Implementation of tobacco cessation quitline practices in the United States and Canada

Reengagement for Long-Term Smoking-Cessation In Military Personnel, Retirees, Family Members (TRICARE): A Randomized Trial

INTRODUCTION

We sought to determine what type of treatment reengagement after smoking relapse would increase long-term cessation.

AIMS AND METHODS

Participants were military personnel, retirees, and family members (TRICARE beneficiaries) recruited across the United States from August 2015 through June 2020. At baseline, consented participants (n = 614) received a validated, four-session, telephonic tobacco-cessation intervention with free nicotine replacement therapy. At the 3-month follow-up, 264 participants who failed to quit or relapsed were offered the opportunity to reengage in cessation. Of these, 134 were randomized into three reengagement conditions: (1) repeat initial intervention ("recycle"), (2) Smoking reduction with eventual cessation goal ("rate reduction"), or (3) Choose #1 or #2 ("choice"). Prolonged abstinence and 7-day point prevalence abstinence were measured at 12 months.

RESULTS

Despite being in a clinical trial advertised as having the opportunity for reengagement, only 51% (134 of the 264) of participants who still smoked at 3-month follow-up were willing to reengage. Overall, participants randomized to recycle had higher prolonged cessation rates at 12 months than rate reduction conditions (OR = 16.43, 95% CI: 2.52 to 107.09, Bonferroni adjusted p = .011). When participants who randomly received recycle or rate reduction were pooled, respectively, with participants who chose recycle or rate reduction in the Choice group, recycle had higher prolonged cessation rates at 12 months than rate reduction (OR = 6.50, 95% CI: 1.49 to 28.42, p = .013).

CONCLUSIONS

Our findings suggest service members and their family members who fail to quit smoking but are willing to reengage in a cessation program are more likely to benefit from repeating the same treatment.

IMPLICATIONS

Finding methods that are both successful and acceptable to reengage people who smoke who want to quit can have a significant impact on improving the health of the public by reducing the portion of the population who smoke. This study suggests that repeating established cessation programs will result in more people ready to quit successfully achieving their goal.

Improving smoking cessation support for Quebec's smokers: an evaluation of Quebec's telephone quitline

INTRODUCTION

Quitlines are an important and widespread intervention that support smokers in their efforts to quit smoking and engage them into treatment services. Quebec's quitline, called "la ligne J'ARRÊTE", has been in operation since 2002. The objectives of this study were to evaluate treatment reach, provide a description of caller characteristics and to provide results on cessation outcome measures for Quebec's smoking cessation quitline.

METHODS

We collected data at intake, assessing new caller volume, caller characteristics and treatment reach. We used a one-group quasi-experimental design to assess 30-day and six-month quit rates, at six-month follow-up. Intake data were collected for 1292 new quitline callers, 18 years of age and older, over a one-year period.

RESULTS

Results indicated that the service reached 9 in 10 000 Quebec smokers. With respect to the total population of smokers in Quebec, the quitline reached proportionately higher numbers of smokers who were women, were 55 years of age and older and had a high school diploma or less. At follow-up, the 30-day point prevalence abstinence rate was 26.7%, while the six-month prolonged abstinence rate was 18.8%.

CONCLUSION

These results indicate that the quitline contributed to helping callers quit smoking. They are in line with findings for other quitlines in Canada and the United States. However, quitline reach is comparatively limited, suggesting that additional investment in promotional efforts and research into ways of recruiting underserved populations into the service would increase public health impact.

The Association between Quitline Characteristics and Smoking Cessation by Educational Attainment, Income, Race/Ethnicity, and Sex

Little research examines how tobacco quitlines affect disparities in smoking cessation in the United States. Our study utilized data from the Tobacco Use Supplement to the Current Population Survey (2010, 2011, 2012, 2015, 2018) (TUS-CPS) and state-level quitline data from the North American Quitline Consortium and National Quitline Data Warehouse. We ran multilevel logistic regression models assessing a state-run quitline's budget, reach, number of counseling sessions offered per caller, and hours of operation on 90-day smoking cessation. Multiplicative interactions between all exposures and sex, race/ethnicity, income, and education were tested to understand potential effect modification. We found no evidence that budget, reach, number of counseling sessions, or hours available for counseling were associated with cessation in the main effects analyses. However, when looking at effect modification by sex, we found that higher budgets were associated with greater cessation in males relative to females. Further, higher budgets and offering more sessions had a stronger association with cessation among individuals with lower education, while available counseling hours were more strongly associated with cessation among those with higher education. No quitline characteristics examined were associated with smoking cessation. We found evidence for effect modification by sex and education. Despite proven efficacy at the individual-level, current resource allocation to quitlines may not be sufficient to improve rates of cessation.

