Roy Castle Fag Ends Knowsley
In 2006, 32.6 per cent of people in Knowsley were defined as being current smokers. To tackle this, a unique partnership was established in 2006 between NHS Knowsley, Knowsley Council and the Roy Castle Lung Cancer Foundation’s ‘Fag Ends’.
The Roy Castle Lung Cancer Foundation is the only charity in the world wholly dedicated to defeating lung cancer. Roy Castle Fag Ends is the Foundation’s stop smoking team and was launched in October 2006. It offers community-based support, with 'the guy round the corner helping the guy round the corner'. It uses a mix of tailored support packages and drop-in cessation groups to make the quitting process as convenient and bespoke as possible.
Four-week quit results
- 2006/07: 1,432 quitters (target 1,225)
- 2007/08: 2,324 quitters (target 1,333)
- 2008/09: 1,868 quitters (target 1,850)
- 2009/10: 2,048 quitters (target 1,850)
In 2009/10 Knowsley had the third highest quit rate in England, with 1,715 per 100,000 people achieving a 4-week quit.
A 2006 prevalence survey identified that 32.6 per cent of people in Knowsley were current smokers – significantly higher than the national level of 25.3 per cent. In addition, it identified that 22.9 per cent of Knowsley’s adult population used to smoke but had quit. This meant that in 2006 more than 55 per cent of Knowsley’s adult population had been regular smokers at some time during their lives.
Smoking prevalence was shown to vary from 12.6 per cent in Roby electoral ward to 46.5 per cent in Page Moss electoral ward. Generally, this variance mirrored social deprivation – high smoking prevalence is associated with high levels of social deprivation.
Aligned with these high smoking rates, Knowsley had rates of lung cancer and respiratory diseases much higher than the national average. The highest Standardised Mortality Ratio (SMT) for both males and females in Knowsley between 2002 and 2004 was accounted for by lung cancer. The female rate was 99 per cent above the national average, while the male rate was 60 per cent above the national average. The variation in lung cancer mortality in Knowsley (2003 to 2005) ranged from 193 per cent above the national average in Whitefield electoral ward in Kirby, and 47 per cent below the national level in Roby electoral ward in South Huyton.
In order to tackle this problem, a unique partnership was established in October 2006 between Knowsley Health and Wellbeing (which is made up of NHS Knowsley, Knowsley Council and local organisations) and the Roy Castle Lung Cancer Foundation’s ‘Fag Ends’ service. The Roy Castle Lung Cancer Foundation’s Fag Ends service had been formed in Liverpool in June 1994, and already provided support groups in Liverpool, Knowsley, and Wirral, and funded a free telephone helpline to cover the whole Merseyside area.
During 2006 to 2007, Knowsley began to develop a strategic social marketing tobacco strategy. This was overseen by the Stop Smoking and SmokeFree Programme Board, which was made up of the following members or representatives:
- Medicines Management
- Stop Smoking Programme Manager
- Health Promotion Training
- Head of Health Promotion
- Stop Smoking Service
- Social Marketing
- Public Health
- Environmental Health
The strategy was developed to encourage identified target groups to:
- Use the community smoking cessation service
- Quit and stay quit
Development of the programme was informed by an in-depth, two-phased research process, which built real customer understanding.
An initial multi-dimensional, low cost research process was carried out, to gain as much understanding as possible about the existing issue, the target population and current service provision. Research included:
- Literature review assessing existing information about the issue and current cessation services
- In-house desk analysis of the SUPPORT stop smoking data (2005/06)
- Externally-commissioned evaluation of the Kirkby Quit and Win scheme (Attitudes to smoking in Kirkby, June 2006)
- Dr Foster chronic obstructive pulmonary disease (COPD) focus group work with members of the target audience (July 2006)
- Capturing anecdotal evidence via focus groups with Knowsley smoking cessation advisors who had worked in the borough for some time – this provided invaluable understanding about the types of people using services and the support they desire
- Existing usage of smoking cessation services were 60 per cent female (35 to 45 years) and 40 per cent male (40 to 55 years)
- People want a friendly, non-judgmental service that is easy-to-access (preferably drop-in with no appointment), close to home and run by ‘people like us’
- Knowsley smokers are not receptive to NHS branding or interventions from health professionals, but prefer receiving stop smoking information from charity organisations that they trust
- Word-of-mouth is one of the most important communication channels amongst tight-knit, deprived communities
- 0800 numbers are not well-received as they are associated with crisis services such as the Samaritans
- Reluctance to be lectured to stop smoking
- Existing attitude that ‘we know it’s bad for us’
- Do not want help in medical or NHS settings
- Services perceived as ‘like Alcoholics Anonymous’
- Cessation service meetings considered inconvenient – not at a good time or a good place and never know when they are happening
- Perception that the stop smoking services cost money
- We want independent help and advice – not coming from the health service or NHS
- Positive and encouraging messages – not health-related or fear-mongering
- Drop-in service, with no appointments or ‘helplines’
- Easy access and close to home
- Other health or cessation services
- National stop smoking campaigns and conflicting media coverage – Many smokers were hostile to national stop smoking media, which they perceived to be grey, negative and scare-mongering. By contrast, national media sometimes glamorises smoking through images of high-profile smoking celebrities or models
- NHS branding – Target audience did not want the new service to be associated with the NHS
- Social pressure – Many communities that would be targeted had high levels of smoking, which meant that if you did not smoke ‘you’re made to feel like a leper’
Based on these insights, a demographic segmentation was used for Phase One, targeting females aged 35 to 45 years and males aged 40 to 55 years.
