Smoking Cessation

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Original Article

A Mixed-Methods Evaluation of the Effectiveness of Tailored Smoking Cessation Training for Healthcare Practitioners Who Work with Older People

Susan Kerr, RN, BA, MSc(Med Sci), PhD, HV, Rosemary Whyte, BA(Hons), PhD, RGN, RCNT, RNT, Hazel Watson, RN, MN, PhD, RMN, RNT, Debbie Tolson, RN, BSc, MSc, PhD, Angus K. McFadyen, BSc, MSc, PhD, FRSS

A B S T R A C T Background: Older people who smoke derive significant health benefits from stopping smoking in

later life. Healthcare practitioners have an important role to play in raising the issue of smoking cessation with this client group; however, they often fail to do so.

Aim: To assess the effectiveness of smoking cessation training for healthcare practitioners who have regular contact with older adults.

Methods: Mixed-methods were used to explore satisfaction with the training, the participants’ learning and any resultant changes in behaviour. The effectiveness of the training was assessed using a two- group parallel design randomised controlled trial, followed by semistructured qualitative interviews. Participants (n = 57) were recruited from a cohort of community nurses and allied health professionals (e.g., occupational therapists) working in Scotland. The intervention was 1-day brief intervention smoking cessation training. Validated measures of knowledge, attitudes and practice, were used to assess learning and behaviour at baseline, 1 week and 3 months post training. Data were analysed using two-factor repeated measure analysis of variance, where the factors were “group” and “time.” Qualitative data were gathered from members of the intervention group during semistructured interviews (n = 8) and were analysed thematically.

Results/Findings: Levels of satisfaction with the training were high. There was a statistically significant improvement in the knowledge and attitudes of the intervention group following the training, with a noticeable, but nonsignificant, improvement in practice. The qualitative findings demonstrate how the training impacted positively on practice.

Conclusions: Smoking cessation interventions in later life are important, as older smokers generally have long-term conditions caused or complicated by smoking. The delivery of brief smoking cessation interventions is known to be highly cost-effective; however, research demonstrates that practitioners often fail to raise the issue of smoking cessation with older adults. This study has demonstrated the effectiveness of a 1-day training course for practitioners. Further research is recommended.

KEYWORDS nurses, allied health professionals, older people, smoking, smoking cessation training, evalua- tion, effectiveness, randomised controlled trial, qualitative research, mixed-methods

Susan Kerr, Reader, Institute for Applied Health Research/School of Health, Glasgow Caledonian University, Glasgow, United Kingdom; Rosemary Whyte, Research Fellow, School of Health, Glasgow Caledonian University, Glasgow, United Kingdom; Hazel Watson, Professor of Nursing, School of Health, Glasgow Caledonian University, Glasgow, United Kingdom; Debbie Tolson, Professor of Gerontological Nursing, Institute for Applied Health Research/School of Health, Glasgow Caledonian University, Glasgow, United Kingdom; Angus K.McFadyen, Reader (Statistics), School of Engineering & Computing, Glasgow Caledonian University, Glasgow, United Kingdom.

Address correspondence to Dr. Susan Kerr, Institute for Applied Health Research/School of Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, United Kingdom G4 0BA; [email protected]

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BACKGROUND

The prevalence of smoking in older people is difficultto determine and to compare across countries as there are differences in the definition of “older people” and in the reporting of data. Recent reports suggest a prevalence of 13% in England and Wales and 9.7% in Australia in people aged 60 years and older (Australian Institute of Health and Welfare 2008; Office for National Statistics [ONS] 2008). In the United States, the prevalence of smoking in people aged 65 years and older has been reported as 7.6% (US National Center for Health Statistics 2009). In Scotland 20% of people aged 60–74 years and 10% of people who are 75 years and older have been identified as smokers (Scottish Government 2010).

What is clear is that a significant proportion of older people smoke and that they generally have long-term conditions that are caused or complicated by smoking (e.g., Department of Health [DoH] 2005; Gooneratne et al. 2010). Older smokers are also more likely to die prema- turely than their nonsmoking counterparts, losing on aver- age 10 years from their projected life expectancy (Doll et al. 2004).

