Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study

In the prospective study of just over 3000 smokers attending NHS Stop Smoking Services in nine areas of England, 41.2% were biochemically validated as abstinent from smoking at 4 weeks post quit date.

“From our prospective study of just over 3000 smokers attending SSSs in nine areas of England, we found that just over 4 in 10 (41.2%) were biochemically validated as abstinent from smoking at 4 weeks post quit date.”

Just fewer than 8% of smokers were still abstinent from smoking 1 year after setting a quit date.

“We found that just fewer than 8% of smokers were still abstinent from smoking 1 year after setting a quit date.”

Cotinine levels for those who relapsed to smoking had not changed from baseline to follow-up, irrespective of NRT use.

“Cotinine levels for smokers who had stopped at follow-up but who used NRT long term had not changed from baseline to follow-up and neither did cotinine levels for those who had relapsed to smoking (irrespective of NRT use).”

Most clients who started on NRT used it for at least 8 weeks.

“Most clients who started on NRT used it for at least 8 weeks and more than one in five (21.5%) used it for longer than the standard 3 months.”

Fewer than 1 in 10 participants (8.4%) were still using non-combustible nicotine products at the 12-month follow-up.

“Long-term use was relatively rare with fewer than 1 in 10 participants still using non-combustible nicotine products at the 12-month follow-up (8.4%).”

Long-term ex-smokers had much higher odds of still using non-combustible nicotine products at the 12-month follow-up than those who relapsed.

“Long-term ex-smokers had much higher odds of still using non-combustible nicotine products at the 12-month follow-up than those who relapsed.”

Concurrent use of non-combustible nicotine products among relapsers was 3.7% compared with 14.0% of continuous abstainers.

“Concurrent use among relapsers was 3.7% compared with 14.0% of continuous abstainers.”

Of clients followed up at 12 months, 61.5% reported that they had used NRT during their quit attempt.

“Of clients followed up at 12 months, 61.5% reported that they had used NRT during their quit attempt.”

The difference in concurrent use between relapsers and continuous abstainers remained significant even after removing those who used e-cigarettes only.

“This difference remained significant even after removing those who used e-cigarettes only.”

Greater levels of cotinine were associated with greater self-reported dependence.

“Greater levels of cotinine were associated with greater self-reported dependence.”

In the secondary analysis of routine data from 49 of 150 services in England, the 4-week quit rate was 48% when self-reported data were included.

“Our secondary analysis of routine data from 49 of 150 services in England found 4-week quit rates of 48% when self-reported data were included, falling to 34% when biochemical validation had occurred.”

E-cigarettes were the most popular single product at 1 year.

“However, e-cigarettes were the most popular single product at 1 year.”

More than one in five (21.5%) clients who started on NRT used it for longer than the standard 3 months.

“Most clients who started on NRT used it for at least 8 weeks and more than one in five (21.5%) used it for longer than the standard 3 months.”

In total there were 202,804 client records included in the database.

“In total there were 202,804 client records included in the database.”

In the secondary analysis of routine data from 49 of 150 services in England, the 4-week quit rate was 34% when biochemical validation had occurred.

“Our secondary analysis of routine data from 49 of 150 services in England found 4-week quit rates of 48% when self-reported data were included, falling to 34% when biochemical validation had occurred.”

QuitManager data were available from 49 services in England.

“Data were available from 49 services in England.”

Cotinine levels for smokers who had stopped at follow-up but who used NRT long term had not changed from baseline to follow-up.

“Cotinine levels for smokers who had stopped at follow-up but who used NRT long term had not changed from baseline to follow-up and neither did cotinine levels for those who had relapsed to smoking (irrespective of NRT use).”

The secondary analysis found that services were reaching up to 10% of smokers in their area in the year from July 2010.

“This same analysis found that services were reaching up to 10% of smokers in their area in the year from July 2010.”

The number of cases used in the bi-variable and multilevel multivariable analysis of the efficacy of the services was 177,291.

“Thus, the number of cases used in the bi-variable and multilevel multivariable analysis of the efficacy of the services was 177,291.”

Few participants reported e-cigarette use at 1 year (2.9%).

“Few participants reported their use at 1 year (2.9%), although these data include smokers and non-smokers and most people had relapsed by 1 year post quit date.”

There were no differences as a function of NRT use and smoking status at follow-up in baseline levels of alpha-amylase, a biomarker of stress.

“There were no differences as a function of NRT use and smoking status at follow-up in baseline levels of alpha-amylase, a biomarker of stress.”

The median number of client records per PCT was 3713 (interquartile range 2101-5136).

“The median number of client records per PCT was 3713 (interquartile range 2101-5136)”

Among the practitioner types, clients of specialist advisers were more likely to quit than clients of other and unspecified practitioner types.

“Among the practitioner types, clients of specialist advisers were more likely to quit than clients of other (and unspecified) practitioner types.”

Carbon monoxide validation rates were lowest among specialist practitioners.

“CO-validation rates were lowest among specialist practitioners.”

Generally unknown and other classifications were associated with less chance of quitting than reference groups.

“Generally unknown and other classifications were associated with less chance of quitting than reference groups.”

The results for carbon monoxide validated quit and self-report quit are mostly similar.

“The results for CO-validated quit and self-report quit are mostly similar so they are discussed simultaneously with differences alluded to.”

Ethnicity was not significantly related to quitting.

“Ethnicity was not significantly related to quitting.”

September, January and February appeared to be particularly successful months for setting a quit date with a Stop Smoking Service.

“September, January and February appeared to be particularly successful months for setting a quit date with a SSS.”

The CO-validation rate for clients who self-reported as quit was 73.3%.

“and the CO-validation rate for clients who self-reported as quit was 73.3%.”

After taking other demographic- and service-related factors into account, there was significant variation in primary care trust validation rates.

“Residuals suggest (Figure 4) that, after taking other demographic-and service-related factors into account, there was significant variation in PCT validation rates.”

As age increased so did the chances of quitting.

“As age increased so did the chances of quitting.”

Ethnicity had no effect on carbon monoxide validation rates.

“Ethnicity had no effect on CO-validation rates.”

Clients who took varenicline, combination NRT or a mixture of medications were more likely to be carbon monoxide validated than those who took single NRT.

“Clients who took varenicline, combination NRT or a mixture of medications were more likely to be CO validated than those who took single NRT.”

There were 157,479 clients where quit rates could be calculated (i.e. did not quit in December or June).

“and 157,479 clients where quit rates could be calculated (i.e. did not quit in December or June).”

The lowest chances of self-reported quitting were found in the primary care trust ranked 1.

“The lowest chances of self-reported quitting were found in the PCT ranked 1.”

The CO-validated quit rate for unique clients aged ≥ 16 years was 34.5%.

“The CO-validated quit rate for these clients was 34.5%”

There were 169,909 unique clients aged ≥ 16 years altogether.

“There were 169,909 unique clients aged ≥ 16 years altogether.”

In the bivariable results pregnant women had the lowest quit rate.

“In the bivariable results pregnant women had the lowest quit rate.”

There was significant variance between practitioners and between primary care trusts even after all fixed effects had been included for both self-report and carbon monoxide validated quit.

“We can safely say that there was significant variance between practitioners and between PCTs even after all fixed effects had been included for both self-report and CO-validated quit.”

The variance between primary care trusts appeared to halve when primary care trust deprivation was entered into the model.

“The variance between PCTs appeared to halve when PCT deprivation was entered into the model.”

Health-care assistants, pharmacy employees and unclassified practitioners were significantly more likely to carbon monoxide validate clients than specialist practitioners.

“Health-care assistants, pharmacy employees and unclassified practitioners were significantly more likely to CO validate clients than specialist practitioners (see Table 6).”

Prisoners were much more likely to be carbon monoxide validated than other groups, approximately four times more likely than routine and manual workers.

“Prisoners were much more likely to be CO validated than other groups, approximately four times more likely than routine and manual workers.”

For intervention type, the highest chances of quitting were among clients who took part in open/rolling groups.

“For intervention type, the highest chances of quitting were among clients who took part in open/rolling groups.”

Compared with clients with routine and manual occupations, clients with intermediate, managerial and professional occupations, the retired, home carers and prisoners were more likely to quit.

“Compared with clients with routine and manual occupations, clients with intermediate, managerial and professional occupations, the retired, home carers and prisoners were more likely to quit.”

Clients aged over 53 years were twice as likely to quit as those aged 30 years or under.

“Clients aged over 53 years were twice as likely to quit as those age 30 years or under.”

As age increased, carbon monoxide validation was more likely.

“As age increased, CO validation was more likely.”

