Ten Million Calls and Counting: Progress and Promise of Tobacco Quitlines in the U.S.

Abstract

In 2019, an unheralded but remarkable milestone was achieved—the National Network of Tobacco Cessation Quitlines (1-800-QUIT NOW) received its 10 millionth call.11-800-Quit-Now: 15 years of helping people quit. Centers for DiseaseControl and Prevention. https://www.cdc.gov/tobacco/features/quitlines/15th-anniversary/index.html. Updated October 7, 2019. Accessed 14 April 2020.Google Scholar This evidence-based treatment, currently available in all 50 states, the District of Columbia, Puerto Rico, and Guam, has helped millions of smokers since its inception. The history of the development of this population-based approach to reducing tobacco use deserves recounting and analysis as it provides both a model for implementing other bold public health actions and clues to how quitlines can have even greater impact. This commentary in this theme issue of the American Journal of Preventive Medicine describes the establishment of the United States Tobacco Quitline Network, reviews the current status and effectiveness of state-based quitlines, and explores the potential of quitlines to accelerate the elimination of tobacco use in the U.S. In 2002, the HHS Secretary, Tommy Thompson, established the Subcommittee on Cessation, the first and only subcommittee of the HHS Interagency Committee on Smoking and Health. Secretary Thompson challenged the subcommittee to develop recommendations to markedly increase rates of tobacco cessation in the U.S. Among its 10 key recommendations, the subcommittee proposed that HHS establish a National Network of Tobacco Cessation Quitlines—a single nationwide 1-800 portal providing uniform access to the state quitlines in existence at that time. The National Network of Tobacco Cessation Quitlines now provides telephone cessation services to individuals in all states and in the District of Columbia, Puerto Rico, and Guam, ensuring broad access to this evidence-based treatment option. This nationwide effort was launched in 2004 with funding from the U.S. Centers for Disease Control and Prevention and NIH via the National Cancer Institute, which together contributed approximately $50 million in initial funding for 1-800-QUIT NOW. The National Cancer Institute manages and supports the telecommunication costs associated with 1-800-QUIT NOW. The Centers for Disease Control and Prevention provides funding to state quitlines as part of its National Tobacco Control Program.2CDC. Frequently asked questions about 1-800-QUIT-NOW and theNational Network of Tobacco Cessation quitlines. https://www.cdc.gov/tobacco/quit_smoking/cessation/pdfs/faq-1800-quit-now-factsheet-p.pdf. Published 2018. Accessed April 14, 2020.Google Scholar This launch followed a recommendation from the Subcommittee on Cessation of the United States Interagency Committee on Smoking or Health that was asked to propose policies that would markedly enhance tobacco cessation and thereby decrease smoking rates in America.3Fiore MC Croyle RT Curry SJ et al.Preventing 3 million premature deaths and helping 5 million smokers quit: a national action plan for tobacco cessation.Am J Public Health. 2004; 94: 205-210https://doi.org/10.2105/ajph.94.2.205Crossref PubMed Scopus (187) Google Scholar State quitlines share core characteristics that have advanced the chief goal set by Secretary Thompson, to increase tobacco cessation in the U.S. They are science-based, and research over the past 2 decades shows that quitlines consistently increase a smoker's likelihood of successfully quitting. A U.S. Public Health Service Clinical Practice Guideline meta-analysis in 20084Fiore MC Jaén CR Baker TB et al.Treating tobacco use and dependence: 2008 update. HHS, U.S. Public Health Service, Rockville, MD2008https://www.ncbi.nlm.nih.gov/books/NBK63952/Google Scholar documented that quitlines increased overall quit rates by about 60% when compared with minimal counseling, no counseling, or self-help. Moreover, these analyses showed that effectiveness was further enhanced when U.S. Food and Drug Administration–approved smoking cessation medications were also provided to callers. Finally, quitlines are highly cost effective.5Hollis JF McAfee TA Fellows JL Zbikowski SM Stark M Riedlinger K The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline.Tob Control. 