A growing body of international literature has demon- strated that older smokers can derive significant health benefits from stopping smoking in later life, despite hav- ing smoked for many years (Molander et al. 2001; Orleans et al. 2001; Taylor et al. 2002; Tait et al. 2007). The bene- fits of cessation are almost immediate for conditions such as heart disease and stroke (Orleans et al. 2001). Stopping smoking also reduces the risk of developing cancer (e.g., Orleans et al. 2001; Bosetti et al. 2006) and stabilises exist- ing conditions such as chronic obstructive pulmonary/lung disease (National Institute for Health and Clinical Excel- lence [NICE] 2004; Gooneratne et al. 2010).

Healthcare contacts provide important opportunities for smoking cessation interventions and there is evidence that interventions delivered by healthcare practitioners can be effective in triggering and supporting cessation attempts (Ferguson et al. 2005; Tait et al. 2007; Rice et al. 2008). Most contacts between members of the public and health services take place in the primary healthcare setting with older adults generally having regular contact with primary care practitioners (ONS 2006; World Health Organisation [WHO] 2010a). Practitioners working in this setting are therefore well placed to raise the issue of smoking/smoking cessation with older people (i.e., to deliver brief smoking cessation interventions).

Brief interventions involve the provision of opportunis- tic advice, discussion and encouragement, and are used internationally to motivate smoking cessation attempts

(WHO 2003; NICE 2008; Centers for Disease Control [CDC] and Prevention 2010). Typically, they take between 5 and 10 minutes and can be delivered in a variety of set- tings, including people’s homes (WHO 2003; NICE 2008). Individuals, who wish to stop smoking, following the de- livery of a brief intervention, should be referred to an ap- propriate organisation for more intensive support during their cessation attempt (e.g., the National Health Service Smoking Cessation Service in the United Kingdom, com- munity programmes to help people stop smoking in the United States). It is this form of specialist intervention that has been shown to be most effective in actually supporting people during a quit attempt (NICE 2008). Intensive sup- port can be delivered face-to-face, either individually or in groups, or over the telephone (NICE 2008; CDC 2010). Behavioural support should be combined with pharma- cotherapy, that is, nicotine replacement therapy, vareni- cline or bupropion (NICE 2008; National Cancer Institute 2010).

Despite confirmation of the benefits of smoking cessa- tion in later life (Molander et al. 2001; Orleans et al. 2001), and compelling evidence that intervening with older adults can be effective (e.g., Ferguson et al. 2005; Tait et al. 2007), a number of studies have demonstrated that healthcare practitioners often fail to raise the issue of smoking cessa- tion with this population (Maguire et al. 2000; Ossip-Klein et al. 2000; Runciman et al. 2006; Doolan & Froelicher 2008). There is therefore a need to improve the smoking cessation practice of practitioners who have regular contact with older adults.

Working collaboratively with the government-funded initiative responsible for the development of smoking ces- sation training in Scotland (i.e., Partnership Action on To- bacco and Health [PATH]), the authors developed and evaluated evidence-based smoking cessation training for community-based practitioners. The aim was to enhance the knowledge, attitudes and smoking cessation practice of this group of professionals.

In the developmental phase of our research (Medical Research Council [MRC] 2008), we gathered evidence to inform the structure and content of the training (Kerr et al. 2004, 2006, Kerr, Watson, et al. 2007). Evidence-gathering activities included a comprehensive review of the litera- ture, with qualitative interviews (reported elsewhere) be- ing used to explore the perspectives of key stakeholders, including older people and practitioners (Kerr et al. 2006, Kerr, Watson, et al. 2007). In this paper, we provide de- tails of the modelling phase of our research (MRC 2008) in which the training and outcome measures were devel- oped. We also report on the mixed-methods evaluation of the effectiveness of the training.