In addition, segmentation was carried out according to smokers’ willingness to quit. 2006 research identified that over 70 per cent of Knowsley smokers were ‘contemplating quitting’. This target group was already the most likely to use stop smoking services and was identified from a number of data sources, including previous stop smoking service data and qualitative research. The main focus of the programme was thus to support already willing individuals to translate their existing intention into successful action.
Once the programme was established, further tailoring was needed. This resulted in a second research phase to develop detailed audience segments and drive strategic development of the programme over the next five years. Phase Two research included:
- A borough-wide prevalence survey – Externally-commissioned and conducted in March 2007, this survey established a clear behavioural baseline for the programme and provided demographic information about existing service users. This allowed national model data sets to be filled in to accurately reflect the situation in Knowsley
- Consultation with Fag Ends Advisors – This qualitative research provided rich, anecdotal evidence about service users, allowing the statistical data to be more fully developed. Advisors were able to talk about their real experiences – what people say when they turn up to the service; what they look like; why they have not been before; what their lives are like; and what they value
The two information sets (prevalence survey and consultation with Fag Ends advisors) were combined and overlaid with additional existing local qualitative research studies relating to the target audiences. This identified and quantified distinct population segments.
The next step was to ratify these proposed segments. Market research agency MRUK Research was commissioned to conduct this research, which involved:
- Seven focus groups with individuals from each of the seven segments, to establish the barriers and incentives to quitting and the distinct types of support valued by each segment
- 1,000 questionnaire-based street interviews to test the accuracy of each segment. Based on this feedback one segment was dropped (for being too middle-class and having low representation within Knowsley) and two were merged to create five final segments
This segmentation allowed targeted propositions to be developed. For instance, if one segment prefers to use pharmacy cessation services, because nicotine replacement therapy (NRT) access is quick and easy and they can attend with their partner, this can be fed into the Fag Ends programme to ensure these service elements are available.
The Roy Castle Fag Ends programme offers community based support, with 'the guy round the corner helping the guy round the corner'.
Because no two people are the same, every smoker needs different support to successfully quit. Roy Castle Fag Ends offers support tailored to each individual, including:
- Drop-in support – Moral support and practical help at sessions run across Knowsley at the same times every week, so that people can choose to drop in to any session whenever they want and see an advisor
- Group sessions – Led by trained advisors, these sessions are friendly, informal gatherings in familiar community settings
- One-to-one support – Private sessions with an advisor to discuss smoking habits and the sort of strategies that are likely to help
- Telephone helpline – Open Monday to Friday from 9.30am through to 8.00pm to give advice, discuss strategies or just help someone through a craving (available across Mersey)
- Text support
- Free NRT
The programme minimises the barrier of perceived financial cost that might prevent people from accessing stop smoking services by emphasising that everything is free (including the helpline, sessions and NRT). This reward element is reinforced by the free goody bag each participant receives when they join the programme and the certificate of success they receive on completion.
The staff at the cessation service are recruited from local communities and are therefore able to build contacts, networks and credibility.
The support service takes place in well-researched community locations to make it as easy to access as possible. Community members can suggest a venue that is used by their community. Roy Castle Fag Ends also conducts research to identify appropriate local venues – based on smoking prevalence, travel links, well-used venues, gaps where a group is needed and community intelligence. This ensures that venues are chosen where local people feel at home – usually in a non-health setting such as community centres, social clubs, pubs or churches.
One of the key benefits of the programme that is emphasised is the community cohesion and ownership it creates. Groups choose the venues where sessions are held, they make new friends, get to know new people and end up attending because the sessions offer social interaction. To bolster this social element, the programme offers a ‘recommend a friend’ card, which encourages individuals to spread the word and bring their friends or family along.
