Stop While You Shop
To tackle higher rates of smoking common in more deprived areas of Southwark borough, NHS Southwark sought to recruit smokers from these areas into the Stop Smoking Service, where they would be more likely to quit successfully than if they went cold turkey.
Research highlighted that entrenched smokers often lacked confidence in their ability to quit smoking, had negative perceptions of non-smokers, and felt that NHS Stop Smoking Services were unsuitable for them. Instead they preferred a friendly, informal and convenient service.
In light of these insights, Stop While You Shop stop smoking clinics were run from 4pm to 8pm in four supermarkets, twice a week, over nine weeks. All smokers were encouraged to sign up to a minimum four-week programme. A comprehensive follow-up service was established with SMS message appointment reminders and weekly call-back consultations. Successful quitters were given a certificate to acknowledge their achievement.
During the course of the 9-week campaign, 468 smokers joined the supermarket clinics and set a quit date. 275 of these successfully achieved a 4-week quit (a conversion rate of 70 per cent). It is estimated that for every £1 spent on the initiative, £16 was saved on future NHS treatments for smoking related illnesses.
Smoking is a major cause of preventable morbidity and mortality in the UK, with approximately 110,000 deaths every year from smoking-related illnesses. In addition, costs to the NHS in the UK of treating illness and disease associated with smoking have been estimated at £15.3 billion a year (in 2011).
Furthermore, smoking has been identified as the primary cause of inequality in death rates between rich and poor. For men in the UK, smoking accounts for over half of the difference in risk of premature death between social classes.
Health inequality has been identified as a problem for the residents of Southwark. For instance, life expectancy for men living in the least deprived parts of the borough is over seven years higher than for those living in the most deprived parts. The difference for women is almost five years. In Southwark the estimated percentage of adult smokers is higher than the England average, with smoking resulting in around 322 deaths in 2008.
Subsequently, NHS Southwark sought to tackle the higher rates of smoking prevalence in the more deprived areas of the borough, such as Peckham and Old Kent Road. It was already understood that more entrenched smokers from the deprived areas of Southwark were not using the Stop Smoking Service (SSS) as much as residents from elsewhere in the borough, and were subsequently more likely to make quit attempts using willpower alone. However, evidence has shown that smokers are four times more likely to quit using NHS SSS when compared to going ‘cold turkey’. So an intervention was needed to get smokers from the deprived areas of the borough to use the SSS to enhance their likelihood of successful quitting.
Social marketing agency onedeepbreath was commissioned to undertake research that would feed into the design and delivery of an intervention with the following aims:
- Increase the numbers of smokers from deprived areas of the borough (likely to be routine and manual workers and/or from black and minority ethnic communities) to make a quit attempt using the SSS
- Increase awareness of the SSS
- Deliver 225 4-week quits over the course of the programme
Scoping began with desk-based secondary research to review appropriate policies and studies focused on social marketing and smoking. Documents reviewed included:
- Choosing Health: Making healthier choices easier (Department of Health, 2004)
- Smoking, Low Income and Health Inequalities (Health Development Agency, 2005)
- Brief interventions and referral for smoking cessation in primary care and other settings (National Institute for Health and Clinical Excellence, 2006)
- Changing Behaviour, Improving Outcomes (DoH Social Marketing Strategy 2011)
- Health Belief Model - Self Efficacy (Rosenstock 1988)
- Going it alone? Improving the Route to Quit (London Social Marketing Unit, 2009)
This work was followed by an assessment of previous smoking social marketing campaigns run by onedeepbreath in boroughs with similar demographics to Southwark, including Tackle Smoking for NHS Lewisham and NHS Southwark, which involved a partnership with Millwall Football Club, and Make Smoking History for NHS Lambeth.
A key insight from the secondary literature and previous social marketing campaigns was that many smokers wanted to quit and would take the opportunity to quit if the process was more accessible, immediate and convenient. For the Tackle Smoking social marketing campaign, onedeepbreath used a road show with a SSS at supermarkets, street markets, libraries and shopping centres. This experience highlighted that while in many of these areas there were agreements with local pharmacists to redeem nicotine replacement therapy (NRT) vouchers, there was still some difficulty in getting the customer to go into the pharmacy and/or getting the pharmacy to book smokers onto the programme. There were high numbers of smokers interested in stopping smoking, but many fell at the first barrier, such as the pharmacy being too far away, the pharmacist being busy, or they did not have time.