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METHODOLOGY

Development of the Training Our aim was to develop brief intervention training. Guided by recommendations regarding the delivery of brief in- terventions (e.g., NICE 2006; CDC 2010), the training emphasised that the role of community-based healthcare practitioners is to: ask people whether they smoke, assess readiness to quit, raise the issue of smoking cessation, seek to motivate a cessation attempt, discuss pharmacological and behavioural support, refer people who wish to attempt to stop smoking to specialist services for support and, doc- ument what has been discussed.

In relation to tailoring the training for practitioners who work with older people, our developmental research with community-based practitioners highlighted that deficits in knowledge and skills were key barriers to the delivery of brief interventions (Kerr et al. 2004, Kerr, Watson, et al. 2007). Other issues included negative/pessimistic attitudes towards raising the issue of smoking cessation with older adults and a lack of clarity regarding their role (Kerr, Wat- son, et al. 2007). Our exploration of the health beliefs of older people who smoke revealed many positive asso- ciations with smoking. The majority of the participants believed that “the damage was done” and that there was little to be achieved by stopping smoking in later life (Kerr et al. 2006). Pessimistic attitudes were also evident, with many believing they would be unable to stop smoking successfully. Finally, there was little knowledge and un- derstanding of smoking cessation services and some con- cern about the safety of nicotine replacement therapy (Kerr et al. 2006).

In light of this evidence, the training also sought to:

� Increase practitioners’ knowledge of smoking/ smoking cessation in later life.

� Encourage practitioners to consider their roles and responsibilities in raising the issue of smoking/ smoking cessation with older adults.

� Ensure that practitioners were aware of how brief interventions fit with wider local and national smok- ing cessation efforts (i.e., the role of brief and more intensive interventions).

� Help practitioners to examine their attitudes and re- flect on their practice when working with older adults who smoke.

� Enhance practitioners’ understanding of why older people smoke, including facilitators and barriers to a cessation attempt.

� Help practitioners to acquire appropriate skills to support the delivery of brief interventions.

The 1-day brief intervention training was formally ap- proved by PATH. In order to facilitate the small group work required for effective training, the intervention group was divided into three, with participants being asked to attend 1 of 3 training days. Training sessions were delivered by an experienced smoking cessation trainer external to the research team. Consistency of the training was maintained by the development and use of a training manual.

Development and Psychometric Testing of Outcome Measures A review of the international literature yielded no demon- strably reliable and valid instruments to measure “knowl- edge,” “attitudes” and “practice,” related to working with older people who smoke. Instruments were therefore de- veloped and tested. Psychometric testing of the instru- ments was undertaken with 250 undergraduate (year 3) and postgraduate nursing students and students of physi- cal therapy, occupational therapy and podiatry studying at a University in the west of Scotland.

Guided by the literature, the knowledge questionnaire focused on: the prevalence of smoking/smoking in later life; the health-related impact of smoking; the benefits of stopping smoking in later life; the effectiveness of behavioural and pharmacological interventions; smoking cessation services; and the role of members of the primary healthcare team. Participants were provided with a list of 18 questions and were asked to respond on a multiple choice and true/false basis. A “don’t know” response was also provided for each question. One point was awarded for a correct response and 0 points for an incorrect or “don’t know” response. The range of possible scores was 0–18, with 18 being the best possible score. Psychomet- ric analyses included tests of stability/test-retest reliability (kappa, sign test, intraclass correlations) and assessment of content validity by a panel of experts (n = 7).

The attitudes questionnaire was adapted from the Al- cohol and Alcohol Problems Perceptions Questionnaire (Cartwright 1979; 1980), originally developed to mea- sure therapeutic attitudes to working with people who drink and since adapted to assess therapeutic attitudes to- wards working with people who use drugs (Drug and Drug Problems Perceptions Questionnaire (Watson et al. 2007). When adapted to assess attitudes towards working with older people who smoke, role adequacy, role legitimacy and motivation (Cartwright 1980) were assessed. Role ad- equacy refers to practitioners’ feelings that they have ap- propriate knowledge and skills to undertake a particular role. Role legitimacy reflects the extent to which practi- tioners regard a particular aspect of work as being their

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professional responsibility. The questionnaire contained 12 statements. Respondents were asked to indicate their strength of agreement on a 7-point Likert scale. Potential scores ranged from 12 to 84; lower scores indicating more positive attitudes. Psychometric analyses included tests of stability/test-retest reliability (weighted kappa, sign test, intraclass correlations); internal consistency (Cronbach’s Alpha); construct validity (principal components analysis) and assessment of content validity by a panel of experts (n = 7).

