Developing the evidence base for addressing inequalities and smoking in the United Kingdom.

AIMS: Smoking is an increasing cause of health inequalities in high-income countries. This supplement describes pilot projects set up in England to develop and test pathways to ensure that disadvantaged groups, where smoking is frequently the norm, are reached, encouraged and supported to stop their tobacco use. Target groups were: smokers attending centres set up for highly deprived parents; smokers with serious and enduring mental illness; pregnant smokers; prisoners/other offenders who smoked; South Asian tobacco chewers; and recent quitters from 'routine and manual' occupational groups.
METHODS: Commonalities observed across the six projects are summarized, alongside recommendations for implementation.
RESULTS: A significant barrier to implementation was the lack of mandatory identification of tobacco users across primary, secondary and community health-care settings and routine use of expired air carbon monoxide monitoring, particularly for high-risk groups. Appropriate use of financial incentives and national guidance is probably necessary to achieve both this and the adoption of 'joined-up' tobacco dependence treatment pathways for these target groups. Further research is needed on the impact of 'opt out' pathways: while resulting in increased referral rates, success rates were lower. In general, smoking cessation service targets were a barrier to implementation. Flexibility and tailoring of interventions were required and most projects trained those already working in relevant settings, given their greater understanding of target groups. Mandatory training of all frontline health-care staff was deemed desirable.
CONCLUSIONS: Implementing the findings of these projects will require resources, for training, incentivizing health-care workers and further research. However, continuing with the status quo may result in sustained tobacco use health inequalities for the foreseeable future.