Now the most motivated ex-smokers have stubbed out their last cigarette, Ingrid Torjesen finds out how services are reaching out to the less enthusiastic would-be quitters

As 2010 draws nearer, the job of smoking cessation services is becoming harder, as the majority of motivated and affluent smokers have already been through the service and quit. The people who remain are those with high nicotine dependency, and those in low socio-economic groups and in ethnic minorities. These services can no longer rely on smokers coming forward themselves to meet their challenging quit targets and will increasingly have to go out to recruit smokers from hard-to-reach groups.

Some services are already finding innovative ways to drive up their success rates. We look at the different approaches that four have taken.

LEEDS: MEN IN URBAN AREAS

Like most services Leeds has adopted a two-tiered approach to smoking cessation. There is a dedicated service with 19 full-time advisers plus an operations lead and a network of registered advisers who have been trained to provide services in the community. These are mainly practice nurses, pharmacists and health visitors, but also include a dental practitioner. Eighty per cent of GP practices have someone trained to provide stop smoking services.

Tobacco control lead and interim Choosing Health topics manager at Leeds primary care trust Heather Thomson says the idea is that patients are sent to an appropriate level of support. "The least dependent smokers would go to the practice nurse and the most dependent would go to the specialist service, although specialist services will take any smokers. We know practice nurses haven't got a huge amount of time to dedicate to smoking cessation, whereas the specialist service will be seeing patients for an hour a week."

Practice nurses assess patients by asking two questions: when does the patient have the first cigarette of the day and have they made a serious attempt to quit in the last year? If the answer to these questions is within 15 minutes of waking and there has been a serious quit attempt, they are supposed to send the person to the specialist service, because they obviously have high nicotine dependency and need a high level of support.

But Ms Thomson admits that some practices keep hold of the high nicotine dependency smokers, which is not in the smoker's best interest. "We get much higher quit rates with the specialised service than the registered advisers do. It's like anything: if you have a specialist service, you would expect them to have higher quit rates. Registered advisers do it as part and parcel of everything else they do."

The four-week quit rate across Leeds is 66.5 per cent, while figures for the specialist service alone show it achieves 69.3 per cent. Leeds is unusual in that it collects 52-week data by telephoning patients. For 2005-06, 18.3 per cent of patients reported that they were still not smoking a year later and the service expects a slightly higher rate this year.

The dedicated service consists of lead advisers, who head up specific service areas, and specialist advisers. There are two community teams and specific teams for the workplace, pregnancy and mental health. The service also goes into prisons, works with black and minority ethnic groups (specifically the South Asian community), young people and community and voluntary organisations.

Success rates

Men make up around 40 per cent of the people seen in Leeds - a much higher proportion than in other services. Most are in the 35-45 year age group and they have a much higher success rate than women.

Ms Thomson says: "My hypothesis is that men use the service when they feel they are more ready to, whereas women will tend to come when they are not as motivated or as ready to stop."

She says take-up of smoking cessation services has been particularly high among men in Leeds because one of the specialist advisers started going out to provide support in workplaces to prepare for the smoking ban, and specifically targeted routine and manual workers. The service is attractive to workers because it is delivered in the workplace and in work time.

Karen Haw, Leeds Smoking Services operations lead, says the take-up by businesses has been "phenomenal". The specialist adviser initially goes into the workplace to do some awareness raising and to get a feel for what sort of service the employees want. "There might be a questionnaire sent out with wage slips, saying is anyone interested in stopping smoking, to find out what the uptake is going to be like. The adviser would then go in but be very flexible."

Promotions in pubs and working men's clubs to prepare for the smoking legislation have also helped to drive up the number of male clients. This included special beer mats and posters with tear-off fliers on toilet doors.

It was emphasised that this was not "a touchy-feely" service but that it was there to give support and the word "group" was avoided. Ms Haw says: "If you mention 'group', it is a massive turn-off for men, so we don't tend to mention group when we have a conversation, we mention 'sessions' and 'help and support'." But the word "drop-in" ticks a box somewhere with a man because they don't feel they are committing to anything, she adds.

The service used to do a lot of advertising in the mass media but found this was not the best way to promote it, so it is moving much more towards community-based marketing, taking the service out to the public rather than expecting clients to seek it out.

As well as promotions in pubs and clubs, there is a smoking cessation bus which the service uses at galas and other community events. The service is also working closely with other professionals such as health trainers to reach out to socially disadvantaged groups.

Skilled advisers

To target the lowest socio-economic groups, the Leeds smoking service is working with the 44 practices in the most deprived areas of the city to develop the service. It is widely believed that success rates in such groups will be lower, but Ms Thomson says this is not the case. "We have found that in Leeds they are exactly the same."

