Quit for a New Life
NHS Stoke-on-Trent set out to reduce smoking in pregnancy rates in two high prevalence neighbourhoods – Meir and Bentilee. This was achieved through reconfiguring the existing ‘Quit For A New Life’ smoking cessation service and introducing a new style of peer support group (Me2 stop smoking club), which focused on rewarding mums and giving them alternatives to the ‘me time’ that cigarettes can offer.
A two-pronged intervention strategy was developed, focusing on professionals and looking at what was needed to develop the ‘sales force’ for the new service, as well as on the target women, ensuring that the stop smoking service met their needs and desires.
- Pilot group sessions: 60 per cent average conversion rate from quit date set to 4-week quitter
- 4-week quit data: At the end of 2007/08 the service had delivered 121 4-week quitters, compared with 38 in 2006/07
Smoking in pregnancy is both a cause and effect of health inequalities and significantly contributes to worsening health outcomes of both mothers and children.
Stoke-on-Trent is a designated ‘spearhead area’. This status recognises the extent of existing deprivation in the city, the entrenched nature of health inequalities and the impact this has on the health status of the local population.
A key target of Stoke-on-Trent’s Infant Mortality Strategy was to reduce the number of women who smoke during pregnancy. The percentage of women smoking during pregnancy in Stoke-on-Trent was approximately 22 per cent in 2006/07, compared with the national figure of 17 per cent and a regional figure of 18 per cent. However there were significant variations in smoking in pregnancy rates between different areas of the city.
The challenge for the Primary Care Trust (PCT) was to increase the number of women accessing the existing ‘Quit for a New Life’ service in the city and for them to ultimately stop smoking. Quit for a New Life, which had been running since 1999, was making good progress it, but was not achieving the results needed to make a significant impact.
A review of the service in 2006 revealed that the PCT had to address the following issues:
- There was a need to develop a better understanding of the needs and wants of pregnant smokers
- There was a need to develop a longer-term strategy to support women to stop smoking before they become pregnant and support women postnatally
- The capacity for training midwives and other key healthcare professionals was limited
- There were currently no formal links with other services such as family planning, teenage pregnancy services, children and family services
- Existing resources needed to be used more effectively to meet current demand and have an impact on smoking in pregnancy rates
Aims and objectives
A social marketing pilot project was set up to help reduce the number of women who smoked during pregnancy in Stoke-on-Trent. A first step would be to try to improve the quality and quantity of the referrals to the service by offering a ‘proposition’ or ‘product’ that would be right for the women it was trying to reach.
Based on the review of the current service, the main objectives were to:
- Explore what it is like to be a pregnant smoker in Stoke-on-Trent
- Identify the factors that influence the behaviour of pregnant smokers in Stoke-on-Trent
- Develop a better understanding of the barriers to accessing existing services
- Improve communications with key stakeholders who could influence women who were smoking in pregnancy
- Review and redesign the Quit for a New Life stop smoking service based on customer insight and develop an intervention that meets the needs of the client group
Setting up the project
To guide and monitor progress, a small action-focused steering group was set up, comprising the following members:
- Stoke-on-Trent PCT Principal Health Improvement Specialist (and Project Lead)
- Specialist Smoking Cessation Midwife
- Smoking Cessation Support Workers
- Stoke-on-Trent PCT Design Team Leader
- NSMC Associate
- Social Marketing Consultant, XL Communications
- Dr Ray Lowry, University of Newcastle-upon-Tyne, who acted as an advisor to the group
Together the team formulated a project plan, with clear task responsibilities and timelines. They identified areas where they would need to bring in external expertise and spent time understanding how best to commission and use this expertise. The project became 1 of The NSMC’s 10 learning demonstration sites and received free, social marketing guidance and support from a dedicated NSMC Associate. The external consultants coached and guided the local team through the social marketing process, although the project was controlled and implemented by the PCT Project Lead and the specialist smoking in pregnancy team.
The group decided to meet approximately every two months during the course of the project and to communicate through email and phone between meetings. The Project Lead chaired all meetings and status reports with clear action points were produced on a regular basis.
A project planning day was organised where the steering group identified the Strengths, Weaknesses, Opportunities and Threats (SWOT) of the existing services available to the target audience. They brainstormed what they hoped to achieve and how they might get there. Members discussed openly the obstacles that might get in the way and looked carefully at their resource base.
