National Social Marketing Centre

A number of interventions were delivered, focusing on reconfiguring existing service provision to better meet the needs of the community.

Outreach at workplaces and organisations (April 2009 – March 2010)
Outreach efforts by the Recruitment and Outreach Workers (ROW)team created unique links with local businesses, notably social housing landlord Lewisham Homes and a company working on the East London line development, which previously had very few links with any NHS services. These new relationships created opportunities to provide stop smoking workshops in workplaces, thereby increasing the numbers of smokers working in the area using and quitting with NHS Stop Smoking Services.

The ROW team also went out to local workplaces and voluntary and community organisations to speak to staff about smoking cessation and support services. These included discussions with teams at Pepys Tenants and Residents Association (TRA), Evelyn TRA, and the John Evelyn Pub.

Extended stop smoking services (from April 2009) 
Direct feedback from the outreach work identified that many people working in routine and manual jobs, such as catering, often worked long hours, which made the existing stop smoking provision in the area inaccessible. Following a mapping exercise of current provision, the hours of service were extended and extra surgeries were held at general practices and leisure centres to increase access. This was particularly relevant on isolated housing estates, where facilities and transport links were limited.

Outreach at schools (May 2009 – December 2010)
Links were made with local schools to create opportunities to talk to parents at coffee mornings, school fairs and parents’ evenings, as well as other promotional events.

GP exercise referral scheme (September 2009)
Prior to the project, there was little additional support for smokers concerned about weight gain as a result of giving up smoking. The scoping research identified that one of the reasons people (particularly females) continued to smoke was the perception that smoking helped to control weight gain. Fitness opportunities (e.g. leisure services) that existed in the ward relied on residents being aware of them and having the time and money to make use of them.

Through negotiations with the local authority, which is the main provider of local leisure and fitness services, the team implemented a GP exercise referral scheme that provided access to subsidised fitness services/classes and a bespoke exercise programme for smokers looking to quit, but were concerned about weight gain.

Workplace stop smoking surgeries (September 2009 - January 2010)
Some of the links made with workplaces in the area resulted in opportunities to provide work-based stop smoking surgeries. During lunch or negotiated breaks, staff could meet with stop smoking advisors to be monitored and receive advice, medication, and other interventions to help support their quit attempt.

Locum pharmacy support was also provided in December 2009 to workplace smoking cessation sessions so that smokers could access the full range of prescribed medication to help them in their quit attempts. This intervention increased the numbers of people signing up to quit programmes and successfully quitting.

Stress management workshops (March 2010)
Stress was identified as one of the reasons why people smoke, find it hard to give up, and take up smoking again after quitting. To help manage everyday or extreme levels of stress and replace the perceived benefits of smoking, stress management workshops were provided at the Waldron Health Centre in New Cross by the South Lewisham and Maudsley Mental Health Trust.

The benefits of quitting smoking and using the NHS stop smoking service were promoted to the target audience through:

• Promotional literature
• Staff newsletters and health e-newsletters
• Features in the local press
• Talks to groups and organisations through outreach
• Face-to-face promotion and recruitment to stop smoking services through local events and tours
• PR and events delivered in partnership with Millwall Football Club (FC)

Secondary research was completed by the NSMC in June 2007 to gather existing data on demographics, current service provision and smokers’ motivations and barriers to quitting.

To further explore why people in Evelyn smoke and what the barriers and motivators are to quitting and using NHS stop smoking services, extensive primary research was carried out by the recruitment and outreach workers, project managers and project worker between December 2007 and June 2009. Focus groups were held with 32 smokers and interviews were held with six health professionals who provided stop smoking services in Evelyn ward. A further focus group was held in a local pub in June 2009 with more hardened smokers, to test their awareness of and attitudes towards smoking cessation services.

A Solutions Group was formed with key community stakeholders and services, such as Pepys community forum, Lewisham refugee network, Sure Start, health improvement and project team members, and One Deep Breath. The group’s knowledge of and links to the target audience was invaluable in reviewing the findings of the research, identifying key insights and developing interventions that met the needs of the target audience. In the latter stages of the project, a smaller team made up of the Stop Smoking Service manager, project manager, NSMC Associate and One Deep Breath was set up to focus on intervention delivery.

Several smokers’ reference groups were held between September 2008 and June 2009, to concept test intervention ideas and pre-test publicity materials to ensure they were appropriate and tailored for the target audience. The groups consisted of parents at a local primary school, smokers who frequented a local pub and various other members of the community. They were recruited through the recruitment and outreach work and liaison with local businesses.

Health improvement programme research was also carried out by NHS Lewisham in 2008. Intended to gain an overview of the issues in the local area from a health perspective, the research focused on health inequalities issues, contributing factors and local and national health statistics.

