The prevalence of smoking in the UK has fallen from 25% to 22% and 23% to 21% between 2005 and 2008 in men and women, respectively [1
]. While government targets to reduce smoking prevalence have been achieved [2
], there is no room for complacency. Smoking remains a major cause of ill health and mortality, accounting for approximately 18% of all deaths in adults aged over 35 years in 2007 [3
]. Furthermore, national statistics from 2008 figures show a widening gap in smoking prevalence between those in professional and managerial occupations, and routine and manual workers; 29% of the latter still smoke, rising to 42% of those currently not employed [1
Government-funded specialist smoking cessation services were implemented in 1999 in Health Action Zones, and were rolled out throughout England in 2000 [4
]. These services offer intensive advice and support to smokers motivated to quit, in group or one-to-one sessions. However, most smokers will not attend formal cessation programmes, preferring to quit on their own, consequently such programmes are consistently underused [5
]. In 2007, 74% of current smokers in Great Britain reported that they want to quit, and 31% had made an attempt to quit in the previous year [9
]. In 2001 to 2002, 2.01% of the adult smoking population in England set a quit date using the National Health Service (NHS) Stop Smoking Services (SSS) [10
], and even now this figure is estimated to be < 5% [11
]. Thus, despite a desire to quit, only a small proportion use the free service provided by the NHS [14
A wide range of factors, such as lack of availability and accessibility, perceived inappropriateness of the service, a perception that help is not necessary, or a sense of a lack of empathy from health professionals, as well as a lack of readiness to quit, will bar smokers from seeking help [15
]. The literature also suggests that many smokers are unaware of, or have insufficient knowledge of or inadequate information about the services available [16
] and this lack of knowledge can also lead to the belief that ‘it wouldn’t help me anyway’ [16
Health professionals are guided to offer brief advice and refer smokers to the services, but the percentage of smokers receiving such advice is small, and only 9% were referred to the cessation services in 2007 [3
]. Moreover, these smokers are generally expected to follow-up their referral and contact the service themselves to make the appointment. Lichtenstein [7
] evaluated an intensive and standardised referral protocol, employing a more proactive method of recruitment and referral by inviting smokers to an intervention with a strong referral message to the service and offering information about what attendance at the service would involve. This intervention included an assessment, measurement of expired-air carbon monoxide (CO) level with an interpretation, a 10-min video of a stop smoking group program featuring former successful group members, a voucher fee waiver, and immediate scheduling of the smoker for the group. With this intervention, 11.3% of smokers attended the first session of the cessation programme, compared with 0.006% of the control group who received brief advice only.
While recruitment methods to cessation services generally employ a reactive approach, in which smokers are expected to seek out and approach the service [16
], evidence suggests that if smokers are proactively and personally invited to use the services, the resultant use will be higher than standard referral by health professionals, or open advertising. In a study exploring the acceptability of proactive contact offering cessation services to smokers, 92.8% 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 [16
]. 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 intensive counselling.
In a study by Murray and colleagues [11
], general practices identified all patients who were recorded as current smokers or with no status recorded, and proactively informed them by letter about the stop smoking services, giving the option of being contacted by an advisor. 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 are interested in receiving help. Hence, novel methods of marketing to engage interested smokers are needed in order to encourage use of the services. Furthermore, general practices were randomized to an intervention group or to a control group. 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. Murray reported a 7.7% increase in smokers using the NHS SSS 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.
The study by Murray and colleagues [18
] was the first to assess a proactive method of recruitment to attract smokers into the services. However more personal methods of recruitment such as the use of tailored self-help materials, intended to meet the needs of one specific person, based on characteristics unique to that person [19
] could further enhance recruitment. The development of these materials has enabled the generation of highly-tailored behavioural feedback reports for smoking cessation [20
]. A computer-based system developed by two of the investigators (HG and SS) to generate individually-tailored feedback reports designed to encourage and help smokers to quit demonstrated a positive effect when used as an adjunct to telephone counselling (via the national Quitline) [21
], a finding consistent with other studies [22
]. These computer-based systems offer a method for further personalising communications to patients and have the potential to engage with and recruit a larger proportion of the smoking population.
In this study we extend the work of Murray and colleagues [18
] by providing a more intensive intervention using computer-tailored feedback to deliver personalised risk information to invite and encourage people to attend the NHS SSS. In addition smokers are offered a no-commitment taster session designed to inform them about the service and what it offers.
Intensive clinical treatment is particularly important for: (1) smokers at high risk because of chronic conditions; and (2) heavily dependent smokers who have been unsuccessful in previous attempts [5
]. Furthermore, a long-term aim of the NHS SSS is to help disadvantaged people to stop smoking. However, government targets to reduce smoking prevalence in the UK in manual groups to 26% by 2010 have not been reached [23
]. Thus, as part of this strategy the delivery of cessation services to poorer communities has been a priority [10
]. While the services have succeeded in attracting smokers from disadvantaged areas [10
], unacceptable smoking-related health inequalities persist [1
]. An advantage of the proactive recruitment method is the ability to target at risk groups. Smokers from the most disadvantaged areas are more interested in receiving help than smokers from areas of low deprivation [11
], thus more attractive methods to inform and engage this group are needed, including the use of medical information on chronic illnesses and high dependence to tailor our communications with smokers.
It is possible that by using methods of direct mail contact, smokers not ready or motivated to quit may be encouraged to attend the SSS, but would be less likely to quit than self-referred patients [14
]. Traditionally smokers with an intention to quit in the next 2 weeks are targeted in the NHS for attendance at specialist clinics, but planning to quit in the near future should not be taken as the only indicator of interest in quitting. Studies have shown that smokers stating that they have no plans to quit have taken part in cessation programmes [25
], and evidence from a recent trial suggests that proactive recruitment can successfully engage smokers with no immediate plans to quit in quitting activity [26
]. There is also evidence of smokers quitting without entering a preparation stage or planning to quit [27
]. Thus, in this study, we include those whose intention to quit is more distant, and those who express an interest in receiving help to quit.
The primary objective of the study is to assess the relative effectiveness on attendance at the NHS services of at least one session, of proactive recruitment by a brief personal letter, tailored to individual characteristics available in medical records, and invitation to a taster session to provide information about the NHS services, over a standard generic letter advertising the service.
Secondary objectives aim to: (1) assess the relative effectiveness of the two recruitment methods on biochemically validated 7-day point-prevalent abstinence rates at the 6-month follow-up; (2) compare the cost-effectiveness of the two invitation methods; (3) assess the relative effectiveness on prolonged abstinence measured by self-report of not smoking for periods of 7 days to 24 weeks 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) determine predictors of attendance at the services, and of attendance at the taster sessions (in the Intervention group); (7) explore reasons for non-attendance and barriers to attendance at the NHS SSS; and (8) explore the effectiveness of the intervention by socioeconomic status, and social deprivation.