A Cost-Utility Analysis of the Syncope: Pacing or Recording in The Later Years (SPRITELY) Trial.

Background: The Syncope: Pacing or Recording in the Later Years (SPRITELY) trial reported that a strategy of empiric permanent pacing in patients with syncope and bifascicular block reduces major adverse events more effectively than acting on the results of an implantable cardiac monitor (ICM). Our objective was to determine the cost-effectiveness of using the ICM, compared with a pacemaker (PM), in the management of older adults (age > 50 years) with bifascicular block and syncope enrolled in the SPRITELY trial. Methods: SPRITELY was a pragmatic, open-label randomized controlled trial with a median follow-up of 33 months. The primary outcome of this analysis is the cost per additional quality-adjusted life-year (QALY). Resource utilization and utility data were collected prospectively, and outcomes at 2 years were compared between the 2 arms. A decision analytic model simulated a 3-year time horizon. Results: The mean cost incurred by participants randomized to the PM arm was $9918, compared to $15,416 (both in Canadian dollars) for participants randomized to the ICM arm. The ICM strategy resulted in 0.167 QALYs fewer than the PM strategy. Cost and QALY outcomes are sensitive to the proportion of participants randomized to the ICM arm who subsequently required PM insertion. In 40,000 iterations of probabilistic sensitivity analysis, the PM strategy resulted in cost-savings in 99.7% of iterations, compared with the ICM strategy. Conclusions: The PM strategy was dominant-that is, less costly and estimated to result in a greater number of QALYs. For patients with unexplained syncope, bifascicular block, and age > 50 years, a PM is more likely to be cost-effective than an ICM.

Contexte: L'essai SPRITELY ( S yncope: P acing or R ecording i n t h e L ater Y ears) a été mené auprès de patients ayant subi une syncope et un bloc bifasciculaire. Elle a montré qu'une méthode de stimulation électrique permanente et empirique du cœur permet de réduire les événements indésirables majeurs plus efficacement qu'une méthode reposant sur les résultats d'un moniteur cardiaque implantable. Notre objectif était de déterminer le rapport coût-efficacité de l'utilisation du moniteur cardiaque implantable par rapport à un stimulateur cardiaque dans la prise en charge de personnes âgées de plus de 50 ans présentant un bloc bifasciculaire et une syncope, inscrits à l'essai SPRITELY. Méthodologie: SPRITELY était un essai contrôlé ouvert et pragmatique à répartition aléatoire, dont le suivi médian était de 33 mois. Le paramètre d'évaluation principal de cette analyse était le coût supplémentaire par année de vie ajustée en fonction de la qualité (AVAQ). Les données sur l'utilisation des ressources et l'utilité ont été recueillies de manière prospective, et les résultats à deux ans ont été comparés entre les deux groupes. Un modèle décisionnel analytique a été utilisé pour simuler un horizon temporel de trois ans. Résultats: Le coût moyen pour les participants répartis aléatoirement dans le groupe utilisant un stimulateur cardiaque était de 9 918 $ CAN comparativement à 15 416 $ CAN pour ceux utilisant un moniteur cardiaque implantable. La stratégie du moniteur cardiaque implantable s'est traduite par une réduction de 0,167 du nombre d'AVAQ par rapport à la stratégie reposant sur le stimulateur cardiaque. Les résultats relatifs aux coûts et aux AVAQ sont sensibles à la proportion de participants répartis aléatoirement dans le groupe du moniteur cardiaque implantable qui ont par la suite dû recevoir un stimulateur cardiaque. Sur 40 000 itérations de l'analyse de sensibilité probabiliste, la stratégie du stimulateur cardiaque a occasionné des économies dans 99,7 % des itérations comparativement à la stratégie du moniteur cardiaque implantable. Conclusions: La stratégie du stimulateur cardiaque était dominante, autrement dit moins coûteuse et, selon les estimations, entraînerait un plus grand nombre d'AVAQ. Pour les patients de plus de 50 ans présentant une syncope idiopathique et un bloc bifasciculaire, un stimulateur cardiaque est plus susceptible d'être moins coûteux qu'un moniteur cardiaque implantable.

Sex Differences in Vasovagal Syncope: A Post Hoc Analysis of the Prevention of Syncope Trials (POST) I and II.