The “practice” questionnaire focused on good prac- tice in the delivery of brief interventions. Construction of the instrument was influenced by contemporary Smok- ing Cessation Guidelines (i.e., Australian Government Department of Health and Ageing, 2004; NHS Health Scot- land/ASH Scotland 2004, NICE 2006; US Department of Health and Human Service 2006). Questions focused on: raising the issue of smoking/smoking cessation; docu- menting smoking status; discussion of readiness to stop smoking; discussion of pharmacological and behavioural support and referral to specialist services for support dur- ing a quit attempt, if appropriate. The final version con- tained questions relating to practice in the previous week, with respondents being asked to state how often they un- dertook the 10 listed activities. Scoring was as follows: Always, 3 points; Often, 2 points; Occasionally, 1 point; Never, 0 points. The scores ranged from 0 to 30; 30 being the best possible score. Psychometric analyses included tests of stability/test-retest reliability (kappa, sign test, in- traclass correlations) and assessment of content validity by the panel of experts.

Following full psychometric analysis, the three newly developed/revised instruments demonstrated satisfactory content and construct validity, test-retest reliability and internal consistency. See Kerr, Whyte et al. (2007) for full details of the psychometric analysis of the instruments.

Evaluation of the Training The mixed-methods evaluation of the training was guided by principles outlined by Kirkpatrick (1998), that is, when evaluating the training, we explored the reaction of par- ticipants (levels of satisfaction with the training), learning (the extent to which knowledge and attitudes changed and skills developed) and behaviour (any resultant changes in practice).

Participants’ views of satisfaction with the training were sought at the end of the training session using a short questionnaire (see the data collection section). The effec- tiveness of the training was assessed in two ways. A ran- domised controlled trial (two group parallel design) was undertaken, in the first instance. This element of the study sought to test the following hypotheses:

� There would be a statistically significant difference in the mean scores of the intervention and control group in relation to: (1) knowledge; (2) therapeutic attitudes and (3) reported practice, post training.

� Any differences in knowledge, therapeutic attitudes and reported practice scores would be maintained over time (i.e., differences at 1-week post training would be maintained at 3 months).

When presenting this element of the study, we have been guided by the CONSORT statement on the reporting of nonpharmacological interventions (Boutron et al. 2008).

On completion of the quantitative element of the study, qualitative interviews were used to explore the practition- ers’ views of their practice before and after the training.

Sample/Participants The sample was drawn from a population of community- based nurses (i.e., district, public health and practice nurses) and allied health professionals (physical thera- pists, occupational therapists, podiatrists and dieticians) working in a large Health Board in the West of Scotland.

It was estimated that 70 participants were required (i.e., 35 in each group) to yield a statistical power in excess of 80%, with the level of statistical significance being 5%. The power calculation was based on estimated changes (5 points) in the scores of the attitude questionnaire, as indi- cated by previous work (Watson & Munro 2003). To allow for attrition, efforts were made to recruit 80 participants.

Study information packs (n = 783) were distributed to community nurses and allied health professionals in the designated geographical area. Those wishing to participate completed and returned a consent form. One hundred and thirteen responses were received; 73 practitioners wishing to participate and 40 declining. The majority of those who declined stated that they had limited contact with older adults. Regular (at least weekly) contact with older people was a requirement.

The 73 participants were randomly allocated to the in- tervention (n = 35) or control group (n = 38). Partic- ipants were initially stratified by professional group and previous smoking cessation training. Randomisation was undertaken by a researcher who had no involvement in the delivery of the intervention, the collection of data or the data analysis process. Given the nature of the intervention, it was not possible to blind participants or the professional delivering the intervention. Participants allocated to the control group were given access to the training after the study was complete. They received no other intervention during the course of the study.