She attributes this to the skills of the advisers and the in-depth analysis that is done. The advisers provide a complete mix of services: drop-in clinics, rolling groups and intensive one-to-one sessions for those who need them.

"We run about 60 clinics per week; we map them out, look at who is coming to each service, the day, time of day, venue and type of clinic offered. We have found that the rolling groups and drop-ins work better in the areas of greater deprivation - those that clients can just tap in and out of rather than saying you will be here every week at 7 o'clock for an hour for the next seven weeks. That does not work as well, as people have got more chaotic lives."

Many of the drop-in clinics, which are held at the same time every week, have a second adviser who will see people quickly and individually if they do not want to stay in a group for an hour. People can come for as long as they want and the rolling groups are easier for doctors to refer to because they can send the patient the next week. The support part of the group usually takes place an hour before new people are told to arrive.

Newcomers are informed about the treatments and how to prepare to stop. All the smoking cessation treatments are first line and the adviser will assess the patient to determine what is most likely to work for them and will discuss side effects and contra-indications. Once the client has decided to quit and chosen a drug treatment, they will then be given a voucher to take to the pharmacy for nicotine replacement therapy or a "dear doctor" letter if they choose a treatment that requires a prescription. The drop-in clinics tend to be linked with a pharmacist so clients can get their nicotine replacement therapy easily.

Ms Haw says the flexibility offered by the Leeds service is a major part of its success. "When I first started, it was 'we see you for this amount and that is all', but now we have brought in some flexibility, some telephone support and using texts a bit more to offer reassurance and motivation."

HILLINGDON: HOSPITAL AND DENTIST

In preparation for the ban on smoking in enclosed spaces in 2007, Hillingdon Stop Smoking Service introduced a Stop Before the Op programme. The aims were to identify smokers due to be admitted for surgery, provide them with smoking cessation therapy while in hospital and offer them longer-term support if they wanted it.

GPs advise patients likely to require surgery when they refer them to a specialist that they will have to give up smoking, at least temporarily, because the hospital is smoke free. Patients will also be told that if they give up smoking before their surgery, they are less likely to experience complications and will have a faster recovery.

A special clinic has been set up at Hillingdon Hospital to cater for these forthcoming inpatients, so they can go and get support when they go to the hospital to see their consultant.

Life plan

Jason Tong, stop smoking co-ordinator for the Hillingdon Stop Smoking Service, says this fits with the whole rationale of the service, which is geared to reaching people at different times of their lives. "When they are pregnant we contact them, when they go for surgery we contact them, and when they go to the GP or the pharmacy, and if they are housebound we can visit them."

Also to prepare for the smoke free legislation, Hillingdon started to run six to eight week intensive one-hour group sessions in workplaces. Mr Tong says that, as well as being convenient for those who attend, these sessions are effective, as the people involved already know each other. This helps with group activities and provides additional support for them outside it.

"They see each other eight hours a day so it is very good for them to support each other," he says, adding that a colleague talking about smoking rather than a family member feels less like nagging.

The stop smoking service will also send an adviser to do home visits if needed. Pregnant women can get home support from midwives trained in smoking cessation. Other professionals have been trained to deliver smoking cessation in the community, including pharmacists, practice nurses, health visitors, district nurses, healthcare assistants and even three dentists.

The dentists' four-week quit rate is extremely high at 78 per cent, compared with 60 per cent for services delivered in GP surgeries and by pharmacists. The highest quit rates (80-85 per cent) are achieved by the dedicated smoking service, and overall Hillingdon has a quit rate of 68 per cent at four weeks.

Dentist approach

Mr Tong believes dentists have much better rates than GP practices because they don't just see patients when they are ill, so their clientele is very different. A doctor can talk about the damage smoking does, but cannot always present the evidence. "People who go to dentists are fairly health conscious but did not know the effect smoking had had on their gums and teeth. The dentist looks at the teeth and says 'you are a smoker' and they cannot say 'it does not affect my health at all'. From a smoker's point of view they want solid proof - and decaying gums and very yellow teeth are fairly solid proof," he asserts.

Like other advisers, dentists can give patients a voucher to get nicotine replacement therapy from a pharmacist or a letter to take to their doctor if the treatment requires a prescription.

People who have been through a fixed-length course, such as one in their workplace or with a pharmacist, and who need further support can go along to a rolling group at a drop-in clinic.

Hillingdon does not have any special facilities for patients who quit and then relapse, but they are encouraged to come back and use the service again after six months. Mr Tong explains: "National Institute for Health and Clinical Excellence guidelines say six months, so we actually have to refuse a lot of people once they relapse. They can't come back for a while. That is a limitation for our services, but we are merely following the guidelines."

