Introduction
Smoking rates in the United Kingdom (UK) have fallen rapidly since the publication of the Smoking Kills White Paper in 1998 [
1], but smoking rates remain high in certain sectors of the population. The UK policy narratives on reducing smoking rates highlight the high smoking rates among people who work in routine and manual occupations and people who live in the 20% most deprived areas [
2,
3]. Smoking rates are particularly high among people experiencing multiple disadvantage and social exclusion, e.g., people experiencing homelessness and people in minority communities [
4]. The National Health Service (NHS) Core20Plus5 approach to reducing health inequalities [
5] emphasises the need to focus on “priority population groups” such as, pregnant and new mothers, people with a long-term mental health condition (particularly people with anxiety, depression, and severe mental illness), people with drug and alcohol dependence, people with a learning disability, and people with long-term physical health conditions (particularly chronic respiratory disease, cancer, and cardiovascular diseases). Given the disproportionate rates of smoking for people experiencing multiple disadvantages [
2‐
4] and given that smoking is a leading cause of preventable chronic illness [
5], to reduce health inequalities, models for the provision of support to stop smoking [
6] need to be better targeted to “priority population groups” [
7,
8].
Community Stop Smoking Services (CSSS) are at the forefront of efforts to reduce smoking in the UK [
9,
10]. They work by receiving referrals from primary and secondary care services, maternity services as well as self-referrals, and supporting service users to work towards stopping smoking. They provide regular support, including behavioural and pharmacological interventions, with the aim of supporting the service user to achieve a 4-week quit. It is well established that engagement with CSSS can lead to increased successful quit attempts [
11‐
13]. However, the low uptake of and engagement with CSSS by priority population groups [
14], suggests that CSSS could be made more accessible to meet the needs of such populations.
During the COVID-19 pandemic, restrictions on the provision of face-to-face support [
15] resulted in CSSS moving to “remote” delivery models, i.e. online and phone-based provision [
16‐
18]. There is evidence that remote approaches are an effective means of delivering stop smoking support [
19‐
22]. Remote provision can increase the availability of stop smoking support, especially in rural communities [
17]. It can also increase the accessibility of support by decreasing the time and costs required by service users to attend support sessions [
16,
20,
23]. Some CSSS have reported that service users had positive perceptions of remote provision during the COVID-19 pandemic [
9,
24]. However, concerns around remote-only provision in terms of its suitability to different population groups, if staff can provide support of the same efficacy over remote mediums, and if wide-scale remote provision is sufficiently resourced, have been noted [
17].
This study reports on a Public Health Intervention Responsive Studies Team (PHIRST) formative evaluation (see Elwy et al. [
25]) of the North Yorkshire Council Living Well Smokefree (LWSF) service. The LWSF service is commissioned by North Yorkshire County Council as part of their strategy to reduce smoking prevalence across the North Yorkshire region [
26]. To continue operating during the COVID-19 pandemic, the LWSF service moved from face-to-face provision, which was the main method of engaging service users, to predominantly remote delivery, with support being typically delivered through voice calls (video calls were provided for those who requested this, but this had a much lower use) [
18]. As COVID-19 restrictions eased, the LWSF service developed a “hybrid” approach that includes three service delivery modalities: (1) “Face-to-face”– support delivered in-person, (2) “Remote”– stop smoking support via voice or video calls; (3) “Mixed”– a flexible combination of both face-to-face and voice or video calls. The motivation for doing so was to retain the positive aspects of remote provision whilst ameliorating issues for service users who would have benefitted from face-to-face support. Further, a hybrid service was seen to offer an equitable option for the county’s population (which is relatively geographically dispersed), providing the potential to overcome differences in service users’ geographical proximity to clinics. North Yorkshire is one of the largest English councils by area, with a sizable rural population [
27], and the LWSF service only has the equivalent of six and a half full-time staff members to provide support over this area. The local authority is among the least deprived in England, ranking 125th least deprived out of 152 upper-tier local authorities for the 2015 Index of Multiple Deprivation (IMD), although there are pockets of high levels of deprivation within the county [
28].
