This document provides guidance for implementing the preventive aspects of the National Service Framework for coronary heart disease at the local level. It focuses on interventions to promote healthier lifestyles through reducing smoking, improving diet and nutrition, increasing physical activity, and reducing overweight and obesity. The guidance covers developing a local strategy and suggested activities in key areas. Up to 43% of coronary heart disease may be attributable to high cholesterol, 35% to physical inactivity, 22% to smoking, and 17% to obesity. Evaluation of interventions is important to assess effectiveness and progress.

1. Coronary Heart Disease
Guidance for implementing the preventive aspects
of the National Service Framework

2. The Health Development Agency
The Health Development Agency (HDA) is a special health authority with a remit
to improve the health of people in England and in particular, to reduce
inequalities in health. It achieves this by:
• Working with key statutory and non-statutory organisations at national,
regional and local level
• Finding out what works and maintaining this evidence base
• Turning the evidence into action by building up the skills and capacity of
those working to improve the public’s health
• Advising on the setting of standards for public health planning and
practice.

3. Contents
iii
INTRODUCTION
Methods used to develop the guidance 1
Focusing on coronary risk factors 3
PREVENTION OF CHD THROUGH
PROMOTING HEALTHIER LIFESTYLES 5
Chapter 1: REDUCING SMOKING PREVALENCE 7
1.1 Introduction 7
1.1.1 The National Service Framework
for coronary heart disease 7
1.1.2 Benefits of smoking cessation for CHD 8
1.1.3 Trends in smoking 8
1.2 Objectives of interventions to reduce smoking 9
1.3 Features of effective interventions 9
1.4 Components of a local strategy 10
1.4.1 Develop smoking cessation services 10
1.4.2 Reduce smoking in public places
including workplaces 12
1.4.3 Support national media campaigns 13
1.4.4 Use media advocacy 13
1.4.5 Monitor the voluntary advertising ban 14
1.4.6 Reduce sales of cigarettes to children
under 16 years old 14
1.4.7 Encourage the introduction of smoking
policies in schools 14
1.5 Reducing inequity 15
1.5.1 Black and minority ethnic groups 15
1.6 Tables of suggested activities to support
local action
Intervention, Evidence, Outcome, Who could be involved?,
Skills and resources, Points to consider, Further information 17
1.7 References 21
Contents

4. Coronary heart disease: guidance for implementing the preventive aspects of the NSF
iv
Chapter 2: IMPROVING DIET AND NUTRITION 25
2.1 Introduction 25
2.2 Objectives of nutritional interventions 25
2.2.1 Professional knowledge and expertise 26
2.3 Features of effective interventions 27
2.4 Components of a local strategy 27
2.4.1 Schools 27
2.4.2 Local/community projects 28
2.4.3 Workplace 28
2.4.4. Healthcare 29
2.5 Reducing inequity 29
2.5.1 Black and minority ethnic groups 30
2.5.2 Children 30
2.6 Tables of suggested activities to support local action
Intervention, Evidence, Outcome,
Who could be involved?, Skills and resources,
Points to consider, Further information 31
2.7 References 40
Chapter 3: INCREASING PHYSICAL ACTIVITY 43
3.1 Introduction 43
3.2 Objectives of physical activity interventions 43
3.3 Features of effective interventions 44
3.4 Components of a local strategy 44
3.4.1 Healthcare interventions 44
3.4.2 Exercise referral schemes 44
3.4.3 Workplaces 44
3.4.4 Mass media 45
3.4.5 Schools 45
3.4.6 Older people 45
3.4.7. Physically active transport 46
3.5 Reducing inequity 46
3.6 Useful sources of information about community
based programmes 47
3.7 Tables of suggested activities to support local action
Intervention, Evidence, Outcome,
Who could be involved?, Skills and resources,
Points to consider, Further information 48
3.8 References 54

5. Contents
v
Chapter 4: REDUCING OVERWEIGHT AND OBESITY 57
4.1 Introduction 57
4.2 Objectives of weight management 58
4.2.1 Definitions of ‘lifestyle’ weight management
interventions 58
4.3 Features of effective interventions 59
4.3.1 Skills 60
4.4 Reducing inequity 60
4.5 Further information 61
4.6 Tables of suggested activities to support
local action
Intervention, Evidence, Outcome,
Who could be involved?, Skills and resources,
Points to consider, Further information 63
4.7 References 68
STRATEGY DEVELOPMENT 71
Chapter 5: DEVELOPING A LOCAL STRATEGY 73
5.1 Establishing a local CHD implementation team 73
5.1.1 Milestones and goals 73
5.2 Developing local delivery plans 73
5.3 Building effective partnerships 74
5.3.1 New freedoms to promote and support
joint working 74
5.3.2 Making the partnership effective 75
5.4 Involving local communities 75
5.4.1 Consulting local communities 76
5.4.2 Developing capacity 77
5.4.3 Engaging ‘excluded’ groups 77
5.5 Health needs assessment 77
5.6 Community profiling 77
5.7 Equity profiling 78
5.7.1 Audit of current provision 78
5.7.2 Personal and professional development audit 78
5.8 Monitoring progress 79
5.8.1 Developing local targets 80
5.8.2 Monitoring frameworks 82
5.9 Illustrative monitoring frameworks
5.10 Further sources of information 87
5.11 References 90
Appendix 91
Contributors 91
Glossary 93

6. Coronary heart disease is the biggest killer of men and women in this country. More than 111,000 people die from
this condition, and about 300,000 have heart attacks every year. The national service framework for coronary heart
disease (NSF CHD), which the government published in March 2000, is our blueprint for tackling this chronic disease.
This document is a key component of that blueprint.
The framework and The NHS plan describe a range of strategies to diagnose, treat and care for people who suffer
from heart disease, and also how to prevent it occurring in the first place. The health service must give people who
want to make changes to their lifestyles, the support and advice that they need. Effective interventions at an early
stage will not only reduce the immediate risks, but also slow down the progression of the disease, identify the early
symptoms and limit the incidence of death and long term incapacity.
This document explains how this is possible at local level. It provides evidence-based examples of effective interventions
for dealing with all the primary risk factors for heart disease – smoking, poor nutrition, physical inactivity, overweight
and obesity. It is, in effect, an early warning system for tackling heart disease.
I am confident that the document will help to transform prevention services throughout the NHS.
Alan Milburn
Secretary of State for Health
Foreword by the Secretary of State for Health
i

7. The prevention of coronary heart disease (CHD) is a
government priority. The white paper Saving lives: our
healthier nation [Department of Health (DH) 1999] set a
target of reducing the death rate from heart disease,
stroke and related conditions by 40% in those aged
under 75 years by the year 2010. CHD is common,
frequently fatal and largely preventable. The burden of
heart disease is higher, and has fallen less in the UK than
many other countries. It is the leading cause of death,
killing over 110,000 people in England in 1998,
including more than 41,000 under the age of
75 years (DH 2000a).
The recently published NHS plan reinforces CHD
as a clinical priority and focuses on preventive
aspects of the disease. The Plan emphasises the
importance of the NHS role of working in
partnership with others to address health
inequalities (DH 2000b). The plan highlights the
importance of the NSF CHD which, for the first time,
sets out national quality standards for preventive
and clinical services.
The HDA, at the request of the DH, has developed this
guidance. It is intended to assist local implementation
teams [health authorities (HAs), primary care groups
(PCGs) and primary care trusts (PCTs), local authorities
(LAs) and other local stakeholders] in developing their
approaches to addressing the preventive aspects of the
NSF CHD. It therefore relates to Standards 1, 2, 3, 4
and 12 (see Box on the next page). The guidance
should be read in conjunction with the NSF CHD
main report (DH 2000c), Chapter 1 of the NSF (DH
2000a) and relevant sections of Chapter 2
(DH 2000d) and Chapter 12 (DH 2000e). The HDA’s
Health update: coronary heart disease and stroke
provides useful information on trends and risk
factors (HDA 2000).
The guidance covers strategy development and
interventions to promote CHD-related healthier
lifestyles (smoking, nutrition, physical activity and
weight management). In the strategy section,
approaches that should underpin all health
improvement work are covered briefly and further
information is signposted where available. In the
sections on risk factors, key objectives are presented
that will contribute to CHD prevention together with
an overview of effective approaches that will promote
healthier lifestyles. In addition to CHD, the risk factors
and the strategies listed in this resource will also
have a significant impact on other initiatives in public
health, such as The cancer plan, the forthcoming
NSF for older people and the NSF on diabetes.
A range of interventions to be developed locally is
suggested, involving a range of players in a variety
of settings, which could link with other local initiatives.
This work is evolving and represents the first stage of
support for those working on preventive aspects of
the NSF CHD at a local level (see box on next page).
The HDA welcomes comment on this document
and suggestions on how to improve the guidance.
Please contact Karen Ford (karen.ford@hda-online.org.uk)
or Hilary Whent (hilary.whent@hda-online.org.uk)
at the HDA.
Methods used to develop the guidance
A range of research and expert opinion has been drawn
upon in preparing this report. Systematic reviews and
literature reviews have been scanned, and literature
searches and consultation with expert informants have
been carried out. Some 65 critical readers were sent a
first draft of this document and amendments were made
in the light of their comments.
Introduction
Introduction
1

8. The HDA takes a broad approach to evidence, valuing a
range of research methods, which contribute to the
multidisciplinary nature of health improvement work.
Implications from the research evidence have been drawn
out and recommendations for local action are made.
Gaps in the evidence base have been highlighted.
A broad front approach: upstream and
downstream
The government recognises the socio-economic
influences on population health. In its strategy to improve
public health, it identifies the complex
interaction of causes of poor health, and
recommends action right across government to
reduce social inequalities in health (DH 1999). The
government’s strategy is informed by the evidence
from the Independent Inquiry into Inequalities in
Health, chaired by Sir Donald Acheson (Acheson
1998). This recommended that a broad front
approach be taken to tackle the underlying,
root causes of inequalities in health. The
inquiry reported that policies to improve
health are needed both ‘upstream’ and
‘downstream’.
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
2
Preventive aspects of the National Service Framework
Reducing heart disease in the population
Standard 1
The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of
coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.
Standard 2
The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the general population.
Milestones: pages 20–21 of NSF CHD (DH 2000c)
Prevention of coronary heart disease in high risk patients in primary care
Standard 3
GPs and primary care teams should identify all people with established cardiovascular disease and offer them
comprehensive advice and appropriate treatment to reduce their risks.
Standard 4
GPs and primary care teams should identify all people at significant risk of cardiovascular disease but who have not
yet developed symptoms and offer them appropriate advice and treatment to reduce their risks.
Milestones: pages 25–26 of NSF CHD (DH 2000c)
Cardiac rehabilitation
Standard 12
NHS trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to
hospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme of
secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of
subsequent cardiac problems and to promote their return to a full and normal life.
Milestones: pages 54–55 of NSF CHD (DH 2000c)

