The problem
Smoking is the leading cause of ill health and mortality, and remains a major public health problem. Approximately 80,000 deaths in England in 2009 were caused by smoking1 and around 5% of all hospital admissions for those aged ≥ 35 years in 2011/12 were attributable to the habit.2 Although the prevalence of smoking in the adult population in Great Britain has fallen by more than half since 1974, from 46% to 19% in 2013, the fall in prevalence has slowed and has changed little since 2007.2 Furthermore, the gap in smoking prevalence between those in professional and managerial occupations and those in routine and manual workers shows no sign of diminishing; those living in the most deprived areas are more than twice as likely to smoke as those living in the least deprived areas.3
A key objective of every UK government over the last two decades has been to reduce the prevalence of smoking,1,4 and various initiatives have been introduced aimed at reducing tobacco use. One of the key strategies to help current smokers quit was to implement government-funded specialist smoking cessation services in Health Action Zones in 1999, which were then rolled out throughout England in 2000.5 These specialist services were established by Primary Care Trusts, operating predominantly in primary care settings, and offered intensive advice and support to smokers motivated to quit, in group or one-to-one sessions. Early evaluations suggested that the services were effective in their aim of supporting smokers to quit6,7 and were reaching smokers from more-deprived groups.8 Since their introduction, the services, now known as the NHS Stop Smoking Services (SSSs), have continued to evolve. The most significant change took place during the course of this research in April 2013, when commissioning of local SSSs was transferred from the NHS to the local authority. The result of this was the tendering out of previously in-house services, leading to some SSSs being run by private and voluntary sector companies.
According to the latest figures available, 61% of smokers indicated more than ‘a little’ inclination to give up, and 26% of all smokers had made an attempt to quit in the previous year.9 This figure has changed little over the years, but along with this evidence that the majority of smokers want to quit, there is a large literature suggesting that, despite this desire, programmes of support are consistently underused. The majority of smokers do not want to participate in formal cessation programmes but prefer to quit on their own.10–13 More recent surveys and reviews have confirmed that this has changed little; although the trend for unassisted quit attempts may be decreasing, effective treatments remain widely underused and the majority of quit attempts are still unassisted.14–16 The proportion of smokers in England using the SSSs is similarly low. Estimates in 2001–2 suggest that 2% of the adult smoking population in England set a quit date using SSSs.8 In 2009, although 43% of smokers had sought some kind of advice or help to quit, the majority of these used self-help leaflets and books, and only 15% had asked a health professional for help. Just 8% were referred or self-referred to a stop smoking group.9 West and Brown17 report that, of all quit attempts reported in 2011, 46.5% were unaided and only 4.1% reported using the SSS. Furthermore, figures from the Health and Social Care Information Centre show that since 2012 the number of smokers attending the SSS has a continuing downward trend.18 Thus, these clinical interventions, provided free of charge by the NHS, reach relatively few self-selected smokers and only a small proportion of the total population of smokers in England.
Recruitment methods to cessation services generally employ a reactive approach, in which smokers are expected to seek out help and approach the service themselves.11 General practitioners (GPs) and health professionals are encouraged to offer brief advice and to provide referral to services, but in 2008–9 only 55% of smokers reported being given advice, and only 8% were referred to the services.9 Moreover, these smokers were generally expected to follow up their referral and contact the service themselves to make the appointment. There is a wide range of factors that will deter smokers from seeking help, these include a lack of time, lack of availability and accessibility of times and locations, perceived inappropriateness of the service, a perception that help is not necessary, a sense of a lack of empathy from health professionals and not wanting the social stigma associated with participation in formal programmes, as well as a lack of readiness to quit.13,19,20
The problem to be addressed then is, given that the majority of smokers say they want to quit, how can more smokers be persuaded and motivated to take the plunge and seek, or accept, help to quit, which would lead to more successful quit attempts.
Rationale for intervention
Mass mailing and proactive strategy
Studies suggest that the direct marketing approach has potential as a population-based strategy for recruiting smokers into support services, and could provide treatment access to individuals who might not otherwise seek cessation care. Paul et al.20 explored the acceptability of direct marketing and proactive contact offering cessation services to smokers. The authors reported that 92.8% of the sample found it acceptable for the health service to contact people to offer assistance and 55.7% said they were likely to take up the offer of individual counselling. This could be an overestimation of actual take-up of the service, but suggests that proactive contact is acceptable and that smokers are open to the idea of intensive counselling. The importance of proactively encouraging smokers to quit has also been demonstrated in studies exploring recruitment to telephone quit lines, lending support to the ‘cold call’ telephone approach. These studies suggested that demand and interest in using services or receiving information about quitting may be greater than is reflected in current usage rates, and that proactively offering services could result in an increase in uptake.21–24 A recent systematic review of recruitment methods for smoking cessation programmes suggested that personal tailored messages and proactive and intensive recruitment strategies can enhance recruitment.25 This review confirmed the conclusion reached by McDonald26 that interpersonal strategies have a positive effect on recruitment into smoking cessation programmes.