Defining the target audience
The audience was segmented geographically by areas covered by the reach of the children’s centres in the city. The two areas of Stoke-on-Trent where local data showed smoking in pregnancy rates were high, namely Meir and Bentilee, were chosen for the pilot intervention.
The audience was further segmented by women’s motivation to stop smoking – those who, after talking to a professional, said they were willing to engage with the service were focused on. The team knew that they needed to gain a greater understanding of what was needed to get women to this point and make quitting a reality.
Getting key stakeholders on board
Communicating with professional stakeholders was fundamental to the overall success of this project. It was critical to ensure that all were informed about the plans and had the opportunity to feedback and influence the direction the project took. Equally important, communication with professionals played an important part in building confidence in and preserving the reputation of the Quit for a New Life service.
A wide range of internal and external stakeholders were communicated with using a variety of methods, including email, letter, newsletter, face-to-face meetings, presentations and training events, but of all these methods the most valuable were the numerous personal face-to-face encounters with key stakeholders. A ‘10 Frequently Asked Questions’ sheet was produced, which outlined the project and explained why a social marketing approach was being taken. The team summarised the project plan and invited stakeholders to contribute where appropriate.
Ultimately, the group succeeded in creating a meaningful, consistent dialogue between the project team and the internal and external stakeholders across the locality.
Learning from best practice
One of the starting points was the pioneering social marketing work of Dr Ray Lowry and his project that successfully reduced the number of women who smoked whilst pregnant in Sunderland. Dr Lowry’s expert advice helped the team understand what they could potentially replicate, but more importantly it helped inform the primary research and ensure that it obtained a clear picture of what would motivate the women of Stoke-on-Trent to access the cessation service. Although Dr Lowry’s interventions could not simply be copied without testing them in Stoke-on-Trent, the results of his work underpinned the way the approach of the project.
A key finding from Dr Lowry’s research was that health professionals were unintentionally creating barriers that were stopping pregnant women accessing stop smoking services, through a lack of understanding and empathy of women’s perspective and circumstance. The women in the Sunderland project felt that they were not being treated as a person and the concern shown by professionals focused almost entirely on the unborn baby. Together with his colleagues, Dr Lowry pioneered the use of role play in training sessions for health professionals that incorporated a scenario (using verbatim quotes) which brought to life the thoughts, beliefs and concerns of pregnant women smokers. Professionals were encouraged to become ‘the sales force’ for referrals to a specialist stop smoking service, which proved to be highly successful in increasing the quality and quantity of women engaging with the service and ultimately substantially increased the number of quitters.
To deliver a service that would be meaningful and motivating to the women, the intervention needed to be based on robust customer insight and in-depth understanding of what was happening in the worlds of the target women. To achieve this, two focus groups were conducted by a specialist company that had experience in health-related qualitative research.
The aims of the focus groups were to:
- Reveal women’s current smoking habits and any changes they had made during pregnancy
- Understand participants’ experiences, attitudes and emotions to smoking during pregnancy
- Identify reasons for stopping smoking and the key barriers to stopping smoking whilst pregnant
- Find out awareness of local support services and participants’ attitudes to them
- Use the insight to design an ideal local support service in Stoke-on-Trent
All participants in the focus groups were mothers of children aged one to four years and all had smoked during their pregnancy.
Current smoking habits and any changes during pregnancy
For most women, there were no great differences between smoking habits before and during pregnancy. However it was perceived that stress levels and emotional intolerance rise during pregnancy, causing the desire to smoke to alleviate these conditions. Only a small number of participants had managed to stop smoking early in the pregnancy or reduced the amount of smoking. It was often the case that once the baby was born, the participant returned to smoking.
In contrast to their smoking habit during pregnancy, once the baby was born, their smoking habits changed in that they smoked outside of their home or in the kitchen away from the children. They strived to protect their children from the harmful effects of smoking and fumes. However, they lacked the drive and support needed to stop smoking before the child was born.
Reasons for smoking
There was a high awareness of the side effects of smoking during pregnancy and most women knew that it could affect the weight and development of the baby. Some revealed that they felt guilty when smoking during pregnancy and some said that they felt under stress due to uncertainty about how it could harm their unborn child.
However it was also quite common for women to know family and friends who had given birth to healthy big babies and smoked throughout their pregnancy. This gave them reassurance that their behaviour was nothing out of the ordinary and lessened any feelings of guilt.
