Lewisham learning demonstration site
This project aimed to increase the number of routine and manual smokers accessing and quitting with NHS Stop Smoking Services in Evelyn ward. It estimated to have the highest smoking prevalence and highest indices of multiple deprivation in the London borough of Lewisham.
The project developed partnerships with various local organisations, such as Millwall Football Club and workplaces, to offer stop smoking surgeries at popular venues and at more convenient times. Recruitment drives and partnership promotional events were held in the area and a dedicated Recruitment and Outreach Workers team was set up to engage with all sectors of the community and foster long-term referral opportunities.
- Service data indicated a 21.3 per cent increase in the number of Evelyn residents using NHS Stop Smoking Services from 2008 to 2009. This was greater than the 12 per cent increase across Lewisham as a whole, suggestive of the project's impact
- The proportion using pharmacy services and sessions run by the outreach workers increased between 2008 and 2009, although the proportion using a GP-based service decreased. These services doubled the number of people quitting during this period
The national tobacco strategy for England and Wales, contained in the 1998 White Paper Smoking Kills (superseded in 2010 by A Smokefree Future), identified smoking as the leading cause of preventable death and health inequalities. Public Service Agreements (PSAs) since 2004 have set targets to increase and support smoking cessation attempts among all adults, particularly in routine and manual (R&M) groups. Targets were set to reduce the overall proportion of cigarette smokers in England to 21 per cent or less by 2010, with a reduction from 32 per cent to 26 per cent or less among manual occupation groups.
Smoking, and its associated health problems, is a particular issue in the ethnically-diverse London borough of Lewisham. At 33 per cent, rates are higher than the national average and there is widespread deprivation. In 2006, only 7 per cent of smokers in Lewisham accessed NHS Stop Smoking Services (SSS) and 45 per cent of these smokers quit. Evelyn ward in Lewisham has the highest deprivation levels and smoking rates (42 per cent) in the borough, as well as a large proportion of the population in routine and manual employment.
The smoking cessation team at NHS Lewisham wished to try a new approach to tackle smoking cessation and take advantage of internal interest in social marketing. In November 2006 the primary care trust (PCT) was selected by the Tobacco Control National Support Team (TCNST) of the Department of Health (DH) to receive support from The NSMC to apply social marketing to increase use of the borough’s SSS. With funding from the TCNST, a formal partnership was developed between the PCT and The NSMC in early 2007 to deliver a pilot smoking cessation project, as part of The NSMC’s Learning Demonstration Sites Scheme.
NHS Lewisham selected Evelyn ward for the social marketing intervention, as part of the delivery of the wider North Lewisham Health Improvement Plan (part of Lewisham’s plan to reduce health inequalities). Other local policy drivers for reducing smoking prevalence levels in the area included the Strategy To Tackle Health Inequalities In Lewisham – Draft 2008/10 and Healthier Lewisham Partnership Board priorities.
A steering group was formed to manage and guide the project. Members included:
- A representative from the TCNST
- Two members from NHS Lewisham (including the SSS Coordinator)
- An Associate from The NSMC, who provided free social marketing guidance and support
A project team, trained in social marketing, was formed to help develop and deliver the project. It included members from the SSS, service providers and community groups.
Aims and behavioural goals
The aims of the project were 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 R&M 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 SSS 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 was compared with data in the previous year to assess impacts of the interventions on smoking prevalence, recruitment to the SSS and quit rates.
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, based on national research. Health improvement programme research was also carried out by NHS Lewisham in 2008. Intended to gain an overview of local issues from a health perspective, it looked at health inequalities, contributing factors and local and national health statistics.
