UCL Research Department of Primary Care and Population Health

1. UCL Research Department of Primary Care and Population Health Encouraging smokers to use the Stop Smoking Services TheStart2quitrandomised trial to increase the uptake of smoking cessation services • Hazel Gilbert • Department of Primary Care and Population Health University College London

2. Background • 19% of the adult population in Great Britain still smoke • Many smokers say they want to quit, and up to 30% each year will make an attempt to quit • Most do not utilisethe publicly available effective quit smoking support services. 

3. The English Stop Smoking Services (SSS) offer smokers a significantly higher chance of stopping smoking compared with quitting without support Successful quitters as a percentage of those setting a quit date 2004/05 to 2014/15

4. Proportion of smokers in England using the SSS: • 2001/2002 - 2.0% • 2011 - 4.1% Number setting a quit date and successful quitters 2004/5 to 2014/15

5. GPs and health professionals are encouraged to offer brief advice and referral to services • 2008/2009 • 55% of smokers reported being given advice by GP • only 8% were referred to the services • Recruitment methods employ a reactive approach: Smokers expected to seek out help, follow up their referral and approach the service themselves to make appointment

6. Start2quit • randomised trial with two-component intervention • employed proactive recruitment strategy using mass mailing Lichtenstein and Hollis (1992) smokers invited to attend a no-commitment introductory session to offer information about what attendance at the service would involve Murray et al (2008) UK study used proactive strategy to identify smokers and inform them about local SSS Studies suggested proactive contact ac­ceptable and smokers open to the idea of counselling Paul (2004) Tzelepis (2009)

7. Intervention • Brief personal risk information letter • contained information pertaining to the recipient’s own individual risk of serious illness if they continue to smoke • fear communications can push people to attempt to quit when combined with reassuring message about efficacy and advice on how to go about it • consistent with the Health Belief Model, which highlights the importance of providing a specific cue to action   • ‘unrealistic optimism’: smokers aware of the well-publicised risks but substantially underestimate own personal risk • used computer-tailoring to customize individual’s risk factors • based on information from the screening questionnaire and from medical records • sent from the GP

8. Personal Health Risk Report and Taster Session Invitation Dear Mr Rubble You recently filled in a questionnaire for the start2quit project. This letter is based on your answers in the questionnaire and on your medical records. It is written for you personally and gives you advice about smoking. We are also inviting you to a Taster Session to help you to become smokefree and improve your health. Your personal risk Based on your smoking habits and your personal health, your current risk of developing a further serious illness and suffering an early death is very high compared to a non-smoker or ex-smoker of your age. Your records show that you also have diabetes, and even by smoking only 10 cigarettes a day you are seriously increasing your risk of high blood pressure leading to heart attack and kidney disease. By going smokefree now, you can prevent further decline and begin to heal. Take control and change your life Stopping smoking is the single most important thing that you can do to improve your health and quality of life. The good news is that if you quit now, at 37, you have greater chance of preventing any further complications and can halve your additional risk of contracting other diseases. By stopping smoking you will slow the progress of your existing condition and live with better health for longer. We recommend that you consider quitting without delay. It could be the best thing you will ever do for yourself.

9. Don’t do it alone • You might think it is hard to stop but you don’t have to do it alone. Help and support is available. The NHS Stop Smoking Service offers free personal support to help you. You have previously quit for a few days. Joining a stop smoking group or getting one-to-one support will increase your chances of staying quit and becoming smokefree. You will also feel less alone and gain the support of other people who are quitting. • A place is reserved for you • So that you can find out more about the Stop Smoking Service, we are inviting you to a ‘Come and Try it’ session at Camden Town Hall on Wednesday 10th January 2011 at 7pm. Please bring the Invitation Card enclosed with you. If you cannot attend this session, please contact Sally Jones on 0118 9234901. We can offer you an alternative time or an immediate appointment with an advisor. • With very best wishes

10. <name> Invitation to a ‘Come and Try it’ Stop Smoking Session at <place> on <day> <date> at <time>. Please bring this card with you to the session. If you are unable to attend, please contact <name> on <tel number>