Many women smoked during pregnancy because it was an enjoyable habit that alleviated stress. Aside from its addictiveness, the main need fulfilled by smoking was for ‘a personal treat’. Smoking was linked with ‘me time’, when they could take a break from the needs of their children and partners. Thus they enjoyed smoking – it provided them with a private, relaxing, uninterrupted moment. They often had a lifestyle that left them feeling very emotional, stressed or depressed, which manifested even greater during pregnancy, so many regarded having a cigarette as their means of escape.
They were also acutely aware of the social stigma connected with smoking in pregnancy, the ‘dirty looks’ they got from strangers and comments from medical professionals or their non-smoking friends and family.
Most of the women in the focus groups had tried to stop smoking at different stages of pregnancy; only a few had succeeded. All agreed that it had to be their own decision to stop smoking and they could not be forced into it if they are not willing to do it. ‘Nagging’ can have a counterproductive response, resulting in defiance and a stubborn refusal to change attitudes or behaviour. The women blamed a lack of willpower or a fear of depression and emotional unrest for continuing to smoke whilst pregnant.
Those who had tried to stop revealed the importance of the support and encouragement of significant others, particularly their partners who often stopped smoking with them. They appreciated support from midwives, who were perceived to be looking after and caring about them (not only about their unborn child).
Awareness of existing services was low among the women who took part in the focus groups. They had very clear views about the type of service that would be attractive to them or others who want to stop smoking. Their key message was that they would only use a stop smoking service if they wanted to, thus the tone of the intervention had to be inviting, helpful, friendly and encouraging.
Ideally a support service for them should:
- Be very locally based
- Be in an informal, supportive and non-judgmental environment
- Invite them to participate in the service – not force or push them into going, avoiding words like ‘refer’
- Run through the day and/or early evenings to enable them to attend outside of the times when their children need them most (like school drop-off or pick-up and bedtime)
- Promote ‘me time’, which would be crucial in terms of how the service was ‘sold’
- Offer group sessions, which were relaxed, informal and based on the Slimming World or Weight Watchers concept, with ‘role model’ clients who would share experiences and had been in similar situations
- Be flexible in response to their individual needs and provide a choice of groups and one-to-one contact – or a combination of methods
Revisiting the target audience
Previously, the smoking in pregnancy service focused only on women who were currently pregnant. Research had confirmed that pregnancy is one of the most difficult times for a woman to stop and although women often attempted to stop during pregnancy, those who succeeded often started smoking again once the baby was born. This confirmed feedback from professionals that the reach of the Quit for a New Life service needed to be expanded.
Subsequently the target audience was redefined as:
- Pregnant women
- Women who were thinking about starting a family
- Women who were between pregnancies
- Women who had children under the age of five
- Self esteem – taking control of their lives
- Stress management, which would include building in ‘me time’ to their lives
- Feeling good, looking good
- Saving money
- Time and involved in attempting to stop
- Peer pressure from family and friends who smoke
- Influence of other women who continued to smoke during pregnancy and gave birth to healthy babies
- Enjoyment of smoking – ‘me time’ – perceived as one of the few things they can do for themselves which helps alleviate stress
Core values for the Quit for a New Life service
Having understood the exchange process, the team agreed a set of core values for the service they wanted to provide. This provided the foundation for the Quit for a New Life brand and underpinned the way the service was promoted to potential users, health professionals and other organisations.
- We are women-centred, providing friendly, non-judgmental support on a flexible and individual basis
- We value the woman, not just her pregnancy
- We aim to make support as holistic and accessible as possible
- We aim to share and promote good practice
- We believe in choice and respect
- We deliver on our commitments
- We will be caring, supportive, reliable, accessible and flexible
These values were agreed with professional colleagues and the Quit for a New Life message was tested with target women. They were highly positive and said:
- The message sent by the term ‘Quit for a New Life’ was very attractive
- The message that the service is ‘for you’ was clearly understood and was highly inspirational due to their need for personal attention
- The non-judgmental and non-patronising tone was greatly welcomed, especially as it was at odds with their perception of current experiences (for example with GPs)
- The word ‘support’ had negative links for the women to being a ‘victim’ – The women were keen to substitute ‘support’ with the more inspirational word ‘encourage’
Two-pronged intervention strategy
The team decided to work on two detailed implementation plans: a professional intervention – looking at what was needed to develop the ‘sales force’ for the new service; and a public intervention – the service to be offered to the target audience.