2007; 16: i53-i59https://doi.org/10.1136/tc.2006.019794Crossref PubMed Scopus (150) Google Scholar,6Fellows JL Bush T McAfee T Dickerson J Cost effectiveness of the Oregon quitline “free patch initiative”.Tob Control. 2007; 16: i47-i52https://doi.org/10.1136/tc.2007.019943Crossref PubMed Scopus (42) Google Scholar In fact, their cost effectiveness compares favorably with other population-based strategies such as digital interventions and hypertension and cholesterol control strategies. A review of 6 studies by the Community Preventive Services Task Force7Tobacco use: quitline interventions. Community Preventive ServicesTask Force. https://www.thecommunityguide.org/findings/tobacco-use-and-secondhand-smoke-exposure-quitline-interventions. Updated August 12, 2020. Accessed September 10, 2020.Google Scholar showed that the median cost per quality adjusted life year (QALY) saved via quitline counseling was $2,358 and that adding nicotine-replacement therapy to quitline counseling increased this amount by $849. Clearly, this level of cost effectiveness compares well with recommended QALY saved benchmarks, which range from $50,000 to $200,000.8Neumann PJ Cohen JT Weinstein MC Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold.N Engl J Med. 2014; 371: 796-797https://doi.org/10.1056/NEJMp1405158Crossref PubMed Scopus (1185) Google Scholar,9Grosse SD Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold.Expert Rev Pharmacoecon Outcomes Res. 2008; 8: 165-178https://doi.org/10.1586/14737167.8.2.165Crossref PubMed Scopus (433) Google Scholar The effectiveness of quitlines may arise from their capacity to efficiently deliver the key elements of evidence-based treatment for tobacco use, as recommended by the 2008 Public Health Service Clinical Practice Guideline for Tobacco Use and Dependence and reinforced in the 2020 Report of the Surgeon General.10HHS. Smoking cessationA report of the Surgeon General. HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2020https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdfGoogle Scholar Such treatment involves the contributions of trained counselors who, in most states, coordinate the provision of Food and Drug Administration–approved pharmacotherapy. Quitlines are not only effective and cost effective, but they also have extraordinary reach into tobacco use populations as there are few barriers to their use: they require no travel, no health insurance, and are free to the user. These advantages have led about half a million callers to contact the quitline each year.11Schauer GL Malarcher AM Zhang L Engstrom MC Zhu SH Prevalence and correlates of quitline awareness and utilization in the United States: an update from the 2009-2010 National Adult Tobacco Survey.Nicotine Tob Res. 2014; 16: 544-553https://doi.org/10.1093/ntr/ntt181Crossref PubMed Scopus (30) Google Scholar These features also make them especially accessible to populations that have a high tobacco use prevalence and that have a dearth of other treatment options (e.g., individuals living in poverty, those who have psychiatric diagnoses such as substance use disorders, and those who are uninsured). The population impact of quitline treatment has been decidedly enhanced by media campaigns that have markedly increased calls to the quitline.10HHS. Smoking cessationA report of the Surgeon General. HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2020https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdfGoogle Scholar,12Using the community guide. The Community Guide.https://www.thecommunityguide.org/about/using-community-guide. Accessed April 14, 2020.Google Scholar Tips from Former Smokers® (Tips®), the Centers for Disease Control and Prevention's national media campaign launched in 2012, has been especially effective in motivating smokers to call the quitline.13Duke JC Davis KC Alexander RL et al.Impact of a U.S. antismoking national media campaign on beliefs, cognitions and quit intentions.Health Educ Res. 2015; 30: 466-483https://doi.org/10.1093/her/cyv017Crossref PubMed Scopus (28) Google Scholar,14McAfee T Davis KC Alexander Jr, RL Pechacek TF Bunnell R Effect of the first federally funded U.S. antismoking national media campaign.Lancet. 