Use and effectiveness of quitlines versus Web-based tobacco cessation interventions among 4 state tobacco control programs

Predictors of Cessation in Men Using a Tobacco Quitline: A Follow-Up Study

INTRODUCTION

Although the effectiveness of tobacco quitline services for people who smoke cigarettes is well established, less is known about other forms of tobacco. This study aimed to compare quit rates and factors contributing to tobacco abstinence in men reporting dual use (smokeless tobacco and one additional combustible tobacco product), smokeless tobacco use only, and cigarette use only.

METHODS

Self-reported 30-day point-prevalence tobacco abstinence at the 7-month follow-up was calculated in males who registered with the Oklahoma Tobacco Helpline and completed a 7-month follow-up survey (N=3,721) (July 2015-November 2021). Logistic regression analysis completed in March 2023 identified variables associated with abstinence in each group.

RESULTS

Abstinence was reported by 33% in the dual-use group, 46% in the smokeless-tobacco-use-only group, and 32% in the cigarette-use-only group. Eight or more weeks of nicotine replacement therapy provided by the Oklahoma Tobacco Helpline was associated with tobacco abstinence in men who reported dual use (AOR=2.7, 95% CI=1.2, 6.3) and exclusive smoking (AOR=1.6, 95% CI=1.1, 2.3). The use of all nicotine replacement therapy was associated with abstinence in men who used smokeless tobacco (AOR=2.1, 95% CI=1.4, 3.1) and who smoked (AOR=1.9, 95% CI=1.6, 2.3). The number of helpline calls was associated with abstinence in men who used smokeless tobacco (AOR=4.3, 95% CI=2.5, 7.3).

CONCLUSIONS

Men in all three tobacco-use groups who fully utilized quitline services showed a greater likelihood of tobacco abstinence. These findings underscore the importance of quitline intervention as an evidence-based strategy for people who use multiple forms of tobacco.

Smoking Cessation Interventions in Indigenous North Americans: A Meta-Narrative Systematic Review

INTRODUCTION

Indigenous North Americans have the highest cigarette smoking prevalence among all racial and ethnic groups in the United States. We seek to identify effective components of smoking cessation interventions in Indigenous people in the United States associated with favorable cessation outcomes.

METHODS

A review of literature studying smoking cessation interventions in Indigenous North Americans (American Indians and Alaska Natives) from January 2010 through August 2021 was completed. The primary objective of this study was to identify components of interventions associated with positive smoking cessation outcomes in Indigenous people. The studies identified were synthesized in a meta-narrative approach.

RESULTS

Ten studies out of 608 titles were included (6 randomized trials, 2 single-arm studies, 1 cohort study, and 1 prospective observational study). Five categories of smoking cessation interventions were identified; phone or web-based tools, culturally-tailored interventions, the inclusion of Indigenous study personnel, pharmaceutical cessation aids, and behavioral health interventions. Phone and web tools, cultural tailoring, and inclusion of Indigenous personnel conditions inconsistently influenced smoking cessation. Pharmaceutical aids were viewed favorably among participants. Individualized behavioral counseling sessions were effective at promoting smoking cessation, as was input from local communities in the planning and implementation phases of study.

CONCLUSION

A successful smoking cessation intervention in Indigenous North Americans includes Tribal or community input in intervention design and implementation; should provide individualized counseling sessions for participants, and offer access to validated smoking cessation tools including pharmacotherapy.

IMPLICATIONS

This study identifies a paucity of smoking interventions utilizing standard of care interventions in Indigenous North Americans. Standard of care interventions including individualized cessation counseling and pharmacotherapy were effective at promoting cessation. The use of novel culturally tailored cessation interventions was not more effective than existing evidence-based care with the exception of including Tribal and local community input in intervention implementation. Future smoking cessation interventions in Indigenous North Americans should prioritize the use of standard of care cessation interventions.