Of the 49 primary care trusts, 28 met the 35% target for carbon monoxide validated quitting.

“Of the 49 PCTs, 28 met this target for CO-validated quitting.”

There were 171,830 unique clients in the secondary analysis (unique clients could not be identified for three PCTs).

“There were 171,830 unique clients (note that unique clients could not be identified for three PCTs)”

This difference was significant for all categories except for carbon monoxide validation among practitioners who held pharmacy posts.

“This difference was significant for all categories except for CO validation among practitioners who held pharmacy posts.”

The fixed effects suggested that primary care trusts that were fairly, but not the most, disadvantaged were three times more likely to be carbon monoxide validated.

“The fixed effects suggested that PCTs that were fairly, but not the most, disadvantaged were three times more likely to be CO validated.”

Of the 49 primary care trusts, 13 achieved carbon monoxide validation rates of 85% or more.

“Of the 49 PCTs, 13 achieved CO-validation rates of 85% or more.”

Two primary care trusts were estimated to have independently added over 400 ex-smokers per 100,000 population between mid-2010 and mid-2011.

“At the other end of the scale, two PCTs were estimated to have independently added over 400 ex-smokers per 100,000 population between mid-2010 and mid-2011 (Table 8).”

Non-pregnant women were more likely to be carbon monoxide validated than men and pregnant women.

“Non-pregnant women were more likely to be CO validated than men and pregnant women.”

Those who paid for prescriptions were more likely to quit than those who were exempt.

“Those who paid for prescriptions were more likely to quit than those who were exempt.”

In general, the services had a positive impact over and above what would be expected from quitting spontaneously or with medication only.

“In general, the services had a positive impact over and above what would be expected from quitting spontaneously or with medication only.”

Self-report quitters who enrolled in open groups were more likely to be carbon monoxide validated.

“Self-report quitters who enrolled in open groups were more likely to be CO validated.”

There was less variance between primary care trusts and between practitioners for self-report quits than carbon monoxide validated quits.

“It is probably also safe to say that there was less variance between PCTs and between practitioners for self-report quits than CO-validated quits.”

The overall quit rates of the entire database without exclusions for missing data in the gender, age or practitioner type variables were 44.1% self-report and 30.7% carbon monoxide validated.

“The overall quit rates of the entire database (see Table 3) without exclusions for missing data in the gender, age or practitioner type variables were 44.1% (self-report) and 30.7% (CO validated).”

Client groups where carbon monoxide validation of 85% was achieved were prisoners and clients enrolled in open groups.

“Client groups where CO validation of 85% was achieved were prisoners and clients enrolled in open groups.”

The CO-validated quit rate of unique clients was 34.4%.

“The CO-validated quit rate of unique clients was 34.4%”

• Also stated in: § Summary of key points · plain

  “The self-reported and CO-validated quit rates were 49% and 34% respectively at 4 weeks post quit date.”

Only one service was judged to have a negative impact when both carbon monoxide validated quitting and all self-report quitting were taken into account.

“However, only one service was judged to have a negative impact when both CO-validated quitting and all self-report quitting were taken into account.”

Taking any medication other than single NRT increased the chances of quitting.

“Taking any medication other than single NRT increased the chances of quitting.”

Primary care trust deprivation was not significantly related to quitting.

“PCT deprivation was not significantly related to quitting.”

Three primary care trusts did not reach the 35% target for self-report quitting.

“Three PCTs did not reach the 35% target for self-report quitting.”

Eligibility for paying for prescriptions and primary care trust deprivation, once extreme primary care trusts were excluded, did not significantly affect carbon monoxide validation rates.

“Eligibility for paying for prescriptions and PCT deprivation (once extreme PCTs were excluded) did not significantly affect CO-validation rates.”

The process of recruiting a client, seeking informed consent, asking the additional monitoring questions and collecting saliva samples added an additional 10-15 minutes to the appointment.

“This was Country Durham and Darlington, where we were able to estimate that the process of recruiting a client, seeking informed consent, asking the additional monitoring questions and collecting saliva samples added an additional 10-15 minutes to the appointment.”

Throughput was significantly associated with impact taking into account all self-reported quits and overall impact.

“but it was significantly associated with impact taking into account all self-reported quits and overall impact.”

Clients who saw specialist practitioners had higher quit rates than those who saw other types of practitioners.

“Clients who saw specialist practitioners had higher quit rates than those who saw other types of practitioners.”

On average 184 ex-smokers per 100,000 population were added.

“and 184 ex smokers per 100,000 population were added.”

• Also stated in: § SECONDARY ANALYSIS OF ROUTINE DATA: FINDINGS · hedged

  “As a result of SSS treatment, the estimated number of ex-smokers per 100,000 population was 184 from mid-2010 to mid-2011.”

Throughput was not significantly associated with quitting or impact, taking into account CO-validated quits.

“Throughput was not significantly associated with quitting or impact, taking into account CO-validated quits”

If all self-report quits were included there were 216 extra ex-smokers per 100,000 population.

“and if all self-report quits were included there were 216 extra ex-smokers.”

The CO-validation rate of self-report quits in the current sample was slightly better than that reported for all PCTs in 2009/10 (69%).

“This was, however, slightly better than that reported for all PCTs in 2009/10 (69%).33”

• cites [33] Department of Health (DH), 2011Not checked yet

  Not checked in the free run.

The mean CO-validated quit rate for unique clients aged ≥ 16 years in the PCTs used for calculations was 36%.

“The mean quit rates for unique clients aged ≥ 16 years in the PCTs used for calculations were 36% (CO validated)”

The majority (79%) of clients received one-to-one behavioural support.

“The majority (79%) of clients received one-to-one behavioural support.”

92.0% (interquartile range 89.7-94.7) of client records referred to unique clients.

“There were 92.0%(interquartile range 89.7-94.7) of client records that referred to unique clients.”

If only CO-validated quits were taken into account there were 152 extra ex-smokers per 100,000 population.

“If only CO-validated quits were taken into account there were 152 extra ex-smokers”

Comparing the QuitManager prospective study extracts with the saliva samples database for the long-term NRT use study revealed further clients who had been initially recruited to the ELONS study (as they had provided saliva samples) but had been dropped from QuitManager owing to lack of progress with their quit attempt.

“Comparing the QuitManager prospective study extracts with the saliva samples database for the long-term NRT use study revealed further clients who had been initially recruited to the ELONS study (as they had provided saliva samples) but had been dropped from QuitManager owing to lack of progress with their quit attempt.”

One-to-one behavioural support was significantly less successful than open rolling groups [aOR open groups 1.28 (95% CI 1.15 to 1.41) compared with one to one].

“This type of support was significantly less successful than open rolling groups [aOR open groups 1.28 (95% CI 1.15 to 1.41) compared with one to one].”

In the current sample, 74% of self-reported quits were CO validated.

“compared with 74% in the current sample.”

Several sites reported a general decrease in the number of people using their service during the study period.

“Several sites reported a general decrease in the number of people using their service during the study period.”

On average 1487 unique clients set a quit date per 100,000 population.

“On average 1487 unique clients set a quit date per 100,000 population”

The median number of unique clients per PCT was 3385 (interquartile range 2169-4603).

“and the median number of unique clients was 3385 (interquartile range 2169-4603).”

The mean self-report quit rate for unique clients aged ≥ 16 years in the PCTs used for calculations was 50%.

“and 50% (self-report) (Table 9).”

By late July 2012 it became clear that the client recruitment rate was considerably below the level that was expected from the previous English long-term evaluation, where up to 80% of clients in the two study areas had been recruited.

“By late July 2012 it became clear that the client recruitment rate was considerably below the level that was expected from the previous English long-term evaluation, where up to 80% of clients in the two study areas had been recruited.18”

• cites [18] Ferguson, 2005, The English smoking treatment services: one-year outcomes, Addiction sourceNot checked yet

  Not checked in the free run.

Two PCTs with particularly low CO-validated quit rates were reaching the highest proportion of smokers in their local area.

“Two PCTs with particularly low CO-validated quit rates were reaching the highest proportion of smokers in their local area.”

Clients who chose not to answer self-assessed health and well-being questions had the lowest chances of stopping smoking.

“Interestingly, clients who chose not answer these questions had the lowest chances of stopping smoking.”

More than 40% of clients who received three of the four specialist types of behavioural support (closed group, open group, and one to one) were CO validated as quit.

“more than 40% of clients who received three of the four 'specialist' type of behavioural support (closed group, open group, and one to one) were CO validated as quit”

Mental health conditions were about twice as common among clients claiming sickness or unemployment benefits as among clients overall (29% compared with 15%; p < 0.001).