9. 3
‘For instance, a policy which reduces inequalities in
income and improves the income of the less well
off, and one which provides pre-school education
for all four year olds are examples of “upstream”
policies which are likely to have a wide range of
consequences, including benefits to health. Policies
such as providing nicotine replacement therapy on
prescription, or making better facilities for taking
physical exercise, are “downstream” interventions
which have a narrower range of benefits’ (Acheson
1998).
This guidance document fully endorses this approach
to improving health.
Where evidence is available on the impact of
upstream policies, it is reported. However, for the
most part, there is greater evidence of the impact of
downstream policies. There are more reported studies
of interventions aimed at individuals (lifestyle and
health related behaviours) than there are of
policies that seek to influence the broader
determinants of CHD.
This preponderance of research aimed at assessing
the effectiveness of downstream policies should not be
seen as evidence that downstream policies are more
effective than upstream policies. It simply reflects the
fact that downstream policies tend to be more amenable
to research efforts that seek to assess the effectiveness
of interventions.
Focusing on coronary risk factors
‘... by April 2001 all NHS bodies, working closely
with local authorities will have agreed and be
contributing to the delivery of local programmes
of effective policies on:
a) reducing smoking
b) promoting healthy eating
c) increasing physical activity
d) reducing overweight and obesity’
(DH 2000c, page 57; DH 2000a, page 18)
The NSF CHD focuses on three main lifestyle behaviours
that are associated with risk of CHD: smoking,
physical activity and diet. It also focuses on obesity,
which is associated with both these last two factors,
and is also independently associated with some
increase in CHD risk. In addition, there is now strong
evidence that a moderate intake of alcohol reduces
the risk of CHD, but an excessive alcohol intake
increases the risk.
Quantifying the impact of risk factors
on CHD
It is hard to give figures for the proportion of CHD that
could be prevented if lack of physical activity, poor diet
(high fat, low fruit and vegetables) and smoking were
successfully eliminated. This is because many people with
heart disease have multiple risk factors, and it is hard to
disentangle the separate effects. The American Public
Health Association did make an attempt at such an
estimate (Smith and Pratt 1993) and the results are
shown in the box below. A similar modelling exercise in
the UK would be expected to produce slightly different
findings because more of the UK population are smokers,
while fewer are obese. However, the information is useful
in giving some indication of the relative importance of
these risk factors in terms of the potential for making an
impact on CHD rates.
In the following sections, information is presented about
effective interventions, which aim to bring about change
in these risk factors. Implications are drawn from the
evidence and suggestions are made for local action at a
number of levels, involving a range of players and linking
to other local initiatives. Further information sources are
also signposted.
The gaps have been identified in the evidence base.
There is an urgent need for more and better designed
evaluations of interventions aiming to improve health and
well being and the dissemination of results. Evaluation is
Introduction
Proportion of CHD attributable to various
modifiable risk factors in the USA
Risk factor Best estimate Range
% %
Cholesterol >200 mg/dl 43 39–47
Physical inactivity 35 23–46
Cigarette smoking 22 17–25
Obesity 17 7–32
Source: Smith and Pratt (1993)

10. a planned set of activities, which helps people to see
how work is progressing and whether or not it is
effective. It should be seen as an integral part of projects
and programmes. Evaluation requires relevant skills and
it is worth considering making links with local researchers
(within the NHS, LAs and academic institutions). There
are many approaches to evaluation and sources of support
are listed on p89.
References
Acheson, D., 1998. Independent inquiry into inequalities in health.
London: The Stationery Office.
DH, 1999. Saving lives: our healthier nation. London: The Stationery Office.
DH, 2000a. National service framework for coronary heart disease:
Chapter 1. Reducing heart disease in the population. London: DH.
DH, 2000b. The NHS plan. A plan for investment. A plan for reform.
London: The Stationery Office.
DH, 2000c. National service framework for coronary heart disease: main
report. London: DH.
DH, 2000d. National service framework for coronary heart disease,
Chapter 2. Preventing coronary heart disease in high risk patients.
London: DH.
DH, 2000e. National service framework for coronary heart disease:
Chapter 12. Cardiac rehabilitation. London: DH.
HDA, 2000. Health update: coronary heart disease and stroke.
London: HDA.
Smith, C. and Pratt, M., 1993. Cardiovascular disease. In: R. Brownson,
P. Remington and J. Davis, eds. Chronic disease epidemiology and
control. Washington: American Public Health Association.
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
4

11. 1.1 Introduction
Smoking is the cause of one out of every seven deaths
from heart disease (nearly one in four deaths among men
and one in 10 among women). Nine in 10 deaths from
lung cancer among men and nearly three in four among
women are estimated to have been caused by smoking –
84% of all lung cancer deaths. Among those aged under
65 years, two in five deaths from stroke were caused by
smoking. Smoking is also linked to many other serious
conditions, including asthma and other respiratory
illnesses, cataracts, peripheral vascular disease,
periodontal disease and brittle bone disease (Callum
1998). Treating the illnesses and diseases caused by
smoking is estimated to cost the NHS up to £1.7 billion
every year (Raw et al. 1998).
Passive smoking – breathing in other people’s tobacco
smoke – is also a major cause of mortality and morbidity.
It contributes to death from heart disease and a range of
other health problems (Royal College of Physicians 1992).
In December 1998, the Government’s first-ever white
paper on tobacco, Smoking kills, set three targets, for
adults smoking, smoking during pregnancy and children
smoking (DH 1998a).
• To reduce adult smoking in all social classes so that
the overall rate falls from 28% to 24% or less by
2010, with a fall to 26% by the year 2005. In terms of
today’s population, this would mean 1.5 million fewer
smokers in England.
• To reduce the percentage of women who smoke
during pregnancy from 23% to 15% by the year 2010,
with a fall to 18% by the year 2005. This will mean
approximately 55,000 fewer women in England who
smoke during pregnancy.
• To reduce smoking among children from 13% to
9% or less by the year 2010, with a fall to 11%
by the year 2005. This will mean approximately
110,000 fewer children smoking in England by
the year 2010.
The cancer plan published in September 2000
introduces new national and local targets to
address inequalities in smoking rates between
socio-economic groups. At a national level the
target is:
• To reduce smoking rates among manual groups from
32% in 1998 to 26% by 2010 (DH 2000a).
1.1.1 The National Service Framework
for coronary heart disease
The NSF CHD (DH 2000b) states that ‘by October
2000 HAs, LAs, PCGs/PCTs and NHS trusts will have
set up, or have firm plans in place [for a range of NHS
smoking cessation services which will enable national
and regional targets for the numbers of smokers
quitting to be met]. By April 2001, HAs, LAs, PCGs/PCTs
and NHS trusts will have agreed and be contributing to
the delivery of the local programme of effective policies
on reducing smoking; as an employer, have implemented
a policy on smoking and be able to refer clients/service
users to specialist smoking cessation services, including
clinics …’
The immediate priorities for implementing the smoking
cessation area of the NSF CHD are:
• By April 2001, health authorities will introduce
specialist smoking cessation clinics, helping 150,000
people
Chapter 1
Reducing smoking prevalence
Reducing smoking prevalence
7

12. • Delivering the early milestones set out in Chapter 1 of
NSF CHD: Reducing heart disease in the population
(DH 2000b).
The requirements of smoking cessation are
detailed in Appendix A, Chapter 1 of NSF CHD: Reducing
heart disease in the population (DH 2000b).
1.1.2 Benefits of smoking cessation for CHD
The costs and benefits of smoking cessation are well
established (Raw et al. 1998).
• Reductions in smoking prevalence are guaranteed
to bring population health gains (Raw et al. 1998;
US Department of Health and Human Services 1990).
• Smoking cessation reduces the risk of dying from
smoking related diseases.
Smokers have about twice the risk of dying from
CHD compared with lifetime non-smokers. This
excess risk is reduced by about half among ex-
smokers after only one year of abstinence and
declines gradually thereafter. After 15 years of
abstinence, the risk of CHD is similar to that of
people who have never smoked (Tang et al. 1992).
Smoking cessation is particularly important in the
secondary prevention of CHD. In smokers with
existing CHD, the risk of premature CHD mortality
can be reduced by 50% or more on giving up (US
Department of Health and Human Services 1990).
• Reductions in smoking prevalence will produce sizeable
reductions in common hospitalised events and costs
(Naidoo et al. 1999).
• The cost savings that can be made through moderate
success in smoking cessation programmes are
significant and cumulative (Naidoo et al. 1999).
1.1.3 Trends in smoking
Adults
The prevalence of smoking in the UK over the past 20
years or so has fallen. In 1998, 27% of adults aged
16 years and over smoked cigarettes compared with 40%
in 1978. However, most of this decline occurred in the
1970s and 1980s. In the 1990s, the decline in smoking
prevalence among adults levelled off (DH 2000c).
The prevalence of smoking is higher among people in
manual than non-manual social classes (32% compared
with 21% in 1998). The widening of this gap over the
past 20 years reflects a steeper decline in smoking
prevalence among non-manual classes compared with
manual classes (DH 2000c).
The social class differentials in smoking are reflected in
the social gradients of deaths caused by smoking. The
percentage of deaths from ischaemic heart disease
caused by smoking ranges from 39% for men aged
35–64 years in social classes I–II to 49% of those in
classes IV–V. For women aged 35–64 years the figures
range between 35% for classes I–II to 46% for
classes IV–V (Callum 1998).
Pregnant women
The proportion of women who smoke during pregnancy
has fluctuated over the past eight years (Owen et al. 1998;
Owen and Penn 1999). In 1999 nearly a third of women
(30%) smoked during pregnancy compared with 27% in
1992. Among young pregnant women (aged 16–24 years)
from social groups C2DE (similar to manual and unemployed
classes), the percentage is even higher, with 51% smoking
during pregnancy in 1999 (Owen and Penn 1999).
Teenagers
In 1999, an estimated 9% of children aged 11–15 years
smoked cigarettes (DH 2000c). This figure has varied
considerably over time, showing a low of 8% in 1988
and a high of 13% in 1996 (DH 2000b). As the majority
of smokers take up the habit in their teens, any increases
in the rates of young smokers will eventually feed
through into adult smoking rates.
Black and minority ethnic groups
Cigarette smoking among minority ethnic groups is
generally less than among the UK population as a whole
(28%1). However, a more detailed examination reveals
important differences between and within groups. The
smoking rate among Bangladeshi men is very high (49%).
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
8
1Differences between the HEA (1999a) and DH (2000c) surveys in
timing and methodology most likely account for the 1% difference in
the estimates of the percentage of adults who smoke.

