Exploring the social context of smoking behaviours: insights from stop-smoking advisors in deprived communities in Northwest of England UK.

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Mzwandile Mabhala, Winifred Adaobi ESEALUKA, Asmait YOHANNES, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4542157/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 May, 2025 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background: The successive UK governments have introduced measures to enhance access to stop-smoking services. However, these efforts have primarily focused on restricting access and promoting individual behaviour changes, overlooking the social conditions that contribute to smoking behaviours. While promoting individual behaviour changes can be beneficial, in the face of growing health inequalities, lasting change requires collective action and structural reforms. This research examines the limitations of individual-focused stop-smoking interventions in deprived communities. It provides a unique perspective by analysing practitioners' experiences promoting stop-smoking initiatives in a disadvantaged neighbourhood in northwest England. It underscores the significance of adopting comprehensive strategies for smoking cessation, drawing on practitioners' insights to address the broader determinants of smoking behaviour. These findings are crucial for understanding the complexities of smoking cessation in deprived communities. Methods : The research used interpretative phenomenology to comprehensively analyse six lived experiences of stop-smoking advisors in Northwest England. Results : The analysis identified four overarching themes fundamental for delivering stop-smoking services in these communities: 1. Developing a skilled, confident, and culturally competent stop-smoking advice team 2. Understanding other complex social, mental, and physical health issues. 3. Bringing the stop-smoking programme to those who need it the most. 4. Adapting the service to meet the user's needs. Conclusions : This article presented evidence indicating that behaviour-oriented interventions have resulted in a disproportionate decrease in smoking rates, with a more rapid decline in the least deprived areas compared to the deprived ones. The inverse care law theory provides a clear framework for understanding these differences. It emphasises the need for both behavioural and structural interventions to address smoking habits in deprived neighbourhoods, highlighting the impact of socioeconomic factors and the limitations of individual behaviour-focused stop-smoking interventions. The study calls for a comprehensive approach that combines behavioural interventions with measures to address the underlying causes of smoking in deprived communities. stop-smoking disadvantaged communities social context community engagement Figures Figure 1 1. Introduction Although the net smoking prevalence is continuing to decline yearly in the United Kingdom (UK) [1-8], with 13.3% smokers in 2021 compared to 13.% in 2020 [1-8], the decline in smoking prevalence is not equally distributed across all population groups [5,9-12]. It remains significantly higher among socially disadvantaged groups [9,13,14]. Table 1 shows the different rates of decline in cigarette smoking in the UK; it indicates that while all groups have experienced a decline in smoking prevalence, smoking remains higher amongst those classified as routine workers and those with no educational qualifications[3-6]. Table 1: Percentages of smokers by socioeconomic indicators: employment status and education qualifications of people aged 18 years and over in the UK between 2015 and 2021. Smokers (%) Smokers (%) Year Overall % smokers Routine workers Managerial and professional 2015 16.9 30.0 9.0 2016 15.8 29.1 7.6 2017 15.1 25.9 10.2 2018 14.7 25.5 10.2 2019 14.1 23.4 9.3 Year Overall% smokers No qualification Degree or Equivalent qualification 2020 13.8 undefined undefined 2021 13.3 28.2% 6.6% 2022 12.9% 22.8% 8.3% The UK government has introduced policy initiatives to improve the accessibility of stop-smoking services. Additionally, they are striving to reduce the attractiveness of tobacco and vaping products, reduce the availability of tobacco products in underprivileged areas, and ultimately narrow the socioeconomic inequalities in smoking habits [15-19]. To achieve this, they introduced a series of measures, such as legislation restricting tobacco advertising, the implementation of standardised packaging, and banning menthol-flavored tobacco products [17-20]. Furthermore, they launched the "Swap to Stop" campaign, which aims to encourage smokers to transition to vaping, invested over 70 million pounds annually to support local authority-led stop-smoking services (SSS) and introduced the Tobacco and Vapes Bill 2024 to create the first-ever smoke-free generation [16]. However, it is important to note that the government's efforts have primarily focused on limiting access and promoting individual behaviour changes, with little consideration given to the social conditions that contribute to smoking behaviours. As a result, these measures yielded greater benefits to the least deprived than the most deprived. Julian Tudor Hart conceptualised these disparities as inverse care law[21]. Several studies have demonstrated that behavioural behaviour-oriented interventions may be less effective in deprived populations, leading to an inverse care law [13,20,22-27]. Therefore, it is crucial to acknowledge the social context of smoking to develop effective stop-smoking interventions and reduce the prevalence of smoking in all segments of society[13,20,22-26,28,29]. While promoting individual behaviour changes can be helpful, it is important to recognise that lasting change requires collective action and structural reforms. Therefore, a more socially oriented approach is necessary to ensure a sustainable future for all. In the face of growing health inequalities[30-33], solely focusing on individual behaviour changes tends to overlook the significance of structural factors, social processes, and local settings affecting people's health and ability to adopt healthy lifestyles. The social determinants of health (SDH), the fundamental cause theory (FCT), the political economy approach, and the eco-social theories provide strategic entry points for policy action to address the structural determinants of smoking behaviour [34]. They offer some insight into the effect of local community-level deprivation on smoking behaviour [34]. They teach us that most individual lifestyle behaviours manifest adverse social conditions. Considering these insights, implementing an upstream approach to smoking cessation, with a focus on education, employment, income, housing, environment, crime prevention and health, would effectively address not only smoking behaviours but also other health-harming behaviours [35,36]. Numerous studies have expanded on these theories to demonstrate the effects of a neighbourhood's level of deprivation and smoking behaviour [13,20,22,25,26]. They argue that the neighbourhood plays a significant role in determining the likelihood of being a smoker and the challenges one may face in quitting, notwithstanding their socioeconomic status[20,23,37-39]. For example, An Australian study by Turrell et al., in line with research from the UK [13] and the US [38,39], reported that after adjusting for individual differences in occupation, education, income, gender, and age, people living in the most deprived communities were less likely to quit smoking (9.3–12.5%) than more affluent individuals (23.1–25%). Galster's [40] study explains the theoretical connection between communities and individual outcomes, proposing theoretical mechanisms to aid in smoking cessation at the neighbourhood level. According to Galster, the mechanisms of neighbourhood effect theory, including social-interactive, environmental, geographical, and institutional factors, play a role in initiating and sustaining smoking in deprived communities. Social-interactive mechanisms are based on the idea that socially disadvantaged communities create conditions that increase the likelihood of initiating smoking and reduce the likelihood of quitting [24,26,41]. These conditions include poor job prospects, as some employers are reluctant to consider people from 'bad areas' [26,41]. In addition, disadvantaged communities provide fewer opportunities for social capital, participation, and interaction with employed individuals [26,41,42]. High levels of unemployment and a lack of basic amenities mean fewer opportunities to engage in positive social interactions that benefit health [26]. The environment where disadvantaged people live tends to increase exposure to stresses produced by higher crime, violence, and incivilities such as littering and vandalism[41]. The evidence suggests that communities facing adverse social conditions tend to resort to maladaptive coping habits such as smoking [42,43]. Galster proposes that disadvantaged communities' geographical location and poor infrastructure create physical and social disconnection from neighbouring more affluent suburbs and larger urban areas[24,26,41]. Furthermore, the poor infrastructure means that if they find employment, they will likely face greater transport and childcare difficulties [26]. By institutional mechanisms, Galster [41] refers to spatial elements and institutions or organisational entities [44,45]. Galster, as several other studies show, that tobacco retailers' densities are higher in the deprived communities than in the least deprived, increasing the access to cigarettes in these areas [29,41,46-52]. Considering the impact of neighbourhood deprivation on smoking habits, it would be logical for the government to give equal consideration to individual behaviour initiatives and the structural factors contributing to neighbourhood deprivation. This could involve targeted initiatives such as creating high-income job opportunities, improving education, providing training and skills development, increasing access to affordable housing, and implementing crime prevention measures. Having reexamined the evidence that demonstrates the unequal distribution of smoking among various population groups, this argued that socioeconomic deprivation is a fundamental determinant of smoking behaviour. We have also examined the government's efforts to reduce smoking rates and scrutinised the limitations of individual behaviour-focused stop-smoking interventions in deprived communities. This study provides a unique perspective by analysing practitioners' experiences promoting stop-smoking initiatives in a disadvantaged neighbourhood in northwest England. It emphasises the significance of taking upstream approaches to smoke cessation in order to tackle the wider determinants of smoking behaviour. 2. Methods The data is derived from an interpretive phenomenology study conducted by the first and second authors. The research took place between March and July 2019 at a local authority-owned lifestyle centre in the most deprived community in northwest England. The name of the local authority is concealed to comply with anonymity stipulated as a condition of access by the ethics committee. Ethical approval was obtained from the relevant university ethics committee. The university and local authorities collaborated, allowing a second author (postgraduate research student) to spend one day a week (between March and July 2019) with the local authorities to observe the stop-smoking advisors and learn from their experiences. The researcher maintained a reflective fieldwork diary to record her observations and reflections. After three months, in-depth one-to-one semi-structured interviews were conducted with the stop-smoking advisors (n=6). The senior researcher and researcher conducted the interviews, each lasting between 45 and 60 minutes. In this local authority, there were six stop-smoking advisors, and all agreed to participate in the interview. The interviews focused on understanding stop-smoking advisors’ experiences delivering stop-smoking programs in deprived communities. The data presented in this study comes from the analysis of the reflective diary and transcripts from 1:1 interviews with the stop-smoking advisors. The centre managers granted access to the participants and premises. Pseudonyms have been used to maintain the participants' anonymity. 