Engagement and Effectiveness of a Smoking Cessation Quitline Intervention in a Thoracic Surgery Clinic

Importance

Smoking quitline programs effectively promote smoking cessation in outpatient primary care settings.

Objective

To examine the factors associated with smoking quitline engagement and smoking cessation among patients undergoing thoracic surgery who consented to a quitline electronic referral.

Design, Setting, and Participants

A retrospective cohort study was conducted from January 1, 2014, to December 31, 2018, among 111 active smoking patients referred to the quitline from a thoracic surgery outpatient clinic visit. Patients were divided into operative and nonoperative cohorts.

Main Outcomes and Measures

Primary outcomes were engagement rates in the quitline program and successful smoking cessation. Secondary outcomes were self-reported point prevalence abstinence at 1 month and 6 months after the smoking quit date.

Results

Of 111 patients (62 men; mean [SD] age, 61.8 [11.2] years) who had a quitline referral, 58 (52%) underwent surgery, and 32 of these 58 patients (55%) participated in the program. Of the 53 nonoperative patients (48%), 24 (45%) participated in the program. In the operative cohort, there was no difference in the smoking cessation rate between quitline participants and nonparticipants (21 of 32 [66%] vs 16 of 6 [62%]; P = .79) or in point prevalence abstinence at 1 month (23 of 32 [72%] vs 14 of 25 [56%]; P = .27) or 6 months (14 of 28 [50%] vs 6 of 18 [33%]; P = .36). Similarly, in the nonoperative cohort, there was no difference in the smoking cessation rate between quitline participants and nonparticipants (8 of 24 [33%] vs 11 of 29 [38%]; P = .78) or in point prevalence abstinence at 1 month (7 of 24 [29%] vs 8 of 27 [30%]; P = .99) or 6 months (6 of 23 [26%] vs 6 of 25 [24%]; P = .99). Regardless of quitline participation, operative patients had a 1.8-fold higher proportion of successful smoking cessation compared with nonoperative patients (37 of 58 [64%] vs 19 of 53 [36%]; P = .004) as well as a 2.2-fold higher proportion of 1-month point prevalence abstinence (37 of 57 [65%] vs 15 of 51 [29%]; P < .001) and a 1.8-fold higher proportion of 6-month point prevalence abstinence (20 of 45 [44%] vs 12 of 48 [25%]; P = .05). Having surgery doubled the odds of smoking cessation (odds ratio, 2.44; 95% CI, 1.06-5.64; P = .04) and quitline engagement tripled the odds of remaining smoke free at 6 months (odds ratio, 3.57; 95% CI, 1.03-12.38; P = .04).

Conclusions and Relevance

Patients undergoing thoracic surgery were nearly twice as likely to quit smoking as those who did not have an operation, and smoking quitline participation further augmented point prevalence abstinence. Improved smoking cessation rates, even among nonoperative patients, were associated with appropriate outpatient counseling and intervention.

The predictive value of intake questions on informing tailored quitline services

The Minimal Data Set are demographic and tobacco use questions asked during enrollment at many quitlines. We tested whether these questions can be used to predict program engagement and success, and to evaluate whether findings can inform the tailoring of protocols to disparate populations. We analyzed 7,920 Arizona Smokers' Helpline treatment records to test a Structural Equation Model of the mediating effects of quitline services and short-term cessation outcomes on the relationship between intake questions and 7-month quit rate. Education (b = 0.05), gender (b = 0.03), Medicaid (b = −0.09), longest length of previous quit attempt (b = 0.05), confidence in quitting for 24 h (b = 0.04), environmental risk (b = −0.05), and life stress (b = 0.04) all significantly (P < 0.05) predicted engagement in quitline services. Program engagement had a direct effect on an in-program cessation outcomes construct (b = 0.47) and 7-month quit rate (b = 0.44). This in-program cessation outcomes construct had a significant direct effect on 7-month quit rate (b = −0.12). This model showing the relationship between program engagement and outcomes suggests that tailoring protocols can focus on engaging clients who have historically not taken full advantage of quitline services.

