Objective To assess the extent of uptake and impact of a nationally disseminated self-help intervention for smoking cessation (‘Quit Kit’).
Methods The kit contained practical tools for supporting quit attempts. Of 480 000 individuals receiving the kit, telephone interviews were conducted with 2347 randomly selected individuals. Interviews assessed the impact of the kit on smoking behaviours and on attitudes to the intervention and to health service support.
Results The majority of interviewees reported the kit as being helpful for stopping smoking (61%) and agreed that, having received the kit, they would be more likely to consider the National Health Service for help with quitting (84%). Younger interviewees were significantly more likely to report the kit as helpful, to say they would recommend it to others and to agree that it increased their confidence in quitting (all p≤0.001). As a result of receiving the kit, 29%, 17% and 11% of interviewees, respectively, reported visiting their doctor, pharmacist or stop-smoking service for help with quitting. The kit was reported to have triggered a quit attempt among around half (57%) of those receiving it. When only including those who had received the kit at least 1 month prior to interview, 26.5% (126/475) of those attempting to quit reported remaining completely abstinent from smoking for at least a month.
Conclusions The findings suggest that distributing a self-help intervention for smoking cessation at a national level may be successful in terms of uptake of the intervention, triggering quit attempts and aiding smoking cessation.
- Smoking cessation
- health services
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In the UK 67% of smokers report wanting to quit, while just 26% report making a quit attempt in the previous year.1 Of these, only 29% successfully quit for more than 6 months.1 The Department of Health in England is committed to encouraging quit attempts, and to maximising their success. While around half of attempts are unassisted, these often relapse within 7 days.2 UK National Health Service (NHS) stop smoking services (SSS) provide the most proven support for cessation; a combination of behavioural support and pharmaceutical aids.3 However, there are barriers around accessing these services.4 5 Only 8% of smokers making a quit attempt in England access the NHS SSS.1 Ways of providing more accessible support are needed. There is evidence to suggest that mailed self-help materials are effective for smoking cessation6; however, we could not identify studies evaluating self-help interventions at a national level. The present study evaluated a nationally disseminated self-help intervention for smoking cessation.
A self-help intervention for smoking cessation (‘Quit Kit’ (QK)) was devised through collaboration between academics and the English Department of Health tobacco control team. Self-help products were reviewed in 2009 and staff at the NHS Centre for Smoking Cessation Training were interviewed. Ideas for elements to be included in the QK were discussed with 12 groups of six to eight smokers (age 18–55, smoking ≥5 cigarettes/day). The following requirements were determined: provide information about SSS and medications; include practical tools; set milestones; promote health and financial benefits; focus on strengthening willpower; include stress management and distraction techniques; involve children (for parents); be fun; increase confidence for quitting; appeal to first time and experienced quitters and to the spectrum of gender, ethnic and socioeconomic groups. To satisfy these requirements the kit included a health/wealth wheel, ‘tangle’ stress reliever, ‘quit plan’ wall chart with stickers (including setting a quit date), willpower assessment quiz, local NHS SSS and pharmaceutical leaflets, motivational postcards, a toothbrush and information on stress management downloads.7
The kit was promoted through national television paid advertisements (appearing daily at their peak), with website and telephone details for ordering the kit. It was also promoted via direct mail, promotional stands, SSSs, websites and distribution in Asda stores. Between January and March 2010, 480 000 kits were issued. When ordering the kit (or obtaining via ASDA/SSS/stands) 422 400 (88%) individuals agreed to be interviewed, 127 872 gave a phone number (and therefore were contactable for interview) and 8242 of these were randomly selected for a 15-minute telephone interview. On commencing the interview individuals were screened to confirm eligibility in terms of having ordered the kit for themselves, opened it, received it at least 2 weeks before interview (to allow time to use kit) and having not quit prior to receiving the kit. A total of 1199 individuals refused to be interviewed, 996 were ineligible, 3700 were non-contactable (invalid number or no answer after multiple attempts), 59 had quit before receiving the kit and 2288 (27.8%) were interviewed by an independent research company (HPI Research) ending March 2010.
As proxies of smoking dependence interviewees reported daily cigarettes consumption and time of smoking their first cigarette after waking.8 9 Further questions assessed demographics, smoking behaviours and attitudes to the kit and NHS support.
The vast majority of interviewees were white, just over half were female and the majority were classified as socioeconomic group (SEG) C2/D/E (see table 1). Pregnancy status was not recorded. Nearly three-quarters (73.3% (1676)) heard about the kit through television. The largest majority ordered the kit via the website (44.4% (1017)), 30.8% ordered by phone, 15.5% collected the kit from their SSS or promotional stands, 8% obtained it from ASDA and 1.3% ordered by SMS/text.