13. This same group of men also has high rates of chewing
tobacco products. Smoking rates are even higher among
middle-aged and older Bangladeshi men (54% and 70%
for men aged between 30–49 and 50–74 years,
respectively). Smoking rates among African-Caribbean
men and women resemble, and sometimes exceed, the
rates for the UK population as a whole. Smoking rates
among African-Caribbean women are higher for younger
women [Health Education Authority (HEA) 1999a].
Poverty and smoking
Traditional measures of social class tend to underplay the
extent to which smoking has become concentrated in the
poorest sections of society. Recent studies have shown
that smoking levels have remained virtually unchanged
among those in the poorest groups, and among lone
mothers smoking levels have risen (Marsh and McKay
1994; Dorsett and Marsh 1998; Jarvis 1998). In a detailed
study, lone parents living in rented accommodation and
relying on social security benefits were found to have
smoking levels in excess of 75% (Dorsett and Marsh 1998).
1.2 Objectives of interventions to reduce
smoking
The importance of a comprehensive approach has long
been recognised (WHO 1979). As well as approaches
aimed at the individual, there has been a recognition of
the need for policy and legislative measures and social
and environmental initiatives as essential components of
any strategy to reduce tobacco use (WHO 1998). Ideally,
each component of such a comprehensive strategy would
encompass the following objectives:
• Promote quitting (not cutting down) among adults and
young people
• Reduce exposure to environmental tobacco smoke
• Create a social environment that is supportive of
non-smoking and cessation.
In the context of reducing smoking among adults, a
secondary objective could include strategies to prevent
the uptake of smoking among young people. However,
it is important to note that there is little evidence that
teenage strategies, especially in the absence of adult
strategies, have any impact on the uptake of smoking
among children (Reid 1996; Hill 1999).
Local strategies to reduce smoking prevalence should
reflect the policies and population groups set out in the
white paper on tobacco Smoking kills (DH 1998a), The
NHS plan (DH 2000d, Chapter 13), NSF CHD (DH 2000b)
and The cancer plan (DH 2000a).
Local strategies should also include an alliance of NHS,
local government, education and commercial interests,
as well as voluntary agencies, to help reduce smoking
and to provide information on smoking by using local
media, creating local activities and promoting debate to
generate interest. Some areas of the country already
have smoking alliances. These cover about 60% of the
population of England and are supported by the DH.
1.3 Features of effective interventions
A comprehensive approach – combining community wide
approaches with economic and regulatory measures –
was identified by the US Surgeon General as the
strategy most likely to have the greatest long-term,
population impact (US Department of Health and
Human Services 2000). Educational and clinical
approaches were considered to be of greater
importance in helping individuals resist or abandon
the use of tobacco.
Community wide approaches typically involve a range
of agencies including health services, voluntary agencies,
the media (paid and unpaid), as well as government and
local authorities (see 5.3, Building effective partnerships,
p74). Together, they undertake a range of activities such
as direct smoking cessation, helplines, training and
resources for health professionals, development of
policies to reduce smoking in public places, media
campaigns and advocacy, reducing sales to minors and
work in schools. Overall, community interventions seek to
influence both individual behaviour and the environmental,
social and cultural conditions that affect tobacco use
(Lantz et al. 2000).
The impact of a comprehensive approach is difficult to
evaluate, especially given the potential for individual
components to work synergistically to produce
combined effects (Chapman 1993; US Department of
Health and Human Services 2000). For example, the
effectiveness of school based programmes appears to
be enhanced when they are included in broad based
community interventions (Lantz et al. 2000). Nevertheless,
Reducing smoking prevalence
9

14. studies that have sought to measure the effects of a
comprehensive approach have yielded encouraging
results (US Department of Health and Human Services
2000; Lantz et al. 2000; Sowden and Arblaster, 2000a,b;
Wakefield and Chaloupka 2000).
It is accepted that population-wide approaches should aim
to reduce both adult and teenage smoking. But where should
the emphasis lie? Experts agree that teenage smoking rates
are unlikely to decline in the absence of a fall in adult rates.
The view that smoking among adults should therefore be
tackled ahead of teenagers was discussed by Hill (1999)
in a recent article. His argument is fivefold:
• First, reducing smoking among adults will lead to a
quicker and bigger reduction of tobacco related
harm, because there is a higher level of smoking
related mortality and morbidity among adults than
teenagers
• Second, reducing smoking among adults will provide
protection to the unborn and recently born against
exposure to direct and indirect tobacco smoke
• Third, quitting by adults (especially by parents) reduces
the likelihood of children taking up smoking
• Fourth, while there are clear ethical reasons for
educating children about what is the largest
preventable cause of death, beyond this, the methods
of delivering interventions are fraught with practical
problems and the evidence of effectiveness of
interventions aimed at young people is poor
• Finally, the fact that the tobacco industry itself
supports antismoking campaigns targeted at teenagers
should be taken as a warning signal: ‘Even Phillip
Morris was confident that [antismoking] youth
campaigns could do them little damage’ (Hill 1999).
1.4 Components of a local strategy
1.4.1 Develop smoking cessation services
• The health improvement programme (HImP) should
emphasise the importance of an integrated service
including primary care advice, specialist smoking cessation
clinics, one-to-one cessation advice [Health Service Circular
(HSC) 1998, 1999; Action on Smoking and Health
(ASH) 2000a,b]. The requirements for smoking cessation
are detailed in Appendix A, Chapter 1 of NSF CHD:
Reducing heart disease in the population (DH 2000b).
• Build upon and develop these guidelines for local
cessation services.
• Provide special services for pregnant women.
The NHS plan (DH 2000d) states that ’the specialist
smoking cessation services will focus on heavily
dependent smokers needing intensive support, and on
pregnant smokers as part of antenatal care. Primary care
groups will take the lead in commissioning – and where
appropriate providing – these services’. In support of the
smoking cessation treatments bupropion is now available
on prescription and The NHS plan recommends that
nicotine replacement therapy (NRT) should also be made
available on prescription. These services followed
evidence based guidelines for smoking cessation
published in December 1998 (Raw et al. 1998). These
guidelines have been updated and will be available in
December 2000. The Committee on Safety of Medicines
will consider whether NRT can be made available for
general sale. An evaluation of the first year of the
development of the national cessation services has
recently been published (Adams et al. 2000).
At a meeting of smoking cessation experts held in July
2000, it was agreed that the smoking cessation services
should offer support to all people who request it. The
focus on particular groups could be achieved through
recruitment to the services – for example by engaging
midwives or promoting the services at antenatal classes
(ASH 2000a,b; http://www.ash.org.uk/?cessation). The
meeting, with representation from the DH, identified a
model approach to smoking cessation services in primary
care, which also sought to provide clarification on the role
of intermediate cessation services. Discrepancies in the
guidelines concerning intermediate services had caused
confusion in some health action zones (HAZs) (Adams et
al. 2000). Both intermediate services and specialist clinics
have been subsumed in the model by the term ‘qualifying
specialist services’ for which a minimum standard of
service to the smoker has been set and for which the
centrally provided smoking cessation budget may be used.
The model of the service is set out in Figure 1 on facing
page. For full details and further guidance see:
http://www.ash.org.uk/?cessation
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
10

15. Model of the service to the smoker
Each smoker contacting the NHS should be offered a
package of both pharmaceutical aids and behavioural
support that meets their particular needs and circumstances.
Given restrictions on who can prescribe drugs, and
limitations on the extent to which those who may
prescribe are able to offer support, it will not always be
possible to provide a ‘one-stop shop’. The aim must be to
make access to drugs and support as straightforward as
possible. The elements of the support package include:
• Influences on smokers’ motivations to quit, including
advice from primary care professionals, national
campaigns, No Smoking Day and manufacturers’
advertising
• Brief opportunistic interventions by the GP and other
primary care professionals
• Prescribing pharmacotherapies: NRT and bupropion
(Zyban)
• Behavioural support. This will need to be tailored to
match the circumstances of the smoker, but the range
of options includes:
Referral to a ‘qualifying’ specialist service – these
would qualify for funding from the smoking
cessation budgets if they offered a certain
minimum service standard
Discussion of other support options (eg telephone,
self-help) that the smoker could consider, if he/she
chose not to attend a qualifying specialist service.
Reducing smoking during pregnancy
For pregnant women, pregnancy specific materials are
more cost effective than less specific, cheaper, standard
information because of their greater effectiveness (Buck
and Godfrey 1994). The intensity of the intervention also
affects outcome. While there is some evidence of the
effectiveness of advice when literature is coupled with
follow up, more intensive interventions (eg a structured
Reducing smoking prevalence
11
Figure 1. Configuration of smoking cessation support services.

16. cessation course based on self-help booklets) provide
stronger evidence (Raw et al. 1998). Public education
campaigns may be effective in shifting pregnant women’s
attitudes and behaviour (Campion et al. 1994). The
difficulties of advising outright cessation in pregnancy has
led some health professionals to suggest cutting down as
an alternative. However, there is little evidence to show
that cutting down is of any health benefit (Raw et al.
1998). Thus quitting as opposed to cutting down needs
to be emphasised.
Many women who do stop smoking in pregnancy go
back to smoking after the birth of the baby. In one
American study over half (56%) of women who stopped
during pregnancy were smoking within one month of the
birth (Secker-Walker et al. 1995). Relapse prevention
interventions with pregnant women and women who
have recently given birth are needed.
• All those responsible for providing antenatal care
should ensure that relapse prevention is included as
a component in the smoking cessation service.
The lower rate of cessation associated with mothers
from lower socio-economic groups, led the Scientific
Advisory Group on Inequalities to conclude that
‘interventions that target the individual behaviour
alone may not be sufficient ... broader policies to
combat inequality are also required’
(Acheson 1998).
Further information on smoking and pregnancy can be
obtained in the following reports:
• Smoking and pregnancy: a survey of knowledge,
attitudes and behaviour 1992–1999 (Owen and Penn
1999)
• Smoking and pregnancy: guidance for purchasers and
providers (HEA 1994a)
• Helping pregnant smokers quit: training for health
professionals (HEA 1994b)
• Smoking and pregnancy: developing a
communications strategy for cessation (Owen
and Bolling 1996)
• Smoking and pregnancy: a growing problem (HEA
1996a).
Mechanisms for delivering cessation services for young
people are outlined in the document Smoking cessation
in young people: should we do more to help young
people quit? (HDA 2000a).
1.4.2 Reduce smoking in public places
including workplaces
Restricting smoking is important not only for limiting the
public’s exposure to toxins in sidestream smoke, but also
for broader policy reasons. First, it puts smoking in a
broader context than one of personal choice and personal
risk and legitimises it as a social problem; second, it may
be the source of litigation against employers or businesses;
and third, the spread of smoking restrictions reduces the
opportunities to smoke and thus reduces consumption
(Borland et al. 1991; Brenner and Mielck 1992; Marcus et
al. 1992; Wakefield et al. 1992; Jeffery et al. 1994;
Glasgow et al. 1997; Brauer and Mannetje 1998).
The Health and Safety Executive (HSE) has been
examining current practice on restricting smoking at work
with a view to issuing an Approved Code of Practice (ACoP).
There are potential legal liabilities for employers who do
not address passive smoking in the workplace. Employees
have recourse to civil law, contract and employment law
and the general provisions of the Health and Safety at
Work Act (1974). The ACoP will clarify the legal position
for both employers and employees, and enable LA
environmental health officers (EHOs) to intervene.
Local plans should include objectives to:
• Ensure that all local hospitals have smoking policies
(DH 1998a; HEA 1999b), and that these are fully
implemented
• Implement policies to restrict smoking in public places
[Scientific Committee on Tobacco and Health (SCOTH)
1998]
• Encourage restaurants, bars and other leisure facilities
to provide smoke free areas.
Many employers now find an advantage in smoking
restrictions through savings on sickness absences,
increased productivity, lower insurance and cleaning
costs. The checklist in Box 1.1 will help managers of
workplaces to develop an effective strategy on smoking.
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
12