Lichtenstein and Hollis27 employed a more proactive recruitment method. They invited smokers attending a medical appointment to an immediate intervention where they were offered information about what attendance at the service would involve, and a strong referral message to the service. Attendance at the first session of the cessation programme increased to 11.3%, compared with 0.006% in a control group who received brief advice only. Fiore et al.28 also showed that many primary care patients identified as smokers will accept treatment ‘if it is free, appropriately incorporated into the health-care delivery system to ensure convenience, and encouraged through proactive recruitment’.
In line with these findings, a major UK study used a proactive strategy to identify individual smokers and inform them about available cessation services. In a cluster randomised controlled trial, Murray et al.29 identified all patients in general practices recorded as current smokers or with no status recorded. These patients were proactively informed by letter about the SSSs and given the option of being contacted by an advisor. Smokers in practices allocated to the intervention group indicating that they would like to speak to an advisor were contacted within 8 weeks by a researcher trained as an advisor and offered advice and an appointment. Smokers in control group practices received no further contact. Overall, the proportion of current smokers expressing interest was 13.8%, suggesting that more than the current 5% of the smoking population setting quit dates within the NHS were interested in receiving help. Furthermore, Murray et al.29 reported a 7.7% absolute increase in smokers using the SSSs in the intervention group over the control group at the 6-month follow-up, and an increase of 1.8% in validated abstinence in those smokers requesting contact over the control group (4% vs. 2.2%).
This study by Murray et al.29 was the first in the UK to assess a proactive method of recruitment to attract smokers into the SSSs. It demonstrated the potential to increase attendance, and also indicated that novel methods of marketing are needed in order to engage interested smokers to encourage use of the SSSs.
Individual computer-tailoring and risk information
One possible way of enhancing recruitment is to use individual characteristics to personalise and tailor communications. Computer-based systems can generate highly tailored materials, defined as ‘any combination of information or change strategies intended to reach one specific person and based on characteristics unique to that person’.30 This technology offers a method for personalisation of communications to patients and can include an individualised risk communication element based on an individual’s own risk factors, more personally relevant to the consumer than information about population ‘average’ risks.31
The use of fear in health promotion has been the subject of debate and is somewhat controversial, with claims that ‘shock tactics’ do not work, are too frightening, or can backfire and prove to be counterproductive by prompting a maladaptive behavioural response. There is also a general notion that healthy lifestyle campaigns and anti-smoking messages should be positive and reflect non-smoking role models rather than dealing with the ‘scary’ health consequences of smoking.32 However, in a review of studies on fear appeals, Sutton33 concluded that increases in fear in communications are associated with increases in acceptance of the recommended action, in a linear relationship. Providing recipients with a reassuring message that adopting the recommended action would be effective, together with clear advice on how to go about it strengthens intentions to follow the advised course of action.34
Fear messages about smoking can indeed push people to attempt to quit. The fear induced by such messages can be dealt with adaptively by a behavioural response that removes the reason to be fearful, such as quitting smoking, or maladaptively by, for example, denying the truth or personal relevance of the threat.32 The likelihood of eliciting the desired response can be maximised by empowering the recipient and giving reassurance that it is possible, and also providing a ‘helping relationship’ that is needed to succeed.35 This has been demonstrated to good effect in mass media campaigns, particularly that of the Australian national anti-smoking advertising campaign, which used graphic fear-based messages as a dominant part of the communication strategy, but tagged with the national quit helpline number and an additional advertisement encouraging calls to that number.36 This strategy is also consistent with social cognitive models such as the health belief model, which posits that a greater perceived risk of a disease and perceived efficacy of the action in preventing it is associated with increased participation in a recommended behaviour. The health belief model also highlights the importance of providing a specific cue to action, which can act as a trigger and increase compliance with the recommended behaviour.37,38
Additional justification for this approach lies in the evidence that smokers do not fully acknowledge their own personal vulnerability. Data show unequivocally that smokers acknowledge that their risks of health problems are higher than those of non-smokers. However, studies indicate that they substantially underestimate their own personal risk and tend to conclude that they are less likely to suffer health effects than other smokers.39 A large literature demonstrates this ‘optimistic bias’ or ‘unrealistic optimism’. Weinstein et al.40 provided further clear evidence that smokers engage in risk minimisation by convincing themselves that they are not as much at risk as other smokers. Moreover, smokers do not perceive the relationship between the amount smoked and their perceived risk. Thus, even if people are aware of the well-publicised risks, they resist the idea that the risks apply to them, and a key factor is getting participants to acknowledge that these risks are personally relevant.
