School-based promotion of cessation support: reach of proactive mailings and acceptability of treatment in smoking parents recruited into cessation support through primary schools

Cigarette smoking constitutes a serious burden to health and economy [1]. Connecting smokers to effective cessation services is a public health priority. The majority of smokers intend to quit smoking and a substantial proportion of smokers make repeated quit attempts [2]. When attempting to quit, relapse is the most probable outcome. Approximately, three-quarters of unaided quitters resume smoking within three months [3]. In a meta-analytic review of unaided smoking cessation, it was concluded that only 7% of unaided quit attempts last longer than 10 months [4]. Several forms of cessation support have been shown effective in increasing the chance of successful smoking cessation [5]. However, only a minority of smokers make use of such programs. In the United States, 37% of smokers who have tried to quit smoking report that they had ever read written material on smoking cessation, 12% had called a quitline, and 9% had attended individual counselling [6]. Similar rates on the use of cessation treatments are reported by Shiffman and colleagues [2]. In the Netherlands, one third of quitters report that they received assistance in quitting and less than 1% of smokers contact the national quitline [7].

Smoking parents represent an important subpopulation among adult smokers. Forty percent of smokers live with a child younger than 18 years old [8]. Twenty percent of parents are self-reported smokers [9]. Parental smoking is detrimental, not only to the parent, but also the child. A recent meta-analysis concluded that the risk of smoking uptake in adolescence is nearly threefold when both parents smoke [10]. Moreover, smoking parents frequently expose their children to second-hand smoke [11, 12], which is associated with a variety of adverse health outcomes including childhood asthma, respiratory infections, and decreased lung growth in children [13, 14]. Smoking parents may be particularly motivated to quit smoking. Smoker’s primary reasons for wanting to quit are concerns about the health consequences of their smoking [15]. Nearly two-thirds of adult smokers express concern for modelling smoking to children [8]. In a telephone survey, 64% of parent smokers indicated that they would accept telephone cessation support if recommended [9]. Also, parents of children with smoking-related illnesses display a particularly high motivation to quit [16, 17]. Connecting smoking parents to cessation support may yield important health benefits for both parents and children. Parents who quit smoking will not only improve their own health, but will also reduce the risk of physical illness [18], smoking initiation [19], and regular smoking [20] in their children.

Proactive outreach may increase use of cessation support. Proactive outreach is the systematic targeting of all individuals in a defined population of smokers and the attempt to engage smokers with varying levels of motivation. Up to this point, efforts to engage smoking parents have almost exclusively focused on clinical settings [17, 21, 22]. While these efforts are valuable, proactive outreach of health care practices and hospitals may not extend to the general population of smoking parents. Public schools are a highly promising but understudied venue for reaching parents who smoke. Promoting cessation support through schools has the potential to reach a major proportion of smoking parents, thus yielding high potential public health impact. Also, schools are likely to constitute a ‘teachable setting’, that is, smokers may be more likely to make use of cessation support when reminded of their role as parents. To date, no study has evaluated the use of primary schools as a venue to promote smoking cessation among parents.

Previous studies have used varying approaches to increase smoker’s exposure to cessation support (e.g., direct mailings, health care provider outreach, telephone recruitment, or media advertisements). Offering cessation support through mailings has been shown to yield response rates between 2-11% in smokers identified from general practice and health care provider records [23‐26]. Recruitment rates tend to be higher for interpersonal recruitment, with recruitment rates ranging between 44-65% [27‐29]. While interpersonal recruitment (e.g., telephone recruitment) may constitute an efficient way to recruit smokers into clinical trials, this approach may be less feasible for implementation into the health care system, where few resources for recruitment are available. Though response rates vary considerably between studies and recruitment approaches, previous studies indicate that proactive outreach has considerable potential to connect smokers to cessation support.

Several forms of cessation support have demonstrated efficacy in increasing the chance of successful smoking cessation [5]. Telephone counselling, or quitline support, has been shown effective in increasing smoking cessation rates in a meta-analytic review [30]. Data from the European Smoking Cessation Helplines Evaluation study (ESCHER), which assesses cessation rates after quitline use in several European countries, showed point prevalent abstinence rates between 12% and 28% and prolonged abstinence rates between 4% and 15% at one-year follow-up [7]. Self-help materials (i.e., didactic materials giving information and advice on how to quit smoking) have also demonstrated efficacy in a meta-analytic review, which concluded that non-tailored self-help materials have a small benefit compared to no intervention [31]. Therefore, self-help materials constitute a cost-effective method to support otherwise unaided quit attempts, which can be disseminated easily and has the potential to help a large proportion of smokers.

The aim of the present study was two-fold: First, we sought to evaluate the reach of mailings distributed through primary schools in recruiting smoking parents into cessation support (i.e., school-based promotion of cessation support using mailings). Second, among smoking parents recruited into cessation support through primary schools, we compared use and acceptability of two cessation treatments with high potential public health impact: telephone counselling versus self-help material.