Patients are sent a questionnaire a year after they have quit to get their feedback on the service and to find out how they are doing. The figures suggest 20-30 per cent are still not smoking a year later, but Mr Tong admits that the response rate is poor.

"It is not a requirement so we don't put much effort in," he says. "It is a way for us to monitor how they are doing and ask them about ways we can improve the service. If you complain about the service, you won't go back again and you will tell other people it is not effective - that is negative advertising for us."

The questionnaire also acts as a method of recycling patients, because if someone is smoking again they might want to come back.

Ineffective advertising

The Hillingdon Stop Smoking Service does not do a lot of mass advertising because it has not found it very effective. Project manager Steven Walker says people have become oblivious to it.

"There is lots of advertising on buses and the TV and it's as if people can't see the wood for the trees. It becomes so much in your face people just don't recognise it any more."

He finds going out into the community and engaging with people works much better.

"What we try to do is actually go out on to the street and talk to people. If they are smoking, approach them, smile, be friendly, ask if they have thought of stopping smoking, give them a leaflet and tell them where the nearest clinic is and put some information in there about it."

Approaching people positively and not pushing the service, just saying "it's there if you want to use it" always gets a good reaction, he says. "Positively" means saying that stopping smoking will reduce your risk of cancer and in 10-15 years your risk of heart disease will be the same as someone who has never smoked, rather than saying smoking kills.

However, he admits that targeting hard-to-reach ethnic groups is problematic because of cultural differences. The service has been trying to establish links with groups in the Somali community, and in the process Mr Walker has realised that this group needs a completely different approach.

Communicating through storytelling

"They don't read brochures and leaflets. How they communicate information is through story-telling so, if we know that, we are going to waste our money producing Somali leaflets. What we need to do is understand how they communicate, talk to people who are enthusiastic and will communicate with them, and develop stories that we can introduce into the community in a way that they are going to understand. That is going to be a much slower process."

Mr Walker is also looking at giving rewards to people who quit because he thinks this would appeal to low socio-economic groups. This might be a free gym or swim pass for someone who has come to a group and has managed to keep off the cigarettes for a week.

"If you talk to community workers," he says, "they say we have got to have a reward, we have got to have a reason for people to turn up, because smoking is often the only thing that is there for them.

"If we are giving GPs and chemists incentives for stopping smoking, why can't we give incentives to the people we are reaching out to?"

The sticking point, he says, is a belief that people should be motivated to stop.

"If people have to come to us and they have kids or they are tired or its too far away, they are actually not going to make the effort, so you could say they are not motivated enough," he explains. "[But] they may just be tired or have kids."

"We need to make it as easy as possible for them to stop so they have no excuse, so if we remove the barriers, they are actually more likely to come to us."

CHISWICK: PHARMACY ROLLING GROUP

Darush Attar-Zadeh, a pharmacist trained in cognitive behavioural therapy, runs a one-hour smoking cessation rolling group for Ealing and Hounslow Stop Smoking Service on Tuesday and Thursday evenings at the Chiswick Health Centre in West London. Patients do not have to come every week and can continue for as long as they feel they need support.

The group is based on the six-session evidence-based model in which a patient comes in and talks about their smoking habit and receives information the first week, quits around the second session and then gets support from four more sessions.

A common frustration for patients is that support is not ongoing, says Mr Attar-Zadeh. After six weeks they get a 12-week prescription for smoking cessation therapy, then they are on their own. He has tried an alternative model, the one-to-one drop-in clinic, but found it also had its drawbacks.

"People don't like waiting around, so what I decided to do was invite everyone in," he says. "They can come in at any stage of their quit attempt and I treat the session as a chat forum rather than a clinic. I don't like using the word clinic because people get put off by it. They get these perceptions that it's like an AA meeting. It is nothing like that.

"They come in and bounce ideas off one another and talk about smoking in general and it can be any topic that just arises on the day. My role would be to steer the group and make sure that the most important aspects are covered."

Nice atmosphere

Mr Attar-Zadeh says the group has a nice atmosphere for newcomers to walk into because he will already have built up a rapport with other members. When someone joins, the first thing he will do is welcome them and ask them why they want to stop smoking, about any previous quit attempts and reasons for relapse. Then, rather than going through all the therapeutic options, he will bring in other members of the group who have already quit - the mentors or his "assistant advisers" as he likes to call them - and ask them 'how are you getting on with this or that treatment?'.