The majority reported the kit as helpful for quitting; nearly three-quarters saying they would recommend it and around two-thirds reported increased confidence and motivation for quitting (see table 1). The vast majority agreed they would be more likely to consider the NHS for help with quitting because of the kit. Moreover, of those reporting that they would not have considered NHS support prior to receiving the kit (38.2% (873/2288)), 61% reported that they would be more likely to consider NHS support as a result of the kit. All elements of the kit were used by at least a third of participants, except for the stress management downloads (24%) and the toothbrush (23%). The health/wealth wheel and ‘tangle’ stress reliever were the most used (64% and 63%, respectively). The majority of interviewees reported the kit as being ‘fine as it is’ (62%). By far the most popular suggestion for improving the kit (26%) was for adding nicotine replacement therapy.
Impact on behaviour
Just over half of interviewees reported attempting to quit completely; of whom 17% (220/1296) reported not smoking at all for at least 1 month since quitting. When only including those who had received the kit for at least 1 month, 26.5% (126/475) of those attempting to quit reported complete abstinence from smoking for at least a month. As a consequence of receiving the QK, 29% of interviewees reported visiting their doctor and 17% reported visiting their pharmacist about quitting. Additionally, 24% reported looking up details of their local SSS, 13% said they had contacted the SSS and 11% reported visiting the SSS.
On an exploratory basis, ANOVAs, χ2 tests and Pearson correlations tested associations between the key demographic and smoking variables (ie, age (continuous variable), gender, SEG (A/B/C1 vs C2/D/E), smoking intake (continuous variable), time to first cigarette (within 30 min vs later) and outcomes for smoking status (not smoking at all vs smoking), how much the kit helped (extremely/very/fairly helpful vs other response), ‘would recommend the kit to others’ (agree strongly/slightly vs other), ‘kit made me more likely to consider NHS help’ (agree strongly/slightly vs other), ‘kit has given me more confidence in quitting’ (agree strongly/slightly vs other) and ‘kit has made me more motivated to stop smoking’ (agree strongly/slightly vs other). Owing to multiple testing, the significance level was set at p<0.002. Younger individuals were significantly more likely to report the kit as helpful (ANOVA, F=15.8), to say they would recommend the kit (F=11.7) and to report that the kit increased their confidence in quitting (F=12.3, all p≤0.001). Heavier smokers and those reporting smoking within 30 minutes of waking were significantly more likely to report complete abstinence from smoking (F=60.0, χ2=20.9; respectively, both p<0.001). No other associations reached significance.
This study was the first to assess a nationally disseminated self-help kit for smoking cessation. The kit was popular, with nearly half a million issued in 3 months. The majority reported the kit as helpful for quitting; saying they would recommend it and reporting increased confidence and motivation for quitting. These views were more common in younger smokers, but otherwise these attitudes were held irrespective of sociodemographic characteristics, suggesting a broad appeal. Encouragingly, over half of interviewees reported attempting to quit since receiving the kit, with half of these declaring not smoking at all/occasionally. More dependent smokers were more likely to report abstinence. This is inconsistent with previous studies of predictors of quitting10–12 and needs confirmation with biochemical validation of abstinence.
The vast majority agreed they would be more likely to consider NHS help with quitting, having received the kit. This view was echoed by nearly two-thirds of those indicating that they would not previously have considered NHS support. The findings suggest that the kit was successful in encouraging smokers to seek support from doctors, pharmacists and SSS. This is important since only 8% of smokers access NHS support annually,1 and supported quit attempts are more likely to be successful.3
Strengths of the study are that the sample was large, randomly selected and nationally representative.13 14 The characteristics of all those ordering the kit were not determined; therefore it was not possible to assess whether those interviewed were representative of the entire intervention group. The study was limited by a follow-up of only 3 months. The low follow-up rate for interview, and exclusion of those not opening the kit, may have biased the findings positively. Also, without a control group, it was not possible to assess the effects of a highly motivated sample self-selecting into the programme. Smoking abstinence was not verified biochemically as it is difficult to obtain saliva for cotinine analysis via the mail.15 However, self-report is generally accurate where there is no social pressure to report abstinence.16 Overall, the findings suggest that disseminating a self-help intervention at a national level is likely to be successful in terms of uptake, positive attitudes, and effects on smoking behaviours, at least in the short term. The kit now needs to be evaluated in a randomised controlled trial, including cost-effectiveness analysis. The QK also needs to be compared with other self-help interventions where there is no contact or minimal contact with therapists.6 The kit may benefit through including other intervention elements that have previously been used in self-help interventions,6 such as information on the adverse effects of smoking, and through having a version tailored to pregnant smokers.17
What is already known
Less than 10% of smokers making an attempt to quit smoking in England access the National Health Service Stop Smoking Service. Ways of providing more accessible support are needed. There is evidence to suggest that mailed self-help materials are effective for smoking cessation.
What this paper adds
A nationally disseminated self-help intervention for smoking cessation (‘Quit Kit’) was shown to have a high rate of uptake; with 480 000 kits mailed across 3 months. Among those interviewed, the kit was reported to have triggered a quit attempt among around half of those receiving it and about one-quarter reported remaining abstinent for at least 1 month. Such an intervention is likely to be a feasible for reducing tobacco use in the UK.
We thank Ann McNeil for her helpful comments on an earlier draft of our manuscript.
Funding English Department of Health, Wellington House, London SE1 8UG. MU and RM are part of the UK Centre for Tobacco Control Studies.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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