The present study sought to evaluate the feasibility and acceptability of connecting smoking parents to cessation support through their children’s primary schools. As with other populations, recruiting smokers into clinical trials is challenging [39, 40]. In the present study, the distribution of 35,000 mailings through primary schools led to the recruitment of 512 smoking parents out of approximately 10,000 households (30%) which are estimated to include at least one smoking parent [37, 38], yielding a response rate of approximately 5%, which is in line with earlier studies that require participants to respond to printed information material or mass media [23‐26]. It should be noted that the response rate yielded by the present approach is likely to be an underestimation of the response rate which may potentially be achieved using the present approach. First, the present study employed several inclusion criteria (e.g., willingness to fill out questionnaires, participation as parent–child dyad). The response rate is likely to be higher when no inclusion criteria are employed. In line with this, the number of smokers who initially responded to the study invitation letters was considerably higher than the number of smokers who eventually enrolled in the present study (i.e., returned informed consent and baseline questionnaire). Second, the number of eligible subjects in the target population constitutes an estimation which may be subject to imprecision. Overestimation of the prevalence of parental smoking and non-adherence to instructions in schools and children may have lead to an underestimation of the actual response rate among smoking parents. However, previous studies have employed similar procedures (i.e., procedures using estimations of the denominator) to determine rates of recruitment in defined populations [24, 26]. It should be noted that, even though the response rate of smoking parents to one-time mailings was rather low, the level of motivation to quit in smoking parents who responded to the mailings was quite diverse (two-thirds of respondents were not ready to quit within one month), providing preliminary evidence that low-intensity outreach targeting both smokers who are not yet ready to quit as well as smokers who are ready to quit may engage smokers with varying characteristics and levels of motivation to quit. In the Netherlands, less than 1% of smokers contact the national quitline [7]. Therefore, even low-intensity outreach (e.g., one-time mailings) may be useful in increasing smoker’s exposure to and use of cessation support. The findings are in line with previous research demonstrating high recruitment efficiency as well as high cost-effectiveness of recruitment strategies which disseminate information material to target audiences through print and media [41]. The fact that half of the approached schools agreed to distribute mailings to parents indicates that schools generally approve of offering cessation support to smoking parents and are willing to participate in school-based smoking cessation promotion programs when demands on schools are kept to a minimum.

The present study offers several directions for future research. First of all, future studies will need to examine factors that influence the response to offers of cessation support in samples of nonvolunteer smokers. Possibly, offering a variety of cessation support services (nicotine replacement therapy, medication, behavioural counselling, web-based support, self-help material) may improve use of cessation support among smokers. Also, periodic mailings may increase the response rate among smokers. In smokers, motivation to quit is unstable over time and may change rather spontaneously [42, 43]. Repeated offers of cessation support may capitalize on these variations in smoker’s motivation to quit. To achieve an impact on smoking parents at the population level, proactive outreach efforts may additionally capitalize on ‘teachable moments’ in clinical settings such as consultancy and hospitalization for respiratory illness in children, prenatal consultancy, or postpartum hospital stays [17, 22].

While recruitment of smokers into cessation support remains challenging, the reported use of cessation support among proactively recruited smokers was high and evaluations of cessation support were remarkably positive. Among all participants randomized to telephone counselling, almost 90% accepted at least one counselling call and more than 80% received three or more counselling calls. Overall, more than 80% of smoking parents were satisfied or very satisfied with telephone counselling. There was very little variability in the evaluation of telephone counselling, indicating that telephone counselling was generally well-received among smoking parents. In addition to telephone counselling, smoking parents also received three accompanying booklets. The accompanying booklets were read by 75% of parents and 72% were satisfied with the booklets. Supplementary materials may provide tailored information to target audiences and may be used as an increment or booster to generic interventions (e.g., telephone counselling), as they were well-received and read by participants who participated in telephone counselling. With regard to the self-help brochure, more than 80% reported that they read at least some parts of the brochure and nearly 70% were satisfied or very satisfied with the brochure. Self-help materials are a cost-effective method to support otherwise unaided quit attempts, which can be disseminated easily. In general, self-help material seems to be well-received and may be of interest to smoking parents, though findings clearly demonstrate that smoking parents are more favourable about telephone counselling than self-help material. Interpersonal contact and the counsellor’s use of motivation interviewing techniques (e.g., empathic listening, non-judgemental exploration of ambivalence) may be one reason for the positive evaluation of telephone counselling among smoking parents. The present findings are in line with previous studies showing that quitline services are well-received, even by non-volunteer smokers [7, 28].

Several limitations should be acknowledged. First of all, the results of the present study are based on self-report. Social desirability or memory biases may have influenced the recall of the use of cessation support. Also, attrition was significantly higher in the telephone counselling condition compared to the self-help brochure condition, indicating selective drop-out (possibly due to differences in contact frequency or differences in satisfaction with treatment). Yet, the attrition rate in the present study was rather low, and few differences were observed between the remaining participants and participants lost to attrition. Also, all results pertain to the intention-to-treat population, therefore satisfaction with treatment is likely to be underestimated rather than overestimated. As study participants were aware of the two-arm design, it is possible that treatment preferences at the start of the study may have affected treatment evaluations, possibly resulting in an underestimation of satisfaction with treatment, particularly among participants receiving the self-help brochure. It should be acknowledged that study procedures that deviated from standard practice procedures may limit generalizability (completion of assessments and use of incentives). The effectiveness of the proactive telephone counselling offered to smoking parents will be examined in a separate manuscript once follow-up data collection has been completed.

To summarize, the present study evaluated use and acceptability of telephone counselling and self-help material among smoking parents who were recruited into cessation support using mailings distributed through primary schools. In the present study, the response rate to offers of cessation support was rather low (5%), though it may be improved by offering varying types of cessation services and employing fewer requirements for participation. Once recruited into cessation support, both telephone counselling and self-help material were well-used and well-evaluated by smoking parents. The findings demonstrate that parents were clearly more positive about telephone counselling compared to self-help materials.

^a Dutch name of brochure: Stoppen met roken: Willen en kunnen.