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- Methods and Measures
Current treatment offered by the National Health Service (NHS) Stop Smoking Service (SSS) consists of advice and medication provided by pharmacists and practice nurses (‘level 2’ service) and more intensive treatment provided by smoking cessation specialists, usually employed for the purpose (‘level 3’ service). The provision of intensive support generally follows the withdrawal-orientated (Maudsley) treatment model , comprising multi-session behavioural support, typically delivered weekly for 4 weeks after a quit day, combined with medication that is usually provided for up to 3 months. Although clients can maintain some contact with the advisers for the duration of medication use, both approaches focus on the acute withdrawal period and are time-limited.
More than 700 000 people use the service every year, approximately half of whom achieve short-term abstinence . However, more than 70% of these short-term quitters return to smoking within a year [3, 4]. As the health benefits of stopping smoking are only realized with long-term abstinence, relapse reduces the public health benefit of investment in smoking cessation.
The Cochrane Review of relapse prevention literature identified 47 randomized trials of behavioural treatments, with no single trial or group of trials showing an effect . Most trials evaluated Marlatt & Gordon's ‘skills-based’ approach, which includes identifying relapse situations and coping strategies . The interventions were often brief and one-off; many trials mixed smoking cessation and relapse prevention interventions, with only 36 randomizing abstaining smokers, and most trials posed significant methodological problems. The Cochrane Review identified the need for good quality research in this key area as the primary priority in the field of smoking cessation.
The lack of proven relapse prevention interventions has not stopped NHS SSS attempting to provide some relapse prevention help for their clients. A survey of current practice reported that most (58%) services were providing some kind of relapse prevention intervention (RPI) . ‘Common-sense’ approaches are usually used, such as an offer of regular drop-in sessions. Anecdotally, some clients find these helpful, but the sessions are usually poorly attended and their efficacy is unknown.
There are several leads in the existing literature and clinical experience that warrant proper evaluation. The main lead includes simply extending the initial support. Maintained contact can provide an ongoing opportunity to offer motivational support, encourage extended and ‘emergency’ use of medications, advise on developing coping strategies and overcoming lapses, and offer an opportunity to re-engage in face-to-face support if needed. As mentioned above, however, the uptake of an offer to attend continuing sessions is normally very low.
Recently, short message service (SMS) messaging (i.e. sending automated messages to clients' mobiles phones to help promote and maintain abstinence) was shown to be effective in helping smokers to quit [7-10]. This approach also seems eminently suitable to maintain contact with clients and to provide an RPI. Previous studies have evaluated the use of SMS messages to help people stop smoking, although some included relapse prevention messages. This pilot focused on relapse prevention by including only clients who had quit smoking for 4 weeks.
This paper describes the development, implementation and subsequent evaluation, in terms of practicability and client response, of a text-based RPI delivered within a routine NHS SSS service.
- Top of page
- Methods and Measures
The text-messaging RPI proved practicable and acceptable to SSS clients and staff.
The platform that was used to send text messages (PageOne) was simple and cheap, as is typical of these types of intervention. Provided that it is efficacious, such interventions would be much less expensive than alternatives such as multi-session face-to-face.
A minor problem was identified concerning automatic responding to interactive messages. The system also does not allow monitoring of whether clients rejoined SSS, so clients would continue to receive text messages not synchronized with their new treatment plan unless they informed the RPI team. One possible remedy would be to integrate RPI with SSS client management programmes, such as QuitManager . Such software is used widely within NHS SSS and has the capability of receiving SMS text messages and sending automated responses at no extra cost. RPI could be triggered when the 4-week smoking status is entered. QuitManager was not used for the RPI because none of the PCTs involved used it at the time and the project needed the flexibility of adapting messages and having manual control.
The main implementation problem we encountered concerned client contact records from level 2 services. Incomplete records and problems with obtaining data on 4-week quitters in other than quarterly intervals presented significant barriers to implementation. There were no problems in implementing the service in level 3 services. SSS practices vary widely across the country, but it is possible that services which rely largely on extensive networks of level 2 advisers may find RPI implementation more challenging than services employing specialist advisers.
Regarding the contents of RPI messages, there may be scope for adjusting the messages to encourage clients who experienced lapse or relapse to remain engaged with the service. Very few clients reported lapses. Feedback from clients suggested that people felt embarrassed and nervous about informing the system of their ‘failure’. This is typical of stop smoking interventions generally, in that people who fail to quit are reluctant to attend follow-up sessions. The messages could perhaps put greater emphasis on encouraging such contact. There may also be the potential to adapt the RPI to develop, for example, a mobile phone application (‘app’), providing more opportunity for interaction and personalization.
An encouraging finding was that two out of five clients accepted the offer of NRT. Initially, we did not think that many people would take up this offer, especially as in our sample the majority of clients used varenicline for their quit attempt. This is not typical of NHS SSS services (in 2011, 64% of clients used NRT and 26% used varenicline ), but is probably reflective of the fact that the majority of the RPI clients used level 3 services.
Clients who responded to interactive messages were mainly those who were doing well. The finding that those who responded to the messages were more likely to be abstinent at 6-month follow-up is likely to be primarily the result of successful clients being more likely to remain successful. However, it is also possible that, to some extent, such reporting may be reinforcing and contributing to an effort to remain successful.
Another encouraging finding was that at least 10 clients who lapsed were abstinent again at 6-month follow-up and RPI helped another 41 people who relapsed to get back in touch with the NHS SSS to restart treatment. A number of clients also reported that they found the RPI helpful in maintaining their abstinence. Such information, of course, does not provide proof of the efficacy of this approach. Only a controlled trial would be able to assess this.
In summary, the main limitation to this project concerned the incomplete client databases in some services, which restricted the offer of the RPI. This, however, also represents a finding relevant to considerations of both a full-scale trial and any practical implementation of the intervention. The strengths of the project include the fact that the RPI was implemented and evaluated within routine NHS SSS delivery, and the robustness of the follow-up procedures.
The observational data from this pilot project do not provide any indication of whether the intervention contributes to preventing relapse. However, the results suggest that the new text-messaging RPI is practicable and well received, and that it has a potential to be implemented with minimal expense throughout the NHS SSS. The next step would be to evaluate the impact of this RPI on relapse in a randomized controlled trial.
Declarations of interest
This research was carried out as part of a programme of inequalities projects implemented by the UK Centre for Tobacco Control Studies and funded by the Department of Health. S.S., K.M., F.S. and J.G. have no conflicts of interest to declare. H.M. and P.H. have received research funding from, and provided consultancy to, manufacturers of smoking cessation medications.