A high proportion of the Evelyn population work in routine and manual jobs and require services that fit around their working patterns. Evening surgeries close to transport links were therefore put in place as part of this project.

Smoking among routine and manual workers was often a core part of their social interactions with friends, family and colleagues. Removing the smoking habit would therefore have an isolating impact on these relationships. Stop smoking surgeries offered a range of advice and reassurance to smokers around coping with these social issues.

In a deprived ward like Evelyn, issues of debt, housing and money management contributed towards people’s high stress levels. Smoking was often considered a refuge and form of stress relief. An essential part of the outreach and recruitment was therefore to make links with local welfare rights, social housing and voluntary sector organisations, to signpost quitters to their services and alleviate some of the contributing stress factors.

Evelyn ward has experienced a variety of social, economic and housing regenerations schemes, which tended to be short-lived. This has contributed to cynicism within the community of new interventions delivered with external funding. In promoting and raising expectations of new and improved smoking cessation services, it was essential to integrate these into existing mainstream service provision, to ensure that they didn’t cease with the end of the project. It was also important to build relationships with local people and organisations, to gain trust and increase referral rates.

The project aimed to:

• Increase the numbers of smokers in the ward signing up to stop smoking programmes
• Increase the numbers of smokers in the ward successfully quitting
• Double the number of four week quits among routine and manual workers in the ward
• Raise awareness of stop smoking provision in the area
• Increase access to stop smoking services in the area

The behavioural goals of the project were for smokers in Evelyn ward to register with NHS stop smoking services and successfully quit smoking.

Routinely-collected PCT data of smoking prevalence and quit rates were used as a baseline and indicator for the project. Data for the implementation period (April 2009 to March 2010) was compared with data in the previous year (April 2008 to March 2009) to assess impacts of the interventions on smoking prevalence, recruitment to the stop smoking service, and quit rates.

A cross-sectional 'pre' and 'post' street survey was conducted in Evelyn ward to assess awareness of and interactions with stop smoking services.

The project initially aimed to target three audience segments:

Male and female smokers aged 35 to 44 expressing a desire to quit
The health benefits for people within this age bracket are highly significant and beneficial. 

Smokers with children of primary school age
Young children can have a strong influence on motivating their parents to quit smoking.

Adult smokers in routine and manual employment
The prevalence of smoking within routine and manual workers is higher than in other socio-economic groups. The impact of reducing smoking prevalence within this target group would therefore be significant in this ward, due to the large proportion of the population employed in this sector.

However, it became apparent that working with such a wide group of target audiences would require a large number of strategies, resources and interventions, which would be unrealistic to deliver within the timescale of the project. The project team therefore decided to just target smokers in routine and manual employment, since this is a key target group nationally and locally and many of them also fall within the other two segments.

The barriers and costs of exchanging smoking habits for a smoke-free lifestyle included:

• Isolation from peers, family members and other social groups
• Having to cope with everyday stresses without the relief of cigarettes
• Psychological impact of breaking well-established habits and behaviours
• Potential weight gain
• Not having a legitimate excuse for regular breaks from work

Benefits and incentives offered to smokers who quit with the interventions included:

• Improved health
• Being able to treat themselves to  other  things with the money saved
• Football match tickets and branded merchandise
• Access to subsidised fitness programmes and facilities
• Friendship and support from group workshops
• Sense of achievement
• Training and advice on stress management and coping strategies
• Signposting to support services for other issues, such as welfare rights

Benefits offered to local delivery partners included:

• Publicity, promotional opportunities and recognition. For example, Millwall FC received a gold standard award for community work as a result of working in partnership with the stop smoking programme
• Better service and more direct and immediate referral opportunities to stop smoking programmes for clients/patients
• Improvements in client/patient health
• Better links to other organisations that complement their own services
• Increased take up of services, such physical activity programmes at leisure centres

The project’s main competitors were:

• Sociability of being part of a smoking group
• Quitting without support services
• Private (non-NHS) stop smoking services
• Marketing of cigarettes

The project team sought to counteract this competition by:

• Highlighting the rising trend of smoking cessation and the opportunity for quitters to be part of a social movement towards a smoke-free society
• Intensive outreach and promotion of the NHS stop smoking service to the target audience in social and work settings
• Improving access to and delivery of stop smoking services
• Offering incentives, such as football tickets/merchandise, access to subsidised fitness facilities, and other support services

Social Cognitive Theory (Bandura 1999) looks at how people learn certain behaviours. It proposes that the development of behaviour is achieved through the interaction of three different factors: personal, environmental and behavioural. The theory also stresses the importance of self-efficacy and belief that the benefits of undertaking a behaviour outweigh the costs.

The project aimed to address these factors by re-designing the stop smoking service, making it more tailored to the needs and concerns of smokers and more accessible through its opening times and locations, as well as delivering visible and wide-reaching recruitment and promotional activities.