The professional intervention aimed to:
- Raise awareness of the Quit for a New Life service
- Promote the referral pathway into the service
- Promote and deliver brief intervention training
- Build positive relationships with professionals
The team wanted to ensure that professionals understood the range of services that were on offer through Quit for a New Life, and when they had contact with target women they felt confident initiating a discussion about women’s smoking behaviour and were able to facilitate access to the service in a timely and effective manner.
A brief intervention training package was developed, using scenarios and role play actors to demonstrate an effective five-minute intervention. Based on Dr Lowry’s work in Sunderland, the training aimed to ensure that women felt that they were important, and encouraged the professionals to show empathy in a positive way. The training was designed to be delivered by the smoking cessation midwife to groups of professionals.
A new referral pack, which includes a description of the service, contact details, a clear referral pathway and information for clients, was tested with professionals. The style and tone of the materials mirrored those used for the public intervention and aimed to make a visual impact that promoted a positive, clear and motivational message, giving professionals confidence in the service.
Public face of the Quit for a New Life service
The intervention had to be the right ‘product’ in the right ‘place’ and time, ‘promoted’ appropriately at the right ‘price’. It was about offering women something that was more valuable and attractive to them than their current lifestyle choice of smoking.
Flexibility and a range of options were important for the majority of women. The team had to think about what activities they could offer women within the constraints of their resources, time and budgets. All ideas were pretested at two further focus groups.
The following was proposed as a viable range of services, which retained many of the features of the existing service but had the significant extra feature of a peer support group:
- One-to-one support (at home or agreed venue)
- Peer support group in a community setting – based on a motivational club, like Slimming World
- Mixture of group work and one-to-one support
- Telephone support
Peer support group
The women wanted group support as one of the services offered – the challenge was how to make this element attractive to them and meet some of their key needs. The groups needed to be set up in a format that encouraged women to stop smoking, but also provided the valuable ‘me time’ they said was so important. The groups aimed to offer a friendly and relaxed environment for women to meet and share their ideas and experiences.
Based loosely on weight management programmes, a model was established where the first part of the session involved a discussion around how the previous week had gone, highs and lows, tips from fellow quitters and how to tackle the challenges they faced in becoming a non-smoker. The second part of the session focused on ‘me time’. This included relaxation and pamper sessions, which would include aromatherapy, massage, reflexology and more. The team worked in partnership with Worker’s Education Authority to design and deliver these sessions.
To be attractive, the groups had to be welcoming and friendly to all participants, make special considerations for women who were not accustomed to attending groups and ensure that the staff running the groups were professional whilst remaining approachable.
Great importance was placed on the branding of the new club and a variety of names were considered for the group and a range of logos designed by the in-house design team at the PCT.
The Me² concept tested best because it represented togetherness, inclusion and friendliness. The term ‘club’ had strong associations with forming new relationships, whilst the term ‘me’ placed the focus on themselves.
Delivering the service
To make the service convenient to women and easily accessible, it was offered in a variety of ways:
- In women’s homes – Women may feel comfortable for someone from Quit for a New Life to visit them at home. This helps the women feel in control and saves them time
- Children’s centres – Many of the target women spend time at children’s centres where there are crèche facilities and an opportunity to socialise with other mums. Testing showed that this would be the ideal place for the Me² Clubs to be piloted
- Community venues – Options for community venues could range from the local community centre to community cafes. The Quit for a New Life team was flexible and happy to consider any appropriate venue where women feel comfortable and happy to attend
- By phone – Supplementary support could be offered to women by phone or texting. Often they just need a little reassurance that they are doing well or encouragement if they are having a ‘bad day’. Reminders about appointments or group sessions could also be sent by text
The research revealed the need to raise the profile of and rebrand the Quit for a New Life service. A variety of visuals for the Quit for a New Life brand were tested with women as shown below:
This was the most appealing option – it sent a highly positive message linked to making a healthier lifestyle choice.
A series of posters, leaflets, promotional materials and portable stands were developed for use in a variety of community settings. In addition, it was agreed that media activity would be used when appropriate.
The publicity materials to promote the Me² Club were pretested and were bright, bold, eye-catching and fun. Women loved the overall look but had a few concerns in terms of what language was used and how it could be interpreted, which were addressed before launch.