“Mental health conditions were about twice as common among clients claiming sickness or unemployment benefits as among clients overall (29% compared with 15%; p < 0.001).”

Clients receiving group-based treatment were more likely to have good levels of well-being than those receiving one-to-one treatment (51-55% vs. 41-44%; p < 0.001).

“Clients receiving group-based treatment were more likely to have good levels of well-being than those receiving one-to-one treatment (51-55% vs. 41-44%; p < 0.001).”

Those who had used some sort of support in their previous quit attempt (e.g. varenicline or the SSS) were significantly more likely to quit than those who had not (33% vs. 46%; p = 0.003).

“Those who had used some sort of support in their previous quit attempt (e.g.varenicline or the SSS) were significantly more likely to quit than those who had not (33% vs. 46%; p = 0.003).”

Short-term quit rates were higher among homeowners compared with those reporting living in rented accommodation.

“Short-term quit rates were higher among homeowners compared with those reporting living in rented accommodation.”

Mental health conditions were about twice as prevalent in the 45-54 years age group as in the youngest and oldest age group (20% compared with 10% and 12% respectively; p = 0.003).

“Mental health conditions were about twice as prevalent in the 45-54 years age group as in the youngest and oldest age group (20% compared with 10% and 12% respectively; p = 0.003).”

Clients who reported that they were married were more likely to have stopped smoking at 4 weeks (p < 0.001).

“Clients who reported that they were married were more likely to have stopped smoking at 4 weeks (p < 0.001).”

Clients who did not provide information about support were less likely to quit: 27% compared with 43-45% (p = 0.007).

“Clients who did not provide information about this type of support were less likely to quit -27% compared with 43-45% (p = 0.007).”

Clients who smoked within 5 minutes of waking were least likely to quit by 4 weeks (41% compared with 42-49%; p < 0.001).

“Clients who smoked within 5 minutes of waking were least likely to quit by 4 weeks (41% compared with 42-49%; p < 0.001).”

Pharmacy clients were less likely to be prescribed varenicline (20% of pharmacy clients were prescribed varenicline compared with ≥ 40% for the other behavioural support types; p < 0.001).

“Pharmacy clients were less likely to be prescribed varenicline (20% of pharmacy clients were prescribed varenicline compared with ≥ 40% for the other behavioural support types; p < 0.001).”

Over half of the sample (54%) had a concerning level of well-being.

“Over a half of the sample (54%) had a concerning level of well-being.”

A concerning level of well-being was more common in people who had a mental health condition (71% vs. 53%; p < 0.001).

“A concerning level of well-being was more common in people who had a mental health condition (71% vs. 53%; p < 0.001).”

There was very little difference in quit rates between the 87% who had sources of support to stop and the 11% who did not.

“There was very little difference in quit rates between the 87% who had sources of support to stop and the 11% who did not.”

Medication was more likely to be recorded on three or more occasions by specialists (46% of clients who received specialist support had medication recorded compared with 36% of clients who received GP or pharmacy services; p < 0.001).

“Medication was more likely to be recorded on three or more occasions by specialists (46% of clients who received specialist support has medication recorded compared with 36% of clients who received GP or pharmacy services; p < 0.001).”

Older clients were more likely to stop smoking at 4 weeks (69% of 65- to 85-year-olds compared with 41% of 16- to 24-year-olds; p < 0.001).

“The older a client, the more likely they were to stop smoking at 4 weeks (69% of 65-to 85-year-olds compared with 41% of 16-to 24-year-olds; p < 0.001).”

There was no significant gender difference in quitting at 52 weeks.

“but there was no significant gender difference at 52 weeks.”

The best 4-week outcomes were found in the managerial/professional and retired groups (65% and 69% self-report compared with 51% and 59% CO validated, respectively).

“The best 4-week outcomes were found in the managerial/ professional and retired groups (65% and 69% self-report compared with 51% and 59% CO validated, respectively).”

Female participants were more likely than male participants to have other smokers in the home (43% vs. 39%; p = 0.007).

“Female participants were more likely than male participants to have other smokers in the home (43% vs. 39%; p = 0.007)”

Clients with a heart, blood or circulation condition were more likely to quit than those without (51% compared with 43%; p < 0.001).

“clients with a heart, blood or circulation condition were more likely to quit than those without (51% compared with 43%; p < 0.001).”

From the available data, there was no relationship between reported education and CO-validated quitting.

“From the data available, there was no relationship between reported education and CO-validated quitting”

Clients of level 2 providers were less determined to quit (43% of clients who attended level 2 providers were extremely determined compared with 52% of specialist clients; p = 0.003).

“Clients of level 2 providers were less determined to quit (43% of clients who attended level 2 providers were extremely determined compared with 52% of specialist clients; p = 0.003)”

At 4 weeks post quit date, 56.6% of study participants reported that they had quit smoking.

“Overall, at 4 weeks post quit date just over a half of study participants reported that they had quit smoking (56.6%).”

Clients who reported paying for prescriptions were more likely to have better 4-week outcomes than those who did not (64% compared with 49% self-report outcomes).

“Clients who reported paying for prescriptions were more likely to have better 4-week outcomes than those who did not (64% compared with 49% self-report outcomes)”

Fewer than 40% of clients who received behavioural support in a GP practice or pharmacy setting, or who attended a specialist drop-in, were CO validated as quit.

“fewer than 40% of clients who received behavioural support in a GP practice or pharmacy setting, or who attended a specialist drop-in were CO validated as quit”

There was a relationship in the expected direction for self-report: better outcomes for clients with a degree than those with no qualifications (63% compared with 57%) (p = 0.011).

“although there was a relationship in the expected direction for self-report [i.e.better outcomes for clients with a degree than those with no qualifications (63% compared with 57%)] (p = 0.011).”

There was not a linear relationship between cigarettes smoked per day and quitting.

“Furthermore there was not a linear relationship between cigarettes smoked per day and quitting.”

Variables that did not reach statistical significance in the 4-week multivariate analyses (marital status, medical conditions, how introduced to the service) did not reach statistical significance in the multivariable model.

“Variables that did not reach statistical significance in the 4-week multivariate analyses (marital status, medical conditions, how introduced to the service) were then added to the model; however, none of these reached statistical significance in the multivariable model.”

Open-group clients were the most likely to be CO validated as quit (53%; p < 0.001).

“open-group clients were the most likely to be CO validated as quit (53%; p < 0.001)”

Clients who had a mental health condition were less likely to quit than those without (39% compared with 45%; p = 0.014).

“clients who had a mental health condition were less likely to quit than those without (39% compared with 45%; p = 0.014)”

At 52 weeks, differences in medication, dependence on tobacco, determination to quit and support from a spouse or partner did not quite reach significance.

“Likewise, at 52 weeks, differences in medication, dependence on tobacco, determination to quit and support from a spouse or partner did not quite reach significance.”

Specialists were more likely to see clients with a mental health condition (16% of specialist clients compared with 12% of level 2 clients; p = 0.041).

“mental health condition (16% of specialist clients compared with 12% of level 2 clients; p = 0.041)”

Over half already knew of their SSS because they had made a previous quit attempt (53%).

“Over half already knew of their SSS because they had made a previous quit attempt (53%).”

Less-disadvantaged people had a quit rate of 10.3% (95% CI 8.4% to 12.7%) compared with a quit rate of 6.2% (95% CI 5.0% to 7.7%) among more-disadvantaged people.

“Less-disadvantaged people had a quit rate of 10.3% (95% CI 8.4% to 12.7%) compared with a quit rate of 6.2% (95% CI 5.0% to 7.7%) among more-disadvantaged people.”

Cessation at 4 weeks was associated with affluence, aOR 1.3 (95% CI 1.1 to 1.6).

“affluence, aOR 1.3 (95% CI 1.1 to 1.6)”

The overall profiles of the ELONS study clients' behavioural support types strongly reflected 'all cases' behavioural support types.

“The overall profiles of the ELONS study clients behavioural support types, however, strongly reflected 'all cases' behavioural support types.”

Participants represented a small proportion of those who accessed SSSs in the study areas during the recruitment period.

“these participants represented a small proportion of those who accessed SSSs in the study areas during the recruitment period.”

A much lower proportion of combination NRT users achieved abstinence at 4 weeks (27% quit compared with 42% of people who took single NRT).

“In fact, a much lower proportion were likely to achieve abstinence at 4 weeks (27% quit compared with 42% of people who took single NRT).”

Only two-thirds of people seen in a GP practice by a health-care practitioner who claimed to be quit were actually validated to be so.

“Only two-thirds of people seen in a GP practice by a health-care practitioner who claimed to be quit were actually validated to be so.”

