Selling smoking cessation
Authors: K Michael Cummings, Matthew J Carpenter
Journal: The Lancet (2017)

Most people who have smoked for any significant length of time would like to stop smoking. Findings from prospective studies examining the natural history of efforts to stop smoking show that smokers often make frequent efforts to stop smoking or reduce their consumption, with little long-term success.1Hughes JR Solomon LJ Fingar JR Naud S Helzer JE Callas PW The natural history of efforts to stop smoking: a prospective cohort study.Drug Alcohol Depend. 2013; 128: 171-174Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar Findings also show that most attempts to stop smoking are unplanned and are typically made without any professional assistance, even though effective support combining behavioural counselling and pharmacotherapy can substantially increase the odds of successfully remaining smoke-free.2Kotz D Brown J West R Prospective cohort study of the effectiveness of smoking cessation treatments used in the ‘real world’.Mayo Clin Proc. 2014; 89: 1360-1367Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar In 1999—some 25 years after the first smoking cessation clinic (the Maudsley Clinic) was established in London, UK, by Michael Russell—a process began to establish a national network of government-funded services to encourage and support smokers to stop smoking across the UK. These Stop Smoking Services (SSS) offer a comprehensive approach that provides ongoing (>4 weeks) specialist behavioural support, and access to either free or subsidised stop smoking medications. Evidence shows that the network of SSS is effective.3Dobbie F Hiscock R Leonardi-Bee J et al.Evaluating long-term outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study.Health Technol Assess. 2015; 19: 1-156Crossref PubMed Scopus (45) Google Scholar, 4West R May S West M Croghan E McEwen A Performance of English stop smoking services in first 10 years: analysis of service monitoring data.BMJ. 2013; 347: f4921Crossref PubMed Scopus (79) Google Scholar Smoking prevalence within the UK has steadily declined from 27% in 2001 to 19% in 2013.5Lifestyles Statistical teamHealth and Social Care Information CentreStatistics on smoking: England 2015.http://content.digital.nhs.uk/catalogue/pub17526/stat-smok-eng-2015-rep.pdfDate: May 29, 2015Google Scholar UK smokers are more likely to receive cessation support for any given quit attempt and more likely to succeed in that attempt compared with their counterparts in other countries.6Gibson JE Murray RL Borland R et al.The impact of the United Kingdom's national smoking cessation strategy on quit attempts and use of cessation services: findings from the International Tobacco Control Four Country Survey.Nicotine Tob Res. 2010; 12: S64-S71Crossref PubMed Scopus (26) Google Scholar However, only about half of smokers in the UK report using any type of support to quit, and the most commonly reported methods are electronic cigarettes and over-the-counter nicotine replacement therapy.2Kotz D Brown J West R Prospective cohort study of the effectiveness of smoking cessation treatments used in the ‘real world’.Mayo Clin Proc. 2014; 89: 1360-1367Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar Less than 5% of smokers report using the SSS as a quit method, despite efforts to increase referrals among health-care providers, although other tobacco control interventions that drive motivation to quit, such as mass media campaigns, have had funding reduced over the past few years.7Hopkinson NS Millett C Glantz S Arnott D McNeill A UK government should fund stop smoking media campaigns not give tax breaks to films with smoking imagery.Addiction. 2016; 111: 2066-2067Crossref PubMed Scopus (5) Google Scholar Low attendance at SSS is a concern because evidence shows that these services are not only a highly cost-effective medical intervention producing higher quit rates than other approaches, but are also effective in reaching smokers from disadvantaged communities.4West R May S West M Croghan E McEwen A Performance of English stop smoking services in first 10 years: analysis of service monitoring data.BMJ. 2013; 347: f4921Crossref PubMed Scopus (79) Google Scholar, 8Godfrey C Parrott S Coleman T Pound E The cost-effectiveness of the English smoking treatment services: evidence from practice.Addiction. 