17. Further information
For examples of case studies of effective practice within
the NHS see Tobacco control policies within the NHS:
case studies of effective practice (HDA 2000b). For further
information on developing, reviewing and amending
tobacco control policies, see Been there, done that: revisiting
tobacco control policies in the NHS (HEA 1999b). Sample
policies and consultation questionnaires can be found in
Smoking policy for the workplace: an update (HEA 1999c)
and Towards tobacco-free environments: guidelines for
local authorities (HEA 1999d). Also see the ASH website:
http://www.ash.org.uk
1.4.3 Support national media campaigns
Mass media campaigns can influence smoking behaviour
(DH 1998a; Lantz et al. 2000; Sowden and Arblaster
2000a,b) and may be especially appropriate for reaching
those who are less educated (Mackaskill et al. 1992) and
those in poor communities (Jenkins et al. 1997). Message
content and the intensity and duration over which the
messages are delivered appear to be important factors in
determining the impact of mass media campaigns (Grey
et al. 2000; Lantz et al. 2000).
Media campaigns should focus predominantly on adults,
since the majority of cigarettes (>95%) are consumed by
adults and adult smokers are a major factor influencing
the uptake of smoking by minors.
Local media may be used to raise the profile of national
campaigns (No Smoking Day). For ideas in planning local
media campaigns see:
http://www.no-smoking-day.org.uk/campaign.htm
Tel: 020 7916 8070.
• Local plans should include links to the network of local
smoking control alliances in England.
1.4.4 Use media advocacy
There is some evidence that the use of media advocacy
(see Box 1.2) may affect tobacco consumption (Buck and
Godfrey 1994), but its major role is in social marketing.
This involves shaping the media agenda, prompting policy
changes and influencing the social norms around
smoking (Reid et al. 1992). Media advocacy techniques
Reducing smoking prevalence
Box 1.1 Management checklist for a
smoking policy
• Review current situation.
• Assess need, capacity to change.
• Make sure you consult with everyone.
• Seek feedback, not permission.
• Decide on the policy details.
• Decide on a total or partial ban.
• Decide what restrictions to impose if a total ban
is not possible.
• Communicate final decisions clearly to all staff.
• Label smoking and smoke-free areas.
• Monitor and review the policy.
Source: HEA (1999c)
Box 1.2 Checklist for setting up local
media advocacy work
First think about the following points:
• What you hope to achieve
• Who your campaign is aimed at
• How much you think it will cost
• How it will be supported by local activity and
action
• How you plan to evaluate it (have you achieved
what you hoped?).
Create a media plan:
• What stories or angles will attract the media?
• What information is needed for a newsworthy
press release?
• Draw up a media list – names and contact
numbers of relevant journalists
• Find out the deadlines for media you are
targeting
• Find out how media contacts want you to
communicate with them (press release, direct
contact)
• Decide who will act as spokespersons
• Coordinate media schedules with partners who
may also be using the media
• If the campaign is a long one, create a media
calendar to ensure a constant supply of news
items.
13

18. may be especially effective with poor communities
(Jernigan and Wright 1993) since low income groups,
including smokers, are high consumers of TV.
For further guidance on media advocacy and factors that
influence its effectiveness, see An investigation into the
potential of media advocacy as a health promotion
strategy (HDA in press).
1.4.5 Monitor the voluntary advertising ban
Indirect marketing of cigarette brands is the growing and
preferred marketing strategy of the tobacco industry,
perhaps in response to threats of advertising restrictions.
Until legislation is introduced, the existing ‘voluntary
agreements’ on tobacco promotion should continue to
be monitored locally, not so much because these
restrictions have been found to be effective in preventing
uptake of smoking, but because infringement of the
rules offers opportunities for media advocacy. Those
provisions include, for example, banning advertising on
billboards near schools and promotions in magazines for
young people.
People working locally should be vigilant in monitoring any
new marketing strategies, for example, using events at
discos, student functions and the Internet to promote brands.
1.4.6 Reduce sales of cigarettes to children
under 16 years old
Combining regular test purchasing with a high profile
media approach has been found to be successful in
reducing the incidents of reported sales of cigarettes to
people under 16 years of age. Overall, the evidence of
effectiveness of sales restrictions suggests that vigorous
local enforcement of the law forbidding sale of tobacco
to under-16s can reduce sales (Stead and Lancaster
2000). This strategy has also been shown to have a
small delaying effect on the uptake of smoking among
children. There is little evidence, however, to suggest that
it has any effect on the uptake of smoking among
children. Considerable resources are required, both in
terms of trading standards officers’ and court time.
The existing law is not being applied effectively (DH
1998a). The Local Government Association and Local
Authorities Co-ordinating Body on Food and Trading are
developing a new enforcement protocol to address this.
Features of the protocol are listed in Box 1.3.
Proof-of-age card schemes have been developed, but the
government recommends that a single system be agreed. The
vending machine trade association, the National Association
of Cigarette Machine Operators, has produced a new,
stricter code for its members to clarify siting arrangements
and monitoring for vending machines (DH 1998a).
1.4.7 Encourage the introduction of
smoking policies in schools
A formal, well publicised school policy on smoking
reinforces non-smoking as the norm in society, supports
health messages in the curriculum and may have
positive effects on smoking levels among pupils, staff
and all adult users of the premises (see Box 1.4).
Additional potential benefits include reduced
absenteeism, reduced costs and elimination of the
harmful effects of passive smoking.
• Provide support to schools to introduce no smoking
policies.
The National Curriculum Science Order recommends that
teaching the harmful effects of tobacco, alcohol and
other drugs should begin at Key Stage 2 (age 7–11
years). The Office of Fair Standards and Training in
Education (OFSTED) 1999 report Drug education in
schools and the Department for Education and
Employment (DfEE 1998) report Protecting young people:
good practice in drug education in schools and the youth
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
Box 1.3 Enforcement protocol
• Local authorities should publish a clear statement
on underage tobacco sales.
• Ensure that all shops and vending machines
display notices stating the law.
• Use test purchases to assess local compliance by
retailers. Gather information about premises
likely to be breaching the law.
• Use media advocacy to raise the profile locally.
• Educate to increase compliance.
• Detail enforcement action taken, prosecutions
and fines, to act as a deterrent.
14

19. service recommend teaching young people from the age
of five years upwards about the risks and consequences
of tobacco, alcohol and drug use, together with teaching
the life skills needed to resist the pressure to misuse these
substances. Teaching should clearly cover issues relevant
to the child’s age and experience. This frequently entails
tackling smoking and alcohol-related issues first, as these
are the substances that young people will generally be
exposed to first.
1.5 Reducing inequity
With little or no decline in the lowest income groups,
smoking has become concentrated in Britain’s poorest
households. For example, among lone parents on benefits
and living in council housing, more than three-quarters
smoke (Dorsett and Marsh 1998). Moreover, recent
research suggests that nicotine dependence is higher in
people experiencing disadvantage (Jarvis and Wardle
1999). In keeping with these findings, the Independent
Inquiry into Inequalities in Health recommended a short-
term strategy to reduce nicotine dependence, which is
likely to be stronger in disadvantaged smokers, through
the provision of free NRT. A complementary, longer-term
strategy aims at removing the cultural and environmental
barriers that disadvantaged people face. Community
based interventions, brief advice from a GP and
specialised smoking clinics are also recommended as
effective settings in which to provide NRT (Acheson 1998).
Attempts to set up community based projects to promote
smoking cessation have met with mixed success. In a
report of initiatives set up in low income communities in
Scotland, the authors concluded that:
‘small grant funding for time limited projects can
promote work on smoking amongst women living
or working in low income communities. Although
reducing smoking was a long term goal for the
majority of the initiatives most did not perceive
themselves as a cessation group. As a result they
did not measure success by the numbers quitting.
Changes in individual smoking behaviours were
noted and these ranged from extending the
period of smoke free time, to restricting smoking
to a specific room or location and trying nicotine
replacement therapy’ (ASH Scotland and HEBS 1999).
Examples of other community based projects funded
through small grants schemes can be found in
Empowering smokers to quit: success principles for
community stop-smoking projects (HEA 1996b).
The use of mass media, especially TV, may be
particularly appropriate for reaching less educated and/or
disadvantaged smokers. This reflects the tendency for the
less educated to receive information from TV more often
than those who are more educated (Buck and Godfrey
1994). Indeed, research has shown that mass media
antismoking campaigns can have a significant impact on
low income and low educational groups (Macaskill et al.
1992; Jenkins et al. 1997).
1.5.1 Black and minority ethnic groups
Little has been published on the impact of smoking
cessation interventions in reducing tobacco use among
black and minority ethnic groups in England. However,
studies from the USA suggest that they can be effective
Reducing smoking prevalence
15
Box 1.4 Checklist for a school’s
smoking policy
• Put the development of a smoking policy on the
agenda.
• Review the current situation.
• Identify staff with sufficient skill and seniority to
take responsibility for developing a new policy if
necessary.
• Form a working party involving key people from
the school and community, if appropriate.
• Establish a rationale for the policy.
• Identify educational, health and economic
reasons for introducing a policy or improving
existing conditions.
• Draft the policy.
• Evaluate the draft policy by consulting with all
relevant parties, identify potential constraints and
problems.
• Inform everyone about the policy before it is
implemented.
• Allow sufficient time for implementation of the
new policy – three to six months is considered a
reasonable time between initiating and
implementing the policy.
• Monitor the operation of the new policy.

20. (Botvin et al. 1992; Elder et al. 1993; Lillington et al.
1995; Elder et al. 1996). In the absence of UK studies,
patterns of tobacco use (HEA 1999a) and research into
the role of tobacco within and between black and
minority ethnic groups (Maltby et al. 2000) can provide
some pointers for the way forward. Examples of these are
highlighted below (HEA 1999a; Maltby et al. 2000).
• The high rates of tobacco chewing, especially
among Bangladeshis, suggests that this practice
should be included in interventions aimed at reducing
tobacco use.
• Sensitivity to gender issues is vital.
• Literature should be multi-lingual and in a style that is
culturally familiar (eg use of vignettes to highlight
health risks associated with tobacco use).
• Information campaigns should be developed to redress
misperceptions about tobacco use (eg belief that
tobacco use can relieve indigestion; belief that healthy
practice in other areas such as diet and exercise will
offset the detrimental effects of smoking).
• Ethnic differences in attitudes and beliefs about
cigarette smoking should be incorporated into smoking
cessation interventions.
Thus, to be successful, a tobacco cessation campaign
must take account of the culture, tradition and
religion of the particular target group. In so doing it
will need to involve community groups, religious groups,
smoking cessation coordinators, local tobacco alliances,
primary health care (PHC) teams, culturally relevant local
and national media as well as key individuals within
different ethnic groups.
In response to ethnic health inequalities, the government
has announced that £1,000,000 will be made available
to help reduce the high rates of smoking among certain
ethnic groups.
Further information on black and minority
ethnic groups
DH, 1996. Directory of ethnic minority initiatives, G60/008 3934 1P 5K
May 96 (23). London: DH.
Gervais, M. and Jovchelovitch, S., 1998. The health beliefs of the
Chinese community in England: a qualitative research study.
London: HEA.
HEA, 1999. Black and minority ethnic groups and tobacco use in
England: a practical resource for health professionals. London: HEA.
HEA, 2000. Black and minority ethnic groups in England: the second
health and lifestyles survey. London: HEA.
McKeigue, P. and Sevak, L. 1994. Coronary heart disease in South
Asian communities. London: HEA.
Sproston, K., Pitson, L., Whitfield, G. and Walker E., 1999. Health
and Lifestyles of the Chinese population in England. London: HEA.
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
16