Cessation at 4 weeks was associated with white (non-British) compared with Asian, aOR 2.5 (95% CI 1.1 to 5.5).

“white (non-British) compared with Asian, aOR 2.5 (95% CI 1.1 to 5.5)”

Cessation at 4 weeks was associated with determination to quit, aOR 2.3 (95% CI 1.7 to 3.0).

“determination to quit, aOR 2.3 (95% CI 1.7 to 3.0)”

Quit rates were similar regardless of the route by which people got to the service.

“The quit rates were similar regardless of the route by which people got to the service.”

Clients who gave a saliva sample were significantly less likely to quit at 4 weeks.

“These clients were significantly less likely to quit at 4 weeks.”

If just looking at periods when the specialists and level 2 providers were actually recruiting, 9% of quit attempts were included in the ELONS study.

“if we just look at periods when the specialists and level 2 providers were actually recruiting, 9% of quit attempts were included in the ELONS study.”

Specialists were more likely to see permanently sick/unemployed clients (23% of specialist clients compared with 14% of level 2 clients; p < 0.001).

“permanently sick/unemployed (23% of specialist clients compared with 14% of level 2 clients; p < 0.001)”

The youngest age groups were most likely to be introduced through friends and family (22% compared with 11% or below for the other age groups; p < 0.001).

“The youngest age groups were most likely to be introduced through friends and family (22% compared with 11% or below for the other age groups; p < 0.001).”

Only 5% of clients had heard about the service through marketing.

“Only 5% of clients had heard about the service through marketing.”

The 'all cases' database contained quit attempts with quit dates at the nine study sites from March 2012 to March 2013 (n = 71,800).

“The 'all cases' database contained quit attempts with quit dates that took place at the nine study sites from March 2012 to March 2013 (the months where any ELONS study client set a quit date; n = 71,800).”

Quit rates were higher among those who were more determined to quit.

“However, quit rates were higher among those who were more determined to quit.”

Combination NRT varied between 66% and 3% between study sites (p < 0.001).

“Combination NRT varied between 66% and 3% between study sites (p < 0.001).”

The more occasions that medication was recorded as being taken, the more likely clients were to quit [68% who had medication recorded on three or more occasions quit compared with 26% who took medication on one or two occasions and 17% where medication was not recorded (p < 0.001)].

“the more occasions that medication was recorded as being taken, the more likely clients were to quit [68% who had medication recorded on three or more occasions quit compared with 26% who took medication on one or two occasions and 17% where medication was not recorded (p < 0.001)]”

Clients who received group support had significantly higher quit rates, 12.1% (95% CI 10.5% to 13.8%), compared with clients who received support from a GP practice or pharmacy service, 5.1% (95% CI 2.8% to 9.3%).

“Clients who received group support had significantly higher quit rates, 12.1% (95% CI 10.5% to 13.8%) compared with clients who received support from a GP practice or pharmacy service, 5.1% (95% CI 2.8% to 9.3%).”

Men were more likely to be introduced by referral from a GP practice (21% compared with 17% of women; p < 0.001).

“Men were more likely to be introduced by referral from a GP practice (21% compared with 17% of women; p < 0.001).”

Cessation at 4 weeks was associated with lower dependence on tobacco, aOR 1.3 (95% CI 1.1 to 1.5).

“lower dependence on tobacco, aOR 1.3 (95% CI 1.1 to 1.5)”

Most clients (87%) were seen by a specialist practitioner.

“Most clients (87%) were seen by a specialist practitioner.”

The more sessions a client attended, the better the 4-week outcome (97% of clients who attended at least nine sessions reported a quit at 4 weeks compared with just 16% of clients who attended two sessions; p < 0.001).

“The more sessions a client attended, the better the 4-week outcome (97% of clients who attended at least nine sessions reported a quit at 4 weeks compared with just 16% of clients who attended two sessions; p < 0.001)”

Differences in medication, dependence on tobacco, social network and support from a spouse or partner did not reach significance for short-term quit rates.

“Differences in medication, dependence on tobacco, social network and support from a spouse or partner did not reach significance for short-term quit rates.”

Varenicline was the most common type of medication (43% used at least once).

“Varenicline was the most common type of medication (43% used at least once).”

Clients who attended open groups were significantly more likely to quit than clients who attended specialist one-to-one sessions.

“Clients who attended open groups were significantly more likely to quit than clients who attended specialist one-to-one sessions.”

Cessation at 4 weeks was associated with attending services in the New Year, aOR 1.5 (95% CI 1.1 to 2.2).

“Cessation at 4 weeks was associated with: attending services in the New Year, aOR 1.5 (95% CI 1.1 to 2.2)”

In the longer term, at 52 weeks, quit rates were higher among older people [mean age of quitters 46.8 years (95% CI 44.4 to 49.2 years) compared with a mean age of 43.3 years (95% CI 42.5 to 44.1 years) for non-quitters].

“In the longer term, at 52 weeks, quit rates were higher among older people [mean age of quitters 46.8 years (95% CI 44.4 to 49.2 years) compared with a mean age of 43.3 years (95% CI 42.5 to 44.1 years) for non-quitters].”

Quit rates were higher among those whose social network was less populated with smokers, 9.1% (95% CI 7.5% to 10.9%) compared with 3.4% (95% CI 2.6% to 4.4%).

“Quit rates were higher among those whose social network was less populated with smokers, 9.1% (95% CI 7.5% to 10.9%) compared with 3.4% (95% CI 2.6% to 4.4%).”

Clients with higher levels of well-being when they began their quit attempt were more likely to quit than those with lower well-being [mean well-being score was 59.3 out of 100 (95% CI 56.5 to 62.1) compared with 52.7 out of 100 (95% CI 51.4 to 53.9) for non-quitters].

“Clients with higher levels of well-being when they began their quit attempt were more likely to quit than those with lower well-being [mean well-being score was 59.3 out of 100 (95% CI 56.5 to 62.1) compared with 52.7 out of 100 (95% CI 51.4 to 53.9) for non-quitters].”

Specialists were more likely to see clients with a higher proportion of smokers among friends and family (23% compared with 16% all or most of friends and family smoke; p = 0.031).

“higher proportion of smokers among friends and family (23% compared with 16% all or most of friends and family smoke; p = 0.031).”

Clients of level 2 providers were less likely to have a heart/blood/circulation condition (2% of level 2 clients compared with 8% of specialist clients; p = 0.002).

“and were less likely to have a heart/blood/circulation condition (2% of level 2 clients compared with 8% of specialist clients; p = 0.002).”

Cessation at 4 weeks was associated with support from a spouse or partner, aOR 1.3 (95% CI 1.1 to 1.5).

“support from a spouse or partner, aOR 1.3 (95% CI 1.1 to 1.5)”

Cessation at 4 weeks was associated with older age, aOR 1.032 (95% CI 1.026 to 1.039).

“older age, aOR 1.032 (95% CI 1.026 to 1.039)”

Cessation at 4 weeks was associated with higher levels of well-being, aOR 1.004 (95% CI 1.000 to 1.007).

“higher levels of well-being, aOR 1.004 (95% CI 1.000 to 1.007)”

Cessation at 4 weeks was associated with taking varenicline, aOR 1.6 (95% CI 1.4 to 1.9).

“taking varenicline, aOR 1.6 (95% CI 1.4 to 1.9)”

There were marked variations in medication type and frequency by study site.

“There were marked variations in medication type and frequency by study site.”

5% of qualifying quit attempts that were made in the nine study sites were included in the ELONS study.

“Thus, 5% of qualifying quit attempts that were made in the nine study sites were included in the ELONS study.”

Clients who attended open groups had the highest ORs of quitting in the short term at 4 weeks, aOR 1.5 (95% CI 1.0 to 2.2).

“clients who attended open groups had the highest ORs of quitting in the short term, at 4 weeks, aOR 1.5 (95% CI 1.0 to 2.2).”

People who used combination NRT were no more likely to quit than those using a single form of NRT.

“People who used combination NRT (taking two or more forms of NRT in the same week and never single NRT) were no more likely to quit than those using a single form of NRT.”

Specialists were more likely to see clients with high dependency on tobacco (6% of specialist clients compared with 5% of level 2 clients scored highest on dependence and 5% of specialist clients compared with 6% of level 2 clients scored lowest on the dependence scale; p = 0.007).

“high dependency on tobacco (6% of specialist clients compared with 5% of level 2 clients scored highest on dependence and 5% of specialist clients compared with 6% of level 2 clients scored lowest on the dependence scale (p = 0.007)”

The Glasgow evaluation had a lower CO-validated quit rate than the ELONS study.

