What are tobacco quitlines?
Quitlines are telephone-based tobacco cessation services. Since the late 1980's, quitlines have been established in many countries, states and provinces. Most are accessed through a toll-free telephone number and provide a combination of services including educational materials, referral to local programs, and individualized telephone counseling. Counselors answer callers' questions about the cessation process and help them develop an effective plan for quitting.
Reactive quitlines only respond to incoming calls. Proactive quitlines handle incoming calls and also follow up the initial contact with additional outbound calls, to help initiate a quit attempt or to help prevent relapse. In some cases, as when smokers give consent in their doctors' offices to be called by a counselor, the contact is entirely proactive. Proactive telephone counseling has been shown to have a marked effect on callers' probability of success in quitting and in maintaining long-term abstinence from tobacco use, comparable to the effects of pharmacotherapies.
Where are they available?
Brazil, Iran, New Zealand, South Africa, many European countries, some countries in Asia, and most Australian, Canadian, and U.S. states and provinces have publicly financed quitlines. Some employers and private health insurers provide quitlines for their employees and members. Many new quitlines have been set up in recent years, as evidence of their efficacy has become more solid and as tobacco control programs worldwide have become more common. Quitlines vary greatly in scale and sophistication.
Why have quitlines become popular?
Easy access. Traditionally, tobacco users have faced various barriers in accessing cessation services, including:
- Sporadic availability, geographically and over time
- Transportation difficulties
- Childcare responsibilities
- Financial cost of participating.
Quitlines reduce these barriers by allowing users to access service from their own homes at a time that is convenient for them, and usually at no cost to themselves. Partly for these reasons, surveys have shown that tobacco users are much more likely to use telephone-based services than face-to- face programs.
Benefits of centralization. Because it provides services over the telephone, a quitline can serve a large geographic area from a single, centralized base of operations. So unlike traditional cessation programs in which it is common for participants to have to wait until a group forms, quitlines are able to operate year-round, often with extended hours of business and multilingual capabilities.
The benefits of centralization include:
- Economies of scale, leading to more efficient utilization of counseling resources
- Standardized training
- Better quality control
- Ease of evaluation.
Ease of promotion. Most comprehensive tobacco control programs include a media component designed to counteract the effects of tobacco industry advertising. This key part of successful anti-tobacco programs can be very costly, necessitating prudent spending decisions. Media programs are a convenient way to promote cessation services, since advertisements can carry a single telephone number and air across a wide area. This is more efficient than promoting an array of local programs, each with its own method of accessing service. And quitlines can refer callers to local programs as appropriate, thus serving both as a direct cessation service provider and as a hub of coordinated services.
Strong evidence of quitline efficacy
Reactive quitlines: Two studies support use of a reactive quitline in the context of a comprehensive tobacco control program. A California study found that a well-promoted quitline providing a single comprehensive counseling session of about 50 minutes increased quit attempts and reduced relapse, relative to an intervention of self-help materials alone (Zhu et al. 1996). Counties in New York State where a quitline was promoted had significantly higher quit rates than those without such promotion, even though the majority of evaluated quitters did not access the service, indicating that quitline promotion in itself may increase cessation on a population level (Ossip-Klein et al. 1991).
Proactive quitlines: The evidence for proactive quitlines is more thorough. Several meta-analytical reviews have established that proactive telephone counseling is an effective intervention for smoking cessation (Lichtenstein et al. 1996, Fiore et al. 2000, Hopkins et al. 2001, Stead et al.
2004). The most recent of these examined 13 studies of proactive interventions and found that callers who received counseling were successful at least 50% more often than those who only received self-help materials (odds ratio of 1.56) (Stead et al. 2004). The U.S. Public Health Clinical Practice Guideline and the Guide to Community Preventive Services recommend proactive quitlines as a way to help smokers quit (Fiore et al. 2000, Hopkins et al. 2001).
A large randomized, controlled trial (n=3,030) that served as the basis for the California Smokers' Helpline, the first publicly supported, statewide quitline, found that telephone counseling increased the percentage of smokers making a quit attempt and decreased the rate of relapse for those
attempts, and found a strong dose-response relationship between the level of intended treatment intensity (i.e., number of follow-up sessions) and the treatment effect (Zhu et al. 1996).
Further research has demonstrated the continued effectiveness of the California quitline after it scaled up to statewide operation (Zhu et al. 2002). Borland et al. (2001) found similar results for a quitline service in Victoria, Australia. These studies increase confidence that the efficacy found in clinical trials can carry over to "real world" settings. With the efficiencies inherent in centralized, telephone-based operations, quitlines appear to be a cost-effective way to deliver cessation assistance (McAlister et al. 2004).