On completion of the quantitative element of the study, all members of the intervention group were invited to

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Figure 1. Allocation to groups and loss to follow-up.

participate in the qualitative element of the evaluation. Our aim was to recruit 25% of the intervention group par- ticipants.

Data Collection Satisfaction. Participants’ views of/satisfaction with

the training were sought by asking them to complete a short questionnaire which invited comments on: the ex- tent to which the training had met its objectives (i.e., to a great extent, to some extent, a little, not at all); how useful the training session had been (very useful, quite useful, of some use, not useful); what element/s of the training they liked most (open question) and how the training could be improved (open question).

Knowledge, attitudes and practice. These were as- sessed using the three validated instruments discussed pre- viously. The self-complete anonymised data were collected from the control and interventions groups at baseline, 1 week and 3 months post training. The data were collected in 2007. As indicated in Figure 1, 16 participants from the original 73 were lost to the study prior to collection of Time 1 data, seven of whom had been allocated to the intervention group and nine to the control group. Reasons for withdrawal included work commitments, ill-health and changes in contact with older people linked to reorgani- sation of services by the Health Board. There was a small attrition rate in both the intervention and control groups

from Time 1 to Time 3 due to participants’ failure to com- plete and return the questionnaires.

Qualitative data. These were collected 4–5 months af- ter the training. Participants were interviewed at their place of work, in a quiet and private environment. A semistruc- tured interview guide was used to explore the participants’ practice before and after the smoking cessation training. Participants were asked to discuss issues around raising the issue of smoking/smoking cessation, the information and advice they provided and their referral practice. They were also asked to comment on factors that had influenced their practice before and after the training. This element of the study was informed by social cognitive theory (Ban- dura 1986), which proposes that behaviour and behaviour change are affected by environmental factors, personal fac- tors and attributes of the behaviour itself. A central tenet of social cognitive theory is the concept of self-efficacy.

The individual interviews were audio-recorded and lasted 30–55 minutes. Ten members of the intervention group consented to participate; however, two were subse- quently unable to do so, one because of workload issues and the other due to ill-health. Therefore, data were col- lected from eight practitioners.

Data Analysis Satisfaction. The data gathered using this question-

naire were analysed using basic descriptive statistics; open questions were subject to content analysis.

Outcome measures (knowledge, attitudes, practice). Two-factor repeated measure Analysis of Variance was used to analyse the quantitative data, where the main fac- tors were “group” and “time” with the interaction term being of most interest. Assumptions of normality and ho- moscedasticity were checked and found to be satisfactory for each of the dependent variables. Statistical significance was set at 5%. Tukey’s post hoc test was conducted, when appropriate, to examine the main time factor means in more detail (i.e., T1vT2, T1vTt3, T2vT3). Finally, within- group repeated measures ANOVA models were used when a group effect was observed. The level of significance for this element of the analysis was set at 1.7%, using a Bonfer- roni correction factor. Analysis of the data was undertaken by a statistician who had no involvement in the delivery of the intervention or collection of data.

Qualitative analysis. The first stage in the qualitative analysis process involved transcription of the interviews. Following transcription, the content was checked for ac- curacy after which the data were entered into the quali- tative software package QSR NVivo v.7. First-level anal- ysis involved grouping data under the broad headings in the interview guide (e.g., prior to training, after training).

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During second-level analysis, social cognitive theory (Bandura 1986) was used to provide a broad theoretical framework to explore the practitioners’ practice, including factors that had influenced practice before and after the training.

A number of strategies were employed to enhance the credibility of the findings (Beck 1993): interviews were audio-recorded and verbatim transcripts were prepared; the data analysis process was subject to peer review (initial analysis by RW, ratified by SK); excerpts from the tran- scripts are used to support the findings.