2013; 382: 2003-2011https://doi.org/10.1016/S0140-6736(13)61686-4Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar Analyses of Tips® have demonstrated strong evidence of quitting, with excellent return on investment. A 2020 health economic analysis15Shrestha SS Davis K Mann N et al.Cost effectiveness of the Tips From Former Smokers® campaign—U.S., 2012–2018.Am J Prev Med. 2020; 60 (406–410)Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar estimated that from 2012–2018, Tips® resulted in about 1.38 million QALYs gained and 129,100 smoking-associated premature deaths avoided in the U.S. The campaign has been extremely cost effective: the cost per quitter was approximately $800, the cost of averting a premature death was approximately $3800, and the cost per QALY gained was approximately $400. Underserved populations can be targeted by such national media campaigns,13Duke JC Davis KC Alexander RL et al.Impact of a U.S. antismoking national media campaign on beliefs, cognitions and quit intentions.Health Educ Res. 2015; 30: 466-483https://doi.org/10.1093/her/cyv017Crossref PubMed Scopus (28) Google Scholar,16Davis KC Alexander Jr., RL Shafer P Mann N Malarcher A Zhang L The dose–response relationship between tobacco education advertising and calls to quitlines in the United States, March‒June, 2012.Prev Chronic Dis. 2015; 12: E191https://doi.org/10.5888/pcd12.150157Crossref PubMed Scopus (22) Google Scholar resulting in enhanced quitline contacts by such populations.17SHiFT IncorporatedSTEPP/Adult Cessation Annual Project Report: Colorado QuitLine TV Campaign with John Lynch and Kyle Johnson. SHiFT Incorporated, Denver, Colorado2007Google Scholar,18Prochaska JJ Gates EF Davis KC Gutierrez K Prutzman Y Rodes R The 2016 Tips from Former Smokers® Campaign: associations with quit intentions and quit attempts among smokers with and without mental health conditions.Nicotine Tob Res. 2019; 21: 576-583https://doi.org/10.1093/ntr/nty241Crossref PubMed Scopus (8) Google Scholar Thus, the combination of barrier-free, easy-access, and targeted promotional activities likely accounts for quitlines’ extraordinary reach into populations that are typically medically underserved; 50% or more of callers to the quitline are uninsured or receive Medicaid.19Swartz SH Cowan TM Klayman JE Welton MT Leonard BA Use and effectiveness of tobacco telephone counseling and nicotine therapy in Maine.Am J Prev Med. 2005; 29: 288-294https://doi.org/10.1016/j.amepre.2005.06.015Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar,20Campaign for Tobacco-Free KidsQuitlines help smokers quit. Campaign for Tobacco-Free Kids, Washington, DC2017https://www.tobaccofreekids.org/assets/factsheets/0326.pdfDate accessed: April 14, 2020Google Scholar Quitlines’ ubiquitous availability and absence of barriers allow them to serve multiple roles in tobacco use treatment,21MDAnderson Cancer CenterUT MD Anderson study shows new approach connecting smokers to quit lines increases smoking cessation treatment enrollment.MD Anderson News Release. 2013; (February 25,)https://www.mdanderson.org/newsroom/ut-md-anderson-study-shows-new-approach-connecting-smokers-to-qu.h00-158827278.htmlDate accessed: April 14, 2020Google Scholar including serving as important treatment extenders in healthcare settings. About 75% of adult cigarette smokers have at least 1 primary care healthcare visit in any given year,22King BA Dube SR Babb SD McAfee TA Patient-reported recall of smoking cessation interventions from a health professional.Prev Med. 2013; 57: 715-717https://doi.org/10.1016/j.ypmed.2013.07.010Crossref PubMed Scopus (31) Google Scholar and quitlines can provide a referral option when clinical staff are reluctant or unable to intervene themselves extensively with patients who smoke. Ideally, the quitline should be offered with complementary support from clinical staff such as medication or follow-up counseling and medical management. Finally, in recent years, the quitlines have served as conduits to additional, diverse forms of tobacco treatment that are offered by quitline providers. These include websites and text-based interventions, which many state quitlines make freely available. Finally, it is important to note that quitlines have broadened their scope of treatment to reflect the modern landscape of tobacco use. For instance, quitlines now provide treatment for all tobacco users, including those using smokeless tobacco or e-cigarettes. Quitlines already play a vital role in tobacco treatment, reaching an estimated half a million