To increase the reach of behavior change apps by implementing electronic signposting for smoking cessation and alcohol reduction in a large, at-risk population that was identified through an acute care hospital electronic health record (EHR).

Project Outline

Smoking and drinking alcohol at risky levels are associated with cancer later on in life.  In England, 15% of adults (17% men and 13% women) smoke cigarettes, and   24% of adults (31% men and 16% women) drink alcohol at risky levels (>14 units per week.  There are services to help people quit smoking and reduce their alcohol consumption, but barriers to accessing these include time to travel and sensitivity of disclosing their smoking or alcohol consumption.  As an alternative, there are digital programs either online or through mobile phones that support people to quit smoking and reduce their alcohol consumption.  But not many people know about these programs and even fewer take advantage of them. 

Digital programs are successful in helping people quit smoking or reduce risky alcohol consumption.  As these programs are available via websites or smartphone applications, they are available at little to no cost and no travel time.  They provide a private form of support for people who would prefer not to speak with their doctor or counselor about these behaviours.  Under their ‘One You’ campaign, Public Health England offers several health apps, which include a Smokefree app for quitting smoking and a Drink Free Days app for encouraging days off drinking.  

Our approach is to use the electronic health record to reach all patients who may benefit from digital programs without adding any time or workload to healthcare professionals and with limited monetary cost to the healthcare system.  We used information in the electronic health record to reach and refer all patients who smoke and/or drink alcohol at risky levels via SMS text-message to Public Health England’s mobile apps for smoking cessation and alcohol consumption.

Key research questions 

  • Objective 1: To establish the feasibility of using the electronic health record to identify adult patients who smoke and/or drink alcohol at risky levels.  We will also determine the characteristics of these patients and the availability of contact details for electronic signposting.
  • Objective 2: To explore the acceptability of receiving electronic signposts that promote smoking cessation and alcohol reduction apps, sent via the electronic health record, before and after messages have been delivered, framed by the Perceived Attributes of eHealth Innovations model, from both patient and staff perspectives.
  • Objective 3: To determine the reach of smartphone apps when promoted by electronic signposts sent via the electronic health care record.  We will also compare the characteristics of people who access the apps with those who do not. 

Research Design and outputs 

This is a multi-phase, mixed method implementation research study: 

Phase 1) Feasibility of sending electronic signposting messages via the EHR will be established by mining the EHR for the number and proportion of eligible participants, their characteristics and contact details; 

Phase 2) Acceptability of sending electronic signposts via the electronic health record was explored using qualitative focus groups before the messages are sent (pre-implementation), and with a quantitative questionnaire after the messages have been sent (post-implementation), both framed by the Perceived Attributes of eHealth Innovations model; 

Phase 3) Reach of apps following promotion in the electronic signposts was determined in a cross-sectional study design.


Settings: The study took place at West Suffolk hospital, based in Bury St. Edmunds, Suffolk, UK.  West Suffolk hospital is an acute hospital that provides short-term care to patients.  It is one of 17 acute NHS Trusts that are internationally recognized providers of exceptional and efficient NHS care via world-class digital technology and information.  

We worked with hospital-based information analysts and the IT team to set-up the automatic messaging system that identifies patients who currently smoke and/or drink alcohol at risky levels.  This system was used to send SMS text-messages that included a link to either the SmokeFree or Drink Free Days app. 


Our electronic signposting strategy used SMS text-messages to promote behavior change apps was found to be acceptable and feasible and had good reach.  

The SMS text-message format was found to be feasible, and the target population was identified by mining the EHR.

Patients and staff contributed to the SMS text-message content and delivery approach, which were perceived as acceptable before and after the delivery of the SMS text-messages.  

The hospital sent 1526 SMS text-messages, signposting patients to either the NHS Smokefree or Drink Free Days apps.  A total of 13.56% (207/1526) of the patients accessed the apps via the SMS text-message, which exceeded our 5% a priori success criterion.  

Our protocol and study findings have been published here:


We have presented the findings at the following conferences:

•    16th International Society of Behavioural Medicine (ISBM) Congress, Virtual, online
     conference, June 2021

•    3rd UK Implementation Science Research Conference, Virtual, online conference, July 2020

•    NCRI National Cancer Research Institute, Glasgow, Scotland, November 2019

West Suffolk Hospital are creating a digital blueprint to disseminate the results of the study directly to a digitally-engaged NHS audience, enabling faster and easier adoption of the innovation and translation of the research into practice.

The research team 

Dr Zarnie Khadjesari (PI) and Tracey Brown (Senior Research Associate)

Dr Lorien Abroms (Department of Prevention and Community Health, George Washington University, Washington DC, USA)
Dr Michael Amato (Truth Initiative, Washington DC, USA)
Dr Sherine Eltoukhy (The National Institute on Minority Health and Health Disparities, The National Institutes of Health, Bethesda, Maryland, USA)
Dr Henry Goodfellow (Department of Primary Care and Population Health, University College London, London, UK)
Dr Helena Jopling (West Suffolk Foundation Trust, Bury St. Edmunds, Suffolk, UK)
Dr Alex Ramsey (Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA)


Cancer Research UK