Benchmark 1: Customer Orientation
Maintains a strong focus on the customer at all times, seeking to understand as much as possible about the presenting issue and the target audience, by using a mix of quantitative and qualitative research.

Development of the Knowsley program was based on an in-depth, two-phased research process, which allowed real customer understanding to be built.

Phase 1
An initial multi-dimensional, but low cost research process was carried out, to gain as much understanding as possible about the existing issue, the target population, and current service provision.

Research included a literature review of all existing information about the smoking prevalence, influencers, and existing cessation services. An externally-commissioned evaluation of another local scheme 'Quit & Win' was also conducted, to understand Knowsley smokers' attitudes, motivations and beliefs4. In addition, an existing qualitative research program with sufferers of chronic obstructive pulmonary disease (caused by smoking) provided important insights into smokers' motivations and barriers when considering stopping smoking.

Anecdotal evidence was also captured from existing smoking cessation advisors from Knowsley. These were professionals who had worked in the borough for some time, and could provide invaluable understanding about the types of people using services, the support they desire, and why they behave in the way they do. This initial desk research phase was conducted fairly quickly, but yielded enough insight to get the program up and running, allowing enough customer understanding for the initial design of the adult community stop smoking service.

Phase 2
Once the program was established, further tailoring was needed. This resulted in a second research phase, to develop detailed audience segments, and to drive strategic development of the program over the next five years.

Phase two research included a borough-wide prevalence survey, which was externally-commissioned and conducted in March 2007. This survey established a clear behavioral baseline for the program, as well as providing demographic information about existing service users.

Further consultation was also conducted with 'Fag Ends' quit smoking advisors. This qualitative research provided rich, anecdotal evidence about service users, allowing the statistical data to be more fully developed. Advisors were able to talk about their real experiences – what people say when they show up to the service; what they look like; why they have not been there before; what their lives are like; what they value, and so on.

These two information sets were then combined, and overlaid with additional existing local data to allow five population segments to be developed and further stratified (see 'Segmentation').

Based on these segments, the program was tailored so that it responds to the different needs or value sets identified through the segmentation research.

Benchmark 2: Insight
Uses the research phase to identify 'actionable insights': key pieces of understanding that will be used to underpin program development.

Phase one research revealed key insights that were used to inform the program's development. Most importantly, research participants said they wanted a friendly, non-judgmental service, which was easy to access (preferably with no appointment necessary), close to home and run by 'people like them'. They were reluctant to receive any kind of intervention from registered health professionals.

Word-of-mouth was identified as being one of the most important communication channels among the tight-knit, relatively deprived communities that have the highest smoking rates in Knowsley. People in Knowsley were also found to prefer receiving their stop smoking information from charitable organizations, and tended to be unreceptive or hostile to National Health Service (NHS) branding. In a related way, 0800 (toll free) numbers were not well-received, as they were seen to be associated with crisis services such as the Samaritans ^v.

Benchmark 3: Behavioral Goals
Focuses on changing people's actual behavior: identifies baselines and sets clear behavioral goals, which, where possible, are specific, measurable and time-bound.

The intervention aimed to achieve the following behavioral goals:

• Target group to use the community smoking cessation service.
• Target group to quit and stay quit.

Benchmark 4: Segmentation
Avoids a 'one size fits all' approach: identifies audience 'segments', which have common characteristics (e.g. socioeconomic; geographic; demographic; attitudinal; behavioral), then tailors interventions appropriately.

Phase one was based around a demographic segmentation, targeting age groups with the highest smoking prevalence: females 35-45 years and males 40-55 years.

In addition, segmentation was carried out according to smokers' willingness to quit. 2006 research identified that more than 70% of Knowsley smokers were 'contemplating quitting'. ⁵ This target group was already the most likely to use stop smoking services, and was identified from a number of data sources including previous stop smoking service data and qualitative research. The main focus of the program was thus to support already willing individuals to translate their existing intention into successful action.

In 2007, a borough-wide prevalence survey was conducted to provide detailed demographic data for Knowsley's smokers. This was combined with information gathered from Fag End's advisors, to create eight initial service-user segments (see 'Customer Orientation'). Further public health research studies were then factored in to help build the lifestyle portraits of each user segments. The next step was to stratify these proposed segments. MRUK Research agency ⁶ was commissioned to conduct this research, which involved two processes.