21. Reducing smoking prevalence
17
Dependsontheparticular
interventionunder
consideration(seebelow).
Candoubletheeffectiveness
ofanintervention,beitbrief
advicefromaGPorintensive
supportthroughaspecialist
clinicorwill-poweralone.
Intervention
Smokingcessation
Nicotine
replacement
therapy
Bupropion(Zyban)
Evidence
Effectivenessandcosteffectiveness
arewellestablished(Fioreetal.
1996;Rawetal.1998).Updated
guidelines(Dec2000).
Doubleschanceofsuccessof
smokerswishingtostop(Fioreetal.
1996;Rawetal.1998).
JustlaunchedintheUK.An
effectivepharmacotherapy(Hurtet
al.1997;Jorenbyetal.1999),itwill
beavailableonprescription.
Whocouldbe
involved?
Healthprofessionals,
LAs,specialist
smokingcessation
coordinators,
voluntarysector,
HAZs,localsmoking
alliance.
PHC,pharmacists,
healthpromotion
specialists.
GPsandthose
approvedfor
prescribingthrough
thePatientGroup
Directive,
PHC,pharmacists,
healthpromotion
specialists.
Skillsandresources
Smokingcessationskills,
carbonmonoxidemonitor,
leaflets.Althoughtraining
schemesareavailable
nationally,accreditedcourses
shouldbeestablished.
Demonstratecultural
sensitivity.
Smokingcessationskills,
accesstoNRTproducts.
Smokingcessationskills.
Pointstoconsider
Majorcomponentof
governmentstrategyto
reducesmokinginEngland.
HSC(1999)hassetout
guidelinesonmonitoringfor
thenewservices.
Theavailabilityand
accessibilityofservicesshould
takeaccountofcultural
differences.
Currently,someareavailable
onprescriptionaswellas
beingavailableoverthe
counter(OTC).Nasalsprayis
OTCand2mggumisalso
availableonthegeneralsales
list(GSL).
Prescriptiononly.
Furtherinformation
HSC(1998,1999),DH
(1998a),Acheson(1998).
CochraneLibrarywebsite:
http://www.update-
software.com/clibhome/
clib.htm
Evaluationofyearoneof
nationalcessationstrategy
(Adamsetal.2000).ASH
(2000a).
Seeabove.
Outcome
Table1.6Suggestedactivitiestosupportlocalaction

22. Coronary heart disease: guidance for implementing the preventive aspects of the NSF
18
BriefadviceinNHS
andprimarycare
Verybriefadvice(three
minutes)canresultina2%
increaseinnumberof
smokersabstinentforsix
monthsorlongercompared
withnoadvice.Briefadvice
(10minutes)canresultina
3%increase.AddingNRTto
briefadvicecanresultina
6%increase.
Comparedwithno
interventionintensivesupport
canresultinan8%increase
inthenumberofsmokers
abstinentforsixmonthsor
longer.
Resultina5%increaseinthe
numberofsmokersabstinent
forsixmonthsorlonger.
Resultina7%increaseinthe
numberofsmokersabstinent
forsixmonthsorlonger.
Quitrateof15.6%(adjusted)
reportedinEnglandwith
massmediacampaign(Owen
2000).
Intensivesupport
(egsmokers’clinics)
Cessationadvice
andsupportfor
hospitalpatients
Cessationadvice
andsupportfor
pregnantsmokers
Telephone
helplines
Fioreetal.1996;Rawetal.1998;
updatedguidelines(Dec2000).
Fioreetal.1996;Rawetal.1998;
updatedguidelines(Dec2000).
Rawetal.1998;Fioreetal.1996;
updatedguidelines(Dec2000).
Evidencebaseforeffectivenessis
growingandThoraxguidelines
indicatethattheymayprovidean
effectiveservice(Rawetal.1998).
Ameta-analysisreportsasignificant
effect(Fioreetal.1996).
Seeabove.
Providersof(national
andlocal)helplines,
workplace,public
places,NHS,
communitygroups,
cessationservices.
InterventionEvidence
Fioreetal.1996;Rawetal.1998;
updatedguidelines(December
2000).
Whocouldbe
involved?
PHCteam,linkwith
othersupport
servicesif
appropriate
[eghealthyliving
centres(HLCs),
hospitalstaff,
doctors,nurses,
midwives].
Skillsandresources
Smokingcessationskills.
Smokingcessationskills.
Smokingcessationskills.
Smokingcessationskills.
Smokingcessationskills,
trainedstaffrequired.
Pointstoconsider
Reachlowerthanthatfor
briefadvice,butassociated
withahighersuccessrate;
resourceintensive;easeof
access(egconvenience,safe
location,timing)andcost
(ifany)areimportant
considerations.
Massreach,easyand
convenientforsmoker.
Guidelinesareavailablefor
thosewantingtosetuplocal
helplines.Alternatively,
activitiesandliteraturecould
beundertakentoraisepublic
awarenessofanduseof
existinghelplines.Canbe
usedtopromoteother
cessationsupportservicesin
locality.
Furtherinformation
Asabove.
Asabove.TheMaudsley
smokers’clinicisanexample
ofgoodpracticehighlighted
inthetobaccowhitepaper
(DH1998a).
Lichtensteinetal.(1996),
NHSDirectHelpline
08001690169,
Quit(Charity)
02073885775,
Quitline0800002200.
Outcome

23. Reducing smoking prevalence
19
Likelyimpactuncertain.
AUSstudyofemployees
reportedareductionof5%
insmokingprevalenceand
10%inconsumptionafter
theintroductionofworkplace
bans.Otherbenefitsinclude
recognitionofnon-smoking
asnorm,protectionofnon-
smokers,increasedpublic
awarenessandacceptanceof
healthrisks.Mayencourage
adolescentsnottostart.
Quitrange0–5%foradult
interventions(Reid1996),
directinfluenceonclimateof
publicopinion.
Reducesmokingin
publicandwork
places
Massmedia
campaigns
Associatedwithreduced
consumption,possiblereductionsin
prevalenceinthelongerterm
(BrennerandMielck1992;Buck
andGodfrey1994;Reid1996).
Canenhancenaturalquitrateand
mayreducerelapse(Reid1996;
McVeyandStapletoninpress);may
alsoreduceuptakeofsmokingin
youngpeople(Sowdenand
Arblaster2000a).
BritishHospitality
Association,The
Restaurant
Association,British
Instituteof
Innkeeping,Brewers
andLicensed
RetailersAssociation,
Associationof
LicensedMultiple
Retailers,employers
andemployees,NHS.
Nationalandlocal
media,community
settingsand
activities,workplaces
andpublicplaces.
Intervention
Othertreatments
Evidence
Insufficientevidenceofeffectiveness
forhypnotherapyandacupuncture,
etc.(Abbotetal.2000;Whiteetal.
2000).
Whocouldbe
involved?
Privatesector,links
withothersmoking
cessationproviders.
Inviewoflackof
evidencebase,
considercontacting
recognised
professional
associationsfor
trainedindividuals.
Skillsandresources
Costly;requiresminimallevel
ofexposureanddevelopment
ofnewmessagestoavoid
consumerburn-out.
Pointstoconsider
Smokersshouldbegiven
informationaboutother
treatmentstoenablethemto
makeaninformedchoice
withoutdiscouraging
attemptstostop.Levelof
traininglikelytovaryfrom
nonetosufficienttojustify
membershipofaprofessional
body(Rawetal.1998).
Charteragreedbetween
governmentandlicensed
hospitalitytrade.TheHSEis
producinganewACoPon
smokingintheworkplace,
whichwillprovidepractical
adviceonhowtocomply
withthelaw.
Highreach;workswellwith
otherinterventionssuchas
taxincreases;cansupport
localcessationservices;focus
shouldbeonadults.
Furtherinformation
BritishHypnotherapy
Association(BHA),1
WythburnPlace,London
W1H5WLTel:0207723
4443,email:
firebird@agonet.co.uk
BritishSocietyof
Hypnotherapists(BSH),37
OrbainRoad,LondonSW6
7JZTel:02073851166
AssociationofGeneral
PractitionersofNatural
Medicine(AGPNM),38Nigel
House,PortpoolLane,
LondonEC1N7UR
Tel:02074052781.
InstituteofComplementary
Medicine(ICM),POBox194,
LondonSE161QZ
Tel:02072375165.
DH(1998a),HEA(1999c,d).
TheNationalHSE(NHSE)is
developingatoolkittohelp
withtheimplementationof
itspolicies.
DHsmokingpolicyteam,
DHcommunicationsteam,
reviewofuseofmassmedia
campaignsinEngland
availablefromHDA(Greyet
al.2000).CochraneLibrary
websitehttp://www.update-
software.com/clibhome/clib
Outcome

24. Coronary heart disease: guidance for implementing the preventive aspects of the NSF
20
Oneyearnetquitrates
estimated0.3–0.5%(Reidet
al.,1992;BuckandGodfrey
1994);influenceonpublic
opinion;providesbasisfor
otherinitiatives;may
contributetoimpactofmass
mediacampaign;
extendsdebateabout
smoking.
Impactofmonitoringlocal
infringementofvoluntary
agreementnotknown,but
doesofferopportunitiesfor
mediaadvocacy.
Localactivitycanreduce
sales;usefulformedia
advocacy;mayhaveasmall
delayingeffectonchildren’s
uptake.
Implementationvariessothat
outcomeisunclear;reinforces
non-smokingasthenorm;
otherpotentialbenefits
includereducedabsenteeism,
reducedcostsandelimination
ofpassivesmoking.
Advertisingban
Reduceillegalsales
Smokingpoliciesin
schools
Possibleeffectonadult
consumptionandteenage
prevalence(Reidetal.1992;
SowdenandArblaster,2000a).
Localactivitycanreducesales.This
mayhaveasmalldelayingeffecton
children’suptakeofsmoking.
Impactonuptakeofsmoking
uncertain.
Government,health
promotionspecialists,
tobaccoadvocates
andotherscan
monitorexisting
voluntary
agreements.
Magistrates,retailers,
localtrading
standardsofficers,
schools,parents,
localgovernment
association,LAs,
NationalAssociation
ofCigaretteMachine
Operators.
Schoolteachers,
governors,heads,
parents,pupils,local
community(for
policiesthatinvolve
non-smokingin
schoolpremisesfor
communityactivities).
Intervention
Mediaadvocacy
andNoSmoking
Day
Evidence
Effectivenesslowerthanmore
intensiveinterventionsbuthighly
cost-effectivebecausethereachis
muchgreater(Reidetal.,1992;
BuckandGodfrey1994).
Whocouldbe
involved?
NHS,local
government,
commercialinterests,
voluntaryagencies.
Skillsandresources
Cheaperthanpaid
advertisingbutsubstantial
resourcesrequiredfor
generatingstories;
goodcontactswithlocal
mediaandtheleisureand
hospitalitytrade.Trainingin
mediaadvocacyneeded.
Requiressubstantial
resources.
Pointstoconsider
Reliesongoodlinkswith
otheragencies(egvoluntary
sector,localgovernment,
hospitalitytrade)tocreate
localactivities.
Localactivitycouldinclude
monitoringinfringementsto
voluntaryagreements(eg
advertisingonbillboardsnear
schools,promotionsin
magazinesaimedatyoung
people).
Existinglawstatesthatitis
illegaltoselltobacco
productstounder16s,but
enforcementisproblematic.
Possiblyaddstoperception
thatsmokingisaforbidden
fruit(KayScottAssociates
2000).
Supportshealthmessagesin
thenationalcurriculum.
Furtherinformation
http://www.no-smoking-
day.org.uk/campaign.htm
Exampleofgoodpractice:
RoyCastleGoodAirAwards
DH(1992).IssuedwithDH
circularEL(92)71.
NationalAssociationof
CigaretteMachineOperators
hasproducedacodefor
members.LocalGovernment
Association(LGA)andLocal
AuthoritiesCoordinating
BodyonFoodandTrading
haveproducedanLA
enforcementprotocol.
HEA(1993,1999e).
Outcome