In order to understand at a local level why people smoke and what the barriers and motivators are to quitting and using NHS SSS, extensive primary research was conducted by a team of recruitment and outreach workers and project workers. Focus groups were held with 32 smokers and interviews were held with 6 health professionals who provided the SSS 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 high proportion of the Evelyn population worked in R&M jobs and so required services that fit around their working patterns. Evening surgeries close to transport links were therefore needed
- Smoking among R&M 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
- 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
- Evelyn ward had experienced a variety of social, economic and housing regenerations schemes, which tended to be short-lived. This 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 would be essential to integrate these into existing mainstream service provision, to ensure that they did not cease with the end of the project. It would also be important to build relationships with local people and organisations, to gain trust and increase referral rates
- Some smokers resented being lectured all the time and expected health professionals to be disapproving non-smokers who do not understand how hard it is to stop. Those who had used a service complained about the wait for a first appointment and sessions being too short, with no support ‘to fall back on’ in the longer term. An ideal service would be like a supermarket – open every day, all day.
- There was no perception of the service as a unified whole with different options from which to choose, either by potential customers or advisors. People wanted a choice of intensity, model and location of service
- Mapping the ward’s existing provision showed obvious gaps. There were two GP practices in the ward – one did not offer an advisory service and one had limited nursing time for smoking cessation. Of the three local pharmacies, one had no advisor in the shop on Wednesday market day and two did not open on Saturdays
The barriers and costs of exchanging smoking habits for a smoke-free lifestyle included:
- Isolation from peers, family members and other social groups
- Not having a legitimate excuse for regular breaks from work
- Having to deal with everyday stresses without the relief of cigarettes
- Psychological impact of breaking well-established habits and behaviours
- Potential weight gain
Benefits of quitting smoking included:
- Improved health
- Financial savings and being able to treat yourself with the money saved
- Sense of achievement
The project’s main competitors were:
- Illegal sales of cheap imported cigarettes
- Marketing of cigarettes
- Private (non-NHS) stop smoking services
The project team sought to counteract this competition by:
- Highlighting the short- and long-term cost savings that can be made by quitting smoking
- Highlighting the rising trend of smoking cessation and the opportunity for quitters to be part of a social movement towards a smoke-free society
- Effective advertising and promotion of the NHS SSS to the target audience
Initially, the target groups for the project were:
- 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 for the long-term health of those who quit
- Smokers with children of primary school age
Young children can be highly effective in gaining an insight into health options and their influence to motivate parents is extremely strong
- Adult smokers in R&M employment
The prevalence of smoking within R&M employment is higher than in other socioeconomic groups. The impact of reducing smoking prevalence within this target group would therefore be significant in this ward, due to the proportion of the population employed in these fields
However, through the scoping phase it became apparent that working with such a wide audience would require a large number of strategies, resources and interventions, and it would be unrealistic to try to deliver these within the timescale of the project. The steering group therefore decided to just focus on R&M smokers, given the national focus on this segment and the fact that many of these smokers also fall within the other two audience groups.
A Solutions Group was formed of key community stakeholders and services, such as Pepys community forum, Lewisham refugee network, Sure Start, health improvement and project team members and a marketing agency working with Millwall Football Club (FC). 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.
Several smokers’ reference groups were also held between September 2008 and June 2009, to test intervention ideas and 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.
A number of interventions were delivered, focusing on outreach work and reconfiguring existing service provision to better meet the needs of the community.
Outreach at workplaces, organisations and schools
The Recruitment and Outreach Workers team went out to local workplaces and 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.
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 and medication or interventions to help support their quit attempt.
Links were also 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.
Extended stop smoking advice services
Direct feedback from the outreach work identified that many people working in R&M 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. Extra surgeries were opened at GP clinics, pharmacies and the leisure centre to create better access and choice for people living in the area. This was particularly relevant on isolated housing estates, where facilities and transport links were limited.
GP exercise referral scheme
Prior to the project, there was little additional support for smokers (particularly females) concerned about weight management and fitness as a result of giving up smoking. The provision of fitness opportunities that did exist in the ward relied on both residents’ awareness of physical activity programmes available and people having disposable income to take up and maintain a fitness regime provided by the leisure services.
Through negotiations with the local authority, the main provider of local leisure and fitness services in the area, the team implemented a GP exercise referral scheme that provided access to subsidised fitness services and classes and a bespoke exercise programme for smokers looking to quit, but were concerned about weight gain.
Stress management workshops
Stress was cited as one of the main reasons why people smoke, are reluctant to give up and take up smoking again after quitting. 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.
