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

Published on 21 March 2017

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.

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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.

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.

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 NHS Stop Smoking Services

Published on 25 January 2017

Gilbert H, Sutton S, Morris R, Petersen I, Wu Q, Parrott S

Health Technology Assessment Volume 21 Issue 3 , 2017

Background The NHS Stop Smoking Services (SSSs) offer help to smokers who want to quit. However, the proportion of smokers attending the SSSs is low and current figures show a continuing downward trend. This research addressed the problem of how to motivate more smokers to accept help to quit. Objectives To assess the relative effectiveness, and cost-effectiveness, of an intervention consisting of proactive recruitment by a brief computer-tailored personal risk letter and an invitation to a ‘Come and Try it’ taster session to provide information about the SSSs, compared with a standard generic letter advertising the service, in terms of attendance at the SSSs of at least one session and validated 7-day point prevalent abstinence at the 6-month follow-up. Design Randomised controlled trial of a complex intervention with follow-up 6 months after the date of randomisation. Setting SSSs and general practices in England. Participants All smokers aged ≥ 16 years identified from medical records in participating practices who were motivated to quit and who had not attended the SSS in the previous 12 months. Participants were randomised in the ratio 3 : 2 (intervention to control) by a computer program. Interventions Intervention – brief personalised and tailored letter sent from the general practitioner using information obtained from the screening questionnaire and from medical records, and an invitation to attend a taster session, run by the local SSS. Control – standard generic letter from the general practice advertising the local SSS and the therapies available, and asking the smoker to contact the service to make an appointment. Main outcome measures (1) Proportion of people attending the first session of a 6-week course over a period of 6 months from the receipt of the invitation letter, measured by records of attendance at the SSSs; (2) 7-day point prevalent abstinence at the 6-month follow-up, validated by salivary cotinine analysis; and (3) cost-effectiveness of the intervention. Results Eighteen SSSs and 99 practices within the SSS areas participated; 4384 participants were randomised to the intervention (n = 2636) or control (n = 1748). One participant withdrew and 4383 were analysed. The proportion of people attending the first session of a SSS course was significantly higher in the intervention group than in the control group [17.4% vs. 9.0%; unadjusted odds ratio (OR) 2.12, 95% confidence interval (CI) 1.75 to 2.57; p < 0.001]. The validated 7-day point prevalent abstinence at the 6-month follow-up was significantly higher in the intervention group than in the control group (9.0% vs. 5.6%; unadjusted OR 1.68, 95% CI 1.32 to 2.15; p < 0.001), as was the validated 3-month prolonged abstinence and all other periods of abstinence measured by self-report. Using the National Institute for Health and Care Excellence decision-making threshold range of £20,000–30,000 per quality-adjusted life-year gained, the probability that the intervention was more cost-effective than the control was up to 27% at 6 months and > 86% over a lifetime horizon. Limitations Participating SSSs may not be representative of all SSSs in England. Recruitment was low, at 4%. Conclusions The Start2quit trial added to evidence that a proactive approach with an intensive intervention to deliver personalised risk information and offer a no-commitment introductory session can be successful in reaching more smokers and increasing the uptake of the SSS and quit rates. The intervention appears less likely to be cost-effective in the short term, but is highly likely to be cost-effective over a lifetime horizon. Future work Further research could assess the separate effects of these components. Funding details This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 3. See the NIHR Journals Library website for further project information.

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%

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

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