2.1 Data analysis The analysis drew on Benner's [53] principles of interpretive analysis. Interviews were transcribed, and observation notes and diaries were completed. The collected data was organised according to the thematic analytic process outlined by Benner [53]. The data analysis was broadly organised according to the two phases of thematic analysis—development of an interpretive plan and identification of paradigm cases—a process summarised in Figure 1. The analysis revealed four themes and corresponding subthemes (see Table 2). These explain how this service is organised and delivered. Developing a skilled, confident, and culturally competent stop-smoking advice team. Understanding other complex social, mental, and physical health issues. Bringing stop-smoking programmes to those who need it the most. Adapting the service to meet the user's needs. Table 2: The overarching themes and corresponding subthemes illustrate how the Lifestyle Centre stop-smoking programme is organised and delivered. Overarching theme Subthemes Developing a skilled, confident, and culturally competent stop-smoking advice team Having accreditation as a stop-smoking advisor Draw from a wide range of backgrounds. Having extensive caring experience Understanding different cultures Understanding each other's roles Understanding complexities Working with people who relapse Working with them on overall lifestyle Creating flexible access Understand their social circumstances. Knowing a person as a whole Bringing stop-smoking to those who need it Health is a small part of the council's priorities - delivering stop smoking in the lifestyle centre, Stop smoking service is integral to the NHS patient's healthcare package. Rethinking the indicators of successful stop-smoking services among young people schools prisons Adapting the service to meet the user's needs. Offering flexible access Recognising that people progress differently Designing service around users' circumstances Establishing how the users' day work Matching the intervention with the right user Establish the motive to stop smoking. 3. Results Stop-smoking advisors in this study highlighted the challenges of delivering smoking cessation services within deprived communities and the limitations of generic individual behaviour-oriented approaches. 3.1 Developing a skilled, confident, and culturally competent stop-smoking advice team The study's advisors recognise that addressing the unique and complex needs of smokers from deprived communities requires more than just generic stop-smoking skills. They identified several elements that they believe are unique and useful to their role as smoking cessation advisors, both individually and collectively as a team: Having accredited training as stop-smoking advisors. Being drawn from a wide range of backgrounds. Having extensive caring experience. Understanding different cultures. Understanding each other's roles. The advisors described the smokers from deprived communities as entrenched, hardened, and hardcore. For example, Danielle provided a typical example of how participants talked about their qualifications. Danielle: Yeah, I’m not saying that nobody has problems ‘cos all the rest of people have problems, but sometimes they come with a range of problems that make it very difficult. So it might be unemployment, it might be mental health issues, it might be money issues, that kind of thing. So, You’ve got so many problems that they don’t see smoking; smoking is down here compared to all these other things that need sorting and help with all these other things, and so that’s why smoking takes, isn’t a priority for them The advisors had to undergo extensive training to develop the skills, credibility, competence, and confidence to address the complex issues surrounding current smokers. Beth described how this training was crucial. Beth: I did all the in-house training, some motivational, CBT, motivational interview and that kind of stuff. That was how I got to the role and applied for the job as the stop-smoking assistant and then the stop-smoking advisor. Then I went to London and did the Maudsley Smoking Cessation Training. I have built up my training like that. Recently, I got the National Centre for Smoking Cessation Training (NCSC) online training, which makes me officially a smoking cessation practitioner. The advisors drew on their extensive experience in working with people. For instance, Alice explained that she had thirty years of experience in caregiving roles within the NHS, including dealing with childhood physical and mental illnesses. Her work and academic experiences led to her current position. Alice: my NHS career started over 30 years ago; originally, I was in child health, so working within the medical facility for child health as it was then in [the Northwest of England]. From there, I went into child health and child psychiatry, all in admin support roles, and then I went into continuing care. So, from the continuing care role, I then progressed to GP practice and from that, I combined health and social care qualifications with the Open University and then saw an opening; it wasn't lifestyles; it was still under the NHS umbrella, for a secondment and training to become a stop-smoking advisor. Similarly, Beth suggests that having experiences in a wide range of settings adds to her approach to stop smoking, implying that she draws upon a wide range of experiences. Beth: I've probably been doing this job for about seventeen years now, so I'm working across the community, doing a lot of work with young people in schools. When I started my job, we were with health promotion, so I've seen all the changes from health promotion to primary care trusts (PCT) and local authorities. The neighbourhood has a large population of migrant smokers. Advisors believe that understanding the culture of the people they work with is essential for the success of their program. Two of them have experience working abroad, which is advantageous in engaging with some of the hard-to-reach groups in migrant communities. They bring knowledge of working with non-English-speaking people. Carl: I think it's important to engage with different cultures or even people who don't speak English as a first language; that's never a barrier to me because I worked in Saudi Arabia, so I had to work with people who couldn't even speak English, so it was good for me, particularly around the culture… Carl believes that understanding other cultures enables the team to transcend cultural barriers. Carl: Sometimes people find it difficult to engage with different cultures or even people who don't have English as their first language, whereas that's never a barrier to me because I worked in Saudi Arabia, so I had to work with people who couldn't even speak English. It is good for me, particularly around the culture ‘cos; when we went into the mosque on Friday for the first time, no one even considered engaging with these groups. The advisors' adaptability and experiences working with diverse populations, including migrants, contribute to the success of the stop-smoking programme. Understanding and transcending cultural barriers are seen as essential for effectively engaging with hard-to-reach groups, emphasising the significance of cultural competence in smoking cessation efforts within deprived communities. 3.2 Understanding other complex social, mental and physical health issues. All advisors observe that smokers have more urgent priorities, such as complex mental health issues, social isolation, poor housing, low literacy, and poverty, rather than focusing on smoking behaviours. Carl describes a typical smoker they deal with regularly. Carl: So, we're dealing with people who relapse, constantly relapse, so and because the smoking prevalence has been reducing, and we're beginning to see more complex clients. So, we've also had to change how we deal with these people. The advisors are critical of the notion that simply providing information will lead individuals to change their smoking habits. They believe that smokers are aware of the detrimental effects of smoking on health but acknowledge that social conditions make lifestyle change difficult. Danielle: I mean, we can keep trying to encourage them to see. They know they would be better off, say, in finance. People who have medical conditions know that they would be better off if they weren’t smoking. Confirming the assertion that the lack of engagement with stop-smoking services among people from deprived communities is not due to a lack of knowledge about the harmful effects of smoking. Advisors interacting with people from these communities concluded that individuals who smoke are aware of the harmful effects of smoking but continue to smoke to cope with their adverse health and social conditions. Therefore, advisors proposed integrating stop-smoking services into other population-based interventions. Ellen: They know smoking is bad for them but do not understand why it's so bad. Some of our roles here as a team are to do less of the traditional smoking offer and more of the education around helping people understand why. We've started working from the individuals’ circumstances… their mental health, home life, housing situation and how they spend their days. The advisors posit that smoking will not be eradicated as long as health inequalities exist. Ellen: These issues may not be completely eradicated regarding health inequalities, probably because people are forced by their circumstances to make lifestyle choices regarding smoking and relapsing. They explain that to overcome the effect of smoking prevalence on the neighbourhood, the local government is setting up smoking cessation services within the most deprived communities, also known as super output areas (SOA). Danielle: they try to put many of their sessions in the SOA areas so they can access them easily because they're the people we want to help the most. They're the people who don't access the service, so it's trying to make it as accessible as possible. It's trying to stay as local to those areas as Furthermore, to increase community engagement with stop-smoking services, they identified a large sum of money given to one of the deprived local communities to tackle health priorities and reduce health inequalities. They earmarked some of that money to promote community engagement with stop-smoking services. However, they asked the communities to identify interventions to reduce health inequalities rather than using a top-down approach. The results were unequivocal: the community felt that stopping smoking was not a priority in their communities. Ellen: So, we approached [Area A] because it is our area with the biggest pockets of deprivation and the highest smoking prevalence of around 38%. They had funding from the housing company in the area, and their council tax was also reduced to help reduce the health inequalities in the area. We asked the community what they wanted and what they prioritised as their biggest health need; smoking didn't come up high. The community decided they'd rather spend the funding on things like swing parks and activities rather than the health and wellbeing of the population. So, it's that challenge where you try to promote smoking cessation when they don't identify as having a problem until they are diagnosed with a smoking-related disease. Advisors observed that people with complex health and social conditions do not see smoking as a problem until they are diagnosed with smoking-related conditions; by then, the habit is so ingrained into their lives that they find quitting difficult. Advisors provided several examples where smokers struggle to quit despite severe physical illness. Beth: I've got a lady who's got severe COPD, and she needs home oxygen, so she can't; they will not install home oxygen if she smokes at home. She's at the point where she's saying, "What's the point of me stopping smoking now"? You know, that's the only thing I've got left in life. They believe tackling the fundamental causes of smoking would be more beneficial than traditional stop-smoking approaches for such people. Alice: Yeah, and I think the people we see now are hardened smokers with many other issues. For any lifestyle change, not only smoking, but I also feel it's so important to get the foundations right first because many people (and I'm not making judgements here), their esteem is on the floor, they're not always working, they've got lots of other problems either themselves, extended family and not always the energy. It is hard enough to manage with one condition if you've got several comorbidities. The model for behavioural change in smoking cessation emphasises that providing knowledge about the health risks of smoking can lead to significant behavioural change. This study confirmed that smokers in disadvantaged communities face significant challenges that may prevent them from making healthy choices. These challenges include issues such as housing instability, social isolation, mental health struggles, and financial difficulties. Stop-smoking advisors observed disparities between government priorities and the needs of the local population. For instance, it emerged in this study that when the public was consulted about local funding priorities, it became clear that there were differences in opinion. While the government prioritised improving access to smoking cessation programs, the public preferred allocating funds to park development. 