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Once upon a time, smoking was considered to be good for you. Ads proclaimed its health benefits and it was a universally accepted habit.

Now the only ads you see are about its harmful effects. And every New Year's Day, people all over the world resolve to quit. But although the desire can be strong, it's not easy, and many smokers find themselves in an endless cycle of giving up and restarting.

One in five deaths in the UK is down to smoking, and 106,000 people die here every year from smoking-related illnesses. With treatment for such illnesses a huge burden on the NHS, it's no surprise the Department of Health (DoH) has a vested interest in being persistent about the preventive benefits of giving up.

Although it already had a tobacco information campaign called Don't Give Up Giving Up in place, it found itself wanting to do more by 2003. Its own research found the main problem was a lack of continuing support, so the DoH enlisted government communication specialist COI and its director of direct and relationship marketing, Marc Michaels, and senior DRM manager Julia Edwards.

Reason to talk

With creative agency Partners Andrews Aldridge on board, it decided on a CRM-type programme that would support quitters every step of the way for six months. "With attitude or behavioural change, you can't do it in one hit," Michaels explains. "And we have to create those excuses for interaction."

So COI created the Together programme: alongside regular mailings, this gives people the option of support via email, SMS, the web, callbacks and the NHS smoking helpline. "We knew we couldn't make people give up - but once they'd decided for themselves, we could help them," says Steve Aldridge, creative director at Partners Andrews Aldridge.

This multi-channel, multi-intervention approach was a new departure for the DoH, and Michaels was keen to find out if it would prove more successful than previous TV-centric efforts in terms of recruiting more smokers and helping them quit in a more cost-effective fashion.

DoH research had found that many smokers keep on trying to give up: 80 per cent of those who called the NHS smoking helpline promoted in the Don't Give Up Giving Up TV ads had tried to do so five times before.

As well as providing support, the aim was to use the programme to give people the skills they needed to give up. But the next challenge was how to get the message across without patronising people. It was vital to get the tone of communications right, and that meant no finger-wagging.

"Advertising is usually all stick and not much carrot," says Michaels. "It's emotional, in your face and scary. But this is of limited value if you don't get support and follow-up."

So rather than using the words of doctors to get the message across, Michaels and Aldridge decided to use ex-smokers. "It was real people talking, real ex-smokers," says Aldridge. "People on the programme related to it and did not feel patronised."

With a pilot launch date of 9 January 2003, the first step was to get people on board, and acquisition activity started in December 2002. The Together programme was publicised in a host of ways, including TV ads and web pop-ups. A door drop went out to regions with higher than average numbers of smokers, and a mailing went out to people who had contacted the helpline before, as well as to prospects from the Postal Preference Service.

Point-of-sale materials were displayed in doctors' surgeries, health centres and libraries. All activity drove people to advisers at the end of a helpline, who set up a stop date for each caller. Crucially, the programme revolved around the individual's stop-date - people weren't sent the same mailing at the same time.

Communications continued for six months for the simple reason that many potential quitters have started smoking again by that time.

Michaels and the DoH had also established that people who attempt big behavioural changes go through various stages, and understanding what these were was vital to the programme.

States of change

This was where the cancer researcher James Prochaska's 'stages of change' model came in handy. This argues that people go through various stages when they change their behaviour: pre-contemplation - before they've even started thinking about giving up - contemplation, preparation, action and maintenance. The communications were based around these stages. "The whole premise of the campaign is that we know this is hard, but it doesn't matter if you do start again because you will eventually succeed," says Michaels.

Everything was carefully timed to hit each individual at each stage of the process. "It had to be done cost-effectively, but we weren't going to batch-process stuff because the individual journey is paramount," Michaels says.

Once a stop date was set, the preparation stage began, with participants receiving a mailing congratulating them on their decision and advising them on what to do next. For those who opted into receiving SMS, email and callback communications, messages went out a week before the stop date, then three days before. Two days before the stop date, they received a survival mailing, preparing them for the next four weeks by explaining what they'll be going through and how to deal with it. On the stop date itself, a good-luck text, email or callback went out.

For those who had opted in, the motivational messages began at two days, one week and three weeks after the stop date. After a month, a double-fronted 'How's it going?' mailing went out - one half addressed those who had stopped, the other the restarters. This was followed by a 'maintenance' mailing at the three-month mark.

Here, a survey enabled the DoH to check how people were doing, with a relapse postcard going out to those who had restarted, offering them the chance to set a new stop date. "People did tell us when they failed," says Aldridge. "That's the nature of the programme."

Finally, at six months, participants received a survey to help them evaluate their progress and to enable the DoH to evaluate the success of the pilot.

"Each element on its own is sort of nothing," says Aldridge. "Each one is a foot soldier in an army. You get the pack and the next day you get a text message referring you back to it. A phone call will then summarise this and bring the message forward to talk to you about the next phase. All 22 pieces of contact were crucial."

The results were carefully measured. "Everyone was focused on ROI, for want of a better word," says Michaels. "We knew the uplifts we'd have to achieve, and it was worth putting extra resources into an individual who had put their hand up."

The proof is in the results. About 15,000 people set stop dates; after six months, 32 per cent of those who had opted into multimedia communications were still non-smokers, and one cell achieved a 49 per cent quit rate. Michaels hit his other targets too, and now has his eye on rolling the programme out fully.

"We reduced cost per acquisition and cost per conversion, and showed it can generate non-smokers," he says. "We're well armed to go forward: the department has the proposal, and we're expecting to press ahead."

A job worth doing

Not only has the programme been a success, but for Michaels and Aldridge it's been a job well worth doing. "There was no evidence it was going to work," says Michaels. "We couldn't believe it wouldn't, but it was a risk - we were asking the department to give money for a pilot when there was no evidence that multiple interventions would impact on the cessation rate."

But it paid off. Michaels says: "It reduces the burden on the NHS and saves lives. Thousands have - and will have - a better quality of life thanks to the programme.

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