The benefits of quitting smoking and using the NHS SSS 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 work
- Face-to-face promotion and recruitment to SSS through local events and tours
- A partnership developed with Millwall FC, which provided two key promotional opportunities to promote the SSS to football fans
- A new Lewisham stop smoking website was launched in January 2010, which signposts visitors to Evelyn’s cessation services
A smaller team made up of the SSS manager, project manager, NSMC Associate and marketing agency was responsible for managing implementation. Several local partners were engaged to support project delivery, including GPs, pharmacies, leisure services and Millwall FC.
Benefits offered to these delivery partners included:
- Publicity, promotional opportunities and recognition – for example, Millwall FC received a gold standard award for community work as a result of partnering with the stop smoking programme
- GPs benefited from direct referral opportunities to stop smoking programmes through the immediacy of getting their patients into local stop smoking advice programmes, several of which were set up as a result of this project
- Improvements in patient or client health
- Better links to other organisations that complement their own services
According to a project plan created in the development stage, the interventions were rolled out from spring 2009.
Outreach at workplaces, organisations and schools (April 2009 to March 2010)
From April 2009 outreach workers started a programme of visits to local workplaces, schools and voluntary and community organisations. This created unique links with local businesses, notably local 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. Locum pharmacy support was provided to workplace smoking cessation sessions so that smokers could access the full range of prescribed medication to help them in their quit attempts.
These new relationships created opportunities to provide stop smoking sessions in workplaces, thereby increasing the numbers of smokers working in the area using and quitting with NHS SSS. The recruitment and outreach work was felt to be the most successful activities delivered, in addition to some of the partnership work carried out with Millwall FC and the landlord of John Evelyn Pub.
Extended stop smoking advice services (from April 2009)
To fill service gaps, weekly sessions were offered in both GP practices. One pharmacy increased its pharmacist advisor time. One pharmacy started to provide Champix medication from February 2010. An evening session was tried in the leisure centre, but unfortunately did not attract enough people to continue. The drop-in service moved to the Waldron Health Centre and proved so popular that it extended its hours. A new pharmacy service opened in the same health centre, providing Champix from February 2010.
Millwall and Lewisham’s service was featured in a national campaign and a second smokefree match in February 2010 raised the profile of the service and its link to healthy heart checks.
GP exercise referral scheme (from September 2009)
Outreach advisors encouraged everyone to take up some physical activity, to help with stress management and weight management. The local GP exercise referral scheme changed its criteria to include people trying to stop smoking and GPs were happy to support referrals initiated by advisors. Unfortunately, the scheme had long delays in assessing people, which reduced the potential benefit of this service and were beyond the scope of this project to change.
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, community advisors running the drop-in and weekly clinics in GP practices advised people to use local welfare rights, social housing and voluntary sector organisations to alleviate some of the problems causing stress.
In March 2010, two stress management workshops were run at the Waldron Health Centre in New Cross by the South Lewisham and Maudsley Mental Health Trust, but were poorly attended. The plan is now to integrate this into the stop smoking programme, rather than offering it as a separate session.
