NHS Stockport set out to increase the number of residents (particularly men and women with preschool age children) accessing smoking cessation services in Brinnington, an estate in the north of Stockport with a particularly high smoking prevalence.
This was achieved through a two-strand process of new service development and interactive communication under the banner of the ‘Lose the Fags’ brand. The central premise of the Lose the Fags social marketing initiative was community partnerships and ownership, with existing local organisations (namely a community gym and a children’s centre) and their staff becoming Lose the Fags champions.
The national tobacco strategy for England and Wales, contained in the 1998 White Paper Smoking Kills (superseded in 2010 by A Smokefree Future), identifies smoking as the leading cause of preventable death and health inequalities.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.
At a local level, increasing the number of successful smoking cessation quit attempts amongst the 20 per cent most disadvantaged communities has been a joint primary care trust (PCT) and local council PSA target since 2006.
Brinnington is among the top three per cent most deprived areas in England and Wales. 53 per cent of adults living in Brinnington housing estate smoke, which is significantly higher than the Stockport average of 18 per cent and the national average of 24 per cent. In 2006 to 2007, only 203 people accessed the local stop smoking services.
Social marketing was identified in 2007 as an emerging concept and tool that Stockport PCT could use to engage with R&M workers, particularly in light of the limited success that previous health promotion campaigns had achieved in reducing smoking in deprived areas. Stockport PCT subsequently approached The NSMC to become 1 of its 10 social marketing learning demonstration sites. The PCT wished to use a social marketing approach to improve its stop smoking service in Brinnington, with the aim of increasing the number of successful quit attempts.
The project was jointly managed and steered by a PCT Public Health Specialist and an NSMC Associate, who provided free, dedicated social marketing expertise and support.
Aims and behavioural goals
The project’s primary aim was to double the number of smokers accessing local smoking cessation services in Brinnington. This was measured through returned data from each of the services that smokers from Brinnington could access. The baseline of people accessing local stop smoking services was 145 in 2007/8.
Secondary (but equally important) aims were to increase the number of successful quits in Brinnington and to decrease the number of smokers on the estate. The standard measure for successful quit attempts is an individual not smoking for four weeks after the quit date. In 2007/08, there were 120 4-week quits in 2007/8 from all smoking cessation services.
Preliminary focus groups
Following a comprehensive phase of desk research, five mixed gender focus groups were held in Brinnington in spring/summer 2007 to gain an initial understanding of the barriers and motivations towards smoking cessation in Brinnington. The groups included:
The objectives of this research were to explore attitudes to services, experiences of successful quitters and those who had dropped out, and why current cessation services had achieved limited success.
A series of interviews were also held with key health professionals in Brinnington to explore possible improvements to smoking cessation services to make them more consumer-centric.
Barriers and motivators
Key barriers and motivations for quitting were largely in line with national research into smoking amongst R&M workers:
After this first phase of primary research, the target audience was segmented by behaviour, geography, gender and lifestage.
The audience most likely to respond to intervention are ‘contemplators’ and ‘preparers’. Contemplators are those planning to quit smoking and have perhaps been unsuccessful in previous attempts. Preparers are those who have made a definite plan to quit, perhaps including making an appointment with a specialist advisor. Given the project’s budget and the ingrained nature of smoking in the local culture, it was not considered appropriate to target ‘pre-contemplators’, who have yet to seriously consider quitting and may be hardened smokers.
The intervention was restricted to those living on the Brinnington estate, to capitalise on the strong community networks amongst the residents and the current facilities and services in the hub of the estate. Local people consider the estate area to be a close network of houses at the top of Brinnington hill, cordoned by the M60 bridge from the rest of Stockport and enclosed on all other sides by the green fields of Reddish Vale.
The stop smoking service in Stockport town centre is well respected, but is a 20-minute, £2.40 bus ride from Brinnington and is therefore not considered by many Brinnington residents. While local residents regularly visit the centre of Stockport, they do so to do their shopping, not to attend a drop-in smoking service.
The project targeted both men (of working age) and women (with preschool age children). However, the scoping research identified that men and women look for different qualities in a smoking cessation service. Women with children of preschool age would benefit from a smoking cessation service in familiar surroundings with trusted advisors and a crèche facility. Men of working age would benefit from an out-of-hours service in a ‘male’ environment, such as a gym with male fitness instructors trained as smoking cessation advisors.
The primary research suggested that while there were some excellent support services for smokers wanting to quit, those underserved were working age men and women with preschool age children.