First, 1,000 questionnaire-based street interviews were conducted in Knowsley, to test the accuracy of each proposed segment. Based on this feedback, the segments were streamlined to create five final segments.

Seven focus groups were also held with individuals from each of the original seven segments, to establish the barriers/incentives to quitting and the distinct types of support valued by each segment.

This segmentation will be used to develop targeted propositions as the program moves forward. For instance, specific segments can be targeted with precise and relevant service propositions. For example, one segment may use the local pharmacy cessation services, because they offer quick and easy access to Nicotine Replacement Therapy (NRT).

Benchmark 5: Exchange
Considers both the benefits and the costs of adopting a new behavior, aiming to maximize the benefits and minimize the costs to create an attractive exchange.

Smoking costs Knowsley Health & Social Care services over £6 million ($8.75 million US) a year ⁷, not including the wider costs to society such as working days lost to sickness leave. On a personal level, the costs of ill-health, sickness and bereavement far outweigh the more short-term, perceived benefits of smoking.

However, despite the potential long-term exchange of addiction for good health, a range of barriers were identified, which prevent uptake of existing smoking cessation services.

There was a widespread hostility to being 'lectured' about stopping smoking, combined with a prevalent attitude that 'we already know it's bad for us'. Support that was provided from medical or NHS settings was extremely unpopular, and these services were described as being 'like Alcoholics Anonymous'. In addition, the inconvenience of existing cessation service meetings was off-putting - they were seen to be held at awkward times, in inconvenient places, and without much information available to let users know when they were happening.

On the other hand, research also revealed a range of possible motivators, which could be incorporated to make the service more attractive to users. Respondents were receptive to the idea of independent help and advice, coming from somewhere other than the health service. They also wanted a move away from health-related, fear-mongering campaigns, and a shift towards a more positive, motivational tone. The idea of drop-in services, without the need for appointments or 'help lines', was also popular, with an emphasis being placed on easy to access, close to home venues.

By assessing service barriers, and incorporating the above user feedback, program planners were able to design a new offer that was as accessible and appealing as possible (see 'Methods Mix').

In addition, 'Fag Ends' deliberately responds to the 'I'm entitled to it' mentality, identified through research. By emphasising that everything is FREE – free helpline, free drop-in sessions, free NRT - the program minimizes the perceived cost barriers that might prevent people from accessing stop smoking services. This reward element is then reinforced by the free goody bag each participant receives when joining the program, and the certificate of success they receive on completion.

The next phase of program development will focus on promoting maintenance of positive behaviors. This may involve more intensive use of incentives and rewards to encourage people to come back to the service and to keep using it.

In terms of non-material gain, one of the key benefits of the program is the community cohesion and ownership it creates. Groups choose the venues where sessions are held; they make new friends; get to know new people; and end up coming because the sessions offer social interaction. In some cases, people who have quit smoking continue to attend the sessions because of the company and social element they offer. Such attendance is encouraged, as it provides groups with positive, relevant role models from within their own community. In many deprived areas, 'health' is seen as unachievable. By seeing people 'like them' who've managed to quit, individuals gain a boost in confidence and aspiration. To bolster this social element, the program offers a 'Recommend a friend' card, which encourages individuals to spread the word and bring their friends or family along.

Benchmark 6: Competition
Aims to understand what competes for people's time, attention, and inclination to change, and to work with or learn from the competition.

The 'Fag Ends' program has faced strong competition from a range of sources, but has used this to guide its own development.

National stop smoking campaigns and conflicting media coverage

Research revealed a negative reaction to national stop smoking campaigns, which were perceived to be grey, de-motivating and scare-mongering. By contrast, there was awareness that the press often glamorizes smoking through images of high-profile smoking celebrities or models. Roy Castle 'Fag Ends' breaks away from both agendas, and from other health-related campaigns. Instead of emphasizing negative health impacts, its branding is positive, upbeat and inspirational, with a clear message: 'they did it, so can you'.

NHS branding

The National Health Service's 'Stop Smoking Service' was set up in 1999, and provides comprehensive services across England, including counseling, group and one-to-one support, and NRT (available on NHS prescription). This service is effective (a smoker who tries to quit with the NHS Stop Smoking Service and NRT is up to four times more likely to succeed than by willpower alone).