Text2Connect: a health system approach to engage tobacco users in quitline cessation services via text messaging

Mobile technology has created the opportunity for health systems to provide low cost tobacco cessation assistance to patients. The goal of the present study was to examine the feasibility and effectiveness of an intervention (Text2Connect) that uses text messages to offer proactive connection to the New York State Smokers' Quitline. The electronic health record at two urban health systems was queried for patients who were current smokers and who had an outpatient visit between March 2015 and February 2016. Smokers (N = 4000) were sent an informational letter. Those who did not opt out (N = 3719) were randomized to one of 6 message sequences in order to examine the effect of theoretically informed message frames on response rates. Participants were sent a series of text messages at baseline and at 1 month and were asked to reply in order to be contacted by the state quitline (QL). After removing 1403 nonworking numbers, texts were sent to 2316 patients, and 10.0% (205/2060) responded with a QL request. Almost one quarter (23.6%, 486/2060) replied STOP and 66.4% (1369/2060) never responded. QL request rates were significantly higher when response efficacy messages were not used (p < .001). There were no differences by message framing on STOP requests (p > .05). The Text2Connect intervention was well accepted with a minority opting out. A 10% QL response rate is noteworthy given that only 5-7 brief outreach text messages were used. Results indicate that simple self-efficacy-focused messaging is most effective at supporting response rates.

Web-Based Tobacco Cessation Interventions and Digital Inequality across US Racial/Ethnic Groups

Introduction

Internet-based tobacco cessation programs have increased in use and popularity in recent years. To examine evidence for racial/ethnic digital inequality in web-only tobacco cessation services offered by US tobacco quitlines, we conducted an analysis of quitline enrollees in five states. We hypothesized that racial/ethnic minorities would demonstrate lower enrollment and utilization of a web-only tobacco cessation program.

Methods

The sample includes enrollees into five state quitlines whose service options included a web-only program in 2015 (N=32,989). Outcomes included web-entry into the quitline, web-only enrollment, establishment of a web account, and the number of times users logged into the program. Regression models tested associations with race/ethnicity.

Results

Compared with Whites, African Americans, Hispanics, American Indians/Alaska Natives, and "others" were less likely to enter the quitline via the web (Ps<.01) and enroll in a web-only (vs counseling) program (Ps<.01). Among web-only program enrollees, all racial/ethnic minority groups were significantly less likely than Whites to establish an online account (Ps<.03), and African Americans were less likely than Whites to log in to the web-only service (P<.01).

Conclusions

This study suggests that digital inequalities exist in web-based tobacco cessation services. Findings have implications for the development and implementation of digital tobacco interventions for racial/ethnic minority communities. The proliferation of digital tobacco interventions could increase disparities, as members of racial/ethnic minority groups may not engage in these interventions.

Implications

The proliferation of digital interventions has the potential to increase tobacco-related disparities, as members of racial/ethnic minority groups may not enroll in, or engage in, such interventions. As the field moves to digitize tobacco interventions, we must remain cognizant of persistent digital inequalities and the potential for widening racial/ethnic tobacco cessation disparities.

Inferring Smoking Status from User Generated Content in an Online Cessation Community

Introduction

User generated content (UGC) is a valuable but underutilized source of information about individuals who participate in online cessation interventions. This study represents a first effort to passively detect smoking status among members of an online cessation program using UGC.

Methods

Secondary data analysis was performed on data from 826 participants in a web-based smoking cessation randomized trial that included an online community. Domain experts from the online community reviewed each post and comment written by participants and attempted to infer the author's smoking status at the time it was written. Inferences from UGC were validated by comparison with self-reported 30-day point prevalence abstinence (PPA). Following validation, the impact of this method was evaluated across all individuals and time points in the study period.