Computer-tailoring can be used to customise an individual’s risk factors, enhancing perceived personal relevance and helping to overcome the tendency to deny that the information in the tailored messages applies to the recipient. These personal communications can both inform the smoker of their own personal risk, while at the same time promoting confidence and providing the helping relationship that is essential to encouraging acceptance of the advice and following the recommended course of action. These basic tenets were put together in the 3Ts (Tension, Trigger, Treatment) model proposed by West and Sohal.41 They proposed that triggers can lead to sudden changes and that creating motivational tension can trigger action in smokers who are predisposed, or motivated, to change. The immediate availability of treatment can then prompt action.
Research has shown that individually tailored self-help materials have a small but useful effect over generic materials on smoking cessation.42 The addition of personalised risk communication that is more personally relevant to the consumer has also been found to increase uptake of screening.31 Computer technology can be used to produce a communication that combines the tenets of this model, and can also be combined with proactive recruitment methods with the potential to engage with and recruit a larger proportion of the smoking population in a relatively inexpensive way.
Opportunity to experience a support service without commitment
In addition to the factors noted as barriers to the use of support services, the literature also suggests that many smokers are unaware of, or have insufficient knowledge of or inadequate information about, the services available.20,43 This lack of knowledge can also lead to the belief that ‘it wouldn’t help me anyway’.20 The combination of ‘why quit’ messages, hard-hitting messages about the consequences of tobacco use and ‘how to quit’ messages, supportive and positive and emphasising quitting resources, was recommended in the Global Dialogue for Effective Stop Smoking Campaigns,44 an international review of the literature. This report also recommended that promotional efforts need to both build awareness that getting help will increase the chances of success and build awareness of and comfort with the quitting services.
Lichtenstein and Hollis27 demonstrated how a proactive and personal approach can be combined with an opportunity to gain more information about the service and what it involves at a no-commitment introductory session. Their intervention included an assessment, measurement of expired-air carbon monoxide (CO) level with an interpretation, video testimonials and the opportunity to ask questions, a voucher fee waiver and immediate scheduling of the smoker for the group. Thus, including a personal invitation with an appointment to a no-commitment introductory session offers the opportunity to gain an insight into what the service can offer, and also has the potential to increase service use.
This research study brings together evidence on proactive and direct mail recruitment, on personalised computer-tailoring and risk information, and on offering the opportunity to experience a support service without commitment, to evaluate a complex intervention comprising all of these elements, in encouraging and increasing attendance at the English SSSs.
The intervention is further enhanced by the addition of a repeated personal letter, with a further invitation sent 3 months after the original to all participants who fail to attend a taster session. This is consistent with recommendations made by Lichtenstein and Hollis27 who proposed that, with repeated advice over time, a greater proportion will be likely to respond.
Aims and objectives
Principal research question
We hypothesised that smokers, identified from general practice records, sent brief personal tailored letters based on characteristics available in their primary care medical records and on a short screening questionnaire, and invited to a ‘Come and Try it’ taster session designed to inform them about the SSSs, were more likely to attend the services than those who received a standard generic letter advertising the service.
Primary objective
The primary objective of the study was to assess the relative effectiveness and cost-effectiveness of a complex intervention, consisting of proactive recruitment by a brief personal letter tailored to individual characteristics available in medical records, and an invitation to a ‘Come and Try it’ taster session to provide information about the SSSs, over a standard generic letter advertising the service, on attendance at the SSSs of at least one session.
Secondary objectives
The secondary objectives were to (1) assess the relative effectiveness of the intervention on biochemically validated 7-day point prevalent abstinence rates at the 6-month follow-up; (2) compare the cost-effectiveness of the intervention; (3) assess the relative effectiveness on additional periods of abstinence measured by self-report of not smoking for periods of 24 hours to 3 months at the 6-month follow-up; (4) assess the number of smokers attending the taster session and the number of smokers completing the 6-week NHS smoking cessation course; (5) assess the number of quit attempts made and any reduction in daily cigarette consumption; (6) explore the effectiveness of the intervention by socioeconomic status and social deprivation; (7) explore reasons for non-attendance and barriers to attendance at the SSS; and (8) determine predictors of attendance at the services and at the taster sessions (in the intervention group).