2005; 100: 70-83Crossref PubMed Scopus (73) Google Scholar In The Lancet, Hazel Gilbert and colleagues' randomised controlled Start2quit trial9Gilbert 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; (published online Jan 24.)http://dx.doi.org/10.1016/S0140-6736(16)32379-0PubMed Google Scholar addresses the issue of low and declining attendance at National Health Service SSS. The study was done in 18 SSS in England, with 99 general practices within the SSS areas, and compared two outreach approaches to encourage increased uptake among smokers: an individually tailored risk letter with an invitation to attend a no-obligation taster session (intervention) or a generic letter advertising the local SSS. 4383 smokers were enrolled and followed up for 6 months to determine their attendance at an SSS and establish their smoking status. Attendance at the first session of an SSS course was significantly higher in the intervention group than in the control group (458 [17·4%] of 2635 vs 158 [9·0%] of 1748 participants; unadjusted odds ratio [OR] 2·12 [95% CI 1·75–2·57]; p<0·0001), as was 7 day point-prevalent abstinence at 6 months (236 [9·0%] vs 97 [5·6%] participants; OR 1·68 [95% CI 1·32–2·15]; p<0·0001). Quit attempts did not differ between groups, suggesting that increased quit rates were due to more smokers enrolling into an SSS. It is not possible to disentangle the effects of the tailored letter from those of the taster session, and they could work individually or synergistically. The tailored letter from a trusted health-care provider might serve as a powerful cue to action. The taster session might offer an opportunity to try out treatment without a firm commitment to change, and thus might represent a softer and potentially more effective approach for encouraging smokers to initiate treatment. Together, these strategies seem to heighten treatment engagement and ultimately increase the likelihood of quitting. Almost 10% of smokers in the control group attended the SSS programme merely as a result of a generic referral letter. This finding shows the potential of proactively reaching out to large numbers of smokers. Proactive identification and engagement of smokers is an effective strategy that could be more effective than reactive methods that rely on smokers to self-initiate treatment.10Tzelepis F Paul CL Walsh RA McElduff P Knight J Proactive telephone counseling for smoking cessation: meta-analyses by recruitment channel and methodological quality.J Natl Cancer Inst. 2011; 103: 922-941Crossref PubMed Scopus (46) Google Scholar Non-intensive proactive follow-up with smokers shortly after a visit with their provider is an inexpensive way to reinforce cessation advice provided during that visit. Technology-based strategies could enhance this outreach even further through any combination of text messaging, email, and automated telephone calls, each engineered to directly link smokers to a local SSS.11Fulton EA Brown KE Kwah KL Wild S StopApp: using the behaviour change wheel to develop an app to increase uptake and attendance at NHS Stop Smoking Services.Healthcare. 2016; 4: 31Crossref Scopus (49) Google Scholar Outreach should also be extended to all smokers irrespective of whether or not they express an immediate interest in quitting. Motivation to quit can be transient and even induced through the same outreach methods as those described in Gilbert and colleagues' study. In fact, studies have reported benefits of engaging unmotivated smokers in treatment and catalysing the cessation process.12Carpenter MJ Hughes JR Gray KM Wahlquist AE Saladin ME Alberg AJ Nicotine therapy sampling to induce quit attempts among smokers unmotivated to quit: a randomized clinical trial.Arch Intern Med. 2011; 171: 1901-1907Crossref PubMed Scopus (17) Google Scholar The robust and impressive findings from the Start2quit trial provide clear evidence for how to improve the delivery of a highly cost-effective life-saving medical intervention. The findings also provide further support for the UK SSS overall. Government authorities should resist any cost-cutting suggestions to decrease support for the SSS on the basis of the obvious and well documented benefits achieved when smokers are enrolled in these services.13Cancer Research UKAction On Smoking And HealthCutting down: the reality of budget cuts to local tobacco control. A survey of tobacco control leads in local authorities in England.http://www.cancerresearchuk.org/sites/default/files/local_authority_survey_2016_report_cruk_finalfinal.pdfDate: November, 2016Google Scholar KMC has received grant funding from Pfizer to study the effect of a hospital-based tobacco cessation intervention, and has received funding as an expert witness in litigation filed against the tobacco industry. MJC declares no competing interests. Effectiveness of personalised risk information and taster sessions to increase the uptake of smoking cessation services (Start2quit): a randomised controlled trialDelivery of personalised risk information alongside an invitation to an introductory session more than doubled the odds of attending the SSS compared with a standard generic invitation to contact the service. This result suggests that a more proactive approach, combined with an opportunity to experience local services, can reduce patient barriers to receiving treatment and has high potential to increase uptake. Full-Text PDF Open Access