BACKGROUND: Vasovagal syncope (VVS) occurs in > 40% of individuals at least once in their lifetime. Sex-dependent differences in presentation and outcomes are not understood. We sought to determine differences in clinical presentation, treatment modalities, and outcomes of VVS between men and women. METHODS: Data were collected as part of the Prevention of Syncope Trials (POST) I and II, 2 multicenter, placebo-controlled, randomized trials testing the effectiveness of metoprolol and fludrocortisone, respectively. Data regarding clinical presentation, outcomes, and time to first syncope event after randomization were compared. RESULTS: Of the 418 patients (280 women and 138 men), women were younger at the time of first syncope event (21 vs 26 years P = 0.002) and had a lower baseline systolic blood pressure (117 vs 124 mm Hg, P < 0.001). Response to heat as a trigger for syncope was more common in women (68% vs 48%, P = 0.011). Clinical presentation in women consisted more commonly of feeling warm, having seizures, and experiencing more postsyncope fatigue (68% vs 54%, P = 0.048; 10% vs 2.7%, P = 0.045; 75% vs 59%, P = 0.017, respectively). Women were more likely to experience recurrent syncope after adjustment for prerandomization syncope burden and randomization assignment (hazard ratio, 1.56; 95% confidence interval, 1.10-2.22; P = 0.012). CONCLUSION: Clinical presentation and provocative factors of VVS differ between men and women, as do recurrent events. Recognition of these differences may help target therapy specifically in men and women.

"It's Easy to Get Fags": A Qualitative Study of Disadvantaged Young People's Perspectives on Cigarette Availability and Access.

INTRODUCTION: Reducing young people's access to cigarettes is a key element of smoking prevention policies. This article explores how young people source cigarettes following the increase in the UK minimum age of sale from 16 to 18 years. METHODS: Semi-structured individual, paired and triadic interviews with 60 disadvantaged young people aged between 12 and 17. Participants were recruited from clubs and voluntary organizations offering advice and support to disadvantaged young people. RESULTS: Most participants said they sourced cigarettes from shops, but understandings of "buying cigarettes from shops" included using intermediaries for proxy purchases. Access from social sources was contingent on reciprocation, and blackmarket sources were avoided. The distinction between potential and actual sources reflected participants concerns about their presentation of self. Those who bought cigarettes directly from shops accrued status and power in negotiating social hierarchies. Participants therefore highlighted their smoking related competencies, that is, ability to secure regular retail access to tobacco, while downplaying the significant difficulties they experienced. CONCLUSIONS: The presentational dimension of youth cigarette access highlights a need for caution in associating self-reported changes in young people's cigarette sources straightforwardly with access policies. The conflation of direct retail purchases with proxy purchases, and the interrelationship between commercial and social cigarette sources also raises issues for interpreting data on "usual" cigarette sources from national surveys. Findings suggest that some young people may still be both reliant on making retail cigarette purchases following the increase in the age of sale in the United Kingdom, and experiencing significant difficulties making these. IMPLICATIONS: This study highlights the self-presentational dimension of youth cigarette access in a particular community context, and the important distinction between the apparent range of sources available and their social acceptability in young people's social networks. Young smokers tended to conflate direct retail purchases with proxy purchases, raising issues for interpreting survey data on "usual" cigarette source. The presentational dimension of youth cigarette access also highlights a need for caution in associating self-reported changes in young people's cigarette sources with access policies. Despite participants' stated easy access, few were able to buy cigarettes directly, underscoring the effectiveness of youth access policies.

An interview study of pregnant women who were provided with indoor air quality measurements of second hand smoke to help them quit smoking.