The GP surgery is popular for advice and is served by a number of GPs, nurses and one smoking cessation adviser available three days a week, who is well-respected and liked. However, men and women did not want to visit the GP practice for smoking advice, as they considered the GP for ‘sick’ people rather than for ill-health prevention. In addition, the irregular shift patterns of working men often made visiting the GP difficult. The pharmacy was not considered a source of advice, although it was well known that NRT was available there.
Quit for Life is the popular Monday morning stop smoking drop-in. Delivered as an informal ‘coffee morning’ group, Quit for Life (now co-branded with Lose the Fags) tends to attract women with children of school age or above. There is no crèche facility and young children can be disruptive and bored. Men commented that they felt outnumbered by the women who went to the group and unaccustomed to the way members discussed their lives and daily issues.
Follow-up focus groups with target segments
Once men and women with preschool age children were chosen as the target audiences for the project, two further focus groups were conducted with representatives of these segments in summer 2007. The purpose of this research was to gain additional insight into their lifestyles, what moves and motivates them, and what their interests, fears and pleasures are.
As the area of highest deprivation in Stockport, Brinnington receives a multitude of health and improvement messages and interventions. There are highly visible back-to-work schemes, health services, social groups and community clubs, and while many people do not participate in these, there is a sense of saturation in Brinnington from external influence.
After the focus groups and interviews were completed, a consultation workshop was held in March 2008 with key members of Brinnington’s community, including health service providers and managers, ex-smokers, current smoking cessation service users, community group leaders and organisers, and smoking cessation service providers. Key findings from the primary research were presented to the group, then participants were split into smaller working parties to discuss ideas for developing appropriate services within the infrastructure in Brinnington for each of the two target segments. The discussions were recorded, transcribed and translated into a report for circulation after the event. The report contained ideas for the development of new services targeting each of the key segments.
The project focused on providing new services that best fit the needs of the two target segments. Men required an after-hours drop-in facility that would relieve them of the stigma of seeking cessation ‘advice’, while still providing the support they need for a successful quit attempt. Women needed an easily accessible and supportive service run by people they recognised and in a familiar setting, which they could attend regularly without the problem of finding childcare.
The new services were delivered through existing community venues, identified though an assets mapping exercise, and by trusted, local staff. Rather than outsiders nagging or prescribing courses of ‘best’ action, the smoking cessation message was promoted by local people themselves.
The service for men was implemented at the Lapwing Centre (the community gym in Brinnington), which enabled men to counter the ill-effects of giving up smoking by using exercise to manage their anger and stress. The Lapwing workers were conscious that anger management is a critical issue for men in Brinnington and so made efforts to introduce new members to methods for coping with stress and anger during their induction process. They also provided regular support in the guise of friendly ‘banter’ during work outs and in the reception area.
Amongst the Lapwing Centre staff are local men who have worked on the estate all their adult lives and are well-known and respected. Seeking advice from these men is viewed as more normal and acceptable than seeking advice from a GP or other health professional, who may have no connection to Brinnington.
The intervention for women was held at the Brinnington Children’s Centre, the largest community nursery and part of Westmoreland School in the centre of the estate. The aim was to counter women’s need for cigarettes as a form of stress relief by providing support from a smoking cessation advisor in a warm and friendly environment, with refreshments and a crèche where women could take a break away from their children. Although a cessation advisor from the PCT was brought in to run the drop-in and one-to-one meetings, the women attending were familiar with the receptionists and all the staff, as they had regular contact with the Centre through their children. Visiting the Centre once more in a week to receive cessation support was not an onerous activity.
Attendees of the smoking cessation clinic were actively encouraged to participate in the Children’s Centre’s other groups, including a Confidence Club, massage and ‘stay and play’.
A second community consultation workshop was held in May 2008, which focused on developing creative communications concepts and involved brainstorming ideas on the creative proposition, branding, media, incentives and relationship building. The session informed the creative brief that was sent to various design agencies. The draft intervention plans, developed as a result of the first community consultation meeting held in March 2008, were also discussed and agreed at this meeting.
A communications strategy was developed to underpin the promotion of new and existing services, with a strong call to action in the form of a freephone number and text-back service. A community stop smoking worker acted as a broker for incoming messages and directed callers to the most appropriate services, ensuring the services encouraged forwarded callers to attend as well.
Through the use of photographs of local residents taken in the area, communications for the project strongly suggested that local people in Brinnington were choosing to stop smoking. This created an atmosphere of support, where quitters did not feel they were alone.
Five creative themes were produced by the chosen design agency and were tested with the community in a series of single-gender focus groups in August 2008. Each of the themes was discussed and tested with various stakeholders, and the ‘Lose the Fags’ concept was agreed.
