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NIHR Signal Personalised letters and a “taster session” help double attendance at NHS stop smoking services

Published on 21 March 2017

doi: 10.3310/signal-000395

Attendance at NHS stop smoking services (SSS) almost doubled after smokers were sent letters showing their personalised risk of serious illness if they continued to smoke alongside invitations to try the service.

Less than 5% of smokers attend these services in England and numbers are on the decline, although this is one of the most effective ways of stopping smoking.

A personalised risk letter was sent to 2,636 smokers alongside an invitation to a local taster session. 17.4% attended, compared to 9.0% of 1,748 smokers who received a standard letter advertising the service. The letter and invitation to a taster session also increased the number who had quit smoking by six months (9% vs. 5.6%).

This proactive recruitment looked likely to be cost effective over a person’s lifetime compared to the usual non-specific invitation.

Those recruited represented only a small proportion of smokers wishing to quit and who may be more motivated than most. There remains a need across all of society to increase accessibility to stop smoking services.

  •   Public Health
Personalised letters and a “taster session” help double attendance at NHS stop smoking services

Why was this study needed?

NHS SSS offer many ways to help smokers who want to quit. However, only a fraction of smokers use them, just 4.8% in 2015/16, and attendance has been declining in recent years.

Helping people to stop smoking, particularly in disadvantaged areas, is a focus of societal efforts to extend healthy life and cut health gaps between rich and poor that are partly attributable to smoking.

This NIHR-funded trial tested whether giving people information about their personal risk of serious illness should they continue to smoke, and inviting them to a SSS taster session, would boost attendance at SSS.

What did this study do?

This randomised control trial included 4,384 adult smokers (aged 16 or over) who wished to quit and had not attended SSS in the preceding year.

Over half (2,636) received a personalised letter from their GP detailing their smoking-related disease risk based on age, gender, medical conditions, smoking habits and other factors. Additionally, they received a personal invitation and appointment to a “Come and Try it” taster session, run by the local SSS.

The comparison group (1,748 smokers) received a generic GP letter advertising the local SSS, therapies available, and asked them to make an appointment.

Eighteen of the 151 SSS’s in England took part, and trial participants represented 4% of all eligible smokers. The low rate of recruitment and the possibility that SSS’s which participated in the study were different from those that didn’t, are potential weaknesses in this study.

What did it find?

  • The personalised risk letter and taster session invite (the intervention) roughly doubled the proportion of smokers attending at least one SSS session (17.4%) compared with the generic letter (9.0%). Odds ratio (OR) 2.12, 95% confidence interval (CI) 1.75 to 2.57.
  • After six months, 9% receiving the intervention had successfully quit smoking for at least seven days (validated by a carbon monoxide test), compared with 5.6% receiving the generic letter (OR 1.68, 95% CI 1.32 to 2.15).
  • The intervention had greater effect on SSS attendance in men (19% intervention vs. 8% control) than in women (15.7 vs. 10.1%), which resulted in more men successfully quitting than women.
  • Attendance at SSS was similar across all five categories of deprivation measured, suggesting the intervention would neither improve nor worsen smoking-related health gaps.
  • The intervention had 27% probability of being a cost-effective use of NHS resources at six months based on the willingness-to-pay threshold of £20,000-30,000 per quality-adjusted life year. However, it was likely to be cost effective over the course of a lifetime (86% probability) compared with the generic letter.

What does current guidance say on this issue?

A 2013 NICE Public Health Guideline identified stop smoking service priorities based on the following criteria:

  • impact on health inequalities
  • impact on health of the target population
  • cost effectiveness
  • balance of risks and benefits
  • ease of implementation
  • speed of impact

The guideline also recommended setting realistic performance targets locally. This includes aiming to treat at least 5% of the estimated local population of people who smoke or use tobacco in any form each year.

What are the implications?

This intervention represents a way of boosting low and declining attendance at Stop Smoking Services in England that would be cost effective in the long-term.

The benefits seen may be inflated because smokers who agree to participate in trials are usually more motivated to quit.

Modifications to the intervention could be explored to further reduce costs and improve accessibility, for example, using email rather a letter.

It is unclear whether the recent decline in use of SSS could be wholly or partly explained by a rise in use of electronic cigarettes (e-cigarettes) over the same period.

Citation and Funding

Gilbert H, Sutton S, Morris R, et al. Start2quit: a randomised clinical controlled trial to evaluate the effectiveness and cost-effectiveness of using personal tailored risk information and taster sessions to increase the uptake of the Unstop Smoking Services. Health Technol Assess. 2017;21(3):1-206.

This project was funded by the National Institute for Health Research Health Technology Programme (project number 08/58/02).

Bibliography

Gilbert H, Sutton S, Morris R, et al. Effectiveness of personalised risk information and taster sessions to increase the uptake of smoking cessation services (Start2quit): a randomised controlled trial. Lancet. 2017;389(10071):823-33.

NHS Digital. Health Survey for England, 2015 [NS]. London: Department of Health; 2016.

NHS Digital. Statistics on NHS Stop Smoking Services England, April 2015 to March 2016. London: Department of Health; 2016.

NICE. Stop Smoking Services. PH10. London: National Institute for Health and Care Excellence; 2008.

ONS. Population Estimates for UK, England and Wales, Scotland and Northern Ireland (Mid-2015). London: Office for National Statistics; 2016.

Expert commentary

The local stop smoking services in England were set up through the NHS in 1999 in order to help smokers quit and reduce health inequalities. They provide access to pharmacotherapy and behavioural support. Long term evaluations have suggested that they significantly increase the chances of quitting, with quit rates of around 35% at 4 weeks, and are cost effective. However, use has declined since 2012. 

Computer-tailored personalised risk letters with an invitation to a taster session from GPs, instead of a standard letter, improved use and quit rates. Thus a more individual centred approach may improve outcomes but additional expenditure should be limited to enhance cost-effectiveness.

Dr Rosemary Hiscock, Research Associate, UK Centre for Tobacco and Alcohol Studies, University of Bath

Definitions

How many people smoke in England, how many of them access Stop Smoking Services, and how many successfully quit?

Summary of stop smoking figures in England in 2015

Description

Male

Female

Total

Health Survey for England current smokers aged 16 and over, 2015

19%

17%

18%

Mid-year ONS estimate 2015 aged 16 and over*

21,700,466

22,680,747

44,381,213

Number of current smokers 2015 aged 16 and over

4,147,906

3,779,129

7,927,035

Number attending SSS and setting a quit date (Apr 2015-Mar 2016)

 

 

382,500

Number successfully quitting using SSS (Apr 2015-Mar 2016, self reported)

 

 

195,170

Number successfully quitting using SSS (Apr 2015-Mar 2016, CO validated)

 

 

139,287

% of current smokers setting a quit date using SSS

 

 

4.8%

% smokers stopping using SSS (self reported)

 

 

2.5%

% smokers stopping using SSS (CO validated)

 

 

1.8%