National trends and state-level variation in the duration of incoming quitline calls to 1-800-QUIT-NOW during 2012–2015

Introduction

The duration of incoming quitline calls may serve as a crude proxy for the potential amount of reactive counseling provided.

Aims

To explore whether call duration may be useful for monitoring quitline capacity and service delivery.

Methods

Using data on the duration of incoming quitline calls to 1-800-QUIT-NOW from 2012 through 2015, we examined national trends and state-level variation in average call duration. We estimated a regression model of average call duration as a function of total incoming calls, nationally and by state, controlling for confounders.

Results

From 2012 through 2015, average call duration was 11.4 min, nationally, and was 10 min or longer in 33 states. Average call duration was significantly correlated with quitline service provider. Higher incoming call volume was significantly associated with lower average call duration in 32 states and higher average call duration in five states (P-value <0.05). The relationship between call volume and call duration was not correlated with quitline service provider.

Conclusions

Variation in average call duration across states likely reflects different service delivery models. Average call duration was associated with call volume in many states. Significant changes in call duration may highlight potential quitline capacity issues that warrant further investigation.

The Potential Impact of the New York State Smokers' Quitline on Population-Level Smoking Rates in New York

Receiving smoking cessation services from telephone quitlines significantly increases quit success compared with no intervention or other quitting methods. To affect population-level smoking, quitlines must provide a sufficient proportion of smokers with effective interventions. Nationally, quitlines reach around 1% of adult smokers annually. From 2011 through 2016, the average annual reach of the New York State Smokers' Quitline (NYSSQL) was 2.9%. We used data on the reach and cessation outcomes of NYSSQL to estimate its current impact on population-level smoking prevalence and to estimate how much reach would have to increase to achieve population-level smoking prevalence reductions. We estimate NYSSQL is associated with a 0.02 to 0.04 percentage point reduction in smoking prevalence in New York annually. If NYSSQL achieved the recommended annual reach of 8% (CDC Best Practices) and 16% (NAQC), state-level prevalence would decrease by an estimated 0.07-0.12 and 0.13-0.24 percentage points per year, respectively. To achieve those recommended levels of reach, NYSSQL would need to provide services to approximately 3.5 to 6.9 times more smokers annually. Given their reach, quitlines are limited in their ability to affect population-level smoking. Increasing quitline reach may not be feasible and would likely be cost-prohibitive. It may be necessary to re-think the role of quitlines in tobacco control efforts. In New York, the quitline is being integrated into larger efforts to promote cessation through health systems change.

Factors Predicting Client Re-Enrollment in Tobacco Cessation Services in a State Quitline

Introduction

Quitlines are an integral part of tobacco treatment programs and reach groups of smokers who have a wide range of barriers to cessation. Although tobacco dependence is chronic and relapsing, little research exists on factors that predict the likelihood of clients re-engaging and reconnecting with quitlines for treatment. The objective of this study was to describe factors that predict the re-enrollment of clients in Arizona’s state quitline.

Methods

This was a retrospective analysis of data collected from clients (N = 49,284) enrolled in the Arizona Smokers’ Helpline from January 2011 through June 2016. We used logistic regression to analyze predictors of re-enrollment in services after controlling for theoretically relevant baseline variables (eg, nicotine dependence, smokers in the home) and follow-up variables (eg, program use, quit outcome).

Results

Compared with clients who reported being quit after their first enrollment, clients who reported not being quit were almost 3 times as likely to re-enroll (odds ratio = 2.89; 95% confidence interval, 2.54–3.30). Other predictors were having a chronic condition or a mental health condition, greater nicotine dependence, and lower levels of social support. Women and clients not having other smokers in the home were more likely to re-enroll than were men and clients not living with other smokers.

Conclusion

Understanding baseline and in-program factors that predict client-initiated re-enrollment can help quitlines tailor strategies to proactively re-engage clients who may have difficulty maintaining long-term abstinence.