"I save myself quite a lot of time because I leave the mentors to talk about their experiences and the newcomers say 'right, I want to try that one'. Obviously, sometimes the mentors give wrong information, which is why it is so important that I am there to steer the group."

Usually newcomers are attracted to the drug that is most popular with the majority in the group at that time. The benefits of having a pharmacist like Mr Attar-Zadeh running the clinic is that he has a detailed knowledge of the drugs and can supply nicotine replacement therapy directly. However, like other advisers, he has to give patients who want Champix or Zyban a "dear doctor" letter.

Discussing treatments

Much of the group's discussion revolves around the benefits and drawbacks of treatments. Mr Attar-Zadeh always ensures the flexibility of treatments is covered. An example is the fact that it is possible to smoke for the first week with Champix, Zyban and certain nicotine replacement patches, which appeals to heavy smokers because they can cut down and quit on a day of their choice.

"If you say 'that is your quit date, you are going from 40 cigarettes all the way down to zero' and they stick a patch on that day, a lot people find that that can be quite pressurising," he explains.

He points out that smokers are more inclined to believe what they are told by someone who has quit rather than an adviser who has never smoked and seeing someone who has given up successfully gives them hope.

At the moment he has one patient who quit three and a half years ago but who has come back because he is finding it hard to come off the nicotine replacement spray. "He is a great asset to the group because whenever a new person comes along and they say 'does it get easier', I say 'why don't you ask this person - he has quit for three and a half years'," he says.

On the flip side, newcomers act as a reminder to the mentors about why they are a non-smoker, because they can see how hard the struggle is in the early days, he adds. "If someone is struggling in the group, they lift each other." The group has a 65 per cent four-week quit rate. No data is collected for longer periods, but he believes the indefinite nature of the group must be beneficial.

Relapse prevention

Like other pharmacists who provide smoking cessation services, Mr Attar-Zadeh is paid for every patient he sees over a six-week period. He receives no money for patients who still come after six weeks, but this does not bother him.

"If I have one new person in the group, I will get funding for that one person and I could have 10 people who have exceeded the six sessions. Why not have them sit there just to help make your life easier as an adviser? They can be valuable to the group and also you are doing a lot of relapse prevention," he explains.

"The only time it is disadvantageous to me is when I have a group of five people and all five of them have exceeded the six sessions and then I am not getting any money for that particular clinic, but that has never happened."

Although Mr Attar-Zadeh puts up posters, he finds he gets most of his patients through word of mouth. The GPs know him well and refer patients to him, and his clients also recommend him to their friends. "I have one person who came in, had a very good experience and told seven other people who are her neighbours, so I have got a clinic of neighbours at the moment, which is really nice. It really creates a lovely environment," he says.

He has also recently had a lot of dads referred to him from the baby clinic run by health visitors just before his group. He says: "One of the health visitors stopped through my clinic, enjoyed the experience and told a few of the dads. She is really selling the fact that Darush is down-to-earth and it is not at all like an AA meeting."

Mr Attar-Zadeh keeps in telephone contact with his patients to check they have not relapsed, and if they have, he encourages them to come back on the programme.

"Some people are embarrassed and feel they are letting me down if they come back. I always say it would be preferable if you don't relapse for yourself, but if you do happen to have one or two, don't feel you can't come back."

DONCASTER: WOMEN AND CHILDREN

When the Doncaster Stop Smoking Service started in 1999, there was a quitline, a generic service and a specialised service targeting pregnant women. It has now grown to a team of five specialist advisers supported by 16 intermediate advisers.

The service has also trained around 40 pharmacists and 50 practice nurses to work as intermediate advisers in the community, providing one-to-one support through a local enhanced service. Smokers who want to quit can choose to see one of these professionals or seek one-to-one support from a clinic at the Doncaster service's offices. This offers booked appointments and a drop-in service Monday to Friday (early to late) and Saturday mornings.

Lisa Fendall, training project manager at the Doncaster Stop Smoking Service, who has been with the service from the start, says it used to offer group sessions but had to stop them because of dwindling referrals.

Most of the motivated, confident, affluent and educated people with transport have come through services, she says, so it is left with the hard to reach and those with specific problems, on whom the dedicated advisers concentrate.

Deprived groups

"The department of health is telling us to look at increasing the number of referrals, but we have got to target the routine manual and most deprived groups now, and obviously we have got to look at innovative ways of reaching them."

One specialist adviser delivers smoking cessation at Doncaster's four prisons. Many prisoners have mental health problems and there is also a big black and minority ethnic population, so this service ticks a lot of the boxes in terms of accessing the hard to reach. The quit rate achieved in prisons is 50-60 per cent at four weeks, the same as the rate across the whole Doncaster service.