“The Glasgow evaluation had a lower CO-validated quit rate.”

95% of CO-validated quitters vs 91% of quit but not CO validated had a CO-validation test at each session.

“Carbon monoxide-validated quitters were slightly more likely to state that they had a CO-validation test at each session than those quit but not CO validated (95% vs. 91%).”

The highest level of satisfaction with supportiveness was among respondents who attended open groups (70% very satisfied).

“The highest level of satisfaction with supportiveness was among respondents who attended open groups (70% very satisfied).”

About half the sample were recorded as only taking medication on one occasion.

“In addition, about half the sample were recorded as only taking medication on one occasion.”

88% of quitters vs 79% of non-quitters felt they would be welcomed back.

“Although the majority of respondent's thought they would be welcomed back, quitters were slightly more likely to say they would be welcomed (88% vs. 79%).”

Helpfulness of information about medication was lower in site 1 (84%) than other sites (or site groups) analysed where over 90% agreed that information about medication was helpful.

“Helpfulness of information about medication was lower in site 1 (84%) than other sites (or site groups) analysed where over 90% agreed that information about medication was helpful.”

96% of respondents would recommend the SSS to other smokers who want to stop smoking.

“In addition, nearly all respondents (96%) said that they would recommend the SSS to other smokers who want to stop smoking.”

Clients whose quit attempt began in the New Year were more likely to quit than those who started during the summer holiday period, aOR 1.7 (95% CI 1.0 to 2.9).

“Clients whose quit attempt began in the New Year were more likely to quit than those who started during the summer holiday period, aOR 1.7 (95% CI 1.0 to 2.9).”

Number of occasions on which NRT was recorded did not have a significant impact on quit rates.

“Number of occasions on which NRT was recorded did not have a significant impact on quit rates”

94% of quitters vs 90% of non-quitters reported being given written information.

“The majority of respondents were given written information, however, those who had stopped smoking by 4 weeks were slightly more likely to report that they had been given written information (94% vs. 90%).”

Clients who at any point took more than one form of NRT on one occasion (combination NRT) were significantly less likely to quit at 4 weeks.

“Clients who at any point took more than one form of NRT on one occasion (thus combination NRT) were significantly less likely to quit at 4 weeks.”

Adherence was much more strongly associated with cessation at 4 weeks than at 52 weeks.

“Adherence was much more strongly associated with cessation at 4 weeks than 52 weeks.”

Starting a quit attempt while taking varenicline is associated with 1-year abstinence, aOR 1.7 (95% CI 1.3 to 2.3).

“Starting a quit attempt taking varenicline was also associated with abstinence in the longer term, aOR 1.7 (95% CI 1.3 to 2.3).”

89% were satisfied or very satisfied with support from SSS staff.

“Respondents were either satisfied or very satisfied with support from SSS staff (89%).”

Similar proportions of clients taking varenicline were recorded taking medication on one or two occasions and on three or more occasions.

“Similar proportions were recorded taking varenicline on one or two occasions and three or more occasions.”

86% found having their CO checked at every visit helpful or very helpful.

“Finally, 86% found having their CO checked at every visit helpful or very helpful.”

There was no evidence that men were more likely to maintain abstinence than women.

“There was no evidence that men were more likely to maintain abstinence than women.”

The vast majority of clients who quit at 4 weeks attended for four sessions.

“Note that the vast majority of clients who quit at 4 weeks did attend for four sessions.”

For every year of age, clients were more likely to quit, aOR 1.011 (95% CI 1.002 to 1.020).

“For every year of age, clients were more likely to quit, aOR 1.011 (95% CI 1.002 to 1.020).”

The odds of quitting were twice as high for clients who received support on a one-to-one basis from a specialist adviser, aOR 2.3 (95% CI 1.2 to 4.6).

“the odds of quitting were twice as high for clients who received support on a one-to-one basis from a specialist adviser, aOR 2.3 (95% CI 1.2 to 4.6).”

Having a social network with fewer smokers is associated with higher odds of quitting, aOR 2.0 (95% CI 1.4 to 2.9).

“Clients whose social network included fewer smokers were more likely to quit, aOR 2.0 (95% CI 1.4 to 2.9).”

Positive feedback was more likely among quitters than non-quitters.

“Perhaps not surprisingly, positive feedback was more likely among 'quitters' (i.e.respondents who had a successful quit attempt at 4 weeks) than 'non-quitters'.”

Only 9% of all service clients in the nine study areas were recruited.

“Only a small proportion (9%) of all service clients in the nine study areas were recruited.”

87% of CSS respondents were very satisfied or satisfied with the SSS overall.

“Clients were asked for their overall opinion of the SSS, with 87% saying they were either very satisfied or satisfied.”

Quit rates of clients who took varenicline on three or more occasions were significantly higher than the quit rates of clients who took combination NRT on one to two occasions or clients who took single NRT on three or more occasions.

“Quit rates of clients who took varenicline on three or more occasions were also significantly higher than the quit rates of clients who took combination NRT on one to two occasions or clients who took single NRT on three or more occasions.”

Taking stop smoking medication and attending support sessions (adherence) was significantly associated with smoking cessation, more so at 4 weeks than at 1 year.

“Taking stop smoking medication and attending support sessions (described here as 'adherence') was significantly associated with smoking cessationmore so at 4 weeks than at 1 year.”

Clients who took varenicline on three or more occasions were significantly more likely to quit than clients who took varenicline on one or two occasions.

“but clients who took varenicline on three or more occasions were significantly more likely to quit than clients who took varenicline on one or two occasions.”

73% of quitters vs 63% of non-quitters found the CO test very helpful.

“Among those who had taken a CO-validated test at each session (see Table 34), quitters were more likely to say it was very helpful than non-quitters (73% vs. 63%).”

96% of quitters said they would return compared with 89% of non-quitters.

“There was a small but significant difference: 96% of quitters said they would return compared with 89% of non-quitters.”

The individual practitioner had a significant influence, at least on short-term quit rates.

“Both the ELONS study secondary analysis and prospective data sets revealed that the individual practitioner had a significant influence, at least on short-term quit rates.”

87% of respondents were very satisfied or satisfied with the support received.

“Satisfaction with the support received was also high; 87% of respondents were either very satisfied or satisfied with the support they received.”

CO-validated quitters were slightly more likely to be very satisfied with the services overall (64% vs 51%).

“Those who were CO validated as having stopped smoking were slightly more likely to be very satisfied with the services overall (64% vs. 51%)”

Lower tobacco dependence is associated with significantly higher odds of quitting at 1 year, aOR 1.5 (95% CI 1.1 to 1.9).

“Clients who were less dependent on tobacco were significantly more likely to quit, aOR 1.5 (95% CI 1.1 to 1.9).”

31% were contacted by the SSS before their first appointment to encourage and motivate them to attend.

“One-third (31%) were contacted by the SSS before their first appointment to encourage and motivate them to attend”

More-affluent clients were more likely to have stopped smoking at 1 year, aOR 1.4 (95% CI 1.1 to 1.9) than less-affluent clients.

“More-affluent clients were more likely to have stopped smoking at 1 year, aOR 1.4 (95% CI 1.1 to 1.9) than less-affluent clients.”

96% of quitters vs 89% of non-quitters found information about medication helpful.

“Of those who had stopped smoking, 96% found information about medication helpful compared with 89% of those who had not.”

Compared with clients who received support from either a GP practice or pharmacy service, the odds of quitting were three times higher for those who received group support, aOR 3.4 (95% CI 1.7 to 6.7).

“Compared with clients who received support from either a GP practice or pharmacy service, the odds of quitting were three times higher for those who received group support, aOR 3.4 (95% CI 1.7 to 6.7)”

Higher well-being is associated with increased odds of 1-year smoking abstinence, with an adjusted odds ratio of 1.007 per 1-point increase on the well-being scale (95% CI 1.0003 to 1.013).

“Clients who had higher levels of well-being were more likely to be abstinent from smoking at 1 year.Thus for every increase of 1 on the well-being scale (range 0-100), clients were more likely to be non-smokers, aOR 1.007 (95% CI 1.0003 to 1.013).”

The majority of clients who took either only single NRT or only combination NRT were recorded taking medication on one or two occasions.

“The majority of clients who took either only single NRT or only combination NRT were recorded only taking medication on one or two occasions.”

Cessation at 4 weeks was associated with low levels of smoking among friends and family, aOR 1.2 (95% CI 1.0 to 1.5).

“or low levels of smoking among friends and family, aOR 1.2 (95% CI 1.0 to 1.5).”