The most successful location for the stop smoking clinics had been in supermarkets. It was therefore decided to develop an intervention based in supermarkets, but which reduced the barriers highlighted by smokers in the previous social marketing initiatives. Subsequently, the team mapped out all the barriers identified to find ways of removing them.
NRT too expensive
Free NRT in supermarket clinics
Pharmacy too far away
In-store pharmacy at the supermarket
Clinic open at inconvenient times
Out-of-hours opening times
Nowhere to park
Large supermarket car park
Stop smoking whilst you do your weekly shop
A pilot clinic was run to allow the project team to test key programme logistics, such as timing and the redemption of vouchers and dispensing of NRT from the in-store pharmacy, alongside key campaign messages and creative.
The creative concept was developed based on the insight that smokers wanted things kept simple, straight to the point and to have a call to action that focused on what the smoker could expect from the four-week clinic and nicotine withdrawal symptoms. This led to a creative that took into consideration the location, the audience and clinic, under the brand ‘Stop While You Shop’. This new brand was merged with NHS and national smokefree branding to give it more weight, whilst also emphasising accessibility and convenience of the local scheme.
The pilot was run for seven weeks at Asda on Old Kent Road in September and October 2009. During these 7 weeks the clinic was held every Thursday between 4pm and 8pm and every Saturday between 11am and 3pm. No appointments were necessary and NRT was free to each smoker for four weeks and was available from the in-store pharmacy.
As part of the pilot, 120 smokers were interviewed to test the creative concept, clinic location and gather their attitudes towards the initiative. A further three interviews were conducted with the pharmacy counter staff. Anecdotal feedback was also recorded from 30 smokers who had successfully completed the 4-week programme.
Key insights from the interviews
Smokers (largely routine and manual workers):
- Often lacked confidence in their ability to stop smoking
- Smoking was heavily entrenched within social circles and used as a form of escapism
- They often had a short-term attitude to life and were generally disengaged by future health issues
- When quitting they focused on the addiction – they did not understand or accept that they also had to tackle emotional habits
- They were unlikely to use SSS to help with a quit attempt due to low awareness of the service provision, difficulty in accessing the service during a regular working week and a general reluctance to get NHS support (they believed the service was unsuitable or not designed for them)
- Many complained about the service offered by their GP, where they felt judged and not given the support they needed
- A lot of the smokers had tried the national free helpline and felt it was a waste of time and that it did not help them
- Many complained about the cost of NRT, but said they would consider trying it if it was free
- None of them knew the pharmacy offered a stop smoking service
- They were particularly motivated by the convenience, friendliness and informality of the service offered in supermarkets – they appreciated the down-to-earth, personal approach
- They liked that they did not have to book an appointment and subsequently felt more in control of their quit attempt
- They preferred the traditional method of prescribing to conducting the whole service, since this was seen as more time efficient, especially in a high footfall environment where queues can form easily
- If there was any sort of queue at the pharmacy, this took priority over any other activity, including a stop smoking consultation
- With so many other services to deliver, pharmacy workload could be too high to deliver a quality SSS
Following the pilot clinic held in Asda in September and October 2009, onedeepbreath worked with NHS Southwark to develop a series of supermarket stop smoking clinics across the borough.
The clinics would provide:
- Four weekly appointments that residents could fit into their weekly shop
- A weekly carbon monoxide test so smokers could see the quick benefits quitting smoking could have on the body as it begins to heal itself
- Free weekly medication (NRT) to aid quitting, which can be picked up from the in-store pharmacy
- Weekly call, text, email or letter of support (which also reminds smokers of their next week’s appointment)
- Free quitter pack full of useful hints and tips to get smokers through their quit attempt
- Certificate on successful completion of the four-week clinic
Clinics were organised in partnership with supermarket and pharmacy managers to run twice a week for seven weeks in the following four supermarkets:
- Morrisons, Peckham
- Tesco, Old Kent Road
- Sainsbury’s, Dog Kennel Hill
- Asda, Old Kent Road
The two clinics each week would run for four hours (4pm to 8pm) within the foyers of these supermarkets, often near cigarette counters, to ensure advisors had the chance to see the highest number of people.