Our study aimed to assess the benefits and challenges of reconfiguring the LWSF service to provide a hybrid mix of face-to-face, remote and mixed support options. We sought to explore the extent to which hybrid approaches are acceptable delivery models to service users and practitioners, are equitable and provide value for money. To do this we drew on elements from evaluation frameworks [
29,
30] to help highlight key considerations from service users, service staff and service managers, and insights from service data. The evaluation design and primary questions that this project aimed to answer were co-developed with the LWSF service stakeholders as part of an initial Evaluability Assessment (see Additional file 1) [
31]. The two evaluation questions were: (1) What are the strengths and weaknesses of the new hybrid approach to service delivery? (2) How could the hybrid service be adapted and improved?
Results
Overall, there was a general preference for remote over face-to-face provision by service users and staff, with over 90% of service users who accessed the service selecting remote support (Table
1). For those who set a quit date, phone support was found to have similar, but slightly higher, 4-week quit outcomes compared to face-to-face support– 76% (279 quits out of 367 quit dates set) vs. 73.9% (17 quits out of 23 quit dates set), but lower than mixed support– 87.5% (7 quits out of 8 quit dates set). However, the early stage of hybrid service implementation, and the small sample sizes on which these comparisons are based, mean that there is too much uncertainty to be able to draw conclusions about differences in quitting outcomes between the different modalities (Table
1).
Reach of the service to priority service user groups
Remote provision was described by service staff as enabling a much wider service offering and facilitating greater access and support for different populations, including for people who were often “geographically excluded” in rural areas far from available clinics, those who struggled to access face-to-face appointments due to mental or physical health issues, and those unable to attend due to time requirements and employment commitments:
“I’m speaking to people I never would have spoken or had a face-to-face with because it wouldn’t have been possible for me to go there. So it has made the service more accessible to those hard to reach rural groups and people who couldn’t attend because of their employment situation and so on.” (FG1– service staff).
There was a suggestion from service staff that more flexible ways were needed to engage with the current smoking population, and that a hybrid service can help to facilitate this:
“We’re at the harder to reach smokers, we’re at the stage of the difficult smokers now, so if anything we need to be even more accommodating to them, this [hybrid service] can solve that really.” (FG3– service staff).
The modality selection preferences for all service users who set a quit date was 92.2% phone support, 5.8% face-to-face support and 2.0% mixed support (see table 1).
This overall pattern was reflected in the priority population groups: pregnant service users (98.2%, vs. 0% face-to-face and 1.8% mixed support), people with mental health conditions (93.4%, vs. 5.1% face-to-face and 1.5% mixed support) and people with long-term physical health conditions (91.2%, vs. 5% face-to-face and 3.8% mixed support) (Table
2).
“It has helped not actually having to have to visit somebody face-to-face…it’s a lot more beneficial to people who have anxiety and mental health issues like me.” (IN12– service user).
Table 2
Quit dates set by priority groups in the period September 2022 to February 2023
Pregnant service users | 55 | 14% | 54 (98.2%) | 0 | 1 (1.8%) | | 42 (76.4%) | 41 (75.9%) | 0 | 1 (100%) |
People with mental health conditions | 136 | 34% | 127 (93.4%) | 7 (5.1%) | 2 (1.5%) | | 99 (72.8%) | 92 (72.4%) | 6 (85.7%) | 1 (50.0%) |
People with long-term physical health conditions | 159 | 40% | 145 (91.2%) | 8 (5.0%) | 6 (3.8%) | | 119 (74.8%) | 109 (75.2%) | 6 (75.0%) | 4 (66.7%) |
Perceived effectiveness of the stop smoking intervention
Privacy and openness
For many service users, phone support was spoken of as enabling more openness in discussions, typically through perceived partial anonymity and a greater level of privacy due to participation from known places of comfort. Further, the perceived protections that remote provision offers acted to reduce potential stigmas (e.g., around smoking during pregnancy) and anxieties (e.g., having to attend clinics in person for people with mental health issues) associated with attending face-to-face clinics, and was noted as important in facilitating engagement and openness during appointments:
“It [remote provision] means people don’t see you going in when you can do it over the phone, so it’s better when you’re pregnant so you know you won’t be judged by anyone.” (IN15– service user).
Carbon monoxide (CO) monitoring
A challenge of remote provision, that some SSA saw as linked to service user engagement and motivation, was the inability to conduct CO monitoring to validate quits. This was commented on as reducing service user accountability, and removing a tangible measure of success, as CO monitoring was seen as something that could motivate service users:
“It’s almost like when people go to slimming world or weight watchers, that scale gives them accountability. And they think that the CO reader is that accountability, it’s like ‘ooh let’s see what I can blow this week’. And it does help motivate people quite a lot” (FG1– service staff).