Support from a spouse or partner for the quit attempt is associated with significantly higher odds of 1-year abstinence, aOR 1.4 (95% CI 1.0 to 1.8).

“Clients whose quit attempt was supported by a spouse or partner were significantly more likely to be abstinent at 1 year, aOR 1.4 (95% CI 1.0 to 1.8).”

Drop-off from attending sessions among ELONS clients was steady, with a little over 10% of the sample not returning following each session.

“As Table 23 shows, drop-off among the ELONS study clients from attending sessions was steady: a little over 10% of the sample did not return following each session.”

The difference between men and women in 4-week cessation was not significant.

“The difference between men and women was not significant.”

68% of quitters were very satisfied with staff supportiveness versus 54% of non-quitters.

“Of the quitters, 68% were very satisfied with staff supportiveness versus 54% of non-quitters.”

High SES was associated with baseline well-being; the most affluent clients had well-being scores 4 points higher than the most disadvantaged clients.

“Other factors with significant associations with well-being at baseline were high SES, with the most affluent clients having well-being scores that were 4 points higher than the most disadvantaged clients.”

Site 8 clients were most likely to be unsure about CO validation or find it unhelpful (13% vs 9% average in other sites).

“Clients in site 8 were most likely to say that they were unsure about CO validation or they found it unhelpful or very unhelpful (13% compared with an average of 9% in all other sites).”

Clients who arrived at the SSS and who had higher levels of well-being at the start of their quit attempt were significantly more likely to be non-smokers at 4 weeks and 52 weeks.

“Clients who arrived at the SSS and who had higher levels of well-being at the start of their quit attempt were significantly more likely to be non-smokers at 4 weeks and 52 weeks.”

• AssumptionRests on an assumption: The WHO-5 Well-being Index is a valid measure of well-being.

Clients who did not manage to quit for 4 weeks had lower well-being at baseline than those who quit.

“Clients who did not manage to quit for 4 weeks had lower well-being at baseline than those who quit (Figure 7).”

Age had a U-shaped relationship with well-being, where well-being was poorest in those aged 45-54 years compared with clients aged 16-24 years and 65-85 years.

“Age had a U-shaped relationship with well-being, where well-being was poorest in those aged 45-54 years compared with clients aged 16-24 years and 65-85 years.”

Attrition in the well-being scores of clients with an absence of mental health conditions was particularly marked when the item 'I feel in control' was added to the model.

“Attrition in the well-being scores of clients with an absence of mental health conditions was particularly marked when the item 'I feel in control' was added to the model.”

The mean well-being at baseline of 52-week quitters was higher than those who did not manage to quit for 52 weeks.

“In addition, the mean well-being at baseline of 52-week quitters was higher than those who did not manage to quit for 52 weeks.”

Clients aged 45 to 54 years had lower well-being scores than younger and older clients at all three time points, although differences were not always significant.

“Clients aged 45 to 54 years had lower well-being scores than younger and older clients at all three time points, although differences were not always significant.”

• AssumptionRests on an assumption: The WHO-5 Well-being Index is a valid measure of well-being.

At 1 year after the quit date, only the ontological security items and being abstinent from smoking at 52 weeks were associated with well-being.

“At 1 year after the quit date, only the ontological security items [I enjoy a challenge, I can do what I want when I want, I feel in control, I feel safe, I worry about things going wrong (reversed), I feel I'm doing well in life, My life has a sense of routine] and being abstinent from smoking at 52 weeks were associated with well-being (see Tables 38 and 47).”

Analysis of client satisfaction between quitters and non-quitters, SSS location and behavioural support types revealed some small but significant differences.

“Analysis of client satisfaction between quitters and non-quitters, SSS location and behavioural support types revealed some small but significant differences:”

• Also stated in: § Satisfaction with services · plain

  “Analysis of client satisfaction between quitters and non-quitters, SSS location and behavioural support types revealed some small but significant differences.”

If ontological security items were not entered, then low dependence on tobacco, no mental health issues, and spouse and partner support were significantly associated with well-being.

“If ontological security items were not entered, then dependence on tobacco (low dependence), no mental health issues, and spouse and partner support were significantly associated with well-being”

Well-being among those who stopped smoking remained higher than that of continuing smokers at all measurement points.

“In addition, well-being among those who stopped smoking remained higher than that of continuing smokers at all measurement points.”

• AssumptionRests on an assumption: The WHO-5 Well-being Index is a valid measure of well-being.

Attrition in the well-being coefficients of the youngest and oldest clients, the highest SES groups and those who had a spouse/partner supporting their quit attempt was particularly marked when the item 'I'm doing well in life' was added to the model.

“Attrition in the well-being coefficients of the youngest and oldest clients, the highest SES groups and those who had a spouse/partner supporting their quit attempt was particularly marked when the item 'I'm doing well in life' was added to the model.”

For cotinine values, greater dependence at baseline was associated with an increase in cotinine levels (p = 0.047).

“For cotinine values, greater dependence at baseline was associated with an increase in cotinine levels (p = 0.047).”

Long-term use was relatively rare with fewer than 1 in 10 participants still using non-combustible nicotine products at 12-months follow-up (8.4%, 95% CI 6.4% to 11.0%; n = 50).

“However, long-term use was relatively rare with fewer than 1 in 10 participants still using non-combustible nicotine products at 12-months follow-up (8.4%, 95% CI 6.4% to 11.0%; n = 50).”

Of clients followed up, 61.5% (95% CI 58.4% to 64.6%, n = 583) claimed that they had used NRT during their initial quit attempt.

“Of clients followed up, 61.5% (95% CI 58.4% to 64.6%, n = 583) claimed that they had used NRT during their initial quit attempt.”

Our prospective study results were broadly comparable with those from routinely collected data from services.

“Our prospective study results were broadly comparable with those from routinely collected data from services.”

Baseline nicotine dependence was the only other significant predictor (p < 0.001).

“Baseline nicotine dependence was the only other significant predictor (p < 0.001).”

Generally, there were few differences between those clients who had relapsed between the 4-week and 12-month follow-up and those who had remained abstinent in terms of their NRT use.

“Generally, there were few differences between those clients who had relapsed between the 4-week and 12-month follow-up and those who had remained abstinent in terms of their NRT use (see Figure 8a).”

Among 3000 smokers attending SSSs in nine areas of England, just over 4 in 10 (41.2%) were biochemically validated as abstinent from smoking at 4 weeks post quit date.

“Among 3000 smokers attending SSSs in nine areas of England, we found that just over 4 in 10 (41.2%) were biochemically validated as abstinent from smoking at 4 weeks post quit date.”

After taking into account multiple comparisons, quitters who used NRT at follow-up did not differ from any other group.

“and after taking into account multiple comparisons, quitters who used NRT at follow-up, did not differ from any other group.”

Those who had stopped smoking at follow-up and were still using NRT had higher baseline cotinine levels than other groups.

“Those who had stopped smoking at follow-up and were still using NRT had higher levels than other groups.”

Cessation rates identified in this study were lower at both 4 and 52 weeks than in our previous research conducted over a decade ago as part of a 'national' evaluation of the services in England shortly after they were established.

“Cessation rates identified in this study were lower at both 4 and 52 weeks than in our previous research conducted over a decade ago as part of a 'national' evaluation of the services in England shortly after they were established.17,18”

• cites [17] Judge, 2005, The English smoking treatment services: short-term outcomes, Addiction sourceNot checked yet

  Not checked in the free run.

• cites [18] Ferguson, 2005, The English smoking treatment services: one-year outcomes, Addiction sourceNot checked yet

  Not checked in the free run.

There was no discernible impact of either smoking status or NRT use on alpha-amylase activity.

“By contrast, there was no discernible impact of either smoking status or NRT use on alpha-amylase activity (see Figure 9b).”

The overall differences in baseline cotinine became barely significant when adjusting for potential confounders (age, gender, ethnicity, occupation, any medical condition and nicotine dependence; p = 0.245).

“However, these overall differences in baseline cotinine became barely significant when adjusting for potential confounders (age, gender, ethnicity, occupation, any medical condition and nicotine dependence; p = 0.245)”

In the longer term, fewer than 8% of smokers were still abstinent from smoking 1 year after setting a quit date with their local service.

“In the longer term, we found that fewer than 8% of smokers were still abstinent from smoking 1 year after setting a quit date with their local service.”

There were no differences as a function of NRT use and smoking status at follow-up in baseline levels of alpha-amylase (p = 0.956).

“There were no differences as a function of NRT use and smoking status at follow-up in baseline levels of alpha-amylase (p = 0.956).”

Over and above an expected main effect of smoking status (p < 0.001), there was a significant NRT use by smoking status interaction (p = 0.021).