BACKGROUND: Maternal smoking can cause health complications in pregnancy. Particulate matter (PM2.5) metrics applied to second hand smoke (SHS) concentrations provide indoor air quality (IAQ) measurements and have been used to promote smoking behaviour change among parents of young children. Here, we present the qualitative results from a study designed to use IAQ measurements to help pregnant women who smoke to quit smoking. METHODS: We used IAQ measurements in two centres (Aberdeen and Coventry) using two interventions: 1. In Aberdeen, women made IAQ measurements in their homes following routine ultrasound scan; 2. In Coventry, IAQ measurements were added to a home-based Stop Smoking in Pregnancy Service. All women were invited to give a qualitative interview to explore acceptability and feasibility of IAQ measurements to help with smoking cessation. A case study approach using grounded theory was applied to develop a typology of pregnant women who smoke. RESULTS: There were 39 women recruited (18 in Aberdeen and 21 in Coventry) and qualitative interviews were undertaken with nine of those women. Diverse accounts of smoking behaviours and experiences of participation were given. Many women reported changes to their smoking behaviours during pregnancy. Most women wanted to make further changes to their own behaviour, but could not commit or felt constrained by living with a partner or family members who smoked. Others could not envisage quitting. Using themes emerging from the interviews, we constructed a typology where women were classified as follows: 'champions for change'; 'keen, but not committed'; and 'can't quit, won't quit'. Three women reported quitting smoking alongside participation in our study. CONCLUSIONS: Pregnant women who smoke remain hard to engage,. Although providing IAQ measurements does not obviously improve quit rates, it can support changes in smoking behaviour in/around the home for some individuals. Our typology might offer a useful assessment tool for midwives.

Mental health nurses' experiences of managing work-related emotions through supervision.

AIM: The aim of this study was to explore emotion cultures constructed in supervision and consider how supervision functions as an emotionally safe space promoting critical reflection. BACKGROUND: Research published between 1995-2015 suggests supervision has a positive impact on nurses' emotional well-being, but there is little understanding of the processes involved in this and how styles of emotion interaction are established in supervision. DESIGN: A narrative approach was used to investigate mental health nurses' understandings and experiences of supervision. METHODS: Eight semi-structured interviews were conducted with community mental health nurses in the UK during 2011. Analysis of audio data used features of speech to identify narrative discourse and illuminate meanings. A topic-centred analysis of interview narratives explored discourses shared between the participants. This supported the identification of feeling rules in participants' narratives and the exploration of the emotion context of supervision. FINDINGS: Effective supervision was associated with three feeling rules: safety and reflexivity; staying professional; managing feelings. These feeling rules allowed the expression and exploration of emotions, promoting critical reflection. A contrast was identified between the emotion culture of supervision and the nurses' experience of their workplace cultures as requiring the suppression of difficult emotions. Despite this, contrast supervision functioned as an emotion micro-culture with its own distinctive feeling rules. CONCLUSIONS: The analytical construct of feeling rules allows us to connect individual emotional experiences to shared normative discourses, highlighting how these shape emotional processes taking place in supervision. This understanding supports an explanation of how supervision may positively influence nurses' emotion management and perhaps reduce burnout.

How do policy advisors and practitioners prioritise the protection of children from secondhand smoke exposure in a country with advanced tobacco control policy?

OBJECTIVES: The aim is to extend understanding of the policy and practice discourses that inform the development of national tobacco control policy to protect children from secondhand smoke exposure (SHSE) in the home, particularly in a country with successful implementation of smoke-free public places legislation. The Scottish experience will contribute to the tobacco control community, particularly those countries at a similar level of tobacco control, as normalising discourses about protecting children from SHSE are becoming more widespread. DESIGN: Case study design using qualitative interviews and focus groups (FGs) with policy makers, health and childcare practitioners during which they were presented with the findings of the Reducing Families' Exposure to Secondhand Smoke (REFRESH) intervention and discussed the implications for their policy and practice priorities. SETTING: Scotland, UK PARTICIPANTS: Qualitative interviews and FGs were conducted with 30 policy makers and practitioners who were purposively recruited. RESULTS: Participants accepted the harm of SHSE to children; however, action is limited by political expedience due to-the perception of a shift of the public health priority from smoking to alcohol, current financial constraints, more immediate child protection concerns and continuing unresolved ethical arguments. CONCLUSIONS: In a country, such as Scotland, with advanced tobacco control strategies, there continue to be challenges to policy and practice development in the more contentious arena of the home. Children's SHSE in their homes is unequivocally accepted as an important health priority, but it is not currently perceived to be a top public health priority in Scotland.

Protecting children from smoking in the home: an ethics of care perspective.