11. Invitation and appointment to attend a ‘Come and Try it’ taster session • Offered the opportunity to experience a support service without commitment • Goal was to offer information about the SSS, to promote the service, to address any concerns or queries smokers may have about the service provided and encourage sign up to a course. • Aimed to build awareness and comfort with the services and confidence in their efficacy • Not intended to replicate the first session of a course • Run by smoking cessation advisors, trained to lead sessions according to a standard protocoland manual • Lasted approximately 1 hour • 5-min DVD showing testimonials and sessions in progress

12. Control • Received a standard generic letter advertising the local SSS and asking the smoker to contact the service to make an appointment

13. Hypothesised that: Smokers identified from general practice records and sent a brief personally tailored risk letter 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.

14. Target Population and Inclusion criteria • Targeted areas of high deprivation and ethnic minorities, where smoking prevalence is high. • Current smokers motivated to quit • aged 16 years and over • motivated to quit defined as answering ‘yes’ to either or both of the following questions: • Are you seriously thinking of quitting in the next six months? • Would you think of quitting if appropriate help were offered at a convenient time and place? • not attended the SSS in the previous 12 months

15. Primary Care Research Network (PCRN) recruited SSSs(n=18) • and General Practices (n=99) • Total list size = 962,548 (practice list size range=2,205 to 26,000) • Practices identified all smokers aged >=16 from medical records (n=141,488) (14.7%) • GPs screened list to exclude anyone unsuitable for the research(n=4,186) • Computer screened out all but one person from the same address (n=25,086) • All remaining on the list (n=112,216) sent • letter from their GP inviting them to participate • Participant Information Leaflet • Assessment questionnaire andConsent Form • Non-responders sent a reminder and duplicate questionnaire after 3 weeks Completed Questionnaires returned to practice Consenting patients randomised to Control or Intervention (n=4,384) (4.1%)

16. Randomisedto Control (n=1748) • Randomisedto Intervention (n=2636) Taster session 1 sent generic letter sent tailored letter and invitation to Taster Session Taster session 2 Taster session 3 Second letter and invitation to all non-attenders Taster session 4 Followed-up 6-months after date of randomisationby telephone interview Control=77.3% Intervention=76.7% Collected sal­ivary sampleto biochemically validate smoking status from participants claiming 7-day abstinence End of quarter following the end of the 6-month follow-up period in each area collecteddata of attendance and from SSSs for each participant (100%) N analysed=4,383 Withdrawn=1

17. Primary Outcome • The proportion of people attending the first session of a course over a period of 6 months from the receipt of the invitation letter, measured by records of attendance at the SSSs • Secondary outcomes • validated 7-day pp abstinence at the 6-month follow-up • validated 3-month prolonged abstinence, additional periods of abstinence measured by self-report: 24hr and 7 day pp, 1-month and 3-month prolonged • the number completing the 6-week SSS course Process measures Number of smokers attending the taster session Perception of the personal risk letters Perception of the taster session

18. England by level of socioeconomic deprivation • 1 Camden • 2 Oxfordshire • 3 Medway • 4 Eastern & Coast Kent • 5 Lincolnshire • 6 Essex • 7 Cornwall • 8 Derby • 9 Brent • 10 Plymouth • 11 Swindon • 12 Durham & Darlington • 13 Hampshire • 14 Portsmouth • 15 Staffordshire • 16 Barnsley • 17 Buckinghamshire • 18 Coventry 12 16 5 8 15 18 2 17 6 11 1 9 3 4 13 14 7 10

19. Demographic and Smoking characteristics Gender male2231 (50.9%) Mean Age 49.3 (range 16–89) Married / Living with a spouse 2390 (54.5%) Deprivation(IMD score) quintile 1: 549 (12.5%) quintile 2: 622 (14.2%) quintile 3: 966 (22.0%) quintile 4: 1130 (25.8%) quintile 5: 1089 (24.9%) Live with smoker 1402 (32.0% ) Dependence score (0-6) low (0-2) 1763(40.2%) medium (3)1431(32.7%) high (4-6) 1160(26.5%) Intention to quit Plan to quit in next 6 months 1862 (42.5%) Previous quit attempt previous quit >1 mth2440 (55.7%) Mean determination to quit (1-5 scale) 3.7 (0.9) Not previously attended SSS 2898 (66.1%) Self-reported health problems 1016 (23.2%) At least 1 QOF disease recorded 2004(45.7%)