Results

Of the 826 participants in the analytic sample, 719 had written at least one post from which content inference was possible. Among participants for whom unambiguous smoking status was inferred during the 30 days preceding their 3-month follow-up survey, concordance with self-report was almost perfect (kappa = 0.94). Posts indicating abstinence tended to be written shortly after enrollment (median = 14 days).

Conclusions

Passive inference of smoking status from UGC in online cessation communities is possible and highly reliable for smokers who actively produce content. These results lay the groundwork for further development of observational research tools and intervention innovations.

Implications

A proof-of-concept methodology for inferring smoking status from user generated content in online cessation communities is presented and validated. Content inference of smoking status makes a key cessation variable available for use in observational designs. This method provides a powerful tool for researchers interested in online cessation interventions and establishes a foundation for larger scale application via machine learning.

Retrospective reports of former smokers: Receiving doctor's advice to quit smoking and using behavioral interventions for smoking cessation in the United States

The study investigated the over-time changes and racial/ethnic disparities in the quality of health care services for cigarette smoking cessation in the U.S. from 2007 to 2015. The primary measures included receiving a doctor's advice to quit smoking in the year before smoking cessation and using behavioral interventions for smoking cessation (telephone helplines and web-based interventions) while trying to quit smoking. The study was conducted from January to July 2018. We used merged data from the 2010-11 and 2014-15 Tobacco Use Supplement to the Current Population Survey. The sample sizes were 7011 and 12,025, respectively, for the analyses corresponding to two primary measures. The rate of receiving a doctor's advice to quit increased significantly from 66% (SE = 2%) in 2007 to 73% (SE = 4%) in 2015. The rate of usage of telephone helplines or web-based interventions for smoking cessation increased only from 3% (SE = 1%) in 2007 to 5% (SE = 1%) in 2015. These positive trends remained even after adjusting for several important factors. For both measures, the rates were consistently lower among Hispanic smokers than Non-Hispanic Black/African American and White smokers. Despite the availability of states' behavioral interventions for cessation of tobacco use, utilization of these interventions remains very low, indicating that smokers may not be aware of these free resources, may have misconceptions about these interventions being evidence-based, or there are barriers for using these interventions.

The Development and Evaluation of Online Smoking Cessation Services: A Narrative Literature Review

Introduction:The use of quitlines for smoking cessation has contracted, with service providers adapting through the development of comprehensive interactive online smoking cessation services. The primary aim of this review is to investigate the continuum of online cessation services, innovations in design and service components, measures used in formative, process and outcome evaluations, as well as evidence of effectiveness.

Methods:This review includes the peer-reviewed literature, scholarly articles and the grey literature material. Databases searched included: PubMed, Google Scholar, SCOPUS and the Cochrane Collaboration.

Results/findings:56 academic journal articles and the 5 grey literature reports met the inclusion criteria for this review. Developmental stages of online/combination services included: static websites, tailored feedback, email and text services, interactive components, social media, pharmacological offers; as well as social and professional support mechanisms. Innovations in online smoking cessation include: chat rooms, new recruitment strategies, mobile apps, service tailoring and messaging support groups. Online cessation services were significantly cheaper and more popular than quitlines; however, abstinence rates appear higher amongst quitline users.

Conclusions:Three likely catalysts for the shift from quitlines to online services are the rapid development of technology, increased internet access and the general movement of the goods and services sector to digital channels. The challenge for online cessation service providers is to leverage their comparative cost advantage and develop strategies that keep pace, engage users and increase service effectiveness.

Implications:Our paper synthesises a wide-range of the literature that evaluates the effectiveness and scope of online smoking cessation programs. Through applying this literature to the stages of evaluation framework, we also provide one of the first detailed roadmaps towards developing comprehensive evaluation methodology for online smoking cessation services.

Determining non-cigarette tobacco, alcohol, and substance use typologies across menthol and non-menthol smokers using latent class analysis

Background

Substance use and mental health are robustly associated with smoking and poor cessation outcomes, but not often examined in combination with menthol cigarette smoking, which is also associated with lower quit rates. This study identified classes of Black and White menthol and non-menthol cigarette smokers based on demographics, alcohol, drug, and other tobacco use behaviors.