3.3 Bringing stop-smoking programmes to those who need them the most. Advisors deliver stop-smoking advice in various healthcare facilities, including GP practices, mental health centres, NHS acute hospitals, prisons, schools, councils, and lifestyle centres, to reach communities needing these services. Their efforts in schools and with young people align with government policy, which targets achieving a hundred quits per calendar year among young individuals. However, they face several challenges. Firstly, designated funding is essential to meet this target. Ellen: We have a target of 100 young people quitting, which we have yet to achieve and haven't for the last decade because many of our services have had funding cuts. Secondly, advisors have found it more difficult to help young people quit compared to adults, often focusing on harm reduction due to the lack of funding, which limits the service to schools with a higher prevalence of smokers. Alice: We're doing less than we used to. In the past, we would go into schools and do sessions with the pastoral care teams. Currently, one of our advisors is doing one of the high schools because it has high numbers of smokers. We did a while with a few smokers in one of the other schools, so we supported more harm reduction. Additionally, the guidelines suggest that individuals who do not quit within a certain period should be removed from the program. However, advisors note that it takes longer to convey the message to younger individuals who are still experimenting with tobacco. Ellen: I always feel real strongly about young people that if a young person comes to us, we're not going to get a four-week to quit from them because they're still learning about quitting; this may be their first experience of stopping smoking; and it's really hard for young people to stop smoking. At this age, they are still experimenting and learning what works and what doesn't. So, if we've managed to get them to cut down, we can measure them for harm reduction rather than a complete quit. Therefore, they believe that measuring harm reduction is a more suitable indicator of success among young people than solely focusing on the number of quits. Danielle: It's harm reduction, which should be measured. That way, there is a thing we can tick on the database because young people, generally, not all of them, but most don't quit. They're very difficult age groups, so it is harm reduction if you can get some to reduce the amount of smoking. Moreover, they have observed that in affluent communities, children who smoke often come from families where one or both parents smoke or are separated, and the children split their time between the two parents. Fran: It depends on the family background. Many of the children I saw were in affluent communities - the parents were smokers or parents had broken up; children spent time between the two parents. The advisors have also successfully implemented a stop-smoking program within prison facilities. The primary objective of this initiative was to train prison staff to deliver the service to prisoners, ensuring its sustainability. This initiative's success led it to become a national flagship, and one of the advisors was even nominated for a national award for their work in prisons, indicating success in this area. Alice: The idea is that we go in, speak to the staff, and try to get very brief advice on interventions so that we can do this in any setting. Then our plan is to do a pilot so that somebody can shadow and take over that role to keep continuity, which sounds great in reality. Beth: [one of our advisors] was nominated for an award for the work he did in the prison... did some really good work with the prison Their work with schools and prisons has received national recognition, and their advisor has been nominated for a national award for their efforts. However, they are still facing challenges in helping young people in these settings to quit smoking. They believe measuring harm reduction is a better indicator of success among young people. Additionally, they have observed that children in affluent communities who smoke often come from families where one or both parents smoke or are separated. Their successful stop-smoking program within prison facilities has been nationally recognised, indicating success. 3.4 Adapting the service to meet the user's needs. The stop-smoking model aligns with UK policy initiatives advocating individual lifestyle changes, including the "Swap to Stop" campaign. In this disadvantaged community, promoting the individual lifestyle model is executed through face-to-face consultations, telephone consultations, and text messaging. Face-to-face consultations offer a distinct advantage, enabling comprehensive discussions and carbon monoxide testing to verify the quits. This personal interaction fosters a deeper understanding of the individual's needs and enhances the program's effectiveness, ensuring that each individual's unique circumstances are considered. In their commitment to inclusivity, the advisors strive to provide the same quality of service regardless of the mode of delivery. They recognise the limitations of telephone consultations and text messaging, which are available for some potential service users who cannot attend face-to-face consultations due to various social, economic, and health reasons. To overcome these limitations, the advisors offer all new service users a half-hour initial consultation and subsequent weekly fifteen-minute face-to-face consultations for existing service users who can attend or a fifteen-minute telephone follow-up or text messages for those who cannot attend in person. This flexible approach ensures that all service users can access the program and receive the support they need regardless of their circumstances. Danielle: if they're a new person to the service, they have a longer appointment, just like the half-hour slot they're booked into. If they're a regular, it's just a fifteen-minute- follow-up telephone appointment. Advisors aim to deliver consistent quality advice to all service users. Advisors explain that the quality of advice service users receive is the same regardless of the access mode. Danielle: … I am actually on telephone support, so that is obviously for the people who cannot attend for work or whatever commitments, so they are just booked into slots. We work our way through the list of people on telephone support. So, they still get the same kind of advice, and we still sort out prescriptions; it is just all done over the phone or by text while obviously in the one-to-one appointments is more in-depth, and also, we do a carbon monoxide testing so that is what we do when we see people face to face as well. Advisors emphasised the importance of designing the programme around the user's personal and social circumstances. They understand that some users may have difficulties accessing the service during typical working hours due to transport, work commitments or childcare. They found that telephone services are particularly useful for users who have work commitments. Fran: We try to ask why they wanted to stop. Once you have got the why, you discuss the smoking habits and work out their dependency on nicotine by doing the Fagerstrom test, and it's just part of building a relationship with the person. It's finding out how their day works, assessing what's going on in their lives, whether they have family and friends' support or live alone and sit there with nothing else to do all day other than smoke. You can get an idea then of how difficult or possible the quits will be. In line with the government's swap-to-stop campaign, advisors present service users with various addiction treatment products, including swapping tobacco products with vaping. They revealed that a mismatch between individual and product could lead to noncompliance and damage clients' confidence. Alice: it is important to match the products with the right patient; it's got to be if somebody has something set in their mind, they will have that confidence in it; you try to steer them to something different if it's not suitable for medical reasons. Some advisors have expressed reservations about promoting vaping. Beth: I was always very weary of e-cigarettes because they weren't tested. So, I would never want to recommend something that hasn't been tested because I want to recommend something I would be happy and comfortable using. Now, because we've got the public health backing and we've got the testing on e-cigarettes, I'm quite comfortable to say to people, this is our guidance from public health; they are 95% less harmful than cigarettes, but we do not know about long-term use, so it is harm reduction. The advisor observed that vaping is popular amongst the hard-to-reach population. Therefore, they must modify their messages from advising against its use to advising them to buy it from reputable sources. Beth: Many people in our hard-to-reach communities like to vape, especially e-cigarettes, so it is just a matter of getting the message to them that you should go to a reputable seller, do not buy from cabins, and get them from reputable sellers. In line with the government's swap-to-stop campaign, advisors present service users with various addiction treatment products, including swapping tobacco products with vaping. Some advisors have reservations about promoting vaping but recognise its popularity among the hard-to-reach population and modify their messages to advise users to buy it from reputable sources. 4. Discussion This study stands out for its unwavering commitment to the principles of health inequalities. It explicitly acknowledges that data collection and analysis were conducted with a laser focus on socioeconomic determinants of health inequalities. As a result, the findings represent our nuanced interpretation of the meanings participants ascribe to their experiences and practices in their respective contexts. The central argument of this study is that if the socioeconomic deprivation of communities significantly impacts smoking habits, then efforts to reduce smoking in this population should incorporate addressing the causes of neighbourhood deprivation. The argument is strategically framed around the crucial distinction between ‘upstream’ interventions focusing on society, social institutions al or policy‐level determinants, such as income, education, housing, environment and crime, and ‘downstream’ interventions focused on individual factors, increasing access to stop-smoking programmes, reducing attractiveness and limiting the availability of tobacco and vaping products [54-60]. This distinction is key to understanding the multifaceted nature of smoking cessation strategies [27,58,59,61]. This study's findings are significant in the context of smoking cessation. It critically examined the limitations of downstream individual lifestyle-focused stop-smoking interventions in deprived communities. It underscored the importance of adopting upstream approaches to smoke cessation to address the broader determinants of smoking behaviour.[62]. The advisors' perspective on the smokers from deprived communities is illuminating. They characterised these smokers as entrenched, hardened, and hardcore and argued that addressing their unique and complex needs requires more than generic individual lifestyle stop-smoking skills. We interpreted their portrayal of a smoker from a deprived community, recognising the uniqueness of these individuals from any other smokers. This understanding acknowledges the impact of the social context in which smoking takes place as the primary factor influencing smoking, surpassing individual choice. We understood their assertion that the " requires more than generic individual lifestyle stop-smoking skills ” to mean that the socially context-oriented intervention would be more appropriate. To our knowledge, no published studies have targeted socioeconomic determinants as part of a multifaceted cessation programme for smokers in deprived communities. In this study, advisors have noted that smokers often encounter challenges associated with poverty, including social isolation, inadequate housing, and financial difficulties. Previous research has concurred with these findings, indicating that factors such as employment status, housing conditions, poverty, and residential stability at the community level are independently associated with smoking. [63-65]. Research has also shown that smokers experiencing financial stress are less likely to quit, and if they do quit, they are more likely to relapse [65]. Siahpush's study further illustrated that smokers experiencing stress are more likely to smoke more, leading to a sense of lack of control.