However concerns were raised as to whether parents would find the strapline ‘give smoking the two fingers’ offensive. The photographs were therefore taken in a way that clearly portrayed the ‘two fingers’ pose, but gestured to an absent cigarette between two fingers plus added smoke.
The word ‘Brinny’ was intended to be used as the keyword for prospective quitters to text to request help. However, the pretest research found that Brinny has negative connotations due to the derogatory way it is sometimes used by outsiders, and so was replaced with ‘quit’ as the key text word.
A suite of branded communications materials, including leaflets, posters and collateral, such as T-shirts, mugs and pens, were developed with the text and freephone numbers clearly displayed. A press pack was later created for women’s lifestyle magazines and commercial radio shows, which involved those featured in the communications campaign.
A launch event was held on 13 March 2009 at Brinnington Community Centre, where local residents and people working in the area were invited to attend. The event generated a huge amount of interest, as well as coverage in The Manchester Evening News of the family who featured in the Lose the Fags communications material. The new text and freephone line were also launched at the event.
Service for men
The Lapwing Centre hosted a Health Day on 24 September 2009 to formally launch its stop smoking service. In addition to covering smoking cessation, residents could talk to teams from alcohol, weight management and health trainers about different aspects of their health and fitness.
Fitness instructors were trained as smoking cessation advisors and could deliver appropriate vouchers for NRT, which could be exchanged at the local pharmacy. They offered advice on an ad hoc basis and when they were approached by clients as a result of seeing promotional material. They also offered advice at gym induction, where signposting and probing questions were incorporated into the standard induction questionnaire. Centre staff were incentivised to proactively approach gym customers who smoked to offer their smoking cessation service.
Service for women
A stop smoking clinic for drop-in or one-to-one appointments was run every Wednesday afternoon at the Brinnington Children’s Centre and was delivered by a central stop smoking team member. Children’s Centre staff, including Parent Participation workers, reception staff and nursery workers, were trained as Level 1 and Level 2 smoking cessation advisors and were incentivised to signpost the Wednesday afternoon sessions to members of the many community clubs and groups that met at the Children’s Centre. The free crèche enabled mothers with preschool age children to attend the sessions without having to arrange separate childcare.
Various roadshows were held around Brinnington in community meeting places, including the library and various community centres, for people to talk to the Lose the Fags team about which service was best for them. These helped generate lots of text requests for signposting and support.
On 11 July 2009, the Lose the Fags team set up a stall at the Brinnington Fun Day, where a local resident (who also featured in the poster campaign) dressed up as ‘Big Cig’ and played penalty shoot-outs with the children. The event helped raise considerable awareness of the Lose the Fags programme, with 10 new clients signing up.
Branded posters and leaflets were disseminated through local venues to encourage prospective clients to text or phone the central service for advice, support and signposting to appropriate services.
A blog and Facebook group were launched in June 2009, attracting many visitors and Facebook ‘friends’.
Considerable PR was achieved during implementation, with articles about Lose the Fags featured in various local papers, including the Council’s Civic Review (delivered to every door in Stockport) and Stockport Express
Stockport MP Ann Coffey was so impressed with the Lose the Fags project that she highlighted the initiative as a model of good practice during the 23 June 2009 Health Questions in the House of Commons.
A quantitative market research company was commissioned to deliver a statistically significant pre-post survey questionnaire. The questionnaire, to be delivered in Brinnington
and a control area, captured the impact of ‘Lose the Fags’ work plus detailed smoking and demographic data.
For internal use only, a two-stage qualitative research programme has been implemented to gather implementation evaluation data. Service delivery staff were interviewed half way through the first 12 months and also at the end of the first 12 months.
The feedback gathered from the service delivery teams, key partners and stakeholders which will be used to improve the sustainability of the intervention.
The research findings for the Lose the Fags programme have been published in academic journal articles.
The project and its innovative approach has been presented at regional and national public health conference as well as the 2nd World Social Marketing Conference in Dublin.
The intervention in Brinnington has been a triumph of community partnership, with numerous community organisations having a genuine stake in the intervention. This approach also brought challenges, in that when management changed at the Children’s Centre, the new Lose the Fags intervention was changed, causing problems with delivery. The Lose the Fags team reacted by having more team meetings and increasing communication between partners. It was also difficult for the fitness instructors and Children’s Centre staff to adopt smoking cessation into their existing roles and considerable support was required to provide them with the skills and confidence to deliver the Lose the Fags intervention on the ground.
However, the project is sustainable because existing, established community organisations have adopted smoking cessation as part of their core offering and the Lose the Fags project has provided a strong brand to support their efforts. Gradually, quitting smoking is becoming a social norm in Brinnington.
Words of advice