“In addition, over and above an expected main effect of smoking status (p < 0.001), there was a significant NRT use by smoking status interaction (p = 0.021).”

We found several examples of good practice where SSSs have offered more than they are required to do by national service standards.

“In addition, we found several examples of good practice where SSSs have offered more than they are required to do by national service standards.96”

• cites [96] Department of Health, 2012Not checked yet

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Consistent with other studies, smoking cessation outcomes varied significantly between different groups of people who accessed SSSs.

“Consistent with other studies, we found that smoking cessation outcomes varied significantly between different groups of people who accessed SSSs.”

In the ELONS sample, 6% reported using NRT at 1 year post quit date.

“with 6% of our sample reporting using NRT at 1 year and 2.9% using e-cigarettes at 1 year post quit date.”

In the ELONS sample, 2.9% reported using e-cigarettes at 1 year post quit date.

“with 6% of our sample reporting using NRT at 1 year and 2.9% using e-cigarettes at 1 year post quit date.”

Clients who managed to stop smoking in the ELONS study and who completed the well-being survey were more likely to agree that they felt in control.

“Clients who managed to stop smoking in the ELONS study and who completed the well-being survey were more likely to agree that they felt in control.”

• AssumptionRests on an assumption: The WHO-5 Well-being Index is a valid measure of well-being.
• AssumptionRests on an assumption: The ontological security items measure ontological security.

As other studies have found, the odds of maintaining a quit attempt increased with age.

“As other studies have found, the odds of maintaining a quit attempt increased with age.89,90”

• cites [89] Hymowitz, 1997, Predictors of smoking cessation in a cohort of adult smokers followed for five years, Tob Control sourceNot checked yet

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• cites [90] Osler, 1998, Psychosocial, behavioural, and health determinants of successful smoking cessation: a longitudinal study of Danish adults, Tob Control sourceNot checked yet

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Important differences in outcomes between forms of behavioural support were also identified.

“Important differences in outcomes between forms of behavioural support were also identified.”

GP practice clients were least comfortable with CO testing.

“GP practice clients were least comfortable with CO testing.”

Drop-ins did not result in as positive cessation outcomes as other types of support types.

“In addition, we found that drop-ins (i.e.where people can simply drop-in to see a SSS practitioner without an appointment) did not result in as positive cessation outcomes as other types of support types.”

Positive well-being at baseline significantly predicted abstinence from smoking 1 year later.

“Positive well-being at baseline significantly predicted abstinence from smoking 1 year later.”

• AssumptionRests on an assumption: The WHO-5 Well-being Index is a valid measure of well-being.

Complete substitution of cigarettes with non-combustible nicotine products long term was just below 10% among NHS SSS clients.

“However, complete substitution of cigarettes with non-combustible nicotine products long term was less common, at just below 10%.”

Over one in five NHS SSS clients who achieved short-term abstinence reported continuing to use NRT beyond the standard treatment length of 3 months.

“We found that over one in five NHS SSS clients who achieved short-term abstinence reported continuing to use NRT beyond the standard treatment length of 3 months.”

Concurrent long-term use of NRT among SSS clients in the study who relapsed to smoking was less than 4%.

“Concurrent long-term use of NRT among SSS clients in the study who have relapsed to smoking, reflecting partial substitution, was much lower, at less than 4%.”

Smokers supported to quit with specialist services (including group behavioural support and one-to-one support from a specialist) were more likely to have stopped smoking in the longer term.

“We found that smokers supported to quit with specialist services (including group behavioural support and one-to-one support from a specialist) were more likely to have stopped smoking in the longer term.”

Clients who were more dependent on tobacco at baseline had lower well-being at all three time measurement points.

“Clients who were more dependent on tobacco at baseline had lower well-being at all three time measurement points.”

• AssumptionRests on an assumption: The WHO-5 Well-being Index is a valid measure of well-being.

At 1 year, a number of client characteristics were associated with either maintaining abstinence or having relapsed to smoking.

“At 1 year, for example, a number of client characteristics were associated with either maintaining abstinence of having relapsed to smoking.”

Those who stopped smoking did tend to have higher well-being than non-quitters at all time points.

“Those who stopped smoking did tend to have higher well-being than non-quitters at all time points.”

• AssumptionRests on an assumption: The WHO-5 Well-being Index is a valid measure of well-being.

More disadvantaged clients were less likely to remain abstinent from smoking at 1 year, as our previous work and that of others has shown.

“More disadvantaged clients were less likely to remain abstinent from smoking at 1 year, as our previous work and that of others has shown.18,91,92”

• cites [18] Ferguson, 2005, The English smoking treatment services: one-year outcomes, Addiction sourceNot checked yet

  Not checked in the free run.

• cites [91] Hiscock, 2010, Social inequalities in quitting: what factors mediate the relationship between socioeconomic position and smoking cessation?, J Public Health sourceNot checked yet

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• cites [92] Hiscock, 2011, Socio-economic status and smoking: a review, Ann N Y Acad Sci sourceNot checked yet

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Use of NRT while smoking did not appear to increase overall nicotine intake.

“The longer-term NRT study found that use of NRT while smoking did not appear to increase overall nicotine intake.”

CO-validated quit rates were significantly lower among clients with a mental health condition (p = 0.014).

“| p-value | - | - | = 0.005 | = 0.014 |”

From the prospective study of just over 3000 smokers attending SSSs in nine areas of England, 41.2% were biochemically validated as abstinent from smoking at 4 weeks post quit date.

“From our prospective study of just over 3000 smokers attending SSSs in nine areas of England, we found that just over 4 in 10 (41.2%) were biochemically validated as abstinent from smoking at 4 weeks post quit date.”

Smokers supported to quit with the specialist service were more likely to stop smoking in the longer term.

“For example, smokers supported to quit with the specialist service were more likely to stop smoking in the longer term.”

The cross-sectional analysis did not detect a significant increase in cotinine levels among ex-smokers using NRT compared with those not using NRT.

“Although the cross-sectional analysis did not detect a significant increase in cotinine levels among ex-smokers using NRT compared with those not using NRT, the within-group analysis suggests that virtually all baseline nicotine may be replaced by NRT among long-term ex-smokers.”

Just fewer than 8% of smokers were still abstinent from smoking 1 year after setting a quit date with their local service.

“We found that just fewer than 8% of smokers were still abstinent from smoking 1 year after setting a quit date with their local service.”

There was no evidence that use of NRT (either concurrently or among ex-smokers) was associated with an increase in alpha-amylase, a biomarker of stress response used as a proxy for potential harm.

“Moreover, there was no evidence that use of NRT (either concurrently or among ex-smokers) was associated with an increase in a biomarker of stress response, alpha-amylase, used as a proxy here to signal potential harm.”

Smokers who had higher levels of well-being when they first started attending services were more likely to be non-smokers at 4 weeks and 1 year later.

“We found that assessment of well-being using a standard set of questions could be included in routine monitoring and that smokers who had higher levels of well-being when they first started attending services were more likely to be non-smokers at 4 weeks and 1 year later.”

In the 4-week analysis, combination NRT was not as effective as other medication forms.

“This may explain some of the differences between the 4-week results that go against the findings of previous studies, 7,17 in particular our findings around combination NRT not being as effective as other medication forms.”

• cites [7] Brose, 2011, What makes for an effective stop-smoking service?, Thorax sourceNot checked yet

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• cites [17] Judge, 2005, The English smoking treatment services: short-term outcomes, Addiction sourceNot checked yet

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Our results do not suggest that NRT use leads to an increased intake compared with continued smoking.

“Our results do not suggest that NRT use leads to an increased intake compared with continued smoking.”

Rolling groups resulted in better longer-term outcomes than other forms of behavioural support.

“In addition, the ELONS study builds on previous research that shows that longer-term outcomes are influenced by the type of behavioural support a smoker receivesrolling groups resulted in better outcomes than other forms of behavioural support.”

Long-term NRT use was associated with continuing high cotinine levels among ex-smokers.

“In contrast, it was associated with continuing high cotinine levels among ex-smokers.”

Long-term use of NRT among former SSS clients who remained abstinent was not uncommon compared with concurrent use among smokers.

“Its long-term use among former SSS clients who remained abstinent was not uncommon compared with concurrent use among smokers.”

Quit rates increased with the number of sessions attended (p < 0.001).

“| p-value | - | - | < 0.001 | < 0.001 |”

Concurrent use of NRT among smokers did not appear to increase their nicotine intake.

“Moreover, confirming previous research, 67,112 the concurrent use of NRT among smokers did not appear to increase their nicotine intake.”