However, there were mixed perspectives from service users around the use of CO monitoring, with some unaware of it being offered, some using and seeing it as a motivating and engaging feature of support, whilst others were indifferent about its use.
Barriers and facilitators to rapport development
There were mixed views over the ability to develop rapport and therapeutic relationships via remote means. Some SSA and service users suggested it was easier and quicker to develop a rapport face-to-face, due to the interpersonal connection such sessions provided. Despite this, many participants noted they were able to develop effective relationships and engagement with service users/SSA through remote means only. A key benefit of mixed provision was the ability to have initial face-to-face contact with a SSA which was noted as facilitating the development of rapport for some:
“I liked it the way it happened with me, where I see them at the start, and then just phone after…then you already know who it is, so, and with phone calls then, it’s still quite personal, because it’s not just a voice, know what I mean.” (IN16– service user).
Interestingly, there was a suggestion from some SSA that, for some service users, remote provision can result in poor engagement with sessions, due to remote support not permitting focus and attention:
“The difficulty we’ve had with telephone support for a lot of the time was that you’d ring and they were like out doing their shopping. I mean in COVID it was different because a lot of people were stuck at home…but sometimes now, you aren’t getting their full attention…They’re not really like engaging with you.” (FG2– service staff).
Accommodation of service users’ needs
Having a hybrid approach was consistently noted as providing the flexibility and accommodation to meet the eclectic needs of service users, to enable support to fit into people’s personal and work lives, and to remove “barriers” around service engagement:
“It’s like, booking time off work for an appointment and stuff like that, whereas doing it remotely, I could just do it at work, just saying I’ll be back in five minutes I’ve got an appointment on the phone…It’s the time and having to go to appointments, know what I mean, it’s just easier on the phone.” (IN3– service user).
Whilst the majority of service users were selecting remote over face-to-face or mixed provision (Table
1), there was still a perceived need and want for face-to-face options from some service users. Further, offering mixed support (typically experienced as being able to move from face-to-face to phone support), was particularly valued at permitting the continuation of support in response to the complexities of everyday life:
“It’s the best of both worlds really, so it’s made it all more accessible for me…, because when I couldn’t make a meeting due to childcare issues, I could still get my support that week over the phone.” (IN4– service user).
Supportive and flexible approaches
It was consistently clear that each service user was different, and thus required support and approaches to meet individual needs and preferences. Having the ability to choose the type of provision received, and having flexibility in support, was valued as an important aspect of engagement which contributed to perceived service satisfaction:
“Having that flexibility in getting support means I can get that support when I need it, it’s like allowing me to make the most of my determination before it’s gone.” (IN6– service user).
The perception of non-judgmental supportive relationships from service staff was noted as crucial in engagement and rapport building for service users. It appeared that the skills of staff to develop relationships, and the levels of care, compassion, and personalised support they provided, helped engagement irrespective of the modality of support:
“I never felt judged, and that’s what I was scared of [being pregnant], but straight away even on the phone [name] made me feel at ease, just really friendly. That helped me open up, because we just got on”. (IN15– service user)
Implementation of the hybrid service
“Quantity vs. quality” of quits
Generally, the SSAs and service managers noted that remote provision was a much more “efficient” use of time, compared to purely face-to-face provision, in terms of increasing SSA caseload capacity and the number of service user contacts they could have. However, due to the nature of remote provision, quits were self-reported and not validated by CO monitoring. In light of the reported lack of national or local requirement for services to achieve CO validated quits, the LWSF service were prioritising offering service users’ choice and flexibility in the support they received. Any national or local change in requirements around achieving CO validated quits was noted as requiring a change in how the hybrid service would be delivered, and the proportion of remote and face-to-face provision offered:
“If you wanted to get to as close to 100% CO validation as possible, you’d need to put a lot of face-to-face clinics on, and then you’d need to not offer as much remote, and that would cut down on your numbers… it’s a difficult balance to strike between getting people in face-to-face, getting CO validation rates up, but seeing the amounts of people we need to, and having flexibility to see people.” (FG4– service managers).
Therefore, achieving CO validated (“quality”) quits was seen to be balanced against the number (“quantity”) of quits and service user engagement that could be achieved through remote provision.