Community nurses are uniquely placed to help protect child health by facilitating the creation of smoke-free homes. However, there are a number of perceived barriers that may concern community nurses in their role of supporting parents in the creation of smoke-free homes, particularly those faced by disadvantaged parents. Arguments against intervening within the private domain of the home focus on concerns about protecting parents' autonomy to smoke within their own home and the potential for stigmatising parents who smoke, particularly mothers. Drawing on an ethics of care perspective, the authors propose an alternative perspective to the intervention in private settings. An ethics of care perspective may help to justify and encourage parents and community nurses to work in partnership to create a healthy environment for children and decrease the likelihood of children becoming smokers in the future.

Creating smoke-free homes for children.

This article describes a tool that was designed to help nurses deliver health education on the subject of passive smoking. The tool is based on a Scottish study, which encouraged mothers to identify their own strategies for reducing smoking in the home in order to protect their children from being exposed to second-hand smoke. It is designed to give nurses and other health professionals who work with families and children the knowledge, skills and confidence they need to raise the issue of second-hand smoke with parents and help them to find their own solutions to reducing smoking in the home. This article also takes into consideration the implications for nursing practice that relate to raising the issue of exposing children to second-hand smoke with parents and carers.

Gynecological and menstrual disorders in women with vasovagal syncope.

PURPOSE: Vasovagal syncope (VVS) is a chronic debilitating condition seen mostly in young women of reproductive age. There are anecdotal reports of increased syncope and presyncope around menstruation. This case-control study assessed the effects of the menstrual cycle on lightheadedness episodes and compared the gynecological and pregnancy history of VVS patients to healthy subjects. METHODS: A custom-designed gynecological and menstrual cycle questionnaire was previously developed for patients with orthostatic intolerance. This questionnaire was administered to female patients with VVS (n = 128) as a part of the multicenter Second Prevention of Syncope Trial, and to gender-matched healthy subjects (n = 92). RESULTS: VVS patients and healthy subjects reported significant variability in self-reported lightheadedness throughout the menstrual cycle. Both cohorts experienced greatest lightheadedness during menses (53 ± 2 vs. 56 ± 4), which decreased during the follicular phase (44 ± 2 vs. 41 ± 4). VVS patients reported less severity in premenstrual symptoms (Fisher's method P = 2.7E-06) compared to healthy controls. There is no difference in the incidence of gynecological abnormalities (Fisher's exact P = 0.193) and pregnancy complications (P = 1.0) between the two cohorts. VVS patients have similar pregnancy rates compared to healthy subjects (P = 0.674). CONCLUSION: The severity of lightheadedness varies during the menstrual cycle and is similar in both VVS patients and healthy controls. VVS patients have no greater risk of gynecological abnormalities and pregnancy complications than healthy subjects.

Parenting support for families with young children - a public health, user-focused study undertaken in a semi-rural area of Scotland.

AIMS AND OBJECTIVES: To work with parents and public health nurses (health visitors), to identify and design a range of public health interventions to provide support to parents of young children. BACKGROUND: In the UK, only vulnerable families are now eligible for pro-active health visiting interventions on an individual family basis beyond the early days. Public health approaches are recommended for the majority of families who are not eligible for one-to-one professional support. DESIGN: Focus groups were carried out with parents of young children, health visitors and other professionals working with them. METHODS: The study was carried out in a semi-rural area of Scotland, consisting of a small town, and the surrounding rural area, including one area of deprivation. The area is served by a team consisting of six health visitors and one health assistant, based in two health centres in the area. Nineteen parents, five members of the health visiting team and 11 other professionals from health, education and social work took part via an invitation to contact the research team. RESULTS: The needs of parents identified by both parents and professionals could best be met by social support, with skilled facilitation and suitable resources. The resolution of tensions between caseload-based and population-based health visiting, as well as the management of the tensions inherent in these changes, seems to be vital in order to implement these approaches. Many parents would like information made available online. CONCLUSIONS: Services to support families with young children need to be designed from the perspectives of parents and their needs. RELEVANCE TO CLINICAL PRACTICE: Services need to be set up in partnership with parents to provide them with information and access to peer and professional support, using public health approaches. Multiagency working, including among senior managers, may be the most effective way of providing this support.

REFRESH--reducing families' exposure to secondhand smoke in the home: a feasibility study.