Ethical Considerations Ethics and Research and Development Approval were granted by the local NHS Board Research & Development Directorate. All participants provided informed consent; the principles of the UK Data Protection Act (2003) were observed.

RESULTS

The participants included 47 nurses and nine allied health professionals. The nurses were district/community nurses (n = 27), public health nurses (n = 7) and practice nurses (n = 13). The allied health professionals (AHPs) included occupational therapists (n = 3), podiatrists (n = 3), a phys- iotherapist (physical therapist), a dietician and a pharma- cist. Analysis of demographic variables demonstrated that the intervention and control groups were similar in terms of professional group (nurses and AHPs), age and any pre- vious smoking cessation training. The mean ages of the intervention and control groups were 46 and 44 years, respectively. Ten members of the intervention group and nine control group members had previously undertaken generic smoking cessation training.

Satisfaction Levels of satisfaction with the training were high. All mem- bers of the intervention group stated that the training had achieved its objectives. Twenty-six of the 27 practitioners stated that they found the training “very useful” or “use- ful,” with one participant stating that it was “of some use.” When asked what they liked most about the training, the majority of the practitioners stated that they had enjoyed “sharing experiences” and the “practice of delivering brief interventions” (including how to ask open questions and how to motivate cessation attempts in older people). The practitioners also stated that, following the training they felt more confident, as their knowledge of smoking ces- sation services and products was greater than it had been previously. In relation to how the training might be im- proved, two practitioners suggested that the training might

TABLE 1 Knowledge scores

INTERVENTION GROUP CONTROL GROUP

TIME MEAN MEAN POINT SCORES SD 95% CI SCORES SD 95% CI

Time 1 8.2 3.3 6.8, 9.5 9.0 2.8 7.9, 10.1 Time 2 14.0 2.2 13.1, 14.9 8.6 2.8 7.5, 9.7 Time 3 13.2 2.1 12.4, 14.1 9.3 2.9 8.1, 10.5

SD = standard deviation; CI = confidence interval.

be condensed, as it was difficult for busy professionals to take a full day off work. No other suggestions were made.

Outcomes The mean knowledge scores at the three data collection time points are highlighted in Table 1. The possible range of scores was 0–18.

The repeated measure ANOVA indicated statistically significant effects in knowledge scores for group (F = 54.86, d.f . = 1, p < 0.001), for time (F = 20.78, d.f . = 2, p = 0.001) and for the group ∗ time interaction (F = 22.27, d.f . = 2, p < 0.001). The within-group analyses yielded no significant time effect for the control group (p = 0.234); however, in the intervention group there were very significant differences between Time 1 and both Time 2 (p < 0.001) and Time 3 (p < 0.001) but not between Time 2 and Time 3 (p = 0.461).

The mean attitude scores at the three data collection time points are highlighted in Table 2. The possible range of scores was 12–84, with lower scores demonstrating more positive attitudes.

The repeated measure ANOVA indicated statistically significant effects in attitude scores for “group” (F = 30.70, d.f . = 1, p < 0.001), for “time” (F = 14.22, d.f . = 2, p < 0.001) and for the interaction (F = 16.76, d.f . = 2, p < 0.001). The within-group analyses yielded no significant time effect for the control group (p = 0.569); however, in the intervention group there were, again, significant differences between Time 1 and Times 2 and 3, both with p < 0.001. No significant difference was detected between Time 2 and Time 3 (p = 0.459). TABLE 2 Attitude scores

INTERVENTION GROUP CONTROL GROUP

TIME MEAN MEAN POINT SCORES SD 95% CI SCORES SD 95% CI

Time 1 40.2 11.4 35.5, 44.8 37.4 10.3 33.5, 41.3 Time 2 25.2 7.9 22.0, 28.3 38.3 11.1 33.9, 42.6 Time 3 27.4 11.2 22.9, 31.8 37.8 10.0 33.7, 41.9

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TABLE 3 Practice scores

INTERVENTION GROUP CONTROL GROUP

TIME MEAN MEAN POINT SCORES SD 95% CI SCORES SD 95% CI

Time 1 17.8 6.9 15.1, 20.6 14.8 7.6 11.8, 17.7 Time 2 20.6 6.1 18.2, 23.0 15.4 8.7 11.9, 18.8 Time 3 20.8 7.0 18.0, 23.6 15.4 8.4 11.9, 18.8

The mean practice scores at the three data collection time points are highlighted in Table 3. The possible range of scores was 0–30; 30 being the highest possible score.