25. 1.7 References
Abbot, N.C., Stead, L.F., White, A.R., Barnes, J. and Ernst, E., 2000.
Hypnotherapy for smoking cessation, Cochrane Review. In: Cochrane
Library, Issue 3. Oxford: Update Software.
Acheson, D., 1998. Independent inquiry into inequalities in health
report. London: The Stationery Office.
Adams, C., Bauld, L. and Judge, K., 2000. Baccy to front. Health Service
Journal, 110 (5713), 28–31.
ASH, 2000a. Smoking cessation in primary care: how to spend NHS money
much more effectively. London: ASH. (http://www.ash.org.uk/?cessation)
ASH, 2000b. Smoking cessation services: Implementing the NHS
National Plan. London: ASH.
ASH Scotland and HEBS, 1999. Women, low income and smoking:
breaking down the barriers. Edinburgh: Action on Smoking and Health
Scotland and Health Education Board for Scotland.
Borland, R., Owen, N., Hill, D. and Schofield, P., et al., 1991. Predicting
attempts and sustained cessation of smoking after the introduction of
workplace smoking bans. Health Psychology, 10 (5), 336–342.
Botvin, G.J., Dusenbury, L., Baker, E., Ortiz, S., Botvin, E.M. and Kerner, J.,
1992. Smoking prevention among urban minority youth: assessing effects
on outcome and mediating variables. Health Psychology, 11 (5), 290–299.
Brauer, M. and Mannetje, A., 1998. Restaurant smoking restrictions and
environmental tobacco smoke exposure. American Journal of Public
Health, 88 (12), 1834–1836.
Brenner, H. and Mielck, A., 1992. Restrictions to smoking at the
workplace and smoking habits: a literature review. Soz Praventivmed,
37 (4), 162–167.
Buck, D. and Godfrey, C., 1994. Helping smokers give up: guidance for
purchasers on cost effectiveness. London: HEA.
Callum, C., 1998. The UK smoking epidemic: deaths in 1995. London:
HEA.
Campion, P., Owen, L., McNeill, A. and McGuire, C., 1994. Evaluation
of a mass media campaign on smoking and pregnancy. Addiction, 89
(10), 1245–1254.
Chapman, S., 1993. Unravelling gossamer with boxing gloves: problems
in explaining the decline in smoking. British Medical Journal, 307, 429–432.
DFEE, 1998. Protecting young people: good practice in drug education
in schools and the youth service. Sudbury, Suffolk: DfEE Publications.
DH, 1992. Effect of tobacco advertising on tobacco consumption: a
discussion document reviewing the evidence (C. Smee, Chair,
Department of Health Economics and Operational Research Division).
London: DH [issued with DH EL(92)71].
DH, 1998a. Smoking kills, white paper on tobacco. London: The
Stationery Office.
DH, 1998b. Directory of African Caribbean initiatives. Birmingham: N Films Ltd.
DH, 2000a. The cancer plan. London: The Stationery Office.
DH, 2000b. National service framework for coronary heart disease.
London: DH.
DH, 2000c. Statistics on smoking: England, 1978 onwards. London: DH
Statistical Bulletin.
DH, 2000d. The NHS plan. A plan for investment. A plan for reform.
London: The Stationery Office. http://www.nhs.uk/nhsplan
Dorsett, R. and Marsh, A., 1998. The health trap: poverty, smoking and
lone parenthood. London: Policy Studies Institute.
Elder, J P., Wildey, M., de Moor, C., Sallis, J.F., Jr., Eckhardt, L.,
Edwards, C., Erickson, A., Golbeck, A., Hovell, M., Johnston, D.,
Levitz, M.D., Molgard, C., Young, R., Vito, D. and Woodruff, S.I., 1993.
The long-term prevention of tobacco use among junior high school
students: classroom and telephone interventions. American Journal of
Public Health, 83 (9), 1239–1244.
Elder, J.P., Edwards, C.C., Conway, T.L., Kenney, E., Johnson, C.A. and
Bennett, E.D., 1996. Independent evaluation of the California Tobacco
Education Program. Public Health Report, 111 (4), 353–358.
Fiore, M.C., Bailey, W.C., Cohen, S.J., Dorfman, S.F., Goldstein, M.G., Gritz,
E.R., Heyman, R.B., Holbrook, J., Jaen, C.R., Kottke, T.E., Lando, H.A.,
Mecklenburg, R., Mullen, P.D., Nett, L.M., Robinson, L., Stitzer, M.L.,
Tommasello, A.C., Villejo, L. and Wewers, M.E., 1996. Smoking cessation,
Clinical Practice Guideline No. 18. Rockville: Agency for Health Care
Policy and Research, US Department of Health and Human Services,
Publication No. 96-0692.
Glasgow, R.E., Cummings, K.M. and Hyland, A., 1997. Relationship of
worksite smoking policy to changes in employee tobacco use: findings
from COMMIT. Community Intervention Trial for Smoking Cessation.
Tobacco Control, 6 (suppl 2), S44–S48.
Reducing smoking prevalence
21

26. Grey, A., Owen, L. and Bolling, K., 2000. A breath of fresh air: tackling
smoking through the media. London: HDA.
HDA, 2000a. Smoking cessation in young people: should we do more
to help young people quit? London: HDA.
HDA, 2000b. Tobacco control policies within the NHS: case studies of
effective practice. London: HDA.
HDA, in press. An investigation into the potential of media advocacy as
a health promotion strategy. London: HDA.
HEA, 1993. Smoking policies in schools: guidelines for policy
development. London: HEA.
HEA, 1994a. Smoking and pregnancy: guidance for purchasers and
providers. London: HEA.
HEA, 1994b. Helping pregnant smokers quit: training for health
professionals. London: HEA.
HEA, 1996a. Smoking and pregnancy: a growing problem.
London: HEA.
HEA, 1996b. Empowering smokers to quit: success principles for
community stop-smoking projects. London: HEA.
HEA, 1999a. Black and minority ethnic groups in England: health and
lifestyles. London: HEA.
HEA, 1999b. Been there, done that: revisiting tobacco control policies in
the NHS. London: HEA.
HEA, 1999c. Smoking policy for the workplace: an update. London:
HEA.
HEA, 1999d. Towards tobacco-free environments: guidelines for local
authorities. London: HEA.
HEA, 1999e. Smoke-free schools: seven steps to success.
London: HEA.
HSC, 1998. Tobacco white paper, HSC 1998/234. London: NHS
Executive.
HSC, 1999. New NHS smoking cessation services, HSC 1999/087.
London: NHS Executive.
Hill, D., 1999. Why we should tackle adult smoking first. Tobacco
Control, 8, 333–335.
Hurt, R.D, Sachs, D.P.L., Glover, E.D., Offord, M.S., Johnston, J.A.,
Lowell, P.D., Khayrallah, M.A., Schroeder, D.R., Glover, P.N.,
Sullivan, C.R., Croghan, I.T. and Sullivan, P.M., 1997. A comparison of
sustained-release Buproprion and placebo for smoking cessation. New
England Journal of Medicine, 337, 1195–1002.
Jarvis, M., 1998. Extra analyses of the General Household Survey
commissioned by the Health Education Authority. London: HEA.
Jarvis, M. and Wardle, J., 1999. Social patterning of health behaviours:
the case of cigarette smoking. In: M. Marmott and R. Wilkinson, eds.
Social determinants of health. Oxford: Oxford University Press, 1999,
240–255.
Jeffery, R.W., Kelder, S.H., Forster, J.L., French, S.A., Lando, H.A.,
Baxter J.E., 1994. Restrictive smoking policies in the workplace: effects
on smoking prevalence and cigarette consumption. Preventive Medicine,
23 (1), 78–82.
Jenkins, C.N., McPhee S.J., Le, A., Pham, G.Q., Ha, N.T., Steward, S.,
1997. The effectiveness of a media-led intervention to reduce smoking
among Vietnamese-American men. American Journal of Public Health,
87 (6), 1031–1034.
Jernigan, D. and Wright, P., eds., 1993. Making news: changing policy.
Case studies of media advocacy on alcohol and tobacco use. Bethesda,
MD: Center for Substance Abuse Prevention.
Jorenby, D.E., Leischow, S.J., Nides, M.A., Rennard, S.I., Johnston, J.A.,
Hughes, A.R., Smith, S.S., Muramoto, M.L., Daughton, D.M., Doan, K.,
Fiore, M.C. and Baker, T.B., 1999. A controlled trial of sustained-release
buproprion, a nicotine patch, or both for smoking cessation. New
England Journal of Medicine, 340, 685–691.
Kay Scott Associates, 2000. Need a fag, need a fag. Smoking and
young people, Report on six qualitative discussion groups. London: ASH.
Lantz, P.M., Jacobson, P.D., Warner, K.E., Wasserman, J., Pollack, H.A.
and Ahlstrom, A., 2000. Investing in youth tobacco control: a review
of smoking prevention and control strategies. Tobacco Control, 9,
47–63.
Lichtenstein, E., Glasgow, R.E., Lando, H.A., Ossip-Klein, D.J. and Boles,
S.M., 1996. Telephone counselling for smoking cessation: rationales and
meta-analytic review of evidence. Health Education Research, 11,
243–257.
Lillington, L., Royce, J., Novak, D., Ruvalcaba, M. and Chlebowski, R.,
1995. Evaluation of a smoking cessation program for pregnant minority
women. Cancer Practice, 3 (3), 157–163.
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
22

