Creating smoke-free environments: public and private places

Abstract

The purpose of the critical review is understood to be a critical reflection and comment on the work presented in the papers. The critical review is centred on the papers, as they form the substance of the submission, and the wider tobacco control literature. This review has not attempted to re-analyse the findings of the studies but attempts to draw wider lessons from the studies and to contribute to the future implementation of tobacco control policy and programmes. It will be claimed that the contribution to the research studies, the publications and the critical review represents a significant body of work and contribution to the advancement of knowledge in tobacco control. The aim of the thesis is to present and critically review six publications on the social de-normalisation of tobacco use, as it relates to public and private smoke-free environments and professional engagement in Scotland. The publications are treated as a coherent body of tobacco control research and draw upon three studies conducted over the period 1999-2007. Breathing Space Study 1: 1999-2002 evaluated an intervention which aimed to produce a significant shift in community norms towards non-smoking in a lowincome area. A process evaluation, as part of a quasi-experimental design, was undertaken in the intervention area, using a range of qualitative methods, including observation, in-depth interviews and focus groups. Papers 1 and 2 explore the context of health promotion professional practice in the development and implementation of tobacco control interventions in one disadvantaged community. The Qualitative Community Study 2: 2005-2007 aimed to explore the impact of the Scottish smoke-free legislation on attitudes and behaviour, at both individual and community levels, in four socio-economically contrasting localities in Scotland. A longitudinal qualitative evaluation was conducted using observation, in-depth interviews with smokers and ex-smokers, key stakeholders and focus groups. Papers 3 and 4 explore qualitative differences in the experience of smoke-free legislation in advantaged and disadvantaged communities, with particular consideration of the unintended consequences of the legislation for some smokers. The Smoke-free Homes Study 3: 2006-2007 aimed to describe changes in smoking behaviour and attitudes to smoking following implementation of the smoke-free legislation. It sought to identify the potential enablers and barriers to reducing SHS exposure in the home. A cross-sectional study was conducted using qualitative interviews. Papers 5 and 6 explore the changing discourses about second-hand smoke exposure, and the development of smoking restrictions in the home, with a particular focus on motivation to protect children. In addition, insight into the changing culture of professional practice in creating smoke-free homes was gained. Key findings A synthesis of key findings from these publications supports the identification of three major themes: the experience of power at each stage of the process of the social de-normalisation of tobacco use; the experience of stigmatisation of smoking as a consequence of policy; and health promotion practice as both barrier to and enabler of the implementation of smoke-free environments in the community and the home. The thesis also highlights the benefits and challenges of two research methodologies, process evaluation and qualitative longitudinal research (QLLR), in capturing both intended and unanticipated aspects of policy and practice implementation. This synthesis of the key findings that cut across the three studies has generated four research questions that are explored in this critical review: 1. How can policy be evaluated in community settings and in the home? 2. How do smokers, particularly disadvantaged smokers, engage with tobacco control policies and interventions? 3. Is professional practice a barrier or facilitator to understanding the impact of tobacco control policies and interventions? 4. What are some of the key unintended consequences of recent tobacco control policies? Conclusion This thesis contributes to knowledge through a critical account of the reshaping of smoking as a collective lifestyle, in both public and private domains. The social de-normalisation of tobacco use is experienced differently in advantaged and disadvantaged social contexts. Population tobacco control strategies may benefit from contextual adjustments, particularly for those smokers who live in areas of disadvantage and thus experience dual stigmatisation. Additionally, the effectiveness of future interventions would be enhanced by a more nuanced understanding of smoking behaviour, as a collective social practice, embedded in specific spaces, places and times.