OBJECTIVE: To study a novel intervention (REFRESH) aimed at reducing children's exposure to secondhand smoke (SHS) in their homes. DESIGN: A randomised feasibility study. SETTING: Aberdeen City and Aberdeenshire. PARTICIPANTS: A total of 59 smoking mothers with at least one child younger than 6 years. Participation took place between July 2010 and March 2011. INTERVENTION: Four home visits over a 1-month period, which involved two 24-h measurements of home air quality (PM2.5) and a motivational interview to encourage changes to smoking behaviour within the home in order to reduce child SHS exposure. The enhanced group received their air quality data as part of their motivational interview at visit 2; the control group received that information at visit 4. MAIN OUTCOME MEASURES: The main outcome measures were comparisons of the data from visits 2 and 4 on the 24-h average concentration of PM2.5, the peak concentration of PM2.5, the percentage of time when household PM2.5 concentrations exceeded a health-based threshold of 35 µg/m(3) and child's salivary cotinine (in nanograms per millilitre). The views of the mothers from the enhanced group about their understanding of the intervention and the measures used were also analysed to assess the acceptability and utility of the intervention. RESULTS: Of the recruited 54 participants, 48 completed the study: 27 from the control group and 21 from the enhanced group. Both groups experienced reductions in PM2.5 concentrations. When testing paired samples for the enhanced group, there was a significant difference (p<0.05) between visit 2 and visit 4 values for maximum PM2.5 (p=0.006) and for percentage of time over 35 µg/m(3) (p=0.017), with average PM2.5 approaching significance (p=0.056). There was no significant difference for salivary cotinine. The qualitative findings showed that mothers were able to understand the data they were shown and were shocked by the values measured in their homes despite being aware of the effects of SHS exposure. They appreciated the intervention taking place in their homes as it allowed them to have personalised data. Many mothers described how they had changed their smoking behaviours in their home and in particular were motivated to protect their own children as a result of the knowledge they had gained. CONCLUSIONS: Providing mothers who smoke with personalised results about the indoor air quality of their homes along with a motivational interview is feasible and has an effect on improving household air quality. Participants found the intervention understandable and acceptable. Taken overall, the results suggest that a future large-scale trial using measurements of indoor air quality as part of a complex intervention to reduce children's SHS exposure should be explored.

'I'm not doing this for me': mothers' accounts of creating smoke-free homes.

This article explores mothers' narratives of changing home smoking behaviours after participating in an intervention (Reducing Families' Exposure to Smoking in the Home [REFRESH]) aimed at reducing families' exposure to secondhand smoke (SHS) in homes in Scotland. An analysis of qualitative findings illuminates quantitative changes in levels of SHS exposure. Prospective quantitative and qualitative data were drawn from 21 smoking mothers with at least one child under 6 years. Quantitative change was measured by home air quality, i.e. fine particulate matter <2.5µg (PM(2.5)). These measurements guided the organization of mothers into categories of change (smoke-free home at baseline [SFB], smoke-free home at final, some change and no change [NC]). Qualitative data from 17 mothers with non-SFB were analysed thematically within and across these categories. Three comparative case studies illustrate the varying changes made, barriers to change and how mothers valued such changes. The outcomes varied post-intervention, with homes smoke-free, partially smoke-free or making NC. The changes in home smoking behaviour were incremental, yet beneficial to reducing SHS exposure, and related to the nature of the restrictions and personal circumstances in the home pre-intervention. Across all change categories, mothers valued the changes they had made and expressed an intention to increase the changes.

Factors influencing exposure to secondhand smoke in preschool children living with smoking mothers.