Another specialist adviser with a nursing background works within secondary care and sees inpatients referred to her pre-operatively. Smokers who decide they only want to abstain temporarily while in hospital can access nicotine replacement therapy short term, and those who want to quit completely are referred on to the main Doncaster service on hospital discharge.

Pregnant women

There is also a specialist adviser who goes into workplaces to deliver services during work time, but where Doncaster really stands out is in its innovative services for pregnant women, children and young people. Ms Fendall says: "We have an extremely robust referral system for pregnant women. Every single pregnant woman fills in a smoking questionnaire on booking and every single woman smoker is referred into us. They have to opt out of the service as opposed to opting in."

Someone from the service will call them, congratulate them on their pregnancy and add: "We understand you smoke; let's just tell you about what we can offer you during your pregnancy."

The pregnancy service was awarded Beacon status by the Department of Health in 2004 and Ms Fendall says this was because it is very much tailored to what pregnant women want. "We know from research that they don't like doing groups and they don't like to travel."

The women can use the drop-in service at a Sure Start or Family Centre, or an adviser will come and visit them at home if it is difficult for them to get to one of the centres. The adviser can also see their partner or other family members during the home visit.

A team of four people offers a tailored service for children and young people, which Ms Fendall says is unique. "There are no clear answers about what works with children. They are a very difficult to reach target group and very hard to work with in terms of the reasons why they start to smoke in the first place. It is all down to experimentation, being rebellious and risk-taking behaviour, so the health messages don't really work very well. The adult model doesn't work on children, so they do need a specific service and not everyone will provide that."

School workers

The team works closely with school nurses, youth workers, learning mentors, sexual health and drugs services and others with links to children, to try to educate young people not to start smoking in the first place and to help those who want to quit. "We will piggy back on the back of anybody who will have dealings with the hard to reach in terms of young people, because what works really well is taking the service through the back door and enhancing a service that they are already accessing," she says.

For example, there is a free weekly support, education and training service for teenage mothers, so the smoking cessation service goes in and is available there. It also goes into seven secondary schools and into youth clubs, and children excluded from school are visited at home. Nicotine replacement therapy is offered to children from the age of 12.

Ms Fendall admits that the service does not have a huge number of BME clients. One GP practice has a Polish interpreter who comes in to help it target that community, but she says what works best is to train and support people who already work with BME communities to deliver smoking cessation services, because these communities do not access general services.

All patients presenting to a smoking cessation adviser have their needs assessed at the first visit to see if they are motivated, prepared and confident about quitting. Those who are can go away with a letter to get smoking cessation therapy, but others may need to do some preparation before they are ready to quit, so are asked to come back the next week to discuss their coping strategies and then a quit date is set.

The adviser will go through the full range of smoking cessation products and discuss what might suit them best, depending on nicotine dependency, lifestyle, what they have tried before and any contra-indications, such as an allergy to plasters (which would make a patch unsuitable). "We give them the full range of advantages and disadvantages of each product, then leave the client with the final choice," she explains.

Direct approach

Unfortunately, some GPs will make their patients try to quit on nicotine replacement therapy before allowing them to use other products that are more expensive, she says, which is wrong. "If you have a client who has tried on NRT before and wants something else, they are not going to succeed on a patch again because their confidence is not going to lie with that product, so we do really feel strongly about it being client led."

The service advertises through local papers, posters, the radio and fliers in GP practices and Sure Start and Family centres, and leaflet drops for specific events. It has also previously put adverts up at bus stops and produced a video advert of a patient being counselled, which was shown on a plasma screen in a shopping centre. Ms Fendall also did an eight-week radio show answering people's smoking cessation questions.

However, she recognises that a more direct approach is often needed, so she has mapped out the 18 most deprived areas in Doncaster and developed a marketing strategy to target the hard to reach in these areas. "For example, I am going to be setting up a market stall and selling the service on the market and doing carbon monoxide readings," she says.

There will also be promotions outside pubs, in supermarkets, at car boot sales and at gala days. "Over Christmas we will be doing regular slots in the town centre and trying to get people to sign up," she adds. "A lot of people quit in January but won't access the help, so we try to get them to sign up because with support and stop smoking treatments, you are four times more likely to quit."

As well as training intermediate advisers to deliver smoking cessation services, the Doncaster service provides an hour-long training session for all frontline PCT staff to encourage them to refer patients. This training is based on a toolkit called smoking cessation in practice, which the Department of Health plans to roll out to the rest of the country.But Ms Fendall admits: "Training alone is not enough. People don't continue to use those skills. We are going to be monitoring them, so we can tell them you have sent in x number of referrals this month and how many came and how many quit."