[65]. Wilkinson and Pickett demonstrated that material deprivation can lead to low self-efficacy in quitting smoking or maintaining a smoke-free behaviour, reducing the likelihood of successful cessation [65,66]. These issues may not be effectively addressed using traditional smoking cessation methods, and advisors trained in conventional behavioural change techniques may lack the necessary skills to implement interventions targeting the underlying causes of smoking. Considering the strong evidence demonstrating the protective effects of income against smoking, it would be advantageous to focus on structural approaches that address education and income in deprived communities. [62,63,65,67-70]. In this study, advisors observed that individuals from disadvantaged communities often engage in multiple health-harming behaviours, such as smoking, alcohol misuse, and diet-related behaviours. Some of these behaviours may require more immediate attention than quitting smoking. For example, an advisor recalled a woman who spent the entire session discussing her plan to drink a bottle of vodka that evening. In this case, intervention to reduce the harmful effects of alcohol was more urgent than addressing smoking. However, advisors are more equipped to deal with smoking behaviour than alcohol harm reduction. This highlights the limitation of behaviour-oriented approaches; another arises as soon as one issue is addressed. Advisors deliver stop-smoking advice in traditional healthcare facilities such as GP practices, mental health centres, NHS acute hospitals and nontraditional facilities such as prisons, schools, councils, and lifestyle centres to reach communities needing these services. The goal is to bring stop-smoking programmes to those who most need them. This approach recognises that smoking cessation efforts have disproportionately benefited the least privileged groups, exacerbating inequalities [27]. This approach aligns with the principles of Julian Tudor Hart's theory of inverse care law, which suggests that interventions may widen inequalities if they benefit advantaged groups more than disadvantaged groups [21,27]. By bringing stop-smoking support to underserved communities, we may reduce inequalities by providing greater benefits to disadvantaged groups[27]. 5. Conclusion This article presented evidence indicating that behaviour-oriented interventions have resulted in a disproportionate decrease in smoking rates, with a more rapid decline in the least deprived areas compared to the deprived ones. This disparity, known as the inverse care law, is a crucial concept that provides a clear framework for understanding these differences. By providing stop-smoking support in underserved neighbourhoods, we can potentially reduce inequalities by offering greater benefits to disadvantaged groups. The study emphasises the need for both behavioural and structural interventions to address smoking habits in deprived neighbourhoods. It highlights the impact of socioeconomic determinants on smoking behaviour and stresses the limitations of individual behaviour-focused stop-smoking interventions in these communities. The advisors suggest that addressing the unique and complex needs of smokers in deprived neighbourhoods requires interventions that consider the broader determinants of smoking behaviour, such as social context and material deprivation. It emphasises the need for collective action and structural reforms to address the social conditions contributing to smoking behaviours. The study suggests that the government's efforts should focus on individual behaviour changes and consider the broader determinants of smoking behaviour. Targeted initiatives such as creating high-income job opportunities, improving education, providing training and skills development, increasing access to affordable housing, and implementing crime prevention measures are recommended to address the impact of neighbourhood deprivation on smoking habits. Overall, the study calls for a comprehensive approach that combines behavioural interventions with measures to address the underlying causes of smoking in deprived communities. 6. Limitations The conclusions drawn relate only to the social and economic context of the participants in this study and, therefore, may not be generalised to the wider population or immediately applied in a different context. It must be acknowledged that there were six stop-smoking advisors in this local authority, and all agreed to participate in the interview. However, the experience of six advisors may not be generalised to the wider population. The methodology used in this study, interpretative phenomenology, is based on the idea that people discuss the essential experiences that are meaningful to them in their contexts. Consistent with interpretative phenomenology, we aimed to uncover the meanings that participants ascribe to their existence within their context. Therefore, the findings represent our nuanced interpretation of the meanings participants ascribe to their experiences and practices in their respective contexts. Declarations Ethics approval and consent to participate The Faculty of Health and Social Care Research Ethics Subcommittee of the University of Chester provided ethical approval to conduct the study. Consent for publication All participants have given consent to publish. Availability of data and material The datasets generated during and/or analysed during the current study are not publicly available due to ethical restrictions and privacy of participant data but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions The authors made the following contributions: conceptualisation MM; methodology MM; formal analysis MM, data collection EWA and MM; writing – original draft preparation MM; review editing MM and JK, review final draft, MM, EWA JK, AY, LP, MT, NAN. All authors agreed on the final version of the manuscript. Acknowledgements The authors wish to thank all Warrington LiveWire Stop-smoking programme without their support, it would not have been possible to undertake the research. Special gratitude goes to the reviewers of this paper, who will have expended considerable effort on our behalf. References Office for National Statistics. Adult smoking habits in Great Britain: 2014- Cigarette smoking among adults including the proportion of people who smoke including demographic breakdowns, changes over time, and e-cigarettes. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4542157","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318631005,"identity":"d80cd6d3-93bd-4dae-8238-172623938853","order_by":0,"name":"Mzwandile Mabhala","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYJACZsYGBhkGCSDrAcMBOSC/gSgtPGAtCQkHjBkYGEnUkthASIvutNOJnwt32PHwz24++CHxx530/vbGBoYfFdtwajG7nbtZeuaZZB6JO8eSJRISnuXOOHOwgbHnzG18WjZI87Yx8zDcyDEAajmc23AjsYGZsQ2vls2/edvqeeRv5H/+AdSSLk+Elm1AWw7zGNzIYQPZkmBAjBbrmW3HeQxvpJlZJKQdNtwI9MtBAn7ZfLuwrVpO7kby4xsfbA7Lyx1vPvjgRwVuLdjBARLVj4JRMApGwShAAwDTQ2Nkuu8SvQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Derby","correspondingAuthor":true,"prefix":"","firstName":"Mzwandile","middleName":"","lastName":"Mabhala","suffix":""},{"id":318631007,"identity":"7140e64a-3020-416f-b735-12ecddebc655","order_by":1,"name":"Winifred Adaobi ESEALUKA","email":"","orcid":"","institution":"St James's University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Winifred","middleName":"Adaobi","lastName":"ESEALUKA","suffix":""},{"id":318631010,"identity":"754a0327-a32c-4d12-9571-0436df579107","order_by":2,"name":"Asmait YOHANNES","email":"","orcid":"","institution":"Mount Sinai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Asmait","middleName":"","lastName":"YOHANNES","suffix":""},{"id":318631011,"identity":"fb794409-6ca3-48a2-903a-56307ca34826","order_by":3,"name":"Amanda Nkolika NWUFO","email":"","orcid":"","institution":"Bulwell Riverside NHS Practice","correspondingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"Nkolika","lastName":"NWUFO","suffix":""},{"id":318631013,"identity":"363a55f5-249b-4ffd-9b93-06ce974bfca1","order_by":4,"name":"Lahja PAULUS","email":"","orcid":"","institution":"Walton Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lahja","middleName":"","lastName":"PAULUS","suffix":""},{"id":318631016,"identity":"a4bcfe86-c29e-4a1d-b400-b258b8e83230","order_by":5,"name":"June KEELING","email":"","orcid":"","institution":"Keele University","correspondingAuthor":false,"prefix":"","firstName":"June","middleName":"","lastName":"KEELING","suffix":""},{"id":318631017,"identity":"77acaaa2-c5dd-4e8d-a8d8-096da62da602","order_by":6,"name":"Meron Tefera","email":"","orcid":"","institution":"University of Chester","correspondingAuthor":false,"prefix":"","firstName":"Meron","middleName":"","lastName":"Tefera","suffix":""}],"badges":[],"createdAt":"2024-06-06 19:08:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4542157/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4542157/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-23110-7","type":"published","date":"2025-05-23T15:57:25+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60184417,"identity":"c21be5c0-ef89-4f67-bec6-2c14f11d87eb","added_by":"auto","created_at":"2024-07-12 18:37:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64821,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eillustrates the two phases of thematic analysis that shaped data analysis.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4542157/v1/f8d09b580c8067248ae99b98.png"},{"id":83460156,"identity":"23a8cde4-5803-4353-8d0e-7adbeffe3ec5","added_by":"auto","created_at":"2025-05-26 16:11:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1159770,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4542157/v1/0ef33647-9ae9-43b5-9f26-bcaecffb6a9f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the social context of smoking behaviours: insights from stop-smoking advisors in deprived communities in Northwest of England UK.","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAlthough the net smoking prevalence is continuing to decline yearly in the United Kingdom (UK)\u0026nbsp;[1-8], with 13.3% smokers in 2021 compared to 13.% in 2020\u0026nbsp;[1-8], the decline in smoking prevalence is not equally distributed across all population groups\u0026nbsp;[5,9-12]. It remains significantly higher among socially disadvantaged groups\u0026nbsp;[9,13,14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1 shows the different rates of decline in cigarette smoking in the UK; it indicates that while all groups have experienced a decline in smoking prevalence, smoking remains higher amongst those classified as routine workers and those with no educational qualifications[3-6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Percentages of smokers by socioeconomic indicators: employment status and education qualifications of people aged 18 years and over in the UK between 2015 and 2021.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmokers (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmokers (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall % smokers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRoutine workers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eManagerial and professional\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e16.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003e9.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e29.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e15.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e25.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e14.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e23.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall% smokers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo qualification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegree or Equivalent qualification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003eundefined\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003eundefined\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e28.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003e6.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.874326750448834%\" valign=\"top\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.673249551166965%\" valign=\"top\"\u003e\n \u003cp\u003e12.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e22.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.754039497307005%\" valign=\"top\"\u003e\n \u003cp\u003e8.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe UK government has introduced policy initiatives to improve the accessibility of stop-smoking services. Additionally, they are striving to reduce the attractiveness of tobacco and vaping products, reduce the availability of tobacco products in underprivileged areas, and ultimately narrow the socioeconomic inequalities in smoking habits\u0026nbsp;[15-19]. To achieve this, they introduced a series of measures, such as legislation restricting tobacco advertising, the implementation of standardised packaging, and banning menthol-flavored tobacco products\u0026nbsp;[17-20]. Furthermore, they launched the \u0026quot;Swap to Stop\u0026quot; campaign, which aims to encourage smokers to transition to vaping, invested over 70 million pounds annually to support local authority-led stop-smoking services (SSS) and introduced the Tobacco and Vapes Bill 2024 to create the first-ever smoke-free generation\u0026nbsp;[16].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, it is important to note that the government\u0026apos;s efforts have primarily focused on limiting access and promoting individual behaviour changes, with little consideration given to the social conditions that contribute to smoking behaviours. As a result, these measures yielded greater benefits to the least deprived than the most deprived. Julian Tudor Hart conceptualised these disparities as inverse care law[21]. Several studies have demonstrated that behavioural behaviour-oriented interventions may be less effective in deprived populations, leading to an inverse care law\u0026nbsp;[13,20,22-27].