PR and advertising
Launch of the new service was supported by an extensive PR and advertising campaign, which was positive and friendly. The PR strategy had two tiers:
- Borough-wide profile raising, to broadcast the new service and set the tone, which ensured people knew that a new service was launching and that it would be friendly, locally-run and community-based
- Specific information giving, to embed times and venues for each locality
This methods mix actively sought to address the sources of competition identified during the scoping phase:
- Other health or cessation services – Resources were invested in factoring in these other services to avoid being in opposition. For instance, if people want services to run from community pharmacies, this can be built into the delivery plan; if they want workplace interventions, this can also be factored in
- National stop smoking campaigns and conflicting media coverage – Roy Castle Fag Ends breaks away from national stop smoking media, which is perceived to be negative and scare-mongering, and national media, which can glamorise smoking, by using messages and branding that are positive, upbeat and aspirational, with a clear message: ‘They did it, so can you’
- NHS branding – Because the target audience did not want a service associated with the NHS, the programme managers had to provide robust supporting evidence to gain approval for removing the NHS branding. By developing an own-branded programme, however, users are given a sense of clear ownership and the feeling that it is a service run ‘by people like us’ and not by health professionals
- Social pressure – The strong social networks have been used to the programme’s advantage, for if one person stops smoking, it can have a domino effect through their immediate community
The Stages of Change Model is a well-known theory of behavioural change. It looks at the different stages that are most common to behavioural change. This theory sees behaviour as a process rather than an event – it also recognises that there are different levels of motivation and readiness to change. The five main stages are:
Roy Castle Fag Ends supports those in the ‘Contemplation’ and ‘Preparation’ stages to move towards ‘Action’ and make successful quit attempts.
However, it is a rolling programme, which recognises that behaviour change is not usually a linear event, but a series of repeated attempts. Users of the service are free to drop in and drop out. Even if they do not make a successful first quit or do not really commit to it, just making that first attendance is an important step and part of the change process. Users are thus encouraged to try and then try again if they do not succeed.
The most successful part of the programme has been its basis in the community and the social interaction it provides. In some cases, people who have quit smoking have continued to attend the sessions because of the company and social element they offer. Such attendance has been encouraged as it provides groups with positive, relevant role models from within their own community. In many deprived areas, health is seen as unachievable, but by seeing people ‘like them’ who have managed to quit, individuals gain a boost in confidence.
Having the services based in the community has also encouraged many members to attend through word-of-mouth recommendations from their friends. It has not been unusual for individuals to turn up to sessions and ask for an exact match of support to that which helped a friend or relation stop: ‘You helped our Julie give up. I don’t want messages or lectures. I just want the same stuff you gave her and the same plan’.
Roy Castle Fag Ends in Knowsley has worked to ensure the service ties into national campaigns and initiatives. This piggy-backing provides a cost effective way to encourage more people to use the service.
“We’ve responded to some of the national advertising campaigns quite quickly. I remember a couple of years ago we got wind that nationally there was going to be a campaign which would be targeting mothers of young children. So we looked at our service data and we up-weighted some of the activity locally to target that group. The rationale being that if nationally they’re amplifying a message that mothers with young children shouldn’t smoke, what we wanted to say locally was Roy Castle Fag Ends is here to help you if you want to give up smoking.” (Phil Morris, Head of Marketing)
As the service has continued over the years, the amount of advertising and PR has been reduced as these can be expensive and are not sustainable. For this reason the service is now concentrating more on word-of-mouth and direct marketing techniques.
“I suppose broadly when we started there was a need to use a lot of above-the-line advertising, because we were announcing that there was a new service in Knowsley and that it was Roy Castle Fag Ends. Our insight was telling us that people warmed to charities, so there was a real need to announce Fag Ends is here. For two years we persisted with that and we tried to become more targeted. But I guess we knew it was unsustainable: a) in terms of the cost of funding above-the-line advertising; and b) the response rates. So the move now is to more direct relationship techniques, which is more appropriate now.” (Phil Morris, Head of Marketing)
Targets for adult stop smoking services have been significantly exceeded.