• cites [67] Beard, 2011, Is use of nicotine replacement therapy while continuing to smoke associated with increased nicotine intake? Evidence from a population sample, Psychopharmacology sourceNot checked yet

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• cites [112] Fidler, 2011, Variation in saliva cotinine as a function of self-reported attempts to reduce cigarette consumption, Psychopharmacology sourceNot checked yet

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In adjusted analyses, having support from spouse/partner was associated with higher 4-week (OR 1.3, 95% CI 1.1 to 1.5) and 52-week (OR 1.4, 95% CI 1.0 to 1.8) CO-validated quit than other.

“| Support from spouse/partner | 1550 | 50.7 | 1.3 (1.1 to 1.5) | 1.4 (1.0 to 1.8) |”

In the null model, practitioner-level variance for CO-validated quit was 0.54 (95% CI 0.51 to 0.58).

“(constant) | (0.20 to 0.53) | (0.51 to 0.58) | (0.07 to 0.20) | (0.38 to 0.43) | (1.03 to 2.63) | (1.23 to 1.42) |”

In adjusted analyses, being very/extremely determined to quit was associated with higher 4-week CO-validated quit (OR 2.3, 95% CI 1.7 to 3.0).

“| Very/extremely determined | 2729 | 89.3 | 2.3 (1.7 to 3.0) | Did not enter |”

Across 40 PCTs, the mean self-report quit rate was 50.0% (SD 8.9%).

“| Self-report quit | 50.0% (8.9%) -0.133 0.414 | 0.505 | 0.001 | 0.735 < 0.001 | 0.675 < 0.001 |”

Sick/unemployed people made up a higher proportion of clients seen at a dedicated SSS shop/stall (33% vs ≤28% at other locations; p<0.001).

“l Sick/unemployed people made up a higher proportion of clients seen at a dedicated SSS shop/stall (33% of a dedicated SSS shop/stall clients were sick/unemployed compared with ≤ 28% at other locations; p < 0.001).”

In adjusted analyses, one-to-one specialist behavioural support was associated with higher 52-week CO-validated quit than GP practice or pharmacy service (OR 2.3, 95% CI 1.2 to 4.6).

“| One-to-one specialist | 1131 | 37.0 | N/A | 2.3 (1.2 to 4.6) |”

After including all fixed effects, practitioner-level variance for CO-validated quit was 0.49.

“| Multivariable model | 0.34 | 0.49 | 0.13 | 0.36 | 1.47 | 0.71 |”

Among CO-verified quitters with no self-reported NRT use, 31 of 141 (22.2%) had cotinine values above the usual cut-off level of 15 ng/ml to identify smokers.

“Of the sample of CO-verified quitters with no self-reported NRT use (n = 141), this means that 31 (22.2%) had values above the usual cut-off level of 15 ng/ml to identify smokers.”

In the prospective study, CO-validated quit rates differed significantly by self-assessment of health (p = 0.002).

“| p-value | - | - | < 0.001 | = 0.002 |”

Across 40 PCTs, the mean CO-validated quit rate was 35.9% (SD 9.7%).

“| CO-validated quit | 35.9% (9.7%) -0.204 0.207 | 0.845 | < 0.001 | 0.439 0.005 | 0.716 < 0.001 |”

In adjusted analyses, group specialist behavioural support was associated with higher 52-week CO-validated quit than GP practice or pharmacy service (OR 3.4, 95% CI 1.7 to 6.7).

“| Group specialist | 652 | 21.3 | N/A | 3.4 (1.7 to 6.7) |”

After including all fixed effects, PCT-level variance for CO-validated quit was 0.34.

“| Multivariable model | 0.34 | 0.49 | 0.13 | 0.36 | 1.47 | 0.71 |”

In adjusted analyses, having 0-1 indicators of low SES was associated with higher 4-week (OR 1.3, 95% CI 1.1 to 1.6) and 52-week (OR 1.4, 95% CI 1.1 to 1.9) CO-validated quit than having 2-5 indicators.

“| 0-1 indicators of low SES | 1123 | 36.7 | 1.3 (1.1 to 1.6) | 1.4 (1.1 to 1.9) |”

Across 40 PCTs, the mean impact (CO validated) was 152 (SD 144).

“| Impact (CO validated) 152 (144) | 0.218 | 0.177 | 1 | - | 0.657 < 0.001 | 0.919 < 0.001 |”

Medical conditions were not predictors of either short- or long-term quitting.

“The analysis presented below suggests that well-being at baseline was a predictor of abstinence from smoking in the short and longer term, but medical conditions were not.”

• Also stated in: § Additional information · hedged

  “This analysis suggested that none of the medical conditions variables predicted either short-or long-term quitting.”

CO-validated quit rate was significantly correlated with CO-validated impact (r = 0.845, p < 0.001).

“| CO-validated quit | 35.9% (9.7%) -0.204 0.207 | 0.845 | < 0.001 | 0.439 0.005 | 0.716 < 0.001 |”

Well-being at baseline was a predictor of abstinence from smoking in the short and longer term.

“The analysis presented below suggests that well-being at baseline was a predictor of abstinence from smoking in the short and longer term, but medical conditions were not.”

In the null model, PCT-level variance for CO-validated quit was 0.36 (95% CI 0.20 to 0.53).

“(constant) | (0.20 to 0.53) | (0.51 to 0.58) | (0.07 to 0.20) | (0.38 to 0.43) | (1.03 to 2.63) | (1.23 to 1.42) |”

CO-validated quit rates differed significantly by Heaviness of Smoking Index score (p = 0.049).

“| p-value | - | - | < 0.001 | = 0.049 |”

Well-being at baseline approximately followed a normal distribution.

“Well-being at baseline approximately followed a normal distribution.”

In adjusted analyses, having half or fewer friends/family who smoke was associated with higher 4-week (OR 1.2, 95% CI 1.0 to 1.5) and 52-week (OR 2.0, 95% CI 1.4 to 2.9) CO-validated quit than other.

“| Half or fewer smoke | 2286 | 74.8 | 1.2 (1.0 to 1.5) | 2.0 (1.4 to 2.9) |”

CO-validated quit rates differed significantly by prescription charge status (p < 0.001).

“| p-value | - | - | < 0.001 | < 0.001 | - | < 0.001 |”

CO-validated quit rates were significantly higher among clients with a heart/blood/circulation condition (p < 0.001).

“| p-value | - | - | = 0.017 | < 0.001 |”

Self-report quit rate was significantly correlated with self-report impact (r = 0.735, p < 0.001).

“| Self-report quit | 50.0% (8.9%) -0.133 0.414 | 0.505 | 0.001 | 0.735 < 0.001 | 0.675 < 0.001 |”

CO-validated quit rates were significantly higher among clients who used some form of support in their latest previous attempt (p = 0.003).

“| p-value | - | - | = 0.001 | = 0.003 |”

Client and service characteristics were associated with well-being at baseline, 4 weeks and 12 months.

“Tables 46 and 47 present multivariable linear regression results, presenting client and service characteristics that were associated with well-being at baseline, 4 weeks and 12 months.”

Well-being at baseline was a predictor of both short-term and long-term quitting.

“Well-being at baseline was a predictor of both short-and long-term quitting (see Chapters 6 and 8).”

A higher proportion of dedicated SSS shop/stall clients were in the youngest age group than was true for all other settings except for well-being centres (18% vs 19% well-being centre vs ≤11% at other locations; p<0.001).

“l A higher proportion of dedicated SSS shop/stall clients were in the youngest age group than was true for all other settings except for well-being centres (18% dedicated SSS shop/stall clients and 19% well-being centre clients compared with ≤ 11% at other locations; p < 0.001).”

Findings from the study team's earlier studies with NHS Stop Smoking Services suggest that group interventions may be more effective in practice.

“Findings from our earlier studies with NHS SSSs suggest that group interventions may be more effective in practice 24 but that smokers, given a choice, will choose one-to-one support.”

• cites [24] McEwen, 2006, Effectiveness of specialist group treatment for smoking cessation vs. one-to-one treatment in primary care, Addict Behav sourceNot checked yet

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If the ELONS results are applied to all of England, then in the year 2012-13 the services supported 36,249 clients to become non-smokers for the remainder of their lives.

“If these results are applied to all of England, then we estimate that in the year 2012-13 the services supported 36,249 clients to become non-smokers for the remainder of their lives.”

• AssumptionRests on an assumption: The 1-year abstinence rate observed in the ELONS prospective cohort is representative of all NHS Stop Smoking Services clients in England.
• AssumptionRests on an assumption: Clients who are abstinent at 1 year will remain non-smokers for the remainder of their lives.