\u0026nbsp;Therefore, it is crucial to acknowledge the social context of smoking to develop effective stop-smoking interventions and reduce the prevalence of smoking in all segments of society[13,20,22-26,28,29].\u003c/p\u003e\n\u003cp\u003eWhile promoting individual behaviour changes can be helpful, it is important to recognise that lasting change requires collective action and structural reforms. Therefore, a more socially oriented approach is necessary to ensure a sustainable future for all. In the face of growing health inequalities[30-33], solely focusing on individual behaviour changes tends to overlook the significance of structural factors, social processes, and local settings affecting people\u0026apos;s health and ability to adopt healthy lifestyles.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe social determinants of health (SDH), the fundamental cause theory (FCT), the political economy approach, and the eco-social theories provide strategic entry points for policy action to address the structural determinants of smoking behaviour\u0026nbsp;[34]. They offer some insight into the effect of local community-level deprivation on smoking behaviour\u0026nbsp;[34]. They teach us that most individual lifestyle behaviours manifest adverse social conditions. Considering these insights, implementing an upstream approach to smoking cessation, with a focus on education, employment, income, housing, environment, crime prevention and health, would effectively address not only smoking behaviours but also other health-harming behaviours\u0026nbsp;[35,36].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNumerous studies have expanded on these theories to demonstrate the effects of a neighbourhood\u0026apos;s level of deprivation and smoking behaviour\u0026nbsp;[13,20,22,25,26]. They argue that the neighbourhood plays a significant role in determining the likelihood of being a smoker and the challenges one may face in quitting, notwithstanding their socioeconomic status[20,23,37-39]. For example, An Australian study by Turrell et al., in line with research from the UK\u0026nbsp;[13]\u0026nbsp;and the US\u0026nbsp;[38,39], reported that after adjusting for individual differences in occupation, education, income, gender, and age, people living in the most deprived communities were less likely to quit smoking (9.3\u0026ndash;12.5%) than more affluent individuals (23.1\u0026ndash;25%).\u003c/p\u003e\n\u003cp\u003eGalster\u0026apos;s\u0026nbsp;[40]\u0026nbsp;study explains the theoretical connection between communities and individual outcomes, proposing theoretical mechanisms to aid in smoking cessation at the neighbourhood level. According to Galster, the mechanisms of neighbourhood effect theory, including social-interactive, environmental, geographical, and institutional factors, play a role in initiating and sustaining smoking in deprived communities. Social-interactive mechanisms are based on the idea that socially disadvantaged communities create conditions that increase the likelihood of initiating smoking and reduce the likelihood of quitting\u0026nbsp;[24,26,41]. These conditions include poor job prospects, as some employers are reluctant to consider people from \u0026apos;bad areas\u0026apos;\u0026nbsp;[26,41]. In addition, disadvantaged communities provide fewer opportunities for social capital, participation, and interaction with employed individuals\u0026nbsp;[26,41,42]. High levels of unemployment and a lack of basic amenities mean fewer opportunities to engage in positive social interactions that benefit health\u0026nbsp;[26]. The environment where disadvantaged people live tends to increase exposure to stresses produced by higher crime, violence, and incivilities such as littering and vandalism[41]. The evidence suggests that communities facing adverse social conditions tend to resort to maladaptive coping habits such as smoking\u0026nbsp;[42,43].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGalster proposes that disadvantaged communities\u0026apos; geographical location and poor infrastructure create physical and social disconnection from neighbouring more affluent suburbs and larger urban areas[24,26,41]. Furthermore, the poor infrastructure means that if they find employment, they will likely face greater transport and childcare difficulties\u0026nbsp;[26]. By institutional mechanisms, Galster\u0026nbsp;[41]\u0026nbsp;refers to spatial elements and institutions or organisational entities\u0026nbsp;[44,45]. Galster, as several other studies show, that tobacco retailers\u0026apos; densities are higher in the deprived communities than in the least deprived, increasing the access to cigarettes in these areas\u0026nbsp;[29,41,46-52]. Considering the impact of neighbourhood deprivation on smoking habits, it would be logical for the government to give equal consideration to individual behaviour initiatives and the structural factors contributing to neighbourhood deprivation. This could involve targeted initiatives such as creating high-income job opportunities, improving education, providing training and skills development, increasing access to affordable housing, and implementing crime prevention measures.\u003c/p\u003e\n\u003cp\u003eHaving reexamined the evidence that demonstrates the unequal distribution of smoking among various population groups, this argued that socioeconomic deprivation is a fundamental determinant of smoking behaviour. We have also examined the government\u0026apos;s efforts to reduce smoking rates and scrutinised the limitations of individual behaviour-focused stop-smoking interventions in deprived communities. This study provides a unique perspective by analysing practitioners\u0026apos; experiences promoting stop-smoking initiatives in a disadvantaged neighbourhood in northwest England. It emphasises the significance of taking upstream approaches to smoke cessation in order to tackle the wider determinants of smoking behaviour.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThe data is derived from an interpretive phenomenology study conducted by the first and second authors. The research took place between March and July 2019 at a local authority-owned lifestyle centre in the most deprived community in northwest England. The name of the local authority is concealed to comply with anonymity stipulated as a condition of access by the ethics committee. Ethical approval was obtained from the relevant university ethics committee.\u003c/p\u003e\n\u003cp\u003eThe university and local authorities collaborated, allowing a second author (postgraduate research student) to spend one day a week (between March and July 2019) with the local authorities to observe the stop-smoking advisors and learn from their experiences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe researcher maintained a reflective fieldwork diary to record her observations and reflections. After three months, in-depth one-to-one semi-structured interviews were conducted with the stop-smoking advisors (n=6). The senior researcher and researcher conducted the interviews, each lasting between 45 and 60 minutes. In this local authority, there were six stop-smoking advisors, and all agreed to participate in the interview. The interviews focused on understanding stop-smoking advisors\u0026rsquo; experiences delivering stop-smoking programs in deprived communities. The data presented in this study comes from the analysis of the reflective diary and transcripts from 1:1 interviews with the stop-smoking advisors.\u003c/p\u003e\n\u003cp\u003eThe centre managers granted access to the participants and premises. Pseudonyms have been used to maintain the participants\u0026apos; anonymity.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e2.1 Data analysis\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe analysis drew on Benner\u0026apos;s\u0026nbsp;[53]\u0026nbsp;principles of interpretive analysis. Interviews were transcribed, and observation notes and diaries were completed. The collected data was organised according to the thematic analytic process outlined by Benner\u0026nbsp;[53]. The data analysis was broadly organised according to the two phases of thematic analysis\u0026mdash;development of an interpretive plan and identification of paradigm cases\u0026mdash;a process summarised in Figure 1.\u003c/p\u003e\n\u003cp\u003eThe analysis revealed four themes and corresponding subthemes (see Table 2). These explain how this service is organised and delivered.\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDeveloping a skilled, confident, and culturally competent stop-smoking advice team. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eUnderstanding other complex social, mental, and physical health issues.\u003c/li\u003e\n \u003cli\u003eBringing stop-smoking programmes to those who need it the most.\u003c/li\u003e\n \u003cli\u003eAdapting the service to meet the user\u0026apos;s needs.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: The overarching themes and corresponding subthemes illustrate how the Lifestyle Centre stop-smoking programme is organised and delivered.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverarching theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubthemes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003eDeveloping a skilled, confident, and culturally competent stop-smoking advice team \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eHaving accreditation as a stop-smoking advisor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eDraw from a wide range of backgrounds.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eHaving extensive caring experience\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eUnderstanding different cultures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eUnderstanding each other\u0026apos;s roles\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003eUnderstanding complexities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eWorking with people who relapse\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eWorking with them on overall lifestyle\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eCreating flexible access\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eUnderstand their social circumstances.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eKnowing a person as a whole\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003eBringing stop-smoking to those who need it\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eHealth is a small part of the council\u0026apos;s priorities - delivering stop smoking in the lifestyle centre,\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eStop smoking service is integral to the NHS patient\u0026apos;s healthcare package.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eRethinking the indicators of successful stop-smoking services among young people\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eschools\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eprisons\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003eAdapting the service to meet the user\u0026apos;s needs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eOffering flexible access\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eRecognising that people progress differently\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eDesigning service around users\u0026apos; circumstances\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eEstablishing how the users\u0026apos; day work\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eMatching the intervention with the right user\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.52487961476726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.47512038523274%\" valign=\"top\"\u003e\n \u003cp\u003eEstablish the motive to stop smoking.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"3. Results","content":"\u003cp\u003eStop-smoking advisors in this study highlighted the challenges of delivering smoking cessation services within deprived communities and the limitations of generic individual behaviour-oriented approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1 Developing a skilled, confident, and culturally competent stop-smoking advice team \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study\u0026apos;s advisors recognise that addressing the unique and complex needs of smokers from deprived communities requires more than just generic stop-smoking skills. They identified several elements that they believe are unique and useful to their role as smoking cessation advisors, both individually and collectively as a team:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eHaving accredited training as stop-smoking advisors.\u003c/li\u003e\n \u003cli\u003eBeing drawn from a wide range of backgrounds.