Smoking prevalence rates (April/March)
- 2006/07: 26.2 per cent
- 2007/08: 23.9 per cent
- 2008/09: 23.7 per cent
- 2009/10: 24.1 per cent (in 2009/10 there was an increase in 4 of the 5 local authorities across Merseyside)
4-week quit rates (April/March)
- 2005/06: 1,325 quitters
- 2006/07: 1,432 quitters (target 1,225) – the programme launched in October 2006
- 2007/08: 2,324 quitters (target 1,333)
- 2008/09: 1,868 quitters (target 1,850)
- 2009/10: 2,048 quitters (target 1,850)
4-week quit rates per 100,000 people (April/March)
- In 2007/08, Knowsley had the second highest quit rate in England, with 1,939 per 100,000 people achieving a 4-week quit
- In 2008/09, Knowsley again had the second highest quit rate in England, with 1,556 per 100,000 people achieving a 4-week quit
- In 2009/10, Knowsley had the third highest quit rate in England, with 1,715 per 100,000 people achieving a 4-week quit
“After failed attempts in the past to stop smoking I am now very grateful for the first class support I received, which combined with my own motivation and the flexibility of the drop-ins. I am now a non smoker.” (Halewood client)
“Thank you to all the staff at Fag Ends who provided encouragement throughout my quit attempt. I would most definitely recommend the service to others who are thinking of quitting.” (Kirby client)
“The Fag Ends staff were so supportive and encouraging. Having extra support in the evening and over the telephone made a real difference. Not having to wait for an appointment meant that I could drop into a session when I was ready.” (Huyton client)
Roy Castle Fag Ends Knowsley won the Association of Healthcare Communicators Award for ‘Best Social Marketing Intervention’ in 2007.
In 2009, a further piece of segmentation research was carried out to differentiate the 38,000 adult smokers in the borough by their lifestyle, environmental factors and attitudes to stopping smoking. This research led to the development of a new initiative to engage with smokers in deprived communities.
What Sort of Quitter are You?
‘What Sort of Quitter are You’ uses a customer relationship marketing approach to engage with smokers in a non judgemental or preaching tone. The initiative asks ‘what sort of a quitter’ an individual is, rather than ‘do they want to give up smoking’. Crucially, it allows the programme to build a relationship with a smoker over a period of time to foster trust and support, as the decision to act to ‘quit’ is not always immediate. The initiative was funded by £30,000 from the Working Neighbourhood Fund. What Sort of Quitter are You? enables smokers to access stop smoking support services that are suitable to their smoking habits. Smokers take a Quick Quit Quiz on the website (www.knowsley.nhs.uk/what-sort-of-quitter-home) to find out what sort of quitter they are, from seven sub-groups:
- Boiling Pot
- Weight Watcher
- Creature of Habit
- Young Invincible
- Serial Quitter
Knowing their ‘quit type’ helps smokers to understand what has stopped them from quitting in the past and allows them to access a specific quit programme tailored to their needs.
In the first week alone, 366 participants signed up to service, 19 per cent of Knowsley’s annual quit target. Currently, the What Sort of Quitter are You? database has an 80 per cent retention rate and a 30 per cent referral rate to services at first contact.
“Things grow organically. We got to a point where we knew we needed to broaden our offering out beyond Fag Ends and that we needed to talk about a choice of services. I suppose the view at that point was, are we going to start promoting choice? But the work we did around What Sort of Quitter are You? told us that no choice wasn’t the thing to do, it would continue to bar the people in the communities that we were having trouble reaching. So the intervention needed was around empowering people to make the decision themselves.” (Phil Morris, Head of Marketing)
Research based interventions
Research can be low cost and effective. Many are surprised by how much research and data is already available and this can provide valuable insights and need not cost a lot. Having gathered insights, it is vital to stick to your guns on the importance of using the research findings to inform the development of the programme. Winning the case to invest based on findings from the target audience, rather than on the assumptions of professionals, is key.
“Some absolute basics – don’t preach at people, give people what they want. Give them something that’s relevant to them.” (Phil Morris, Head of Marketing)
Position ‘giving up smoking’ as something positive
Many stop smoking campaigns focus on the negatives of smoking rather than the benefits of quitting. Hardened smokers have however learnt to ignore these scare-mongering techniques. Roy Castle Fag Ends has found that framing messages in a positive tone can be highly successful and does not discourage smokers.
Time and time again feedback from clients has highlighted that the personal support for smokers that Roy Castle Fag Ends provides has been vital in enabling them to quit.
“We would wholly advocate a direct approach. People do want health organisations to keep in touch with them. We might be very anti double glazing companies ringing us up and holding our details, but whole heartedly across the board when we ask people can we have your information and stay in touch, they say yes. That costs a lot less than pursuing traditional advertising.” (Phil Morris, Head of Marketing)
The success of this programme, coupled with other social marketing successes in the borough, has led to a change in commissioning approaches to increasingly put the customer at the centre in a range of public health and other commissioning areas.