The repeated measure ANOVA indicated statistically significant effects in practice scores for group (F = 16.25, d.f . = 1, p < 0.001) but not for time (F = 1.11, d.f . = 2, p = 0.333) or for the interaction (F = 22.06, d.f . = 2, p = 0.636). With no significant interaction ef- fect present, within-group ANOVA analysis was techni- cally unwarranted. The almost constant mean practice- level score within the control group over time (14.8, 15.4, 15.4) should, however, be highlighted in compari- son to the gradual average increase in scores (17.8, 20.6, 20.8) for the intervention group, given that the level of variation within the intervention group was also slightly lower.

In sum, the results demonstrate a significant improve- ment in the knowledge and attitudes of the intervention group with a noticeable, but nonsignificant, improvement in practice.

Qualitative Findings The practitioners were asked to comment on their smok- ing cessation practice since undertaking the training and to compare this to their practice prior to the training. All stated that their practice had improved. Personal fac- tors that appeared to have influenced practice included changes in knowledge, attitudes and enhanced levels of self-efficacy. As indicated below, the practitioners be- lieved that the environmental factor that had caused these changes was attendance at the smoking cessation training course.

Some of the changes discussed related to raising the issue of smoking/smoking cessation:

[05] I certainly discuss it more, so if I bring smoking up and they say they smoked, then I would definitely go into more detail. “Why, you know, why do you think you still smoke, or have you tried to give up before, have you thought about giving up recently, those sorts of things,” whereas, I wouldn’t really have gone into any detail (before the training).

Participants also discussed the enhanced quality of in- terventions:

[06] I think my approach has been different and more varied . . .. I listened (during the training) to other people and how they approach it . . .. (Since the training), I have been more enthusi- astic and asked more questions about how they felt about their smoking.

[01] Since (the training) I have got leaflets and things . . . so that I’ve got a few in my bag . . . (And) I have changed my practice and I will definitely now record in my notes if I’ve mentioned it and what has been discussed.

The participants were also more likely to refer older people for more intensive support.

[03] I just explain the benefits (of attending groups), you know, more people tend to stop longer term by going to the groups. I’ll say to them “You’re not told to stop smoking, nobody’s going to lecture you, they are there to help you. You choose when you want to stop, you know, you pick a date” . . .. And then I’ll explain the pharmacy as well.

The excerpts below highlight issues relating to increased knowledge levels following the training.

[05] I have much more knowledge after the training. My knowl- edge was very limited before the training. I couldn’t go into it in much detail or have much of a conversation with [patients].

[07] It has been very helpful to be able to give people actual statistics and especially the knowledge that even older people stopping who have smoked for years, that [stopping smoking] does have an immediate effect on their health.

Practitioners also indicated that there had been posi- tive changes in their attitudes to smoking cessation in later life as a direct result of information obtained during the training. This had contributed to changes in their prac- tice. Before the training several practitioners believed that older people would find it too difficult to stop smoking and as a result they were reluctant to pursue the subject. Following the training, participants were aware that older people could be successful in stopping smoking and, con- sequently, improve their health and quality of life.

[05] I just presumed, as I said, that they wouldn’t give up, they just wouldn’t give up and then the training obviously highlighted that people do give up and the reasons why they give up as well.

[08] Just the fact that it is effective giving them this advice. I mean honestly the way I felt before was “Och it’s too late why bother giving up at that time.” So that changed my attitude. Completely, 100%.

The impact of enhanced levels of knowledge and more positive attitudes had clearly impacted on levels of self- efficacy within the intervention group.