\u003c/li\u003e\n \u003cli\u003eHaving extensive caring experience.\u003c/li\u003e\n \u003cli\u003eUnderstanding different cultures.\u003c/li\u003e\n \u003cli\u003eUnderstanding each other\u0026apos;s roles.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe advisors described the smokers from deprived communities as entrenched, hardened, and hardcore. For example, Danielle provided a typical example of how participants talked about their qualifications.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDanielle: Yeah, I\u0026rsquo;m not saying that nobody has problems \u0026lsquo;cos all the rest of people have problems, but sometimes they come with a range of problems that make it very difficult. So it might be unemployment, it might be mental health issues, it might be money issues, that kind of thing. So, You\u0026rsquo;ve got so many problems that they don\u0026rsquo;t see smoking; smoking is down here compared to all these other things that need sorting and help with all these other things, and so that\u0026rsquo;s why smoking takes, isn\u0026rsquo;t a priority for them\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe advisors had to undergo extensive training to develop the skills, credibility, competence, and confidence to address the complex issues surrounding current smokers. Beth described how this training was crucial.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBeth: I did all the in-house training, some motivational, CBT, motivational interview and that kind of stuff. That was how I got to the role and applied for the job as the stop-smoking assistant and then the stop-smoking advisor. Then I went to London and did the Maudsley Smoking Cessation Training. I have built up my training like that. Recently, I got the National Centre for Smoking Cessation Training (NCSC) online training, which makes me officially a smoking cessation practitioner.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe advisors drew on their extensive experience in working with people. For instance, Alice explained that she had thirty years of experience in caregiving roles within the NHS, including dealing with childhood physical and mental illnesses. Her work and academic experiences led to her current position.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAlice: my NHS career started over 30 years ago; originally, I was in child health, so working within the medical facility for child health as it was then in [the Northwest of England]. From there, I went into child health and child psychiatry, all in admin support roles, and then I went into continuing care. So, from the continuing care role, I then progressed to GP practice and from that, I combined health and social care qualifications with the Open University and then saw an opening; it wasn\u0026apos;t lifestyles; it was still under the NHS umbrella, for a secondment and training to become a stop-smoking advisor.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSimilarly, Beth suggests that having experiences in a wide range of settings adds to her approach to stop smoking, implying that she draws upon a wide range of experiences.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBeth: I\u0026apos;ve probably been doing this job for about seventeen years now, so I\u0026apos;m working across the community, doing a lot of work with young people in schools. When I started my job, we were with health promotion, so I\u0026apos;ve seen all the changes from health promotion to primary care trusts (PCT) and local authorities.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe neighbourhood has a large population of migrant smokers. Advisors believe that understanding the culture of the people they work with is essential for the success of their program. Two of them have experience working abroad, which is advantageous in engaging with some of the hard-to-reach groups in migrant communities. They bring knowledge of working with non-English-speaking people.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCarl: I think it\u0026apos;s important to engage with different cultures or even people who don\u0026apos;t speak English as a first language; that\u0026apos;s never a barrier to me because I worked in Saudi Arabia, so I had to work with people who couldn\u0026apos;t even speak English, so it was good for me, particularly around the culture\u0026hellip;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCarl believes that understanding other cultures enables the team to transcend cultural barriers.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCarl: Sometimes people find it difficult to engage with different cultures or even people who don\u0026apos;t have English as their first language, whereas that\u0026apos;s never a barrier to me because I worked in Saudi Arabia, so I had to work with people who couldn\u0026apos;t even speak English. It is good for me, particularly around the culture \u0026lsquo;cos; when we went into the mosque on Friday for the first time, no one even considered engaging with these groups.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe advisors\u0026apos; adaptability and experiences working with diverse populations, including migrants, contribute to the success of the stop-smoking programme. Understanding and transcending cultural barriers are seen as essential for effectively engaging with hard-to-reach groups, emphasising the significance of cultural competence in smoking cessation efforts within deprived communities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Understanding other complex social, mental and physical health issues.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll advisors observe that smokers have more urgent priorities, such as complex mental health issues, social isolation, poor housing, low literacy, and poverty, rather than focusing on smoking behaviours. Carl describes a typical smoker they deal with regularly.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCarl: So, we\u0026apos;re dealing with people who relapse, constantly relapse, so and because the smoking prevalence has been reducing, and we\u0026apos;re beginning to see more complex clients. So, we\u0026apos;ve also had to change how we deal with these people.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe advisors are critical of the notion that simply providing information will lead individuals to change their smoking habits. They believe that smokers are aware of the detrimental effects of smoking on health but acknowledge that social conditions make lifestyle change difficult.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDanielle: I mean, we can keep trying to encourage them to see. They know they would be better off, say, in finance. People who have medical conditions know that they would be better off if they weren\u0026rsquo;t smoking.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConfirming the assertion that the lack of engagement with stop-smoking services among people from deprived communities is not due to a lack of knowledge about the harmful effects of smoking. Advisors interacting with people from these communities concluded that individuals who smoke are aware of the harmful effects of smoking but continue to smoke to cope with their adverse health and social conditions. Therefore, advisors proposed integrating stop-smoking services into other population-based interventions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEllen: They know smoking is bad for them but do not understand why it\u0026apos;s so bad. Some of our roles here as a team are to do less of the traditional smoking offer and more of the education around helping people understand why. We\u0026apos;ve started working from the individuals\u0026rsquo; circumstances\u0026hellip; their mental health, home life, housing situation and how they spend their days.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe advisors posit that smoking will not be eradicated as long as health inequalities exist.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEllen: These issues may not be completely eradicated regarding health inequalities, probably because people are forced by their circumstances to make lifestyle choices regarding smoking and relapsing.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThey explain that to overcome the effect of smoking prevalence on the neighbourhood, the local government is setting up smoking cessation services within the most deprived communities, also known as super output areas (SOA).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDanielle: they try to put many of their sessions in the SOA areas so they can access them easily because they\u0026apos;re the people we want to help the most. They\u0026apos;re the people who don\u0026apos;t access the service, so it\u0026apos;s trying to make it as accessible as possible. It\u0026apos;s trying to stay as local to those areas as\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, to increase community engagement with stop-smoking services, they identified a large sum of money given to one of the deprived local communities to tackle health priorities and reduce health inequalities. They earmarked some of that money to promote community engagement with stop-smoking services. However, they asked the communities to identify interventions to reduce health inequalities rather than using a top-down approach. The results were unequivocal: the community felt that stopping smoking was not a priority in their communities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEllen: So, we approached [Area A] because it is our area with the biggest pockets of deprivation and the highest smoking prevalence of around 38%. They had funding from the housing company in the area, and their council tax was also reduced to help reduce the health inequalities in the area. We asked the community what they wanted and what they prioritised as their biggest health need; smoking didn\u0026apos;t come up high. The community decided they\u0026apos;d rather spend the funding on things like swing parks and activities rather than the health and wellbeing of the population.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo, it\u0026apos;s that challenge where you try to promote smoking cessation when they don\u0026apos;t identify as having a problem until they are diagnosed with a smoking-related disease.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdvisors observed that people with complex health and social conditions do not see smoking as a problem until they are diagnosed with smoking-related conditions; by then, the habit is so ingrained into their lives that they find quitting difficult. Advisors provided several examples where smokers struggle to quit despite severe physical illness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBeth: I\u0026apos;ve got a lady who\u0026apos;s got severe COPD, and she needs home oxygen, so she can\u0026apos;t; they will not install home oxygen if she smokes at home. She\u0026apos;s at the point where she\u0026apos;s saying, \u0026quot;What\u0026apos;s the point of me stopping smoking now\u0026quot;? You know, that\u0026apos;s the only thing I\u0026apos;ve got left in life.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThey believe tackling the fundamental causes of smoking would be more beneficial than traditional stop-smoking approaches for such people.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAlice: Yeah, and I think the people we see now are hardened smokers with many other issues. For any lifestyle change, not only smoking, but I also feel it\u0026apos;s so important to get the foundations right first because many people (and I\u0026apos;m not making judgements here), their esteem is on the floor, they\u0026apos;re not always working, they\u0026apos;ve got lots of other problems either themselves, extended family and not always the energy. It is hard enough to manage with one condition if you\u0026apos;ve got several comorbidities.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe model for behavioural change in smoking cessation emphasises that providing knowledge about the health risks of smoking can lead to significant behavioural change. This study confirmed that smokers in disadvantaged communities face significant challenges that may prevent them from making healthy choices. These challenges include issues such as housing instability, social isolation, mental health struggles, and financial difficulties.\u003c/p\u003e\n\u003cp\u003eStop-smoking advisors observed disparities between government priorities and the needs of the local population. For instance, it emerged in this study that when the public was consulted about local funding priorities, it became clear that there were differences in opinion. While the government prioritised improving access to smoking cessation programs, the public preferred allocating funds to park development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Bringing stop-smoking programmes to those who need them the most.