tobacco users in the U.S. each year, and they have the potential to play an even bigger role in reducing tobacco use, costs, and disparities. Fax referral has been widely used to link patients who smoke with quitlines in healthcare settings; however, recent research indicates that quitline referral and use is enhanced by newly developed electronic health record–based referral methods (eReferral), which can increase quitline referrals 3- to 6-fold.23Jenssen BP Muthu N Kelly MK et al.Parent eReferral to tobacco quitline: a pragmatic randomized trial in pediatric primary care.Am J Prev Med. 2019; 57: 32-40https://doi.org/10.1016/j.amepre.2019.03.005Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar,24Fiore M Adsit R Zehner M et al.An electronic health record-based interoperable eReferral system to enhance smoking quitline treatment in primary care.J Am Med Inform Assoc. 2019; 26: 778-786https://doi.org/10.1093/jamia/ocz044Crossref PubMed Scopus (15) Google Scholar Moreover, eReferral systems, such as interoperable closed-loop feedback, return quitline treatment outcomes to referring healthcare systems and clinical personnel via electronic health record messages.24Fiore M Adsit R Zehner M et al.An electronic health record-based interoperable eReferral system to enhance smoking quitline treatment in primary care.J Am Med Inform Assoc. 2019; 26: 778-786https://doi.org/10.1093/jamia/ocz044Crossref PubMed Scopus (15) Google Scholar, 25Adsit RT Fox BM Tsiolis T et al.Using the electronic health record to connect primary care patients to evidence-based telephonic tobacco quitline services: a closed-loop demonstration project.Transl Behav Med. 2014; 4: 324-332https://doi.org/10.1007/s13142-014-0259-yCrossref PubMed Scopus (48) Google Scholar, 26Baker TB, Berg KM, Adsit RT, et al. Closed loop electronic referral from primary care clinics to a state tobacco cessation quitline: effects using real-world implementation training. Am J Prev Med. 2021;60(3S2):S113–S122.Google Scholar Such innovations more fully integrate quitline treatment with the patient's ongoing health care. Minimally, this serves to remind busy clinicians to follow-up and address a patient's tobacco use. In sum, more widespread and consistent implementation of interoperable eReferral strategies with closed-loop feedback should further drive quitline utilization, reduce tobacco use disparities,26Baker TB, Berg KM, Adsit RT, et al. Closed loop electronic referral from primary care clinics to a state tobacco cessation quitline: effects using real-world implementation training. Am J Prev Med. 2021;60(3S2):S113–S122.Google Scholar and reduce tobacco use prevalence and harms. The reach and effectiveness of quitlines reflects their funding support. There is a clear correlation between funding of quitline services and promotion on the one hand and quitline use on the other. Although federal support of the quitlines has been ongoing, state funding has varied across time. Research shows that states that boosted funding for quitline services and promotion (e.g., New York, Maine)19Swartz SH Cowan TM Klayman JE Welton MT Leonard BA Use and effectiveness of tobacco telephone counseling and nicotine therapy in Maine.Am J Prev Med. 2005; 29: 288-294https://doi.org/10.1016/j.amepre.2005.06.015Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar,27Mann N Nonnemaker J Chapman L Shaikh A Thompson J Juster H Comparing the New York State Smokers’ Quitline reach, services offered, and quit outcomes to 44 other state quitlines, 2010 to 2015.Am J Health Promot. 2018; 32: 1264-1272https://doi.org/10.1177/0890117117724898Crossref PubMed Scopus (5) Google Scholar typically saw substantial increases in call volume, sometimes rising to 3%–5% or more of adult tobacco users per year versus an average of 1% nationwide.10HHS. Smoking cessationA report of the Surgeon General. HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2020https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdfGoogle Scholar However, the converse is also the case: when quitline funding decreases, call volume and quitline use declines. In addition to funding that supports quitline services and promotion, other tobacco control policy actions also affect quitline utilization. For example, in Wisconsin, 2 approximately contemporaneous actions markedly increased quitline utilization: a substantial increase