Methods

Using screening data from two studies, latent class analysis (LCA) was conducted to classify n = 1177 menthol and non-menthol cigarette smokers on demographic characteristics, heavy smoking, alcohol and drug use, desire to quit smoking, other tobacco product use, and use of psychotropic medication.

Results

Three latent classes were identified that differentiated smokers on substance use, menthol cigarette smoking, and other tobacco use behavior. One class consisted primarily of young adults who used a wide array of other tobacco products, reported the highest prevalence of other drug use, and showed the lowest desire to quit smoking cigarettes in the next 6-months. Class 2 comprised primarily of Black male menthol smokers, all of whom used cigarillos in addition to cigarettes, and who displayed moderate drug use. The third class was categorized as primarily older cigarette smokers, who engaged in very little other tobacco use or drug use, but who were most likely to self-report being prescribed psychotropic medication.

Conclusions

LCA allowed for the identification of distinct classes of smokers based on factors related to poor cessation outcomes, including menthol use, that have not previously been examined in combination. Interventions should target specific groups of smokers, rather than take a “one size fits all” approach.

The Effect of Tailored Web-Based Feedback and Optional Telephone Coaching on Health Improvements: A Randomized Intervention Among Employees in the Transport Service Industry

Background

Lifestyle-related health problems are an important health concern in the transport service industry. Web- and telephone-based interventions could be suitable for this target group requiring tailored approaches.

Objective

To evaluate the effect of tailored Web-based health feedback and optional telephone coaching to improve lifestyle factors (body mass index—BMI, dietary intake, physical activity, stress, sleep, tobacco and alcohol consumption, disease history, self-perceived health, and motivation to change health habits), in comparison to no health feedback or telephone coaching.

Methods

Overall, 3,876 employees in the Swedish transport services were emailed a Web-based questionnaire. They were randomized into: control group (group A, 498 of 1238 answered, 40.23%), or intervention Web (group B, 482 of 1305 answered, 36.93%), or intervention Web + telephone (group C, 493 of 1333 answered, 36.98%). All groups received an identical questionnaire, only the interventions differed. Group B received tailored Web-based health feedback, and group C received tailored Web-based health feedback + optional telephone coaching if the participants’ reported health habits did not meet the national guidelines, or if they expressed motivation to change health habits. The Web-based feedback was fully automated. Telephone coaching was performed by trained health counselors. Nine months later, all participants received a follow-up questionnaire and intervention Web + telephone. Descriptive statistics, the chi-square test, analysis of variance, and generalized estimating equation (GEE) models were used.

Results

Overall, 981 of 1473 (66.60%) employees participated at baseline (men: 66.7%, mean age: 44 years, mean BMI: 26.4 kg/m²) and follow-up. No significant differences were found in reported health habits between the 3 groups over time. However, significant changes were found in motivation to change. The intervention groups reported higher motivation to improve dietary habits (144 of 301 participants, 47.8%, and 165 of 324 participants, 50.9%, for groups B and C, respectively) and physical activity habits (181 of 301 participants, 60.1%, and 207 of 324 participants, 63.9%, for B and C, respectively) compared with the control group A (122 of 356 participants, 34.3%, for diet and 177 of 356 participants, 49.7%, for physical activity). At follow-up, the intervention groups had significantly decreased motivation (group B: P<.001 for change in diet; P<.001 for change in physical activity; group C: P=.007 for change in diet; P<.001 for change in physical activity), whereas the control group reported significantly increased motivation to change diet and physical activity (P<.001 for change in diet; P<.001 for change in physical activity).

Conclusion

Tailored Web-based health feedback and the offering of optional telephone coaching did not have a positive health effect on employees in the transport services. However, our findings suggest an increased short-term motivation to change health behaviors related to diet and physical activity among those receiving tailored Web-based health feedback.