27. Macaskill, P., Pierce, J.P., Simpson, J.M. and Lyle, D.M., 1992.
Mass media-led antismoking campaign can remove the education
gap in quitting behaviour. American Journal of Public Health, 82 (1),
96–98.
Maltby, S., Simmons, R., Choudry, S., Warrant, M. and Haggett, C.,
2000. Research on tobacco use among black and minority ethnic
groups. London: HDA.
Marcus, B.H., Emmons, K.M. and Abrams D.B., 1992. Restrictive
workplace smoking policies: impact on non-smokers’ tobacco exposure.
Journal of Public Health Policy, 13 (1), 42–51.
Marsh, A. and McKay, S., 1994. Poor smokers. London: Policy Studies
Institute.
Naidoo, B., Stevens, W. and McPherson, K., 1999. A report for the
Health Education Authority on modelling the short-term consequences
of smoking cessation in England on the hospitalisation rates for acute
myocardial infarction and stroke. London: London School of Hygiene
and Tropical Medicine.
OFSTED, 1997. Drug education in schools. London: The Stationery
Office.
Owen, L., 2000. Impact of a telephone helpline for smokers who called
during a mass media campaign. Tobacco Control, 9, 148–154.
Owen, L. and Penn, G., 1999. Smoking and pregnancy: a survey of
knowledge, attitudes and behaviour 1992–1999. London: HEA.
Owen, L., McNeill, A. and Callum, C., 1998. Trends in smoking during
pregnancy in England, 1992–7: quota sampling surveys. British Medical
Journal, 317, 728.
Owen, L. and Bolling, K., 1996. Smoking and pregnancy: developing a
communications strategy for cessation. London: HEA.
Raw, M., McNeill, A., and West, R., 1998. Smoking cessation guidelines
for health professionals. Thorax, 53 (suppl 5).
Reid, D., 1996. Tobacco control: overview. British Medical Bulletin, 52
(1), 108–120.
Reid, D., Killoran, A., McNeill, A. and Chambers, J., 1992. Choosing the
most effective health promotion options for reducing a nation’s
smoking prevalence. Tobacco Control, 1, 185–197.
Royal College of Physicians, 1992. Smoking and the young. London:
Royal College of Physicians.
SCOTH, 1998. Report of the Scientific Committee on Tobacco and Health.
London: The Stationery Office.
Secker-Walker, R.H., Solomon, L.J., Flynn, B.S., Skelly, J.M., 1995.
Smoking relapse prevention counselling during prenatal and early
postnatal care. American Journal of Preventive Medicine, 11, 86–93.
Sowden, A.J. and Arblaster, L., 2000a. Mass media interventions for
preventing smoking in young people, Cochrane Review. In: Cochrane
Library, Issue 2. Oxford: Update Software.
Sowden, A. and Arblaster, L., 2000b. Community interventions for
preventing smoking in young people, Cochrane Review. In: Cochrane
Library, Issue 2. Oxford: Update Software.
Stead, L. and Lancaster, T., 2000. A systematic review of interventions
for preventing tobacco sales to minors. Tobacco Control, 9, 169–176.
Tang, J.L., Cook, D.G. and Shaper, A.G., 1992. Giving up smoking: how
rapidly does the excess risk of ischaemic heart disease disappear?
Journal of Smoking-Related Diseases, 3, 203–215.
US Department of Health and Human Services, 1990. The health
benefits of smoking cessation, a report of the Surgeon General, DHHS
Publication No. CDC 90-8416. Rockville, MD: National Centers for
Disease Control and Prevention, Office on Smoking and Health.
US Department of Health and Human Services, 2000. Reducing tobacco
use, a report of the Surgeon General, DHHS Publication No. CDC20402,
S/N017-001-00544-4. Rockville, MD: National Centers for Disease
Control and Prevention, Office on Smoking and Health.
Wakefield, M. and Chaloupka, F., 2000. Effectiveness of comprehensive
tobacco control programmes in reducing teenage smoking in the USA.
Tobacco Control, 9, 177–186.
Wakefield, M.A., Wilson, D., Owen, N., Esterman, A. and Roberts, L.,
1992. Workplace smoking restrictions, occupational status, and reduced
cigarette consumption. Journal of Occupational Medicine, 34 (7),
693–697.
White, A.R., Rampes, H. and Ernst E., 2000. Acupuncture for smoking
cessation, Cochrane Review. In: Cochrane Library, Issue 3. Oxford:
Update Software.
WHO, 1979. Controlling the smoking epidemic, WHO Technical Report
Series No. 636. Geneva: WHO.
WHO, 1998. Guidelines for controlling and monitoring the tobacco
epidemic. Geneva: WHO.
Reducing smoking prevalence
23

28. Box 2.1 Identification of barriers to healthy eating and interventions to address them:
an example
Chapter 2
Improving diet and nutrition
Improving diet and nutrition
25
2.1 Introduction
Diet plays a fundamental role in the development of
CHD. The type and amount of fat and its relationship to
blood cholesterol levels have been recognised for some
time as being particularly influential. Salt intake has been
implicated in relation to blood pressure and, more recently,
an increased intake of fruit and vegetables has been
identified as an important factor in reducing the
rates of both heart disease and some cancers (DH 1994,
1998). The promotion of healthy eating is important in
reducing the risk not only of CHD but also of other
chronic conditions, such as obesity and diet related
cancers.
Effective strategies to promote healthy eating are generally
those that work at several levels. It is important to identify
the barriers to dietary change in the local population and
then select interventions to address them (see Box 2.1).
2.2 Objectives of nutritional interventions
Diet is one of the key modifiable risk factors in the
prevention of CHD. The government’s Committee
on the Medical Aspects of Food and Nutrition Policy
(COMA; DH 1994) recommended a reduction in fat
(particularly saturated fat), a reduction in salt and an
increase in complex carbohydrates. In addition, fruit
and vegetable consumption should be increased by at
least 50% (to at least five portions per day). The
recommendations are summarised in nutrition
briefing papers produced by the HEA (1992, 1996).
Also, it has been estimated that around one-third
of all cancers might be influenced by diet. In 1998,
COMA reviewed the evidence on diet and cancer in the
UK (DH 1998). The working group recommendations
were consistent with other dietary recommendations
made for the prevention of obesity, diabetes and
cardiovascular disease.
Barrier
• Belief that the family is already eating enough fruit
and vegetables
• Dislike of taste of vegetables and lack of confidence
in cooking and preparing them; fear of waste and
of rejection by the family
• Difficulty in finding affordable, good quality fruit
and vegetables locally
Intervention
• Information about five portions a day and portion
sizes
• Set up cooking skills clubs and tasting sessions, or
develop cooking sessions as part of the activities of
existing groups (eg women’s groups, youth groups)
• Set up community owned retailing and food
cooperatives to introduce affordable supplies

29. 26
In promoting a healthy balanced diet to reduce the risk of
cardiovascular disease and diet related cancers in the
population, interventions should focus on the following:
• Reducing the amount of fat, and in particular, the
amount of saturated fat
It has been estimated that a 10% reduction in
saturated fat intake within the UK population would
be associated with a reduction in CHD mortality of
between 20% and 30% (Marmot 1994). Therefore, to
help achieve a healthy diet, people should be
encouraged to use reduced fat spreads and dairy
products in place of full fat versions, to replace oils and
fats high in saturates with those high in
monounsaturates, to reduce the amount of fat used in
cooking, to trim fat from meat and to reduce the
amount of products such as biscuits, pastries, cakes,
and crisps in the diet.
• Increasing the amount of fruit and vegetables
eaten to at least five portions each day
Apart from being rich sources of carbohydrate, dietary
fibre, antioxidants and other bioactive factors, fruit and
vegetables are also rich sources of potassium, which is
associated with lower blood pressure and a lower risk
of stroke (Joshipura et al. 1999). For many people, this
will mean almost doubling their intake. It will mean
having fruit and vegetables at most meals, and as
snacks between meals. Access to affordable, good
quality supplies of fruit and vegetables must be
ensured and skills and confidence to prepare and cook
fruit and vegetables should be developed [National
Heart Forum (NHF) 1997].
• Increasing the intake of fibre rich, starchy foods,
such as bread, potatoes, pasta and rice, by half as
much again
Make these foods the main part of most meals, and
replace fattier snacks.
• Reducing the average salt intake by around a
third
There is now a consensus that dietary sodium is a
factor in the development of high blood pressure
(DH 1994). People should be encouraged to gradually
reduce the salt they add to food, both in cooking and
at the table. Also, people should be more aware of
low-salt alternatives to processed foods if available and
should recognise the salt content of processed foods
by reading food labels.
• Increasing the amount of fish eaten to at least
two portions each week, one of which should be
an oily fish
Encourage people to eat fish more often: this may
mean working with communities to develop their
cooking skills and confidence to cook fish.
A useful tool to support health promoters in promoting a
balanced diet is The balance of good health [HEA, DH and
Ministry of Agriculture, Fisheries and Foods (MAFF) 1994].
It shows what proportion of the diet should come from
the different food groups and could provide a consistent
and easily understood message about a balanced diet1.
The balance of good health has also been modified for
use with black and minority ethnic groups. The British
Dietetic Association and Sainsburys have developed an
African-Caribbean version and the British Nutrition
Foundation has produced a model suitable for use with
the Chinese community. Dietitians at Wandsworth
Community Health Trust, with support from Spillers
Milling, formed a healthy alliance and produced a version
suitable for use with South Asian groups.
2.2.1 Professional knowledge and expertise
Identifying the barriers and developing an integrated
programme of complementary activities will require the
input of staff with a range of skills. While most areas
have access to a community dietitian, it is quite common
for clinical duties to interfere with the dietitian’s ability to
spend time in the community. In planning the resources
needed to implement the strategy, it may be worth
considering ring fencing a block of dietitian time to
devote to community work. Public health nutritionists can
provide the expertise to develop and implement a public
health nutrition strategy and to work on other nutrition
issues at a population level. In recent years, the Nutrition
Society has introduced a registration system for public
health nutritionists (RPH Nutr). In addition, the Nutrition
Society has recently developed an associate registration
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
1The balance of good health does not apply to children under two years
of age, who need a diet that is higher in fat and lower in fibre rich,
starchy foods, to children aged between two and five years (a gradual
transition towards a diet consistent with The balance of good health is
needed here) or to people with special dietary requirements or those
under medical supervision.

30. • Clear goals were set, based on theories of behavioural
change, rather than relying on the provision of
information alone
• There was personal contact with individuals or small
groups sustained over time
• Participants received personalised feedback on any
changes in their behaviour and risk factors
• Changes in the local environment were promoted, for
example in shops and catering outlets to help people
choose a healthy diet.
Providing information alone is not a solution. Improving
people’s knowledge about diet does not necessarily
lead to behaviour change. Improvements in knowledge
should be accompanied by the development of skills
and provide the opportunity to put the knowledge into
practice. For example, there is little point in
encouraging people to eat more fish, in particular oily
fish, if access to these foods is not available, and if
people lack the skills and confidence to prepare and
cook fish. Integrated programmes of activity could be
more effective if they first identify the barriers to
dietary change, and then provide the information, skills
and opportunities to put the suggestion into practice
(NHF 1999).
2.4 Components of a local strategy
2.4.1 Schools
A meta-analysis of 12 intervention studies to promote
heart-healthy eating behaviour in schools concluded that
they can have a significant effect (McArthur 1998).
Two reviews have identified the following features of an
effective school intervention (Contento 1995; Roe et al.
1997):
• Nutrition education interventions are more likely to be
effective when they employ educational strategies that
are directly relevant to a particular behaviour (eg diet
or physical activity) and are derived from appropriate
theory and research
• Interventions need adequate time and intensity
to be effective
Improving diet and nutrition
27
scheme for newly qualified public health nutrition
professionals who have not yet accumulated the
three years’ experience required for full registration
as a public health nutritionist. The Register of
Public Health Nutritionists can be found on
http://www.nutsoc.org.uk/RPHNutr.html or contact Jackie
Landman at the Nutrition Society (020 7602 0228) for
further information on the associate scheme.
Local people are an important addition to this skill base.
Research suggests that the efficiency and effectiveness of
community based interventions can be improved by using
local people to complement the work of health
professionals. McGlone et al. (1999) suggested that ‘if
local food projects are to work, then they must genuinely
involve local people’. Services provided by local people
are often considered more appropriate and more
accessible for the health needs of the community. Such
services foster self-reliance, community participation and
can help overcome barriers. They also allow access to
groups that are typically hard to reach and can be
particularly beneficial for black and minority ethnic
groups. These benefits are two way, as local people have
the opportunity to develop their own skills. Exploratory
work with this peer education approach (Hodgson et al.
1995; Kennedy et al. 1999) showed that it was possible
to achieve both significant increases in nutrition
knowledge and potentially beneficial changes in the
dietary practices of low income families. The best
approach appears to be one in which guided ‘hands on’
food preparation/cooking sessions allow the participants
to acquire knowledge and skills. However, it was noted
that this approach was resource intensive, particularly in
professional staff time, and there is little evidence of
effectiveness in terms of dietary change. This approach
may result in potential health, social and economic
benefits and therefore warrants further study.
2.3 Features of effective interventions
A meta-analysis of randomised controlled trials shows
that dietary interventions can be effective in reducing
CHD risk factors (Brunner et al. 1997). A systematic review
of the effectiveness of interventions to promote healthy
eating found that characteristics of a successful
intervention had the following features (Roe et al. 1997):
• It focused on diet alone, or diet plus physical activity
rather than tackled a range of risk factors