Quitlines as part of comprehensive tobacco control programs
Most quitlines are supported by state or national health agencies, through tobacco taxes or other public funds. They are often the government's chief or only contribution to providing direct tobacco cessation services, with the rest of its tobacco control funding earmarked for other efforts such
as educating people about the harm caused by tobacco use, preventing initiation of tobacco use among young people, and reducing exposure to second hand smoke. If resources were not available to make progress in these areas, it is doubtful that a quitline alone would be a worthwhile investment of public health funds. But in the context of comprehensive tobacco control efforts, a quitline can help to advance larger goals of the program, such as normalizing cessation and eliminating disparities in tobacco use or access to treatment.
The range of services provided: Quitline callers have a wide range of expectations, so most well established quitlines offer a wide range of services. Adult smokers wanting help to quit are the most common callers, but there are also those who are not yet ready to quit, or who have already quit. There are smokers of cigarettes, cigars, and pipes, and callers who use chewing tobacco or other smokeless tobacco. There are callers of all ages, including minors, and callers who speak different languages. In all of these categories, some want counseling; others just want printed information or referral. Some callers have particular needs such as learning more about smoking while pregnant, or quitting tobacco while managing a psychological condition such as bipolar disorder or schizophrenia. There are non-tobacco-users calling on behalf of friends and family members, and health care professionals or others trying to decide whether to refer their patients, students, or neighbors. Comprehensive quitlines develop protocols, resources, and staff training for each situation.
Evidence-based structured protocols guide the flow of counseling sessions and remind counselors of topics considered to affect quitting success. Counselors using clinically validated protocols help clients to:
- Clarify and enhance their motivation to quit
- Boost their self-efficacy for quitting
- Identify situations that will trigger an urge to use tobacco, and plan effective strategies for getting through them without tobacco
- Identify ways to get the social support they need
- Commit to a quit date, often with counselor follow-up for accountability and extra support.
Staffing: Quitlines are staffed to meet demand, which is largely determined by the intensity and timing of promotion. Rather than staying open around the clock, most quitlines focus their resources on peak daytime and evening hours. The staffing plan must take into account both the overall demand for service over time, and the demand at any given moment, especially during the "bursts" of calls that occur when mass media advertisements are aired. For new quitlines, the number of staff required may be calculated by estimating the likely number of callers, which in turn may be done by comparing the promotional plan with similar campaigns elsewhere. Most quitlines require between 30 minutes and two hours of counselor time per caller, depending on the intensity and number of counseling sessions provided. Maintaining a balance between counselors' productivity and their availability for incoming calls is one of the main challenges of quitline operations, but one which becomes more manageable as the scale grows.
When recruiting counselors, it is helpful to keep in mind that most of the evidence for the efficacy of quitlines is based on the work of paraprofessional counselors using structured protocols, indicating that postgraduate education and licensure are not necessary. Instead of graduate training, most quitlines look for candidates with natural counseling skills such as empathy, reflective listening, and the ability to guide clients through a structured problemsolving process. These skills are crucial to quitline quality and effectiveness.
Training and supervision: A quitline's training program is another key to assuring quality in its services. At a minimum, a good training program addresses:
- The psychology of tobacco use and the process of habit formation, maintenance, and extinction
- General principles of counseling and motivational interviewing
- Effective counseling techniques for behavior modification
- Challenging counseling scenarios, such as crisis calls and callers with psychiatric issues
- Multicultural counseling
- Effective case management practices, including use of protocols
- Health issues related to tobacco use and cessation
- NRT and other quitting aids.
Following up the initial training with a regular program of continuing education helps counselors continuously develop their skills and ensures that their knowledge of the field is up to date.
Besides providing training, quitline supervisors and managers oversee coverage of incoming calls, effective case management, and productivity. They monitor and debrief sessions and make sure the services provided are helpful, appropriate, and factually accurate. They also ensure the program's compliance with applicable laws and ethical guidelines governing the provision of telephone counseling.
Evaluation: Successful and sustainable quitline operation requires rigorous evaluation. Baseline data include, at a minimum, how callers heard about the quitline, demographic variables such as age, ethnicity, and education, type of tobacco used and level of consumption. Process data include percentage of calls answered live and number of callers (especially members of target populations) receiving each type of service. Follow-up data include quit status, length of abstinence, and satisfaction with quitline services. For quitlines serving large numbers of callers, following up a randomly selected sample is adequate. It may not be feasible or even desirable for every quitline to conduct its own clinical trial to ensure efficacy, but all quitline funding should include an allocation for program evaluation to address key questions:
- What contribution is the quitline making to the overall tobacco control program?
- Is it successful in reaching target populations, especially high-risk and underserved groups?
- Are callers satisfied with services received?
- What percentages of callers make a quit attempt, and maintain abstinence (e.g., for 6 months)?
- Are the results comparable to other published outcomes?
It is important when citing results to identify clearly any characteristics of the population that received service that may have had a bearing on their success, and to address whether and why any participants were excluded from the analysis.
