure support from the UNSW, Australia. VCB is supported by a National Drug and Booze Enquiry Heart PhD scholarship. It is funded by a research grant from Cancer Enquiry UK. RJC is supported by a Cancer Institute New Southward Wales Early on Career Inquiry Fellowship (GNT14/ECF/i–46). RPM is supported past an NHMRC Principal Research Fellow grant (GNT1045318).

Availability of data and materials

The data that back up the findings of this study may exist available upon request from the corresponding author VCB. Due to the data containing data that could compromise research participant privacy/consent, the data are not publicly available.

Author data

Affiliations

1. Academy of New South Wales (UNSW), National Drug and Alcohol Research Centre (NDARC), 22-32 Rex Street, Randwick, NSW, 2031, Australia

   Veronica C. Boland, Richard P. Mattick & Ryan J. Courtney

2. Wolfson Institute of Preventive Medicine, Queen Mary University of London, EC1M 6BQ, London, Great britain

   Hayden McRobbie

3. Section of Health Promotion, Social and Behavioral Wellness, University of Nebraska Medical Center, Omaha, NE, USA

   Mohammad Siahpush

Contributions

VCB and RJC conceptualised, designed, collected and analysed the data. VCB wrote the commencement draft of the manuscript and all remaining authors (RPM, HM, MS, RJC) provided comprehensive editing, interpretation of the data, and refinement of the manuscript. All authors have reviewed drafts of the manuscript and approved the final manuscript.

Corresponding author

Correspondence to Veronica C. Boland.

Ethics declarations

Ethics approving and consent to participate

The study received ethics approving from the University of New S Wales (UNSW) Human Research Ethics Commission (HC15523). Informed consent was obtained from all participants using the UNSW consent form canonical by the UNSW ethics committee.

Consent for publication

Participants consented to their de-identified information existence published at the time of informed consent via the institutional consent form.

Competing interests

HM has received investigator-led research funding and honoraria for speaking at educational meetings from Pfizer Inc. He has too received honoraria from Johnson and Johnson for speaking at educational meetings and an advisory board meeting. The remaining authors practice not take a financial conflict of interest to declare.

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Boland, V.C., Mattick, R.P., McRobbie, H. et al. "I'm non potent enough; I'm not good enough. I can't do this, I'm failing": a qualitative study of low-socioeconomic status smokers' experiences with accessing cessation support and the role for alternative technology-based back up. Int J Equity Health xvi, 196 (2017). https://doi.org/x.1186/s12939-017-0689-v

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• Received: 24 May 2017

• Accustomed: 30 October 2017

• Published: 13 November 2017

• DOI : https://doi.org/ten.1186/s12939-017-0689-5

Keywords

• Smoking cessation
• Qualitative
• Cessation support
• Electronic cigarettes
• mHealth

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