31. • Family involvement enhances the effectiveness
of programmes for younger children
• Incorporation of a self-evaluation or self-assessment
and feedback is effective in interventions for
older children
• Effective nutrition education includes consideration of
the whole school environment and community
• Interventions in the larger community can enhance
school nutrition education
• The most effective interventions focus on diet alone or
diet and physical activity.
2.4.2 Local/community projects
This section includes a range of interventions from
small-scale local projects to well funded community
interventions. Little rigorous evaluation of the
effectiveness of the small scale projects has been
carried out.
Roe et al. (1997) concluded that intensive, smaller scale
projects generally resulted in positive changes in diet and
blood cholesterol, at least in the short term. However,
many large community-wide studies failed to show a
similar effect because they were conducted in the 1980s,
a time when awareness of CHD risk factors had increased
in the population. Therefore, in one study, the reduction
in blood cholesterol observed in the intervention
communities was also found in the comparison
community. In addition, there was a diversity of other
informational and educational interventions; therefore,
the investigators were unable to attribute any change to
their specific intervention.
Effective community interventions appear to:
• Focus on diet or diet plus physical activity
• Use a theoretical model
• Use diverse multiple interventions at individual, group,
community and environmental level
• Include small-group interventions (Contento 1995; Roe
et al. 1997).
McGlone et al. (1999) identified the characteristics of
projects that appear to have been ‘successful’ using a
range of criteria:
• Flexibility needed by agencies to respond to the needs
of particular communities
• Access to secure, and ongoing, funds
• Professionals work in partnership with a community
• Projects need to involve local people, and ensure equal
respect
• Evaluation should not be confined to narrow clinical and
behavioural measures. Include food purchasing patterns,
structural changes and social outcomes, for example
• Strike a balance between partnerships and local
ownership
• Local and national networks should enable sharing of
experiences
• Training for professionals and members of the
community to acquire skills for a new way of working
• Government policies that do not deter volunteers (eg
social welfare benefits)
• Provide incentives for local projects and small
businesses, such as tax relief
• Allow time for community projects to develop, on the
basis that there is no ‘quick fix’ and that local policy
should support realistic time frames for community
food projects.
However, to date, there has been no systematic
evaluation of the effectiveness of local projects.
2.4.3 Workplace
Three out of four good-quality interventions showed
positive effects of nutrition workplace interventions, with
decreases in blood cholesterol of between 2.5% and
10% (Roe et al. 1997). An HEA review of the
effectiveness of health promotion interventions in the
workplace (Peersman et al. 1998) identified four studies
Coronary heart disease: guidance for implementing the preventive aspects of the NSF
28

32. Another systematic review (Roe et al. 1997) included
interventions in the primary healthcare setting. Four
‘good quality’ studies were identified in the past
10 years. Modest and sustained effects on both blood
cholesterol and dietary fat intake were achieved for
dietary interventions only, or for multifactorial
interventions.
Characteristics of an effective healthcare intervention
include:
• Small group or one to one counselling sessions
• Targeting higher risk groups, which is also more cost-
effective (Van der Weidjen 1998; Wood et al. 1998)
• Family counselling and education for those at increased
risk
• Tailoring to the personal characteristics of individuals
• Educational and behavioural frameworks which are
client centred
• Staff training and development (topic based
knowledge and counselling skills)
• Low intensity interventions, such as mailed, computer
generated, personalised, nutrition education material
for well-motivated groups (Roe et al. 1997).
2.5 Reducing inequity
There are inequalities in diet between those on
higher and lower incomes (Acheson 1998). The
most striking difference is that people in lower
socio-economic groups tend to eat less fruit and
vegetables. The 1997 National Food Survey
(MAFF 1998) found that consumption of fruit and
vegetables by those in the upper socio-economic
groups was a third higher than that of those in lower
groups. This social class difference has also been
reported in children (Gregory et al. 2000). Studies
have shown that people on a low income can
describe a healthy diet as well as those on higher
incomes (Lobstein 1997). Food poverty, affordability
and access to a healthy and varied diet have been
identified as possible barriers (Lobstein 1997;
DH 1996).
Improving diet and nutrition
29
on healthy eating with adequate methodologies. Three
showed positive effects on fat, fruit and vegetable intake,
intention to change the diet and self-efficacy.
Characteristics of an effective workplace intervention
include:
• Visible and enthusiastic support and involvement from
management
• Involvement by employees at all levels in the planning
and implementation phases
• A focus on definable and modifiable risk factors rather
than multiple risk factor interventions
• Screening and/or individual counselling
• Changes to the composition of best selling foods
provided in canteens and vending machines
• Tailoring to the characteristics and needs of the
employees
• Use of local resources in organisation and
implementation of the intervention
• Combine population based policy initiatives with
intensive individual and group oriented interventions
• Built-in sustainability.
2.4.4 Healthcare
In a meta-analysis by Brunner et al. (1997), the study
participants were well motivated. Most studies were
conducted in either a healthcare or an institutional
setting. Interventions included dietary advice to reduce
fat or sodium and to increase fibre. The authors
estimated that, if changes in dietary behaviour were
sustained, they could lead to a reduction in the incidence
of CHD by 14% and the incidence of stroke by 9%.
A meta-analysis by Yu-Poth (1999) reported a 10%
reduction in plasma total cholesterol with a low intensity
intervention, and a 13% reduction with the high intensity
intervention. Tang et al. (1998) reported reductions in blood
cholesterol following individual dietary advice to modify fat
intake: 8.5% at three months and 5.5% at 12 months.

33. raised by the recent National Diet and Nutrition Surveys,
of children aged 11⁄2 to 41⁄2 years (Gregory et al. 1995)
and 4 to 18 years (Gregory et al. 2000). Acheson (1998)
concluded that ‘pre-school education or day care may be
especially effective in improving the achievement and
health of the most disadvantaged children’. A recent
review by Tedstone et al. (1998) of the effectiveness of
interventions to promote healthy eating in pre-school
children aged 1–5 years found that pre-school and day
care centres were likely to be appropriate settings for
interventions, and that parental involvement may
enhance the effectiveness of interventions and
should be facilitated. In more detail, the review
reported that:
• Traditional, video or computer-based teaching
methods were successful at increasing nutrition
knowledge and the effectiveness was enhanced by the
inclusion of parents
• Behavioural modification techniques using repeated
exposure to initially novel foods were successful in
increasing willingness to consume the foods only if
tasting was facilitated as part of the exposure
• The use of reward to encourage consumption of foods
was not successful once the reward had been removed
• One to one diet counselling that was ‘needs focused’
was successful at bringing about improvements in UK
mothers.
Acknowledgement
Information in Table 2.6 concerning some of the
local community interventions was drawn in part from
Making Links – a toolkit for local food projects (Sustain
2000).
30
The Acheson report (Acheson 1998) recommended
further development of policies that will ensure adequate
retail provision of food to those who are disadvantaged.
A report by Policy Action Team (PAT) 13 (1999)
confirmed that accessing affordable, good quality fruit
and vegetables within some local areas might be difficult.
However, access should not be seen purely in terms of
physical proximity, and other kinds of access need to be
considered, for example, financial access, knowledge and
information (HEA 1998a). In areas where a large proportion
of the population is unemployed, on low income or in
receipt of benefits, interventions to improve people’s
access to a healthier diet are likely to be a key priority.
2.5.1 Black and minority ethnic groups
Improving the health of minority ethnic groups is also a
priority in the government’s drive to reduce social
exclusion and inequalities in health. Further impetus was
provided by Acheson (1998), who recommended that the
needs of black and minority ethnic groups be considered
specifically. The HEA (2000) found that among black and
minority ethnic groups, understanding of healthy eating
messages varied widely across groups and knowledge of
foods high in complex carbohydrates, fibre, fat and
saturated fat was often poor across all ethnic groups.
There is, therefore, a need to raise awareness of the links
between diet and CHD among these groups and to
promote culturally relevant messages.
2.5.2 Children
Early childhood experiences strongly influence dietary
preference and good eating habits. While they may not
have an immediate effect on the rates of CHD, strategies
to promote healthy eating among children will benefit in
the longer term. They will help to address the concerns
Coronary heart disease: guidance for implementing the preventive aspects of the NSF

34. Improving diet and nutrition
31
Outcome
Compliancewithlegal
requirement;givesasound
basistoawholeschool
approach;willcontributeto
achievingtheNational
HealthySchoolsStandard
(NHSS);clearguidanceand
frameworkformonitoring
willbeprovided;willensure
goodnutritionalstandardsfor
freemeals.
Intervention
Nutritional
standardsfor
schoollunches
FromApril2001,
newlegislationwill
requireschool
lunchestomeet
minimumnutritional
standards.
Evidence
Roeetal.(1997)identifiedtwo
goodqualitystudiesrelevantto
schoolmeals.Ellisonetal.(1989,
1990)showedthatpassive
manipulationoffatcontentreduced
saturatedfatintakeby2%witha
similarincreaseinpolyunsaturated
fatintake.Whitakeretal.(1994)
showeda3%increaseinlowfat
choiceswhenpromoted.
Whocouldbe
involved?
Localeducation
authority(LEA),direct
serviceorganisation;
contractcaterersand
in-housedietitians;
LocalAuthority
Caterers’Association
(LACA):http://www.
laca.co.uk
SchoolsNutrition
ActionGroup(SNAG)
initiativecanhelp
schoolsindeveloping
aschoolfoodpolicy.
Localhealthyschools
programme.
ChildPovertyAction
Group:
http://www.cpag.org.
uk
Skillsandresources
Supportforcaterersfrom
communitydietitianorpublic
healthnutritionistintraining
inhealthiercateringpractices
andinmonitoringcompliance
withthestandards.
Pointstoconsider
Pricingofhealthierchoices–
andcaterers’perceptionsof
thehigherproductioncosts;
introducingaschoolfood
policytosupportadoptionof
thestandards;opportunityto
reviewsnackprovisionsat
sametime,aswellas
breakfastclubsandvending
machines.
Meetingandmonitoring
standardswillbealegal
requirement.
Furtherinformation
DepartmentforEducation
andtheEnvironment(DfEE)
http://www.nutritional.stand
ards@dfee.gov.uk
NationalStandardsfor
SchoolLunches,England.
Regulations2000.Statutory
Instrumentnumber1777.
TheStationeryOffice.£1.50.
Eatingwellatschool:dietary
guidanceforschoolmeal
providers(1997).DfEE
Publications,POBox5050,
Annesley,Nottingham,
NG150DJ.Tel:0845
602260.Freeofcharge.
SchoolMealsAssessment
Pack(SMAP;computer
packageassessingthe
nutritionalqualityof
secondaryschoolmeals)
producedbytheNHF.
SMAP,POBox7,London
W52GQ.£45.00,cheques
payabletoBSS.
Schoolfoodpolicyguide
producedbySNAG.
ContactJoeHarvey,Health
EducationTrust(tel/fax:
01789773915).
Nutritionguidelinesfor
schoolmeals(1992)available
fromTheCarolineWalker
Trust,22KindersleyWay,
AbbotsLangley,Herts,WD5
0DQ.Cost£10including
postageandpacking(p&p).
Whataretoday’schildren
eating?TheGardnerMerchant
SchoolMealsSurvey2000.
GardnerMerchant
(tel:01793512112).
Table2.6Suggestedactivitiestosupportlocalaction