Figure 2. NHS logo

Figure 3. 'Fag Ends' logo

However, research in Knowsley showed that the target audience wanted the classic NHS branding to be removed from materials, as they didn't want the new service to be associated with conventional health services.

In theory, all local stop smoking services should use the NHS branding on their materials, but faced with robust supporting evidence (based on user testing) program managers for 'Fag Ends' were able to gain official approval for removing the NHS branding.

By developing an own-branded program, 'Fag Ends' was able to give users a sense of clear ownership, and the feeling that it was a service run 'by people like them', and not by health professionals.

Social pressure

Roy Castle 'Fag Ends' runs in hardened communities, where almost everybody smokes. This means that if you don't smoke, you can be made to feel ostracized. However, there are also unusually strong social networks in these communities, which have been used to the program's advantage: if one person in a social group stops smoking, it can have a domino effect through the immediate community. It is not unusual for individuals to attend sessions and ask for the same treatment which helped a friend or relative stop.

Benchmark 7: Methods Mix
Uses a mix of methods to prompt and facilitate behavior change, including education, support, control and design techniques. Does not rely solely on raising awareness.

Roy Castle 'Fag Ends' offers community based support, with 'the guy round the corner helping the guy round the corner'. All staff at the new cessation service are recruited from local communities and are therefore able to build contacts, networks and credibility within their own community.

In addition, the support service takes place in a central community location, to make it as easy to access as possible. Community members can suggest a venue that's used by their community. 'Fag Ends' also conducts research to identify appropriate local venues - based on smoking prevalence; travel links; well-used venues; gaps where a group is needed; and community intelligence. This ensures that that venues are chosen where local people feel at home - usually in a non-health setting such as community centers, social clubs, pubs, or churches.

The variety and quantity of locations where individuals can access help has been one of the key strengths of this program, and an important factor for success. In addition, 'Fag Ends' sessions are held all over Knowsley at the same time and in the same place every week, so people can just drop in on a location whenever they want.

As well as being easily accessible, support is individually tailored. 'Fag Ends' offers a service that is customised for each individual, based on an initial needs assessment session. This mix can include intensive one-to-one help, group sessions, nicotine patches and gums or simply support and encouragement from a distance (e.g. phone support and text messaging).

The launch of the new 'Fag Ends' service in Knowsley was supported by an extensive advertising and PR campaign, which emphasized the positive and friendly tone of all communications. This strategy had two tiers. First, a borough-wide profile raising campaign was undertaken, to broadcast the new service and set the tone. This ensured people knew that a new service was launching, and that it would be friendly, locally-run and community-based. Secondly, a specific information giving strategy was run, to embed times and venues for each community 'drop in' support group so that local people understood where and how to access new services. This allowed the service to utilize community networks and word-of-mouth to endorse and communicate the time and venue of each 'drop in' support group.

Benchmark 8: Theory
Uses behavioral theories to understand human behavior, and to develop programs around this understanding.

Prochaska and DiClemente's Transtheoretical (Stages of Change) Model8 is a well known theory of behavior change.

This theory sees behavior as a process rather than an event. It also recognizes that there are different levels of motivation and readiness to change. The five main stages are:

1. Pre-contemplation: an individual does not consider or intend to undertake the behavior
2. Contemplation: they understand and consider changing. At this stage they may seek more information about the behavior
3. Preparation: here, an individual undertakes the final steps of consideration, reaffirms reasons for changing and makes a commitment to do so
4. Action: change occurs and an individual undertakes the desired behavior
5. Maintenance: the behavior is sustained and consolidated. However, an individual could also relapse into his original state.

The theory suggests that people do not always move through these stages at the same rate, and sometimes might remain at a stage for a long time. Therefore, it is valuable to look into the reasons why some people stay at particular stages and why others move on. It discusses factors that might help people go through these changes, including:

• Decisional balance: This is the balance of the positives and negatives of a behavior, depending on the consequence, this can affect levels of motivation
• Self efficacy: this is the level of confidence in ability and capabilities to undertake the behavior

'Fag Ends' supports those in the 'Contemplation' and 'Preparation' stages to move towards 'Action', and make successful quit attempts.

However, it is a rolling program, which recognizes that behavior change is not usually a linear event, but a series of repeat attempts. Users of the service are free to drop in and drop out. Even if they don't make a successful first quit, or do not really commit to it, just making that first attendance is an important step and part of the change process. Users are thus encouraged to try and then try again if they don't succeed.