INTRODUCTION: The health effects on young children of exposure to secondhand smoke (SHS) are well described. Recent work suggests that over one quarter of school-aged children in Scotland are regularly exposed to SHS in the home. The study was designed to describe SHS exposure in preschool children whose mothers smoked and identify factors that influence exposure. METHODS: Smoking mothers with at least one child aged 1-5 years were recruited to the Reducing Families' Exposure to Secondhand Smoke in the Home study. Concentrations of airborne particulate matter less than 2.5 µm in size (PM(2.5)) in the home were measured together with child's salivary cotinine. Demographics including age, accommodation type, socioeconomic status, and number of cigarettes smoked at home were recorded. RESULTS: Data were collected from 54 homes. In 89% of the homes, concentrations of PM(2.5) exceeded health-based guidance values at some point of the day. Household PM(2.5) concentrations were highest during the evening hours of 6 p.m. to midnight. Younger children had higher salivary cotinine concentrations than older children, and the geometric mean of salivary cotinine was 2.36 ng/ml. Household smoking restrictions and maternal confidence in enforcing smoking restrictions in their own home were strongly associated with child's SHS exposure. CONCLUSIONS: Preschool children's exposure to SHS in homes where the mother smokes is considerable. Interventions and policy development to increase parental awareness of the health effects of SHS and provide parents with the confidence to implement smoke-free households are required to reduce the SHS exposure of preschool age children.

The re-shaping of the life-world: male British Bangladeshi smokers and the English smoke-free legislation.

OBJECTIVE: To explore how male Bangladeshi smokers adapted to the English smoke-free legislation. DESIGN: We draw on data derived from the Evaluation of Smoke-free England (ESME), a qualitative, longitudinal study conducted between 2007 and 2008 in two English metropolitan areas. Repeat interviews (n = 34) were conducted before and after the legislation with 15 male Bangladeshi panel informants and from two focus groups: one with Bangladeshi men and the other with Bangladeshi women. RESULTS: Bangladeshi smokers who participated in this study had largely accommodated to the smoke-free legislation and most had reduced their consumption of cigarettes, albeit to a modest degree. However, at the same time some Bangladeshi smokers appeared to have increased their use of shisha, a popular alternative method of smoking tobacco in this community. Smoke-free legislation also had an impact on the social and cultural forces that shape smoking behaviour in this group. In particular, family homes continued to be a key space where tobacco is consumed, although the legislation may have helped to shift the balance in favour of forces that oppose smoking and against enduring cultural pro-smoking norms. Smoking in public was also less socially acceptable, especially in the vicinity of local mosques and at community events. In some older groups, however, smoking remains a deeply embedded social habit which can undermine smokers' efforts to quit. CONCLUSION: For maximum impact, tobacco control interventions aimed at whole populations may need to be supplemented by culturally sensitive measures in local areas where there is a high concentration of Bangladeshi people. Similar considerations may apply to other minority communities with a high prevalence of smoking.

Volunteered, negotiated, enforced: family politics and the regulation of home smoking.

The protection of children from secondhand smoke in their homes remains a key objective for health agencies worldwide. While research has explored how parents can influence the introduction of home smoking restrictions, less attention has been paid to the role of wider familial and social networks as conduits for positive behaviour changes. In this article we explore how people living in Scotland have introduced various home smoking restrictions to reduce or eliminate children's exposure to tobacco smoke, and how some have gone on to influence people in their wider familial and social networks. The results suggest that many parents are willing to act on messages on the need to protect children from smoke, leading to the creation of patterns of smoking behaviour that are passed on to their parents and siblings and, more widely, to friends and visitors. However, while some parents and grandparents apparently voluntarily changed their smoking behaviour, other parents found that they had to make direct requests to family members and some needed to negotiate more forcefully to protect children, albeit often with positive results.

The social context of change in tobacco consumption following the introduction of 'smokefree' England legislation: a qualitative, longitudinal study.

Legislation implemented in England on 1st July 2007 to prohibit smoking in enclosed public places aimed primarily to limit exposure to second-hand smoke, thereby reducing smoking-related morbidity and mortality. We conducted a qualitative study between April 2007 and December 2008 in six contrasting localities in two metropolitan areas in the north and south of England, which examined the impact of the legislation on individuals, families and communities. Using a multi-level longitudinal case study design, we collected data at community and individual levels, from three months prior to the legislation to a year after its enactment through a range of methods, including semi-structured interviews with panel informants and observations in locality settings. Drawing on theoretical understandings of the relationship between structure, agency and practice, this paper examines the social and cultural contexts of change in tobacco consumption. Observations in a variety of community settings identified reduced smoking in public places post-legislation. More than half of panel informants reported decreased consumption at one year post-legislation; a minority had quit, maintained or increased their smoking levels. The dominant pattern of reduced consumption was attributed primarily to constraints imposed by the legislation. This suggests that the law may have provided an impetus for some smokers to cut down or quit. Smoking behaviour was, however, strongly influenced by the social networks in which smokers were embedded, indicating that, while individuals had the power to act, any changes they made were largely shaped by social structural factors. Our findings support the need for a comprehensive tobacco control strategy that takes account of the complex array of contextual factors that constrain and enable smoking.

