1. Does poor health and wellbeing affect smoking cessation? Rosemary Hiscock, Fiona Dobbie, Linda Bauld UKNSCC 12 th -13 th June 2014, London

2. Outline Background Definitions of health and wellbeing Health and wellbeing and smoking Health and wellbeing in the ELONS study Results Wellbeing basic characteristics Regression analysis Do health and wellbeing at baseline predict quitting 1 year later? What predicts wellbeing? Discussion

3. BACKGROUND

4. Health & wellbeing Health: ‘a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity’ (WHO 1946 ) Wellbeing: ‘positive mental state enhanced and supported by various social, environmental and psychological factors’ (See DEFRA, 2007) Wellbeing over TIME: More than just momentary mood Builds up overtime i.e. resilience

5. Dimensions of wellbeing Objective Subjective Conditions for a good life internal – need to talk to /observe person

6. Dimensions of wellbeing Objective Subjective Conditions for a good life internal – need to talk to/observe person Physical health Socioeconomic status

7. Dimensions of wellbeing Objective Subjective Conditions for a good lifeinternal – need to talk to/observe person Hedonic Eudemonic Emotions e.g are you content? Interests e.g. are you bored? Physical health Socioeconomic status

8. Dimensions of wellbeing Objective Subjective Conditions for a good life internal – need to talk to/observe person Hedonic Eudemonic Emotions e.g are you content? Interests e.g. are you bored? Physical health Socioeconomic status

9. WHO_5 wellbeing Index Over the last two weeks: Over the last two weeks: I have felt cheerful and in good spirits I have felt cheerful and in good spirits I have felt calm and relaxed I have felt calm and relaxed I have felt active and vigorous I have felt active and vigorous I woke up feeling fresh and rested I woke up feeling fresh and rested My daily life has been filled with things that interest me My daily life has been filled with things that interest me Response scale Response scale All of the time=5, All of the time=5, Most of the time=4 Most of the time=4 More than half the time=3 More than half the time=3 Less than half the time =2 Less than half the time =2 Some of the time=1 Some of the time=1 At no time=0 At no time=0

10. Medical conditions & smoking Cancer (90% lung cancers) Heart disease Circulatory disease (stroke) Respiratory disease (COPD, exacerbates athsma) Infertility and impotence http://www.nhs.uk/chq/Pages/2344.aspx?CategoryID=53

11. Unclear whether tobacco control measures aimed at smoking reduction improve wellbeing (satisfaction) Unclear whether tobacco control measures aimed at smoking reduction improve wellbeing (satisfaction) (Beard et al 2014, Gruber & Mulleinathan 2002, Odermatt & Stutzer 2012, Bordeur 2013) (Beard et al 2014, Gruber & Mulleinathan 2002, Odermatt & Stutzer 2012, Bordeur 2013) Quitting smoking associated with Quitting smoking associated with Increased quality of life & positive affect Increased quality of life & positive affect Decreased stress, depression & anxiety Decreased stress, depression & anxiety (Metaanalysis: Taylor, McNeill et al 2014) (Metaanalysis: Taylor, McNeill et al 2014) Quitting smoking associated with increased happiness Quitting smoking associated with increased happiness (Shahab & West 2009, 2012) (Shahab & West 2009, 2012) Psychological distress associated with failing to quit Psychological distress associated with failing to quit (Lawrence et al 2011) (Lawrence et al 2011) Wellbeing and smoking

12. METHODOLOGY

13. ELONS study 3057 smokers setting a quit date at one of nine English NHS Stop Smoking Services (SSS) 3057 smokers setting a quit date at one of nine English NHS Stop Smoking Services (SSS) Enhanced monitoring data collected at baseline included WHO_5 Wellbeing Index, medical conditions Enhanced monitoring data collected at baseline included WHO_5 Wellbeing Index, medical conditions CO validated abstinence assessed CO validated abstinence assessed @4 weeks by SSS advisor @4 weeks by SSS advisor @12 months by BMRB (market research company) @12 months by BMRB (market research company)