Comparing the New York State Smokers' Quitline Reach, Services Offered, and Quit Outcomes to 44 Other State Quitlines, 2010 to 2015

PURPOSE

To summarize the reach, services offered, and cessation outcomes of the New York Quitline and compare with other state quitlines.

DESIGN

Descriptive study.

SETTING

Forty-five US states.

PARTICIPANTS

State-sponsored tobacco cessation quitlines in 45 US states that provided complete data to the Centers for Disease Control and Prevention's National Quitline Data Warehouse (NQDW) for 24 quarters over 6 years (2010-Q1 through 2015-Q4).

INTERVENTION

Telephone quitlines that offer tobacco use cessation services, including counseling, self-help materials, and nicotine replacement therapy (NRT), to smokers at no cost to them.

MEASURES

Percentage of adult tobacco users in the state who received counseling and/or free NRT from state quitlines (reach), services offered by state quitlines, and cessation outcomes among quitline clients 7 months after using quitline services.

ANALYSIS

Reach, services offered, and cessation outcomes for the New York Quitline were compared with similar measures for the other 44 state quitlines with complete NQDW data for all quarters from 2010 through 2015.

RESULTS

New York's average annual quitline reach from 2010 through 2015 was 3.0% per year compared to 1.1% per year for the other 44 states examined.

CONCLUSION

Although the New York Quitline was open fewer hours per week and offered fewer counseling sessions and a smaller amount of free NRT than most of the other 44 state quitlines, the New York Quitline had similar quit rates to most of those state quitlines.

SHAPING THE EVOLUTION OF THE INFORMATION FLOW: THE CENTRALIZING MECHANISMS IN THE EVOLUTION OF THE NORTH AMERICAN TOBACCO QUITLINE CONSORTIUM

The research reported here is an analysis of the evolution of the relationships that comprise a single public health network, focusing especially on the position of the network administrative organization (Provan and Kenis, 2008) in the flow of knowledge among a large number of organizations providing similar services. Our study examines the North American Quitline Consortium (NAQC), a multi-sector network that spans the US and Canada and whose members provide telephone-based tobacco cessation services to anyone interested in quitting smoking. Data were collected using web-based surveys at three different points of time. Implications are discussed for network organizing, for both theory and practice, focusing especially on the importance of the network administrative organization in shaping the evolution of the whole network information flow.

Global tobacco prevention and control in relation to a cardiovascular health promotion and disease prevention framework: A narrative review

The purpose of this review is to emphasize the role of tobacco prevention and control in cardiovascular health (CVH) promotion and cardiovascular disease (CVD) prevention, including the importance of these endpoints for measuring the full impact of tobacco-related policies, programs, and practices. In this review, we describe an overview of tobacco control interventions that have led to substantial declines in tobacco use and the relationship between these declines with CVH and CVD. We review interventions that have had success in high-income countries (HICs) as well as those that are gaining traction in low- and middle-income countries (LMICs). We emphasize the challenges to comprehensive tobacco prevention and control strategies faced by LMICs, and highlight the special role of cardiovascular health professionals in achieving CVH promotion and CVD prevention endpoints through tobacco control. Tobacco prevention and control strategies have a strong scientific basis, yet a distinct gap remains between this evidence and implementation of tobacco control policies, particularly in LMICs. Health professionals can contribute to tobacco control efforts, especially through patient-level clinical interventions, when supported by a health care system and government that recognize and support tobacco control as a critical strategy for CVH promotion and CVD prevention. Understanding, supporting, and applying current and evolving policies, programs, and practices in tobacco prevention and control is the province of all health professionals, especially those concerned with CVH promotion and CVD prevention. A new tobacco control roadmap from the World Heart Federation provides a strong impetus to the needed interdisciplinary collaboration.

Global Bridges: Development and Analysis of a Tobacco Treatment Network

The Framework Convention on Tobacco Control (FCTC) set standards for global tobacco control, including the implementation of evidence-based tobacco dependence treatment. However, efforts to implement tobacco treatment programmes globally have been few. In order to expand tobacco treatment expertise and programmes, a new network called Global Bridges (GB) was established. This network provided training in tobacco treatment and opportunities to share best practices on implementation of tobacco dependence treatment and training programmes. In this analysis of the GB network, we found that 75% of the network members attended trainings, 60% disseminated knowledge gained through GB training, and network centralization was high (0.85). These results demonstrate initial success in network implementation, and create a foundation for expanded focus on tobacco treatment globally.