Trained advisors would consult with smokers about their smoking habits and record their smoking behaviour (such as how many they smoked a day, for how long, and how soon after waking they needed their first cigarette), ensuring their consultation style was empathetic rather than judgemental. Any previous quit attempts would be discussed and reasons for smoking explored. Because motivation is based on more than just reason, it would be important to consider habits, reactions to NHS trained advisors, desires and future plans. At this stage the advisors would discuss the programme logistics, such as no appointment being necessary, different times available, prescribed NRT vouchers collectable from in-store pharmacies free of charge, and weekly testing to measure carbon monoxide levels. All smokers would be encouraged to sign up to a minimum four-week programme.
A comprehensive follow-up service would be used for those who signed up to the four-week programme. Smokers on the programme would receive SMS message appointment reminders and weekly call-back consultations to give them the opportunity to talk about any problems they might have and to remind them of their next appointment. At the end of the programme successful quitters would be given a certificate to acknowledge their achievement.
To pre-promote the supermarket clinics, a Stop While You Shop advert appeared in the Southwark News for two consecutive weeks prior to the clinic start dates.
At the start of each clinic, recruitment of smokers was slow, with many walking past, not interested in the messages and the programme that the advisors were trying to ‘sell’. However, once conversations began with a few people and they sat down to give a 20-second carbon monoxide breath test, others became interested and would approach the clinics themselves. If people who did not live or work in the borough approached the clinic, the advisors passed on their details to other smoking cessation services for follow-up.
There were occasions where redeeming the NRT in-store caused queues at the pharmacy dispensing counters. As it was important for the clinic not to hinder the normal workings of the supermarket, when queues did begin to form due to people wishing to collect NRT, the advisors asked the smokers to drop off their prescription, do their shopping and then collect their NRT afterwards.
Smokers who enrolled on the programme often brought a friend or family member along to the next clinic so they could also sign up to the programme. So while the advertisements and promotions were important for publicising the campaign, word-of-mouth actually proved to be the most successful mechanism for recruiting more smokers to the programme.
The most successful aspect of the clinics was the comprehensive follow up with an assigned advisor. Many of the smokers who enrolled on the programme appreciated the personal touch and the empathetic and non-judgemental attitudes of the advisers. Some advisors even received personal gifts (which of course could not be accepted) or ‘thank you’s’ from the smokers who had successfully completed the programme.
“Smokers on the programme believed that their advisors had personally invested a great deal of time and energy into helping them beat their addiction, so many smokers felt an emotional obligation to quit not just for themselves but also for their advisor.” (Steve Jamieson, onedeepbreath)
Another key success was the use of carbon monoxide monitoring. This allowed smokers to see quick tangible results from giving up smoking.
“Smokers had to blow in a carbon monoxide monitor each week and saw their health measurably improving. This was often a huge ‘YES!’ moment with a punching of the air or high-fives all round, giving them a real sense of achievement and success.” (Steve Jamieson, onedeepbreath)
The informal, non-clinical format of the drop-ins meant that many people believed the supermarket clinics were organised by the supermarket rather than the NHS. This proved to be advantageous in attracting those who would normally not approach an NHS SSS. However, there were some people who questioned why the service was not running in other branches of the supermarket.
To boost recruitment, two weekend clinics were added to the schedule on Saturdays from 11am to 3pm – the footfall was much higher on Saturdays than during the week. The campaign period was also extended by a further two weeks following the initial seven-week timescale to ensure completion of the four-week quit programme and target.
The programme was evaluated against the data collected by the SSS, specifically four-week quits, and smokers were asked to complete evaluation forms following the conclusion of the programme to understand the consumer experience.
The target was to deliver 225 successful 4-week quitters into NHS Southwark’s SSS, and this target was exceeded. In total over 2,000 smokers were engaged by the Stop While You Shop service, 468 smokers joined the supermarket clinics and set a quit date, and 275 of these successfully achieved 4-week quits (success rate of 70 per cent).