14. Medical conditions Any medical condition Any medical condition Heart, blood & circulation Heart, blood & circulation Respiratory & lungs Respiratory & lungs Mental illness Mental illness Other condition Other condition

15. Wellbeing scale Derived scoring Derived scoring Continuous: Sum the scores for each item and multiply by 4. Continuous: Sum the scores for each item and multiply by 4. Case: Case: Concerning level of wellbeing: if score<13 or any item scores 0 to 1 Concerning level of wellbeing: if score<13 or any item scores 0 to 1 Good level of wellbeing Good level of wellbeing Categorised wellbeing score Categorised wellbeing score 0 to 20 0 to 20 21 to 40 21 to 40 41 to 60 41 to 60 61 to 80 61 to 80

16. RESULTS

17. Mental conditions vs wellbeing Mental condition OR Wellbeing B Models controlling for location and time of year

18. Histogram of Wellbeing Skew = -.326

19. Mean* wellbeing 53 (52 to 54) Not quitQuit Client who in 4 weeks time would be:51 (50 to 53)55 (54 to 57) Clients who in 52 weeks time would be:53 (51 to 54)59 (56 to 62) Mean* weighted for age, gender, SES, behavioural support and takes into account cluster by location

20. Regression modelling of 52 week quit StageControls added to model DesignBehavioural support type, Location, Time of year +Demog Age, gender, Ethnicity +SES N indicators disadvantage +Dependence on tobacco Took varenicline @ 1 st session +ChampixSmoked within 5 mins of waking or >30 cigs per day +Support Support for quit attempt from spouse/ partner Half or more of friends and family don’t smoke + health or wellbeingOne health or wellbeing variable tested

21. Medical conditions predict 52 week quit? Odds ratios Controls No medical condition No heart, blood, circulation No respiratory No mental health No other medical condition Design 1.17 (0.91 to 1.50) 1.10 (0.79 to 1.53) 1.19 (0.87 to 1.63) 1.69 (1.15 to 2.50) 1.24 (0.87 to 1.77) +Demog 1.34 (1.03 to 1.75) 1.39 (0.98 to 1.99) 1.23 (0.89 to 1.68) 1.66 (1.12 to 2.45) 1.20 (0.83 to 1.73) +SES 1.27 (0.97 to 1.65) 1.32 (0.93 to 1.89) 1.32 (0.96 to 1.82) 1.53 (1.03 to 2.27) 1.21 (0.84 to 1.74) +Depend 1.23 (0.94 to 1.61) 1.31 (0.92 to 1.88) 1.27 (0.92 to 1.76) 1.45 (0.97 to 2.15) 1.20 (0.83 to 1.72) +Champix 1.20 (0.92 to 1.56) 1.28 (0.89 to 1.84) 1.22 (0.89 to 1.69) 1.33 (0.89 to 1.98) 1.16 (0.80 to 1.68) +Support 1.17 (0.90 to 1.53) 1.24 (0.86 to 1.78) 1.20 (0.87 to 1.66) 1.34 (0.90 to 2.00) 1.12 (0.78 to 1.63)

22. Wellbeing predict 52 week quit? (odds ratios) ControlsContinuousCase (good vs concerning) Design 1.011 (1.0051 to 1.017) 1.26 (0.98 to 1.62) +Demog 1.011 (1.0047 to 1.017) 1.29 (1.00 to 1.66) +SES 1.011 (1.0049 to 1.017) 1.22 (0.95 to 1.58) +Depend 1.010 (1.0035 to 1.016) 1.17 (0.91 to 1.51) +Champix 1.008 (1.0023 to 1.015) 1.14 (0.88 to 1.47) +Support 1.007 (1.0013 to 1.014) 1.10 (0.85 to 1.43)

