Title: Understanding the facilitators and barriers that impact on the attendance of electronic cigarette users at NHS stop smoking services: a mixed methods investigation
Funder: Health Education England

Abstract: Background CHAR(13) + CHAR(10)Tobacco remains the greatest risk factor for avoidable morbidity and mortality in the UK [1]. Some 10 million people still smoke (approximately 20% of the adult population), with strong differences along sociodemographic lines, such as far higher rates in disadvantaged communities [2, 3]. CHAR(13) + CHAR(10)E-cigarettes are devices delivering nicotine in vapour form, avoiding the vast majority of toxins released from combusting tobacco [4]. Since 2012, prevalence of use has tripled to an estimated 2.1 million UK smokers, of which approximately 90% also smoke conventional cigarettes [3, 5]. CHAR(13) + CHAR(10)When asked about reasons for e-cigarette use, 83% of smokers using them report attempting to quit smoking [6]. Yet the limited evidence to date suggests e-cigarettes may only be moderately effective as quit aids, with a conservative estimate suggesting they may have contributed 0.05% to national reductions in smoking prevalence [7, 8]. CHAR(13) + CHAR(10)Conversely, consistent evidence has demonstrated considerably greater efficacy for NHS stop smoking services, which are particularly successful in helping disadvantaged smokers [9, 10]. Yet over the period e-cigarette use tripled, attendance at these services showed a sustained (and accelerating) decrease for the first time, falling 11% in 2012/13 and 19% in 2013/14 [11]. CHAR(13) + CHAR(10)Around 2% of smokers accessing NHS support report e-cigarette use, a proportion ten times lower than the roughly 20% of smokers nationally that report e-cigarette use [3, 12]. Uptake of these services may be affected by sociological barriers amongst smokers, but may also reflect variable policies towards e-cigarettes adopted by local services around the country [13]. Either way, the most effective intervention available for smoking cessation may be being neglected by smokers using e-cigarettes. Given the growing popularity of these new devices, this could have important, unexplored health and inequalities implications [3]. CHAR(13) + CHAR(10)No studies undertaken to date with smokers using e-cigarettes have examined factors influencing their intentions of accessing NHS stop smoking services. CHAR(13) + CHAR(10)Research questions How does intention to access NHS stop smoking services differ between smokers who use e-cigarettes and those who do not? How do smokers' reasons for accessing or not accessing NHS stop smoking services differ between those who use e-cigarettes and those who do not? Do these reasons vary between smokers from different sociodemographic backgrounds, particularly more disadvantaged smokers versus others? How do the local polices which different NHS stop smoking services adopt towards e-cigarette users act as barriers or facilitators to the uptake of such services by this group, and how does this compare to broader factors that influence their attendance? What factors influence the local policies that different NHS stop smoking services adopt towards e-cigarette users? What are the implications for (i) effective provision of services and (ii) inequalities in smoking? Plan of investigation Workstream 1. Using a national survey: Questions will be added to the Smoking Toolkit Study survey (the country's most authoritative source of regular, national smoking data) to: a) Collect nationally representative data on facilitators and barriers to attendance at NHS services amongst smokers who use e-cigarettes versus smokers who do not. b) Compare responses between different sociodemographic groups to assess potential for inequalities in this area. Workstream 2. Using semi-structured interviews: a) Explore with local smokers their perceptions and experiences of their NHS stop smoking service. b) Explore with the local NHS stop smoking staff factors influencing their service's policy towards e-cigarettes. Outputs A clear set of recommendations will be developed, jointly with practitioners and smokers, for how services could be attracting higher numbers of smokers using e-cigarettes. To help address inequalities, this will include different approaches required to attract smokers from different sociodemographic groups. An advisory group with wide expertise will guide the fellowship's pathways to impact.

Lay abstract: Background CHAR(13) + CHAR(10)Tobacco remains the UK's leading cause of ill health and death [1]. Just under 20% of adults smoke, with rates much higher amongst poorer communities [2-3]. E-cigarettes are devices that contain nicotine in liquid form and so avoid the most dangerous chemicals that result from burning tobacco in normal cigarettes [4]. Although these new electronic products have soared in popularity in recent years, evidence about how effective they really are at helping people to quit smoking is in fact very limited to date [5, 7]. Amongst all methods of quitting, including e-cigarettes, the strongest evidence for effectiveness is for NHS stop smoking services [9-10]. These are freely available services within the NHS that offer structured support over time for people aiming to quit smoking. While the use of e-cigarettes has risen rapidly in recent years, the number of people attending these services has shown a sustained drop over the same period, for the first time since their establishment [11]. Data from the NHS stop smoking services themselves shows that smokers using e-cigarettes appear to be much less likely to use these services than other smokers, despite this support still being freely available to them [12]. There is therefore a clear need for research to better understand the important developments taking place in this area of public health, such as the factors that influence smokers using e-cigarettes when deciding whether or not to access NHS support (including the impact that variable local NHS policies on e-cigarettes may be having on this). Aims This fellowship aims to understand what influences smokers who also use e-cigarettes when determining whether or not to access NHS stop smoking service support. It will investigate both the potential influences that may exist amongst these smokers (e.g. perceptions that the NHS services are not relevant to them) and the potential influences that may exist amongst NHS staff (e.g. restrictive attitudes or policies that may hinder support to smokers who use e-cigarettes). It will also assess whether the influences on attendance vary between different groups of smokers (e.g. whether there are important differences between poorer smokers and wealthier ones) and identify implications for smoking-related inequalities. Plan of investigation To meet these aims, the fellowship will undertake a mixed methods' study (involving both survey and interview data): New questions will be added to an established, national monthly survey of 1800 adult smokers run by University College London (the Smoking Toolkit Study'), the most authoritative source in the country for regular data on smoking. These new questions will collect national data on smokers' intentions to access NHS stop smoking services, their previous experiences with them and other factors that have influenced their decisions on whether or not to attend them. This survey will be of sufficient scale to allow analysis of any differences between smokers who use e-cigarettes and those who do not. It will also allow for examination of whether these factors that influence attendance vary between smokers from different backgrounds. A series of interviews will then be run with smokers using e-cigarettes in different parts of the country. These will drill down into the findings from the national survey in far greater detail, collecting in-depth data on these smokers' experiences and perceptions of their local NHS stop smoking services. Interviews will also take place with local NHS stop smoking service staff in the same areas. These will explore what the main factors are that have influenced the service's local policy on e-cigarettes, and how this policy is reflected in the types of support they offer to smokers using e-cigarettes. Outputs and benefits This research will enable a clear set of evidence-based recommendations to be provided to the NHS on how the decline in the number of people attending NHS stop smoking services could be addressed. Given that studies suggest that these services increase smokers' chances of quitting more highly than any other routes - including using e-cigarettes in isolation - this could ultimately help more smokers avoid the major health risks caused by tobacco [9-10].

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;7.3 MANAGEMENT AND DECISION MAKING
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;RESPIRATORY;STROKE