20. Results

21. Subgroup analysis Gender • Intervention more effective for males SSS attendance p for interaction=0.01 • 7day pp abstinence • p for interaction=0.01

22. Social deprivation SSS attendance Differential greater in IMD Quintiles 2, 3 and 4 (p for interaction=0.005) • 7day pp abstinence • No interaction

23. Age SSS attendance • 7day pp abstinence

24. Effect of repeat reminders • Time from randomization to attendance at the SSS

25. Variation in outcome by SSS

26. Taster Session organisation and attendance • mean number invited to an initial session = 24.4 (2-78) • mean number invited to follow-up session = 49.6 (7-168) • Total Attendance = 739/2635 (28%) • Mean Attendance at sessions that went ahead = 5.6 (1-19) • Attendance and smoking status outcome • Participants were more likely to attend the SSS if they had attended a taster session (45.7% vs. 6.3%) • Participants who received the intervention and attended the SSS were most likely to be 7-day abstinent (28.7%)

27. Intervention group=2635 Control group=1748 Numbers attending a Taster session, the SSS and achieving validated 7-day point prevalent abstinence Attended taster =739(28%) Not attended taster =1896(72%) Not attended SSS =1590(91%) Attended SSS =338(45.7%) Not attended SSS =401(54.3%) Attended SSS =120(6.3%) Not attended SSS =1776(93.7%) Attended SSS =158(9%) 7- day validated abstinent 97 (28.7%) 40 (10%) 21 (17.5%) 78 (4.4%) 23 (14.6%) 74 (4.7%)

28. Perception of the personal risk letter Intervention Control n=1740 n=1170 Remembered letter 90.2% 88.5% Read letter 87.2% 83.5% Discussed letter 37.6% 29.7% Mean score: scale 1-5 Written for me 3.43 3.22 Felt more confident 3.18 2.95 Felt more determined 3.36 3.10 Liked the tone 3.68 3.54 • Highly acceptable: • easy to read 95.8% • easy to understand 96.8% • interesting 61.2% • useful 66% • Few respondents felt: • angry 4.1% • anxious 8.2% • depressed 4.5% • 67% felt at least moderately optimistic

29. Perception of the Taster session ‘well organised and informative and the first time I have tried 'group therapy'. I was anxious about group therapy as giving up but it was all cool and helpful’ ‘very welcoming and informal and friendly informative and non judgmental’ ‘very good. Without trying to 'preach' or exert undue pressure’ ‘‘informative and knowing I can discuss my problems with someone has made my decision to try to quit easier’ ‘nice to know that such a service exists’ ‘quite enlightening’ ‘an interesting concept’ ‘time well spent - increasing my determination to quit’

30. Summary • Use of stop smoking services can be encouraged by • more proactive recruitment methods • personal risk information • offering an opportunity to attend no-commitment taster session • Intervention more effective for men • Participants found the tailored personal risk letter acceptable, few were upset by it • The taster session was well-received

31. Caveats • Seems that both parts of the intervention worked in concert to increase attendance • Further research is needed to investigate the effectiveness of each component of this intervention. • Mean costs: £54 per intervention participant; £0.9 per control participant • In the short-term, the personal risk information and taster session is expensive compared with the generic letter. • Considering long-term costs and health benefits,, the intervention has an 86% probability of being more cost-effective compared with the generic letter.

32. UCL Research Department of Primary Care and Population Health Principle Investigator: Dr Hazel Gilbert hazel.gilbert@ucl.ac.uk Co Investigators: Professor Irwin Nazareth UCL Medical School Professor Richard Morris (Trial Statistician) UCL Medical School Dr Irene Petersen (Statistician) UCL Medical School Professor Stephen SuttonUniversity of Cambridge Steve Parrott University of York DrSimon Galton Camden Stop Smoking Service Funding Acknowledgement:This project was funded by the National Institute for Health Research HTA Programme (Project Number 08/58/02)Department of Health Disclaimer:The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HTA Programme, NIHR, NHS or the Department of Health.