Managing increased caseloads
Offering primarily remote provision was described by some SSA as resulting in, at times, considerable workloads and extremely large caseloads, specifically during “peak” periods. Further, many SSA felt their roles went beyond stop smoking support to various aspects of social and mental health support, which was described as “draining”:
“A lot of people talk about their problems during their phone calls, and actually, that can be very draining as well.” (FG2– service staff)
These issues were particularly pertinent during the COVID pandemic and were noted to have been exacerbated by the consecutive “back-to-back” nature of phone support sessions, and the lack of formal and informal team support accessible through complete working from home:
“[It’s] a little bit isolating. Because you’re working from home, you don’t have any colleagues that you see every day, you’re not having those corridor talks or those five minutes for a coffee in the canteen… being able to sit and have a chat with somebody, and a moment to sorta say ‘oh did you find that!’ and ‘oh I’ve been struggling with that!’. And a lot of that is missing.” (FG1– service staff)
Maintenance of the hybrid service
Data-led service delivery decisions
To inform future service adaptations to the needs of the local population, it was noted that data on the hybrid service was needed over a longer period of implementation. This would better determine the relative effectiveness of the remote, face-to-face and mixed pathways (in terms of the number of people setting and achieving 4-week quits) and how this varied by population demographics (e.g., ages, genders, ethnicities, geographies) and priority groups (e.g., maternity, mental health, substance misuse). See Table
2, and Additional file 3 for emerging data around variations in quit outcomes between the different pathways for different priority groups.
We estimated that the additional cost of providing a face-to-face option in the period September 2022 to February 2023 was £692 per month. In the average month from September 2022 to February 2023, 149 people were referred to the LWSF service. Using the percentages from Table
1, the service could expect 4 of these people to achieve a 4-week quit using either the face-to-face or mixed pathways. Dividing the total cost by the total quits gave a cost per 4-week quit from the additional face-to-face option of £175. (See Additional file 3 for further detail and breakdown around the calculation of return on investment for the face-to-face offering). Whilst information on the “cost-per-quit” for each of the three pathways was noted as important, offering service users a choice of pathways was perceived as crucial and potentially more important than any differences in the value for money among the pathways provided.
There were discussions around offering all service users a choice around pathway options and providing a more tailored and targeted approach for different populations and priority groups. This again was discussed in terms of a “quantity vs. quality” perspective, with a perceived need for targeted support for some smokers, but reflection that this could be a more time and resource-intensive approach. National and local priorities around guidance on what the LWSF service should be offering, as well as ongoing data collection, were suggested to be the key influences on the promotion and adaptation of support pathways going forward.
Improving awareness of the hybrid service
The most consistent suggestion for service improvement was for better service information and knowledge to be available, advertised and disseminated, specifically around the hybrid offering and the flexibility of provision:
“I think most people think that it is just like face-to-face appointments and if people are working they struggle to get to appointments or if they’ve got young kids. So, if it’s made clear that there are both face-to-face appointments and over the phone whichever works best for them, that could make a big difference.” (IN1– service user)
Several service users who were “referred in” from primary and secondary services noted receiving little information about the LWSF service, in terms of the modalities of support available, how support was provided and the flexibility of support. This information was noted as important in reducing anxieties and encouraging engagement.
Discussion
The LWSF service’s shift towards remote provision was seen to have enabled a greater level of service accessibility, removing barriers to support for those who were previously excluded, unable or struggling to attend and participate in face-to-face provision. The re-introduction of face-to-face provision, and offering of mixed support, to form a hybrid approach was seen to expand service user choice and access. For some staff, remote provision was noted to have produced increased efficiency in terms of the number of people receiving support, but also increased caseloads. There was a perceived trade-off between the “quantity vs. quality” of quits, where face-to-face contact was seen to produce a smaller number of “higher quality” CO validated quits vs. the greater quantity of quits that could be achieved through more “efficient” remote provision. Tailoring support pathways to specific populations was noted as potentially more resource-intensive than offering a flexible choice of support options to all, but it was also noted that this might be required in order for the service to effectively support these populations.
Personal contact, perceived connection and interpersonal relations between service users and providers have consistently been noted as important in engagement and treatment adherence [
15,
16,
39] and in supporting, encouraging and motivating health-promoting behaviours [
20,
40]. Remote provision was noted as beneficial in engaging priority groups by removing barriers around engagement, such as stigma, and fear of judgement [
41], which can facilitate openness during sessions [
42]. It was suggested in the accounts of the SSA that remote provision, especially now post-COVID lockdown policies, when people were not restricted to their homes, was resulting in lower levels of engagement for some service users. It has been noted in previous work that remote sessions are less engaging, and that service users spend more time participating in face-to-face provision than online/remote sessions [
23]. Thus, remote sessions may have greater accessibility, but at the potential cost of less engagement for some. In our study, whilst there was a suggestion that developing effective relationships through remote provision could be more difficult [
20,
43,
44], it was still achievable. Regardless of the modality of care, our service user participants discussed the importance of a supportive therapeutic relationship upon their engagement, with non-judgmental and personalised approaches from service staff facilitating rapport building.