[01] Since doing the training I feel more confident that I can bring it up, that I can talk to them . . . I can broach the subject much more easily and I’m not embarrassed to . . . talk about it.

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[02] I am certainly more confident in raising the issue . . .. Before I might have been kind of holding back, but there were actually wee tips and kind of guides in how to approach it, just the brief intervention side of it. It actually gives me a wee kind of boost mentioning it (after the training), rather than kind of mention it but kind of feeling in the pit of your stomach . . . this isn’t going to work. I actually got more confident (after the training). I think that comes over as well to patients.

The qualitative findings provide useful detail on how the training impacted positively on the smoking cessation practice of the practitioners. These findings complement the quantitative results.

DISCUSSION

Limitations A potential limitation to the generalisability of the quan- titative results is the fact that the response rate was low. Also, the study was conducted in one region. Given the confines of the study, we were not able to observe the participants’ practice and we therefore cannot be certain that what they reported was accurate. Finally, it would have been interesting to explore any differences in results between the nurses and the AHPs or to explore intradisci- plinary differences (e.g., public health nurses compared to practice nurses); however, the sample size precluded this type of analysis.

Discussion of Results/Findings The quantitative evaluation of the training demonstrated a significant improvement in the knowledge and attitudes of the intervention group, with a noticeable, but non- significant, improvement in practice following the training, which was maintained over time. The qualitative evalua- tions showed that prior to the training, members of the intervention group had limited knowledge, negative atti- tudes and a lack of skills to initiate and sustain a discussion of smoking/smoking cessation. This often resulted in lim- ited self-efficacy. Analysis of practitioners’ practice after the training clearly demonstrated improvement. Improve- ments were reported as a result of increased knowledge lev- els, more positive attitudes and skills developed during the training. Enhanced levels of self-efficacy were described.

The negative health effects of smoking in later life are well established. Smoking not only increases risk of prema- ture death but it also affects the health and quality of life of older people as they have a greater risk than nonsmokers of being disabled by long-term conditions such as chronic ob- structive lung disease, stroke, heart disease and cognitive decline (e.g., Gooneratne et al. 2010; Kelly-Hayes 2010; Peters et al. 2008). People with long-term conditions can benefit enormously from being supported to self-care; they

are likely to live longer, have a better quality of life and be more active and independent (DoH 2009). Long-term con- ditions are managed principally in primary healthcare set- tings and community-based practitioners have a key role to play in encouraging self-care (DoH 2009). While different self-care frameworks exist internationally (NHS Institute for Innovation and Improvement 2006), interventions gen- erally aim to empower and support people with long-term conditions to understand their own health needs and to make informed choices about care/lifestyle. Brief smoking cessation interventions form an important part of the pub- lic health response to the management of long-term con- ditions (Canadian Nurses’ Association 2002). The aim is to provide information, enhance confidence and motivate a smoking cessation attempt. Crucially, a body of interna- tional evidence demonstrates that older adults can and do stop smoking if provided with appropriate support (e.g., Ferguson et al. 2005; Tait et al. 2007; Doolan & Froelicher 2008; Sachs-Ericsson et al. 2009).

CONCLUSIONS

Smoking cessation interventions in later life are impor- tant as older smokers have long-term conditions that are caused or complicated by smoking. The delivery of brief opportunistic smoking cessation interventions by health- care practitioners is known to be highly cost-effective (NICE 2006); however, previous research has shown that practitioners often fail to raise the issue of smoking cessa- tion with older adults (e.g., Runciman et al. 2007; Doolan & Froelicher 2008). This mixed-methods evaluation has demonstrated that a 1-day smoking cessation training course can result in improvements in the smoking cessa- tion knowledge, attitudes and practice of practitioners who work with older adults. Further quantitative evaluation of the impact on practice is, however, recommended, as the improvement that was noted (group ∗ time interaction) was not significant.

With the demographic ageing of the population in the developed and developing worlds (WHO 2010b) smoking cessation interventions for older people are increasingly relevant. The effective delivery of evidence-based inter- ventions is key to improving the health and well-being of this client group.

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