The evaluation study, carried out independently by the London School of Hygiene and Tropical Medicine (LSHTM), involved three components:
- A cross-sectional street survey, with a pre-sample of 209 and post-sample of 204 people living and working in the Evelyn ward area
- Analysis of routinely-collected service data from Evelyn ward for the periods January to December 2008 and January to December 2009
- Qualitative interviews with eight key stakeholders
Results of street survey
- More pre respondents said they had seen information about SSS compared to the post respondents (75 per cent compared to 49.8 per cent). The most likely source of information for both pre and post groups were ‘TV, radio, internet, print media’; ‘GP, clinic, health centre’; and ‘chemist’. More people in the post sample reported that they had seen information in Deptford market and on the Millwall bus, although the numbers are relatively small
- A higher proportion of pre respondents than post respondents were aware of help available (75 per cent compared with 62.5 per cent respectively). More people in the post group said help was available from a GP or chemist or that they did not know where help was available compared to the pre group. Fewer people in the post group identified that help was available from a stop smoking advisor, helpline or stop smoking group
- 34.1 per cent of pre- and 41.6 per cent post-intervention respondents were regular or occasional smokers. Around a third (32.4 per cent) of both groups reported that they had tried to give up in the previous three months. The majority of those who tried to quit only managed to stop for a few days
- Most respondents in both the pre and post survey groups said that they received no help to quit. However, far more in the post-intervention group said that they had got help in the area where they lived than in the pre-intervention group (nine versus four people respectively). More people in the post-intervention group answered that they had used medicine from a GP or chemist or had sought help from a stop smoking advisor, GP or chemist
Results of service data
- There was a notable increase (21.3 per cent) in the number of residents entering the service from Evelyn ward. This was proportionately greater than the 12 per cent increase across Lewisham as a whole, suggestive of the project’s impact
- There was an increase in the overall numbers of residents from Evelyn quitting, although the proportion of residents entering the service and quitting decreased
- There was an increase in the number of residents from Evelyn ward accessing pharmacy services and stop smoking services
- While there was a notable increase in numbers entering services, targets to double the numbers entering and quitting from Evelyn were not met. However, the SSS and pharmacy services in Evelyn did double the number of people quitting between 2008 and 2009
Results of stakeholder interviews
- It was felt that the key aim of doubling the number of four-week quits among R&M workers was largely driven by government targets
- Opinion on the success of the social marketing components was mixed. It was thought that a positive change in the PCT was the use of evidence and research to improve customer orientation
- However, most interviewees felt that the principle of exchange had not been adequately addressed and the barriers to behaviour change were too great to be truly addressed by the links with extended services. Some stakeholders thought that the factors that kept the target group smoking (such as their socioeconomic situation, social values and cultural norms) were too entrenched and beyond the project’s scope
- Some of the lasting benefits of the project were felt to be wider links and networks with other organisations, improved knowledge of the target group and Evelyn ward, and improved service provision
Despite certain challenges, the application of learning from the project to other areas is encouraging. Recent data shows that there are more smoking quits in the most deprived areas in Lewisham and that this trend has doubled in 2009 to 2010.
Advisors in Bellingham in 2009, another deprived ward with high smoking prevalence, took advice from the project manager for this project on who to consult and how to develop their work in Bellingham. They canvassed local people’s views, met with community leaders and visited workplaces, organisations, businesses and shops in the area, before setting up an evening stop smoking drop-in at the leisure centre. This is promoted through their ongoing work in the ward and word-of-mouth from satisfied customers. Advisors have been invited into a bus garage, school and youth project, which increases interest and take-up in the area.
Factors felt to facilitate the project:
- Exchange of learning with The NSMC’s nine other learning demonstration sites
- Added capacity of a project manager with local knowledge
- Guidance provided by The NSMC Associate
- The NSMC project management and social marketing tools
Factors felt to be hindrances:
- Confusion of roles and responsibilities
- PCT capacity and internal organisational barriers
- Insufficient tools and guidance on certain areas of project management
- Lack of continuity in staffing at all levels during the course of the project
What worked well:
- Outreach and recruitment strategies adopted within the ward were highly beneficial to the intervention, as it created strong connections that increased local awareness and referral rates to quit programmes
- Expansion of service provision to include extended stop smoking surgeries increased access and attendance among people in R&M jobs
- Some of the advice surgeries attracted people with complex needs, such as those with mental health problems and long-term entrenched addiction. Specialist services and psychological support alongside stop smoking advice services would benefit these people
- Partnership work with Millwall FC created good publicity and promotion opportunities
What worked less well:
- The initial scoping report was too wide-ranging and detailed and was never summarised
- Long delays at the start of the project lost momentum and potential members of the solutions group
- The baseline research was undertaken after activity in the ward had already begun, which skewed the findings of awareness about the service pre and post intervention
- More senior, strategic support for the project from the PCT would have helped increase the success of the interventions and create long-term service change within the NHS to improve provision
- Ring-fencing the recruitment and outreach work may have prevented it being put on hold to facilitate the wider work of the stop smoking team