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdvisors deliver stop-smoking advice in various healthcare facilities, including GP practices, mental health centres, NHS acute hospitals, prisons, schools, councils, and lifestyle centres, to reach communities needing these services.\u003c/p\u003e\n\u003cp\u003eTheir efforts in schools and with young people align with government policy, which targets achieving a hundred quits per calendar year among young individuals. However, they face several challenges. Firstly, designated funding is essential to meet this target.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEllen: We have a target of 100 young people quitting, which we have yet to achieve and haven\u0026apos;t for the last decade because many of our services have had funding cuts.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSecondly, advisors have found it more difficult to help young people quit compared to adults, often focusing on harm reduction due to the lack of funding, which limits the service to schools with a higher prevalence of smokers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAlice: We\u0026apos;re doing less than we used to. In the past, we would go into schools and do sessions with the pastoral care teams. Currently, one of our advisors is doing one of the high schools because it has high numbers of smokers. We did a while with a few smokers in one of the other schools, so we supported more harm reduction.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, the guidelines suggest that individuals who do not quit within a certain period should be removed from the program. However, advisors note that it takes longer to convey the message to younger individuals who are still experimenting with tobacco.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEllen: I always feel real strongly about young people that if a young person comes to us, we\u0026apos;re not going to get a four-week to quit from them because they\u0026apos;re still learning about quitting; this may be their first experience of stopping smoking; and it\u0026apos;s really hard for young people to stop smoking. At this age, they are still experimenting and learning what works and what doesn\u0026apos;t. So, if we\u0026apos;ve managed to get them to cut down, we can measure them for harm reduction rather than a complete quit.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTherefore, they believe that measuring harm reduction is a more suitable indicator of success among young people than solely focusing on the number of quits.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDanielle: It\u0026apos;s harm reduction, which should be measured. That way, there is a thing we can tick on the database because young people, generally, not all of them, but most don\u0026apos;t quit. They\u0026apos;re very difficult age groups, so it is harm reduction if you can get some to reduce the amount of smoking.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMoreover, they have observed that in affluent communities, children who smoke often come from families where one or both parents smoke or are separated, and the children split their time between the two parents.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFran: It depends on the family background. Many of the children I saw were in affluent communities - the parents were smokers or parents had broken up; children spent time between the two parents.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe advisors have also successfully implemented a stop-smoking program within prison facilities. The primary objective of this initiative was to train prison staff to deliver the service to prisoners, ensuring its sustainability. This initiative\u0026apos;s success led it to become a national flagship, and one of the advisors was even nominated for a national award for their work in prisons, indicating success in this area.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAlice: The idea is that we go in, speak to the staff, and try to get very brief advice on interventions so that we can do this in any setting. Then our plan is to do a pilot so that somebody can shadow and take over that role to keep continuity, which sounds great in reality.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBeth: [one of our advisors] was nominated for an award for the work he did in the prison... did some really good work with the prison\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTheir work with schools and prisons has received national recognition, and their advisor has been nominated for a national award for their efforts. However, they are still facing challenges in helping young people in these settings to quit smoking. They believe measuring harm reduction is a better indicator of success among young people. Additionally, they have observed that children in affluent communities who smoke often come from families where one or both parents smoke or are separated. Their successful stop-smoking program within prison facilities has been nationally recognised, indicating success.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Adapting the service to meet the user\u0026apos;s needs.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe stop-smoking model aligns with UK policy initiatives advocating individual lifestyle changes, including the \u0026quot;Swap to Stop\u0026quot; campaign. In this disadvantaged community, promoting the individual lifestyle model is executed through face-to-face consultations, telephone consultations, and text messaging. Face-to-face consultations offer a distinct advantage, enabling comprehensive discussions and carbon monoxide testing to verify the quits. This personal interaction fosters a deeper understanding of the individual\u0026apos;s needs and enhances the program\u0026apos;s effectiveness, ensuring that each individual\u0026apos;s unique circumstances are considered.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn their commitment to inclusivity, the advisors strive to provide the same quality of service regardless of the mode of delivery. They recognise the limitations of telephone consultations and text messaging, which are available for some potential service users who cannot attend face-to-face consultations due to various social, economic, and health reasons. To overcome these limitations, the advisors offer all new service users a half-hour initial consultation and subsequent weekly fifteen-minute face-to-face consultations for existing service users who can attend or a fifteen-minute telephone follow-up or text messages for those who cannot attend in person. This flexible approach ensures that all service users can access the program and receive the support they need regardless of their circumstances.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDanielle: if they\u0026apos;re a new person to the service, they have a longer appointment, just like the half-hour slot they\u0026apos;re booked into. If they\u0026apos;re a regular, it\u0026apos;s just a fifteen-minute- follow-up telephone appointment.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdvisors aim to deliver consistent quality advice to all service users. Advisors explain that the quality of advice service users receive is the same regardless of the access mode.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDanielle: \u0026hellip; I am actually on telephone support, so that is obviously for the people who cannot attend for work or whatever commitments, so they are just booked into slots. We work our way through the list of people on telephone support. So, they still get the same kind of advice, and we still sort out prescriptions; it is just all done over the phone or by text while obviously in the one-to-one appointments is more in-depth, and also, we do a carbon monoxide testing so that is what we do when we see people face to face as well.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdvisors emphasised the importance of designing the programme around the user\u0026apos;s personal and social circumstances. They understand that some users may have difficulties accessing the service during typical working hours due to transport, work commitments or childcare. They found that telephone services are particularly useful for users who have work commitments.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFran: We try to ask why they wanted to stop. Once you have got the why, you discuss the smoking habits and work out their dependency on nicotine by doing the Fagerstrom test, and it\u0026apos;s just part of building a relationship with the person. It\u0026apos;s finding out how their day works, assessing what\u0026apos;s going on in their lives, whether they have family and friends\u0026apos; support or live alone and sit there with nothing else to do all day other than smoke. You can get an idea then of how difficult or possible the quits will be.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn line with the government\u0026apos;s swap-to-stop campaign, advisors present service users with various addiction treatment products, including swapping tobacco products with vaping. They revealed that a mismatch between individual and product could lead to noncompliance and damage clients\u0026apos; confidence.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAlice: it is important to match the products with the right patient; it\u0026apos;s got to be if somebody has something set in their mind, they will have that confidence in it; you try to steer them to something different if it\u0026apos;s not suitable for medical reasons.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome advisors have expressed reservations about promoting vaping.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBeth: I was always very weary of e-cigarettes because they weren\u0026apos;t tested. So, I would never want to recommend something that hasn\u0026apos;t been tested because I want to recommend something I would be happy and comfortable using. Now, because we\u0026apos;ve got the public health backing and we\u0026apos;ve got the testing on e-cigarettes, I\u0026apos;m quite comfortable to say to people, this is our guidance from public health; they are 95% less harmful than cigarettes, but we do not know about long-term use, so it is harm reduction.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe advisor observed that vaping is popular amongst the hard-to-reach population. Therefore, they must modify their messages from advising against its use to advising them to buy it from reputable sources.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBeth: Many people in our hard-to-reach communities like to vape, especially e-cigarettes, so it is just a matter of getting the message to them that you should go to a reputable seller, do not buy from cabins, and get them from reputable sellers.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn line with the government\u0026apos;s swap-to-stop campaign, advisors present service users with various addiction treatment products, including swapping tobacco products with vaping. Some advisors have reservations about promoting vaping but recognise its popularity among the hard-to-reach population and modify their messages to advise users to buy it from reputable sources.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study stands out for its unwavering commitment to the principles of health inequalities. It explicitly acknowledges that data collection and analysis were conducted with a laser focus on socioeconomic determinants of health inequalities. As a result, the findings represent our nuanced interpretation of the meanings participants ascribe to their experiences and practices in their respective contexts. The central argument of this study is that if the socioeconomic deprivation of communities significantly impacts smoking habits, then efforts to reduce smoking in this population should incorporate addressing the causes of neighbourhood deprivation. The argument is strategically framed around the crucial distinction between \u0026lsquo;upstream\u0026rsquo; interventions focusing on society, social institutions al or policy‐level determinants, such as income, education, housing, environment and crime, and \u0026lsquo;downstream\u0026rsquo; interventions focused on individual factors, increasing access to stop-smoking programmes, reducing attractiveness and limiting the availability of tobacco and vaping products\u0026nbsp;[54-60]. This distinction is key to understanding the multifaceted nature of smoking cessation strategies\u0026nbsp;[27,58,59,61]. This study\u0026apos;s findings are significant in the context of smoking cessation. It critically examined the limitations of downstream individual lifestyle-focused stop-smoking interventions in deprived communities. It underscored the importance of adopting upstream approaches to smoke cessation to address the broader determinants of smoking behaviour.[62].