'Waiting until they got home': gender, smoking and tobacco exposure in households in Scotland.

The introduction in March 2006 of legislation banning smoking in public places in Scotland raised concerns that smokers would smoke more at home and so increase the exposure of those living with them to tobacco smoke. Drawing on interviews from two qualitative studies conducted after the implementation of the legislation, this article uses a gendered analysis to explore where and why smokers, who lived with non-smokers including children, continued to smoke in their homes. Although very few people attributed any increased home smoking to being a direct consequence of the legislation, many who already smoked there continued, and most women reported little or no disruption to their home smoking post-legislation. Also, because of the changing social environment of smoking, and other life circumstances, a minority of women had increased their levels of home smoking. Compared to the men in these studies, women, particularly those who didn't work outside the home, had restricted social lives and thus were less likely to have smoked in public places before the legislation and spent more time socialising in the homes of other people. In addition, women with children, including women who worked outside their homes, were more likely to spend sustained periods of time caring for children compared to fathers, who were more likely to leave the home to work or socialise. Although home smoking was linked to gendered caring responsibilities, other issues associated with being a smoker also meant that many women smokers chose to keep smoking in their homes.

"But it just has that sort of feel about it, a leper"--stigma, smoke-free legislation and public health.

INTRODUCTION: The Scottish smoke-free legislation has had considerable success, with high compliance resulting in significant health benefits and the increased denormalization of smoking. International literature on the impact of smoke-free legislation has mostly focused on the success of such policies. Relatively little consideration has been given to the potentially negative, albeit unintended, consequences of smoke-free policies within different social and cultural contexts, in particular the increased stigmatization of smokers. METHODS: A 3-wave longitudinal qualitative study in 4 localities in Scotland using repeat in-depth interviews. Participants comprised a panel of 40 current and recent ex-smokers, interviewed before and after implementation of the legislation in 2 socioeconomically advantaged and 2 disadvantaged localities in Scotland. RESULTS: Smokers perceived the smoke-free legislation to have increased the stigmatization of smoking. By separating, albeit temporarily, those who were smoking from those who were not had led to increased felt stigma. This had led to a social milieu that fostered self-labeling and self-stigmatization by smokers of their own smoking behavior, even when they were not smoking. While there was little reported direct discrimination, there was a loss of social status in public places. Smokers attempted to ameliorate stigmatization by not smoking outside, reducing going out socially, joining in the stigmatization of other smokers, and/or acknowledging the benefits of smoke-free environments. DISCUSSION: The unintended negative consequences of smoke-free legislation for some suggest that tobacco control strategies need to consider how smokers who experience increased stigma are supported by public health to address their smoking while continuing to create smoke-free environments.

Public places after smoke-free--a qualitative exploration of the changes in smoking behaviour.

The social context of smoking behaviours is explored after the introduction of Scottish smoke-free legislation. A longitudinal qualitative study was conducted in four contrasting localities. Whilst post-legislation changes in smoking behaviour were evident in all four localities, they were most apparent in the disadvantaged localities. Changes in the patterns of smoking were linked to the ways in which people interacted in social contexts and how people re-negotiated habitual smoking behaviours in public spaces. Pre-legislation differences in the communities appeared to influence the extent of these changes. Cultural and social contexts are important in shaping smoking behaviours and locating change within public places.

Smoking cessation for older people: neither too little nor too late.

Community nurses are uniquely placed to facilitate smoking cessation with older people. Older people who smoke in the home expose not only themselves to the many health risks associated with tobacco use but also partners, children and grandchildren through second-hand smoke. Yet research has found that community nurses have several concerns about raising the issue of smoking in the home with older people including taking away one of their few pleasures; fear that the damage is done; damaging the professional relationship and a lack of knowledge about smoking cessation advice and services. In this article the authors acknowledge and challenge these concerns to encourage community nurses to embed smoking cessation in their daily practice with older people.