Example customer feedback
- “They called me at least twice a week to check on me and I valued and needed the support. Now in just 4 weeks I have quit a 13-year habit”
- “It’s thanks to you guys I’ve quit…The day I signed up I was going to Asda to get my 100 fags for the week. You’ve saved me over £200 and now I’ve booked my holiday to Turkey”
- “I originally went to my doctor’s and did not receive the support that I have received from these guys. The support offered by Stop While You Shop was fab, I could not have asked for anything more”
Overall, the initiative reached 125,000 residents through press, in-store advertising and PR coverage, which helped raise awareness of NHS Southwark’s SSS.
In addition, relationships were developed further with supermarket store and pharmacy managers to allow the campaign success to be repeated and expanded in the future. The project also raised awareness of existing services within the in-store pharmacies and increased uptake into the service following the end of the campaign.
Value for money
The financial resources required were:
- Staffing costs: £41,942
- Scoping and implementation: £6,528
- Follow-up and evaluation: £6,496
Therefore the total project budget was £54,966 and the cost per quit (having achieved 275 quits) was £199.88. Based on an estimated cost-saving to the NHS of £3,115 per person having quit, this equates to a return on investment ratio of 1:16. So every £1 spent on the initiative, £16 was saved on future NHS treatments for smoking related illnesses.
Building on the success of the original campaign, a follow-up campaign was run over a 10-week period during May to July 2010. During the original campaign burst, Lucy Cope – a chronic obstructive pulmonary disease sufferer – became a successful quitter. Lucy championed the scheme in June 2010 when she was nominated for a Southwark Heroes Award and the campaign was further promoted in the South London Press.
Full evaluations of the Stop While You Shop campaign have been presented to key stakeholders and case studies have been prepared and distributed to other London boroughs.
The campaign has been held up by World Class Commissioning as an innovative way to engage hard-to-reach groups that would not usually use NHS services. The campaign has been held up by World Class Commissioning as an innovative way to engage hard-to-reach groups that would not usually use NHS services. It has also been successfully implemented in several other boroughs outside of Southwark, including Hackney, Ealing and Lewisham.
Convenient, informal and non-clinical environments
Hard-to-reach, entrenched smokers are not receptive to formal NHS SSS, which they see as unsuitable for them. Instead, they want an easy-to-access, friendly and non-judgemental service. This is why it is extremely important to keep the interventions informal, relaxed and not too clinical to build personal relationships with smokers. Supermarkets proved to be a very successful location for achieving this and the convenience was a major factor in the success of the project.
“We understood that smokers often didn’t have time to make an appointment to see their GP or visit their local pharmacist, so this model fitted in perfectly with a routine activity like shopping.” (Steve Jamieson, onedeepbreath)
Consistency and relationship building
For this target audience personal relationships are paramount. Therefore, ensuring that clinic times are consistent and that the weekly follow-up calls are conducted by the same advisors who conducted the initial supermarket consultation is vital. This helps build better relationships between smokers and advisors, which strengthens the links between the smokers and the service.
“The success of these clinics is largely dependent on the behavioural support that a smoker receives – being able to dedicate as much time to each individual as they need helps hugely. To anyone intending to carry out similar interventions – and seriously addicted smokers generally need more intense support – the importance of follow-up and relationship building cannot be stressed enough.” (Steve Jamieson, onedeepbreath)
Non-judgemental and empathetic
Participants highlighted in their feedback that a key aspect of the clinics that appealed to them was that they did not feel judged or pressured and this was fundamental in making them come back each week. It is therefore imperative that teams running the clinics understand the importance of empathy and relationship building.
Free NRT from in-store pharmacies and clinics
Free NRT was an excellent incentive and convenient to collect from in-store pharmacies. However, during the campaign NRT stock levels within the pharmacies were sometimes too low. In future, more work could be conducted with in-store pharmacies prior to the campaigns to ensure they had sufficient NRT supplies. In addition, having samples of NRT at the clinics could be beneficial for smokers, since pharmacies often do not have the time or capacity to give those collecting prescribed NRT demonstrations and advice on its use.