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe advisors\u0026apos; perspective on the smokers from deprived communities is illuminating. They characterised these smokers as entrenched, hardened, and hardcore and argued that addressing their unique and complex needs requires more than generic individual lifestyle stop-smoking skills. We interpreted their portrayal of a smoker from a deprived community, recognising the uniqueness of these individuals from any other smokers. This understanding acknowledges the impact of the social context in which smoking takes place as the primary factor influencing smoking, surpassing individual choice. We understood their assertion that the \u0026quot;\u003cem\u003erequires more than generic individual lifestyle stop-smoking skills\u003c/em\u003e\u0026rdquo; to mean that the socially context-oriented intervention would be more appropriate.\u0026nbsp;To our knowledge, no published studies have targeted socioeconomic determinants as part of a multifaceted cessation programme for smokers in deprived communities.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, advisors have noted that smokers often encounter challenges associated with poverty, including social isolation, inadequate housing, and financial difficulties. Previous research has concurred with these findings, indicating that factors such as employment status, housing conditions, poverty, and residential stability at the community level are independently associated with smoking.\u0026nbsp;[63-65].\u0026nbsp;Research has also shown that smokers experiencing financial stress are less likely to quit, and if they do quit, they are more likely to relapse\u0026nbsp;[65]. Siahpush\u0026apos;s study further illustrated that smokers experiencing stress are more likely to smoke more, leading to a sense of lack of control.[65]. Wilkinson and Pickett demonstrated that material deprivation can lead to low self-efficacy in quitting smoking or maintaining a smoke-free behaviour, reducing the likelihood of successful cessation\u0026nbsp;[65,66]. These issues may not be effectively addressed using traditional smoking cessation methods, and advisors trained in conventional behavioural change techniques may lack the necessary skills to implement interventions targeting the underlying causes of smoking. Considering the strong evidence demonstrating the protective effects of income against smoking, it would be advantageous to focus on structural approaches that address education and income in deprived communities.\u0026nbsp;[62,63,65,67-70].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study, advisors observed that individuals from disadvantaged communities often engage in multiple health-harming behaviours, such as smoking, alcohol misuse, and diet-related behaviours. Some of these behaviours may require more immediate attention than quitting smoking. For example, an advisor recalled a woman who spent the entire session discussing her plan to drink a bottle of vodka that evening. In this case, intervention to reduce the harmful effects of alcohol was more urgent than addressing smoking. However, advisors are more equipped to deal with smoking behaviour than alcohol harm reduction. This highlights the limitation of behaviour-oriented approaches; another arises as soon as one issue is addressed.\u003c/p\u003e\n\u003cp\u003eAdvisors deliver stop-smoking advice in traditional healthcare facilities such as GP practices, mental health centres, NHS acute hospitals and nontraditional facilities such as prisons, schools, councils, and lifestyle centres to reach communities needing these services. The goal is to bring stop-smoking programmes to those who most need them. This approach recognises that smoking cessation efforts have disproportionately benefited the least privileged groups, exacerbating inequalities [27]. This approach aligns with the principles of Julian Tudor Hart\u0026apos;s theory of inverse care law, which suggests that interventions may widen inequalities if they benefit advantaged groups more than disadvantaged groups [21,27]. By bringing stop-smoking support to underserved communities, we may reduce inequalities by providing greater benefits to disadvantaged groups[27].\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis article presented evidence indicating that behaviour-oriented interventions have resulted in a disproportionate decrease in smoking rates, with a more rapid decline in the least deprived areas compared to the deprived ones.\u0026nbsp;This disparity, known as the inverse care law, is a crucial concept that provides a clear framework for understanding these differences. By providing stop-smoking support in underserved neighbourhoods, we can potentially reduce inequalities by offering greater benefits to disadvantaged groups.\u003c/p\u003e\n\u003cp\u003eThe study emphasises the need for both behavioural and structural interventions to address smoking habits in deprived neighbourhoods. It highlights the impact of socioeconomic determinants on smoking behaviour and stresses the limitations of individual behaviour-focused stop-smoking interventions in these communities. The advisors suggest that addressing the unique and complex needs of smokers in deprived neighbourhoods requires interventions that consider the broader determinants of smoking behaviour, such as social context and material deprivation. It emphasises the need for collective action and structural reforms to address the social conditions contributing to smoking behaviours. The study suggests that the government\u0026apos;s efforts should focus on individual behaviour changes and consider the broader determinants of smoking behaviour. Targeted initiatives such as creating high-income job opportunities, improving education, providing training and skills development, increasing access to affordable housing, and implementing crime prevention measures are recommended to address the impact of neighbourhood deprivation on smoking habits. Overall, the study calls for a comprehensive approach that combines behavioural interventions with measures to address the underlying causes of smoking in deprived communities.\u0026nbsp;\u003c/p\u003e"},{"header":"6.\tLimitations","content":"\u003cp\u003eThe conclusions drawn relate only to the social and economic context of the participants in this study and, therefore, may not be generalised to the wider population or immediately applied in a different context. It must be acknowledged that there were six stop-smoking advisors in this local authority, and all agreed to participate in the interview. However, the experience of six advisors may not be generalised to the wider population.\u003c/p\u003e\n\u003cp\u003eThe methodology used in this study, interpretative phenomenology, is based on the idea that people discuss the essential experiences that are meaningful to them in their contexts. Consistent with interpretative phenomenology, we aimed to uncover the meanings that participants ascribe to their existence within their context. Therefore, the findings represent our nuanced interpretation of the meanings participants ascribe to their experiences and practices in their respective contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Faculty of Health and Social Care Research Ethics Subcommittee of the University of Chester provided ethical approval to conduct the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants have given consent to publish.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are not publicly available due to ethical restrictions and privacy of participant data but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors made the following contributions: conceptualisation MM; methodology MM; formal analysis MM, data collection EWA and MM; writing \u0026ndash; original draft preparation MM; review editing MM and JK, review final draft, MM, EWA JK, AY, LP, MT, NAN. \u0026nbsp;All authors agreed on the final version of the manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank all Warrington LiveWire Stop-smoking programme without their support, it would not have been possible to undertake the research. Special gratitude goes to the reviewers of this paper, who will have expended considerable effort on our behalf.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOffice for National Statistics. Adult smoking habits in Great Britain: 2014- Cigarette smoking among adults including the proportion of people who smoke including demographic breakdowns, changes over time, and e-cigarettes. Available online: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2014 (accessed on 28/03/2023).\u003c/li\u003e\n\u003cli\u003eOffice for National Statistics. Adult smoking habits in the UK: 2016- Cigarette smoking among adults including the proportion of people who smoke, their demographic breakdowns, changes over time, and e-cigarettes. 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Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening. \u003cem\u003ePLoS One \u003c/em\u003e\u003cstrong\u003e2021\u003c/strong\u003e, \u003cem\u003e16\u003c/em\u003e, e0251264, doi:10.1371/journal.pone.0251264.\u003cem\u003e\u003c/em\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"stop-smoking, disadvantaged communities, social context, community engagement","lastPublishedDoi":"10.21203/rs.3.rs-4542157/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4542157/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The successive UK governments have introduced measures to enhance access to stop-smoking services. However, these efforts have primarily focused on restricting access and promoting individual behaviour changes, overlooking the social conditions that contribute to smoking behaviours. While promoting individual behaviour changes can be beneficial, in the face of growing health inequalities, lasting change requires collective action and structural reforms. This research examines the limitations of individual-focused stop-smoking interventions in deprived communities. It provides a unique perspective by analysing practitioners' experiences promoting stop-smoking initiatives in a disadvantaged neighbourhood in northwest England. It underscores the significance of adopting comprehensive strategies for smoking cessation, drawing on practitioners' insights to address the broader determinants of smoking behaviour. These findings are crucial for understanding the complexities of smoking cessation in deprived communities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: The research used interpretative phenomenology to comprehensively analyse six lived experiences of stop-smoking advisors in Northwest England.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The analysis identified four overarching themes fundamental for delivering stop-smoking services in these communities:\u003c/p\u003e\n\u003cp\u003e1. Developing a skilled, confident, and culturally competent stop-smoking advice team\u003c/p\u003e\n\u003cp\u003e2. Understanding other complex social, mental, and physical health issues.\u003c/p\u003e\n\u003cp\u003e3. Bringing the stop-smoking programme to those who need it the most.\u003c/p\u003e\n\u003cp\u003e4. Adapting the service to meet the user's needs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: This article presented evidence indicating that behaviour-oriented interventions have resulted in a disproportionate decrease in smoking rates, with a more rapid decline in the least deprived areas compared to the deprived ones. The inverse care law theory provides a clear framework for understanding these differences. It emphasises the need for both behavioural and structural interventions to address smoking habits in deprived neighbourhoods, highlighting the impact of socioeconomic factors and the limitations of individual behaviour-focused stop-smoking interventions. The study calls for a comprehensive approach that combines behavioural interventions with measures to address the underlying causes of smoking in deprived communities.\u003c/p\u003e","manuscriptTitle":"Exploring the social context of smoking behaviours: insights from stop-smoking advisors in deprived communities in Northwest of England UK.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 18:37:03","doi":"10.21203/rs.3.rs-4542157/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-25T05:53:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-13T23:14:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-13T23:13:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-06-06T19:07:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"46d54050-0de7-4b50-ac20-aff1fced42bd","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T16:05:15+00:00","versionOfRecord":{"articleIdentity":"rs-4542157","link":"https://doi.org/10.1186/s12889-025-23110-7","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-05-23 15:57:25","publishedOnDateReadable":"May 23rd, 2025"},"versionCreatedAt":"2024-07-12 18:37:03","video":"","vorDoi":"10.1186/s12889-025-23110-7","vorDoiUrl":"https://doi.org/10.1186/s12889-025-23110-7","workflowStages":[]},"version":"v1","identity":"rs-4542157","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4542157","identity":"rs-4542157","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}