A planned programme of in-depth specialist training was provided for frontline staff, who are the ‘sales force’ of the service. This included a new brief intervention training package using ‘role play actors’ to demonstrate an effective five-minute brief intervention, which was well received. By tapping into planned training days, the team were able to keep frontline staff up to date with the project’s progress and obtain feedback on the referral process and new materials.
An outside consultancy was commissioned to produce a DVD of the training, which significantly increased the number of professionals the project was able to reach, including those working in children’s centres.
All key frontline staff and managers had the opportunity to attend an introduction to social marketing course, which helped staff understand the approach the team took to this project.
The Me² Stop Smoking Clubs were launched in February 2008 at the Treehouse Children’s Centre in Bentilee and the Crescent Children’s Centre in Meir.
The clubs were launched as a six-week rolling programme and were refined to suit participant’s needs. Each session was structured around:
- Meet and greet
- Tips and techniques to help quit smoking
- Help with managing stressful times
- Building self-esteem
- An opportunity to relax, try some pamper treats and enjoy some ‘me’ time
No appointments were needed and each session ran for around 90 minutes. Free crèche places were welcomed by the women.
Small incentives, including Me2 branded products, were provided to members when they joined and when they reached their individual goals.
The clubs had an open-door policy and women were free to return if they failed to quit at the first attempt, contributing to an environment where women were free from being ‘nagged’ and judged.
To attract women to the club, the team attended community events and provided taster sessions in the run up to the launch. The clubs were promoted by word-of-mouth from midwives, as well as leaflets and posters that were displayed and distributed by local retailers. To increase the capacity of the service, two new support workers were introduced.
Data on the percentage of women who smoke during pregnancy citywide was disappointing. However, the data relating to children’s centre areas was encouraging. The percentage of women reported as smoking during pregnancy in the Treehouse Children’s Centre area in Bentilee (where the pilot intervention took place) declined from 31.9 per cent in 2006/07 to 29.2 per cent in 2007/08.
Feedback from women who took part in the pilot group sessions was very positive and suggested that the PCT is now delivering a service that better meets the needs of the women it is trying to reach.
The table below shows the activity data for the Quit for a New Life service over three years. At the end of 2007/08, the year when the new service model was implemented, the service had delivered 121 4-week quitters, compared with just 38 in 2006/07.
|Year||No. quit dates set||No. 4-week quits||Quit rate|
The Me² Club in Bentilee was especially well received, delivering an average conversion rate from quit date set to 4-week quitter of 60 per cent. Group members also reported increased levels of self-esteem and wellbeing.
Unfortunately the club in Meir was not so successful due to a number of factors, including the day of the week it was held. Women who attended the focus groups during the scoping stage said that they would prefer a Friday meeting, but this did not prove to be the case.
The Me2 Club in Meir was re-evaluated in order to meet women’s needs and the team worked with Children’s Centre staff to assess the most appropriate way forward. Also, the activities offered by the club were further developed and rolled out to other children’s centres in Stoke-on-Trent.
The team were delighted to win the Health Service Journal’s Best Social Marketing Project Award and have shared their experiences with many organisations who wanted to test these findings in their own local areas. These included two other learning demonstration sites (based in Stockport and in Lewisham) that also aimed to increase smoking cessation. A comprehensive final report was also produced for distribution to internal and external stakeholders.
- Social marketing is not a quick fix – it needs time to fully engage with the process
- Have a small (we had six people), action-focused steering group and agree a clear project plan that sets out timelines and responsibilities at the beginning of the project. Review and revise this as the project progresses
- Arrange training to ensure that key staff are familiar with the tools and techniques of social marketing
- Be clear on your objectives and clearly define behavioural goals
- Ensure key stakeholders are involved from the outset and report back to them during the project. Let them know exactly what is happening, why and when
- Have a clear internal and external communications plan
- Commission experts where necessary. We used social marketing consultants and a market research company with experience in health-related work to recruit and conduct our focus groups
- Take advantage of best practice. We were able to learn from Dr Ray Lowry’s social marketing work
- Don’t be afraid to think outside of the box. For example, be prepared to look again at your segmentation – your target audience may not be who you first thought
- Pretesting intervention ideas was critical to the success of the project
- Be prepared to be challenged. Remember it is what resonates with your target audience that is important (not necessary what resonates with the professionals)
- Understanding that this project was not about creating new leaflets and posters, but creating a service that was motivating and meaningful to the women of Stoke-on-Trent, was crucial to success