23. Wellbeing categorised & 52 week quit

24. Individual wellbeing items 4 week quit after controls 4 week quit after controls I have felt calm and relaxed I have felt calm and relaxed My daily life has been filled with things that interest me My daily life has been filled with things that interest me 52 week quit after controls 52 week quit after controls I have felt cheerful and in good spirits I have felt cheerful and in good spirits

25. Predictors of wellbeing 0 50 100 Number points increased:

26. DISCUSSION

27. Implications Feelings of wellbeing predict quitting 1 year later Feelings of wellbeing predict quitting 1 year later Specialist services treat more clients with mental health issues than level 2s Specialist services treat more clients with mental health issues than level 2s However feelings of wellbeing more important than the presence/absence of a medical condition However feelings of wellbeing more important than the presence/absence of a medical condition Clients with higher wellbeing access groups Clients with higher wellbeing access groups

28. Implications (2) Predictors of wellbeing often similar to predictors of quitting Predictors of wellbeing often similar to predictors of quitting Services should perhaps assess clients wellbeing and see if they can improve wellbeing BEFORE client makes a quit attempt e.g. Services should perhaps assess clients wellbeing and see if they can improve wellbeing BEFORE client makes a quit attempt e.g. reducing dependence, reducing dependence, improving support improving support treatment for mental health issues treatment for mental health issues

29. Caveats Differences between advisors and locations suggests different modes of assessment may affect wellbeing Differences between advisors and locations suggests different modes of assessment may affect wellbeing Ethnic differences Ethnic differences Possible translation issues e.g. ‘vigorous’ ‘some of the time’? Possible translation issues e.g. ‘vigorous’ ‘some of the time’? Those with extremely high wellbeing not so likely to quit e.g. answered ‘all of the time’ Those with extremely high wellbeing not so likely to quit e.g. answered ‘all of the time’ Social deception? Social deception? Unable to deal with challenges? Unable to deal with challenges?

30. Conclusions Wellbeing at baseline has long term implications for smoking cessation Wellbeing at baseline has long term implications for smoking cessation Wellbeing an important concept for further study Wellbeing an important concept for further study What can advisors do to enhance or maintain wellbeing in their clients? What can advisors do to enhance or maintain wellbeing in their clients?

31. Acknowledgements Funders: This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 09/161/101) and will be published in full in Health Technology Assessment. Funders: This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 09/161/101) and will be published in full in Health Technology Assessment. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health. ELONS Project team: Linda Bauld, Paul Aveyard, Leonie Brose, Tim Coleman, Fiona Dobbie, Carol Anne Greenan, Rosemary Hiscock, Maureen Kennedy, Jo Leonardi-Bee, Andy McEwen, Hayden McRobbie, Susan Murray, Richard Purves, Lion Shahab, Sarah Simm. ELONS Project team: Linda Bauld, Paul Aveyard, Leonie Brose, Tim Coleman, Fiona Dobbie, Carol Anne Greenan, Rosemary Hiscock, Maureen Kennedy, Jo Leonardi-Bee, Andy McEwen, Hayden McRobbie, Susan Murray, Richard Purves, Lion Shahab, Sarah Simm. UK Centre for Tobacco and Alcohol Studies, North51, National Centre for Smoking Cessation and Training, NHS Stop Smoking Services, PCRN/CLRN, TNS-BMRB UK Centre for Tobacco and Alcohol Studies, North51, National Centre for Smoking Cessation and Training, NHS Stop Smoking Services, PCRN/CLRN, TNS-BMRB For further information contact: Fiona Dobbie, ELONS Project Manager, School of Management, University of Stirling, Stirling FK9 4LA, Tel: 01786 467369, Email -fiona.dobbie@stir.ac.uk For further information contact: Fiona Dobbie, ELONS Project Manager, School of Management, University of Stirling, Stirling FK9 4LA, Tel: 01786 467369, Email -fiona.dobbie@stir.ac.uk

32. Thank you r.hiscock@bath.ac.uk