There does not appear to be a single approach that will universally suit all service users, but a key theme evident in our study was how valued a flexible, patient-centred approach was. This echoes findings from the wider literature where there is a consistent recommendation of a patient-centred approach (for example, the recent calls for personalisation in health care [
45]), and where the modality of care is designed, chosen and delivered in conjunction with service users [
16,
44]. It is important to note that despite flexibility and choice being valued by service users, some populations may require more targeted or tailored ways of provision (e.g., [
46,
47]). Such considerations around offering “flexible choice” or “targeted” provision are crucial for services in the establishment, adaptation and promotion of support. Our results suggest that whilst there were similar 4-week quit outcomes for priority groups (see Table
2), there were some variations in quit outcomes between the different pathways for different groups (e.g. a higher percentage of 4-week quits were achieved with face-to-face support (85.7%,
n = 6) compared to phone support (72.4%,
n = 92) for people with mental health conditions (see Table
2). However, the short time that the LWSF hybrid service had been in operation and the small sample sizes in some subgroups leads to high uncertainty in conclusions. Longer-term data around the outcomes of different pathways for different populations, will inform and guide services around designing, targeting and tailoring provision to best support and engage service user engagement and access.
Misconceptions of what smoking services offer, their proximity and how they can be accessed have been noted as barriers to engagement [
48]. Such issues were commented on in our study, with service user participants highlighting a general lack of awareness around available service provision options before and during their referral. Therefore, ensuring that accurate knowledge of CSSS and their offer is received by potential service users is important, and may facilitate initial engagement.
Similarly, despite mixed awareness and perceptions from service users of CO testing, promoting this may be beneficial in engagement and encouraging uptake of face-to-face appointments by providing an additional motivation via a tangible marker of success [
49]. Additionally, there is the ability for CSSS to employ remote CO monitoring (e.g., via the home delivery of devices and undertaking self-reported or video-monitored checks, undertaking home visits to complete tests, or organising verification at local clinics/chemists [
50‐
53]. However, conducting remote CO verification of smoking has associated challenges, including issues around digital inequalities for service users, the accuracy of devices and recording [
50], and crucially the costs of remote CO devices for CSSS [
54]. Nevertheless, if remote support is to continue to be offered by CSSS and primarily selected by service users, it may be important for CSSS to consider strategies around delivering remote CO monitoring.
Strengths and limitations
The main strength of our study is the formative evaluation approach that was designed to identify potential and actual influences on the progress and effectiveness of implementation efforts from the point of view of informing future service adaptations and responses [
55]. Our formative evaluation was preceded by an Evaluability Assessment process in which the aims, objectives, and design of the subsequent evaluation were co-developed through a participatory process with service stakeholders (see Additional file 1) [
56]. Evaluability Assessment is a rapid, systematic, and collaborative way of deciding how a programme or policy can be evaluated [
31]. Our formative evaluation approach enabled us to deliver emerging findings back to the LWSF team, allowing data to help inform, improve and adapt the service during the evaluation process [
57]– for example, around the value of more clearly presenting the hybrid offering and flexible options for potential service users.
The main limitation is that our study was based on only one stop smoking service in England, which was at an early stage of implementing its new hybrid service offering. The evaluation occurred under “real life” conditions, and thus there was no randomisation of service users to groups of remote, face-to-face or mixed provision, with service users selecting which provision mode they preferred at the start of their treatment. We worked with our LWSF project partners to try and represent the heterogeneity of participants the service engages with, but due to the nature and challenges of our recruitment methods, we were only able to sample service users opportunistically. Thus, our findings reflect the perspectives and experiences of the service users who had engaged and nearly completed their treatment. Future work could explore the experiences and perspectives of those who disengaged from support, or employ a targeted outreach approach to explore the experiences of marginalised populations often excluded from CSSS (e.g. the most disadvantaged groups [
58,
59], such as homeless populations [
60]).
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