Impact of Canadian tobacco packaging policy on quitline reach and reach equity

OBJECTIVE

To examine the impact of the new Canadian tobacco package warning labels with a quitline toll-free phone number for seven provincial quitlines, focusing on treatment reach and reach equity in selected vulnerable groups.

METHODS

A quasi-experimental design assessed changes in new incoming caller characteristics, treatment reach for selected vulnerable sub-populations and the extent to which this reach is equitable, before and after the introduction of the labels in June, 2012. Administrative call data on smokers were collected at intake. Pre- and post-label treatment reach and reach equity differences were analysed by comparing the natural logarithms of the reach and reach equity statistics.

RESULTS

During the six months following the introduction of the new warning labels, 86.4% of incoming new callers indicated seeing the quitline number on the labels. Treatment reach for the six-month period significantly improved compared to the same six-month period the year before from .042% to .114% (p<.0001) and reach equity significantly improved for young males (p<.0001) and those with high school education or less (p=.004).

CONCLUSIONS

The introduction of the new tobacco warning labels with a quitline toll-free number in Canada was associated with an increase in treatment reach. The toll-free number on tobacco warning labels aided in reducing tobacco related inequalities, such as improved reach equity for young males and those with high school or less education.

Meeting the Tobacco Cessation Coverage Requirement of the Patient Protection and Affordable Care Act: State Smoking Cessation Quitlines and Cost Sharing

OBJECTIVES

We explored whether various key stakeholders considered cost sharing with state telephone-based tobacco cessation quitlines, because including tobacco cessation services as part of the required essential health benefits is a new requirement of the Patient Protection and Affordable Care Act (ACA).

METHODS

We analyzed qualitative data collected from interviews conducted in April and May of 2014 with representatives of state health departments, quitline service providers, health plans, and insurance brokers in 4 US states.

RESULTS

State health departments varied in the strategies they considered the role their state quitline would play in meeting the ACA requirements. Health plans and insurance brokers referred to state quitlines because they were perceived as effective and free, but in 3 of the 4 states, the private stakeholder groups did not consider cost sharing.

CONCLUSIONS

If state health departments are going to initiate cost-sharing agreements with private insurance providers, then they will need to engage a broad array of stakeholders and will need to overcome the perception that state quitline services are free.

Integration of tobacco cessation services into multidisciplinary lung cancer care: rationale, state of the art, and future directions

Tobacco use is the largest risk factor for lung cancer and many lung cancer patients still smoke at the time of diagnosis. Although clinical practice guidelines recommend that all patients receive evidence-based tobacco treatment, implementation of these services in oncology practices is inconsistent and inadequate. Multidisciplinary lung cancer treatment programs offer an ideal environment to optimally deliver effective smoking cessation services. This article reviews best practice recommendations and current status of tobacco treatment for oncology patients, and provides recommendations to optimize delivery of tobacco treatment in multidisciplinary practice.

Improving the continuity of smoking cessation care delivered by quitline services

OBJECTIVES

This study identified smokers' intended use of new quitline features aimed at improving smoking cessation such as having the same quitline advisor for each call, longer-term telephone counselling and provision of additional cessation treatments.

METHODS

Smokers who had previously used quitline counselling completed a computer-assisted telephone interview examining intended use of potential quitline enhancements.

RESULTS

The majority of smokers (61.1%) thought their chances of quitting would have increased a lot/moderately if they had the same quitline advisor for each call. Most smokers reported likely use of longer-term quitline telephone support after a failed (58.3%) or successful (60%) quit attempt. Smokers were likely to use quitline support long-term (mean=9.9 months). Most smokers would be likely to use free or subsidised nicotine replacement therapy (NRT) (74.9%) if offered by quitlines. Younger smokers had greater odds of being likely to use text messages, whereas less educated smokers had greater odds of being likely to use free or subsidised NRT.

CONCLUSIONS

Smokers appear interested in quitlines offering longer-term telephone support, increased continuity of care and additional effective quitting strategies.

PRACTICE IMPLICATIONS

Quitlines could adopt a stepped care model that involves increasingly intensive treatments and extended telephone counselling delivered by the same quitline advisor.