Evaluation and Results

No independent evaluation is yet available, but a further Prevalence Survey is planned for 2010 to measure against the initial benchmark prevalence study. In addition, hard data from the stop smoking service demonstrates that the number of four-week smoking quitters in Knowsley has increased significantly and that targets for adult stop smoking services have been significantly exceeded, as below.

In England, 'successful quitters' are referred to as those people who are successfully quit at the four-week follow-up. A client is counted as a 'self-reported 4-week quitter' if, when assessed four weeks after the designated quit date, they declare that they have not smoked, even a single puff on a cigarette, in the past two weeks. This information is collected by service providers on NHS Stop Smoking Services returns ^vi in line with requirements from the Department of Health (DH). Clients who self-report as having quit at the four week follow up are required to have their Carbon Monoxide levels monitored as a validation of their quit attempt (unless the intervention was by telephone). This information is collected on NHS Stop Smoking returns in line with requirements from DH.

In Knowsley, successful four-week quitters have increased over the life of the program as follows:

• 2003-04: 1,056 quitters
• 2004-05: 1,070 quitters
• 2005-06: 1,325 quitters
• 2006-07: 1,432 quitters (official launch of 'Fag Ends' in Knowsley, October 2006)
• 2007-08: 2,324 quitters
• 2008-09: 1090 quitters (April to December 2008)
• (The latest figures for April to March 2009 are 1,720)

As well as these successful quits, referral rates to the service are high: 2,719 smokers were referred to the 'Fag Ends' service between October 2006 and March 2007 alone, and increased service usage in Knowsley occurred in parallel with significant decreases across other stop smoking services for the same period. According to 2007-2008 national league tables, Knowsley came in second out of England's 152 PCTs, with more people quitting smoking in Knowsley than in any other PCT in England (except for Hartlepool) ⁹.

A search is currently underway to find an economic model to calculate a value of a smoking cessation campaign 'per quitter'. At face value it is expensive 'per quitter' but we are confident the expenditure per quitter is less than the cost of care 'per smoker' over their life time.

Lessons Learned

The success of 'Fag Ends' even within its first year, coupled with previous social marketing success in the borough, is leading to a change in commissioning approaches across the region, and an increasing emphasis on putting the customer at the center in a range of public health and other commissioning areas.

The liaison carried out with the Roy Castle 'Fag Ends' service in Liverpool showed how important working partnerships are for program success. In addition, effective data is vital for measuring program impact.

One key piece of learning is that research can be low cost and effective by using what's already available. A surprising amount of knowledge already exists, and good insight need not cost a lot.

Acknowledgements

Anne Pennington, Research & Evaluation Officer
Ben O'Brien, Assistant Director, Marketing &Communications
Diana Forrest, Director of Public Health

References

1. Health Survey for England (2002-2004 combined). Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/PublishedSurvey/HealthSurveyForEngland/DH_632. Accessed 12 may 2009.
2. Roy Castle 'Fag Ends' website. Available at: http://www.stopsmoking.org.uk/. Accessed 12 May 2009.
3. 'Knowsley Health & Lifestyle Survey', (unpublished data, 2006).
4. 'Attitudes to smoking in Kirkby', (unpublished data, June 2006).
5. 'Knowsley Health & Lifestyle Survey', (unpublished data, 2006).
6. MRUK research website. Available at: http://www.mruk.co.uk/. Accessed 12 May 2009.
7. The Roy Castle Lung Cancer Foundation website. Available at http://www.roycastle.org/pr/pr01,16,10,06.htm. Accessed 12 May 2009.
8. Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin; 1984. Prochaska JO, Norcross JC, DiClemente CC. Changing for good: the revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: W. Morrow; 1994.
9. Statistics on NHS Stop Smoking Services: England, April 2007 to March 2008. Available online at: http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/nhs-stop-smoking-services/statistics-on-nhs-stop-smoking-services:-england-april-2007-to-march-2008-annual-report. Accessed 12 May 2009.

Author Information

Phil Morris is Head of Marketing for NHS Knowsley. He started his marketing career in the commercial sector, working across leisure, retail and financial services sectors. He then moved into the public sector working for the Police, where he began developing his expertise in Social Marketing.

Phil has worked for the NHS for the last four years and his social marketing work in smoking and cardiovascular disease has been nationally recognized.