Dr. Aimee Grant aimee.grant@wales.nhs.uk

1. A qualitative exploration of NHS Stop Smoking Service clients’ experiences of Carbon Monoxide testing Dr. Aimee Grant aimee.grant@wales.nhs.uk Insert name of presentation on Master Slide

2. Overview • The use of CO testing • Parallels with other interventions • Research design • Findings • Taking the test • Impact of test results • Stigma and shame • Implications for practice Aimee.Grant@wales.nhs.uk

3. The use of CO testing in smoking cessation • Maudsley Model (Raw et al, 1998) • Russell Standard (West, 2005) • Objective measure; motivation • Part of many SSS (Michie et al., 2011) • 4 week quit (Michie et al., 2011) • NCSCT training (McEwan, 2012) Aimee.Grant@wales.nhs.uk

4. Parallels: weigh-ins • Commercial weight loss groups v NHS (Allan et al., 2010) • ‘surveillance’ (Darmon, 2012) • Leader as ‘judge’ • Use of stigma/shame • Some clients also shame others • benign intentions • Some clients desired/needed surveillance Aimee.Grant@wales.nhs.uk

5. Research design • Service evaluation • 23 clients randomly selected • Telephone interviews • quasi-Grounded Theory • CO identified as important to clients • Inductive and deductive Aimee.Grant@wales.nhs.uk

6. Taking the test • 7/23 described taking the test • Anxious (5/23) – ‘worried’ ‘terrified...I’m going be the worst’ ‘mortified when you get that first reading...’ • Poorly explained: ...we were all given all these breathing apparatus and (the advisor) didn’t seem to have a lot of patience, you know it was something I’d never done before but ...and that was rushed ... I didn’t expect (the test)... and I guess you know feeling rushed didn’t help but it was good to know the information how much carbon monoxide is in your body. (client 23, female, 57) • Interested (2/23) Aimee.Grant@wales.nhs.uk

7. Test results • All described their results • Belief test was objective (23/23) You know, you can’t fool the machine... (client 4, male, aged 58). • 22/23 – results were useful • ‘seeing’ health improvement • Rewarding abstinence • Preventing a lapse Aimee.Grant@wales.nhs.uk

8. Motivated by ‘seeing’ health improvement • Because you can't actually see that your health is improving, it's very subtle, isn't it?...And I may have added a couple of years to my life but you can't ever prove that and things like that but the CO2 readings were just sort of spot on, this week is much lower than last week and that was good (client 10, female, aged 34) • ...it was really good to see that you’re coming down - you can see yourself, you can almost see that you’re healthier, if you know what I mean, which is good...And I was also quite surprised how quickly it happened as well, I mean by week three I was classed as a non-smoker. (client 9, female, aged 32). • ...I like to see that what I’m doing is having an effect...You know, that’s not going to make up for the 25 years I smoked, but it’s going to show that from a health perspective there is an instant benefit. (client 22, male, aged 51). Aimee.Grant@wales.nhs.uk

9. Rewarded for continued abstinence • I thought, God, Christ, all that, you know, suffering through the week, you know, working hard at non-smoking...I’ve been struggling with it and then when I blew it through that I thought gosh, you know, it was worth it... (client 16, male, aged 58). • it’s definitely a boost to, I don’t know if ego boost is the right word but a morale boost, showing that you’ve done another week or a few days or whatever and showing that “Yes, I can do this!” (client 17, male, aged 36). Aimee.Grant@wales.nhs.uk

10. Responses to low scores • Pride • Satisfaction • Relief • Sharing with friends (external to group) Aimee.Grant@wales.nhs.uk

11. Other clients’ scores • All referenced at least one other clients’ score • Usually used to show that they were not the ‘worst’ client • Also found in poverty research • “othering” (Lister, 2004) Aimee.Grant@wales.nhs.uk

12. ‘Othering’ in smoking cessation • I mean one woman they actually said they didn’t know how she was still alive because her reading was so high and they said they’d never seen a reading that high before because it was in the 80s or something like that...And I think mine had started off on about six or seven because it has been a few days and then come the end it was like nought, one or two. (client 12, female, aged 28). • I was quite interested to see what my reading was and very relieved that it was quite low, very surprised at how high some of the other people’s were... (client 21, female, aged 53). Aimee.Grant@wales.nhs.uk

13. Testing and lapses • 1/23 lapsed • Determined not to again following CO test • Proactively prevented a lapse • Long lasting effects (1/23) • One client reported client was shamed and did not return following lapse • Issue if client has lapsed; may be shamed into non-return Aimee.Grant@wales.nhs.uk

14. Lessons for practice • Essential to explain CO testing (NCSCT, 2012) • Advisor as ‘judge’ • Acknowledge role of shame in testing • Manage levels of shame and stigma in those who lapse Aimee.Grant@wales.nhs.uk