Promotion: Increasing public awareness of quitline services can be done in various ways. Mass media advertising - television, radio, newspapers, billboards, and other media - usually plays a central role in promotion. Successful mass media campaigns identify their target audience and do thorough marketing research before launching ads. Cultural and linguistic appropriateness is especially important. Low-cost promotional strategies have been successfully used in some countries, such as requiring manufacturers to print the quitline telephone number on cigarette packages. Health care providers are natural partners for quitlines and can play a major role in increasing their utilization. Providers who ask all patients whether they use tobacco, advise quitting, and refer patients to quitlines for comprehensive cessation counseling can have a profound impact on patient health. Therefore many quitlines make special efforts to build linkages with health care providers. As with mass media advertising, promoting quitlines through health care systems not only generates calls and helps callers quit, but also increases cessation among people who do not call the quitline.
Technology: A robust and scalable telephone system greatly facilitates operations by allowing quitlines to:
- Queue calls and route them to counselors according to pre-established priorities
- Monitor calls
- Track and report on performance (e.g., percentage of calls answered live)
- Expand capacity as needed.
Information systems are very important to the smooth functioning of proactive quitlines, which over time may serve hundreds of thousands of callers, each receiving service spread out over several calls, in some cases with different counselors. Computer networks and databases must be able to store sufficient information on all contacts with individual callers to ensure a seamless delivery of services. Integration of the communication and information systems, using off-the-shelf Computer Telephony Integration (CTI) software, can greatly enhance efficiency. Other technologies have the potential to expand the range of services offered. Interactive Voice Response (IVR) systems, for example, allow callers to access personalized automated messages based on information they provide. Other emerging options include web-based interfaces, integration with email, and sending text messages or even images and short films to cell phone users.
Costs: The costs of establishing and running a quitline can vary widely. Communications and information systems can be a significant start-up cost, although fairly inexpensive options with limited functionality are available. The two largest ongoing expenses are usually for promotion and staffing. The U.S. Centers for Disease Control and Prevention recommend that new quitlines spend as much money on promotion in the first couple of years as on all other direct costs combined. (Quitline promotion, it should be remembered, not only generates calls to the quitline but also promotes cessation in the general population.) Over time, the cost for promotion may stabilize or even decrease as the quitline builds referral relationships with organizations and individuals in the community. Staffing costs, on the other hand, tend to increase steadily over the years.
Steps in setting up a quitline
- Assess the need for cessation services in the population, considering the prevalence of tobacco use in various communities and their readiness to respond to cessation messaging.
- Determine how direct provision of service fits into the overall plan for decreasing tobacco use in the population.
- Identify a reliable funding source and determine a funding level appropriate to the quitline's intended role in the overall tobacco control program. Tobacco taxes, where available, are a commonly used resource for quitlines.
- Determine a budget and strategies for promotion. Promotional budgets that are roughly equivalent to operational budgets are common.
- Create a competitive process to select a quitline operator. A Request for Proposals (RFP) process, in which the funding agency provides a thorough description of the quitline services to be provided and invites proposals from interested parties, is common.
- Create a similar process for selecting a media contractor. Require both contractors to coordinate their activities with each other.
- Write contracts with the selected providers that include firm deadlines for delivery of service.
- Closely monitor the contracts to ensure adherence to standards and deadlines. Perform ongoing evaluation to ensure the quitline's effectiveness and continued relevance to the overall tobacco control program.
Careful planning, an adequate budget, and rigorous evaluation will help ensure a successful quitline.
Key Resources for More Information
Anderson CM, Zhu SH. The California Smokers' Helpline: A Case Study. Sacramento, CA: California Department of Health Services; May 2000.
Borland R, Segan CJ, Livingston PM, Owen N. The effectiveness of callback counselling for smoking cessation: a randomized trial. Addiction. 2001; 96:881-889.
Centers for Disease Control and Prevention. Quitline Resource Guide: Strategies for Effective Development, Implementation, and Evaluation. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004.
European Network of Quitlines: Guide to Best Practice. Available at www.enqonline.org.
Lichtenstein E, Glasgow RE, Lando HA, Ossip-Klein DJ, Boles SM. Telephone counseling for smoking cessation: rationales and metaanalytic review of evidence. Health Education Research: Theory and Practice 1996;1:243-257.
Stead LF, Lancaster T, Perera R. Telephone counselling for smoking cessation (Cochrane Review). In: The Cochrane LibraryIssue 2, 2004.
Chichester, UK: John Wiley & Sons, Ltd. Zhu SH, Anderson CM, Tedeschi GT, Rosbrook B, Johnson CE, Byrd M, Guti¨¦rrez-Terrell E. Evidence of real-world effectiveness of a telephone quitline for smokers. New England Journal of Medicine 2002; 347(14):1087-1093.
Zhu SH, Stretch V, Balabanis M, Rosbrook B, Sadler G, Pierce JP. Telephone counseling for smoking cessation: effects of singlesession and multiple-session intervention.Journal of Consulting and Clinical Psychology 1996; 64:202-211.