in the state cigarette excise tax and enactment of a comprehensive statewide smoke-free indoor air law.28Sheffer MA Redmond LA Kobinsky KH Keller PA McAfee T Fiore MC Creating a perfect storm to increase consumer demand for Wisconsin's Tobacco Quitline.Am J Prev Med. 2010; 38: S343-S346https://doi.org/10.1016/j.amepre.2009.11.014Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar In the first 3 months of 2008 following the implementation of these policies, the quitline received more than 30,000 calls. Previously, calls had averaged 10,000 across an entire year. This reinforces the message conveyed by other evidence: the public health impact and reach of quitlines can be dramatically enhanced by funding and policy actions.10HHS. Smoking cessationA report of the Surgeon General. HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2020https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdfGoogle Scholar Quitlines also present a tremendous research opportunity. As demonstrated in this supplement issue of the American Journal of Preventive Medicine, because quitlines can effectively engage underserved, priority populations, they offer the opportunity to develop and evaluate the effectiveness of tailored interventions for such populations. They also offer the opportunity to tailor interventions for other important groups of tobacco users such as nondaily smokers, dual users of cigarettes and e-cigarettes, youth, and e-cigarette users. In addition, because many quitlines offer multiple forms of intervention, they offer the opportunity to use factorial experiments29Collins LM Baker TB Mermelstein RJ et al.The multiphase optimization strategy for engineering effective tobacco use interventions.Ann Behav Med. 2011; 41: 208-226https://doi.org/10.1007/s12160-010-9253-xCrossref PubMed Scopus (162) Google Scholar, 30Graham AL Papandonatos GD Jacobs MA et al.Optimizing text messages to promote engagement with internet smoking cessation treatment: results from a factorial screening experiment.J Med Internet Res. 2020; 22: e17734https://doi.org/10.2196/17734Crossref PubMed Scopus (8) Google Scholar, 31McClure JB Peterson D Derry H et al.Exploring the “active ingredients” of an online smoking intervention: a randomized factorial trial.Nicotine Tob Res. 2014; 16: 1129-1139https://doi.org/10.1093/ntr/ntu057Crossref PubMed Scopus (30) Google Scholar to determine which combinations of treatment resources (e.g., quitline counseling, websites, text messaging, social media, adjuvant cessation medications) work best for which users. Finally, owing to robo-calling, a great many Americans have stopped answering their phones. In fact, estimates are that only about a quarter of phone calls from unidentified callers are answered.32Meek A Spam calls have stopped people from answering their phones.New York Post. 2019; (January 30,)https://nypost.com/2019/01/30/spam-calls-have-stopped-people-from-answering-their-phones/Date accessed: May 4, 2020Google Scholar This may be why only a minority of individuals who accept a quitline referral during a healthcare visit end up accepting a call from the quitline (e.g., around only 35%–40%).24Fiore M Adsit R Zehner M et al.An electronic health record-based interoperable eReferral system to enhance smoking quitline treatment in primary care.J Am Med Inform Assoc. 2019; 26: 778-786https://doi.org/10.1093/jamia/ocz044Crossref PubMed Scopus (15) Google Scholar Researchers should explore new strategies such as warm hand-offs (i.e., a healthcare clinician contacts the quitline and connects a patient directly to its services during a healthcare visit) to increase follow through with quitline referral.24Fiore M Adsit R Zehner M et al.An electronic health record-based interoperable eReferral system to enhance smoking quitline treatment in primary care.J Am Med Inform Assoc. 2019; 26: 778-786https://doi.org/10.1093/jamia/ocz044Crossref PubMed Scopus (15) Google Scholar,33Richter KP Faseru B Shireman TI et al.Warm handoff versus fax referral for linking hospitalized smokers to quitlines.Am J Prev Med. 2016; 51: 587-596https://doi.org/10.1016/j.amepre.2016.04.006Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Although existing quitline treatment is certainly cost effective and clinically effective, evidence shows that it could have a greater population-based impact with expanded funding for both quitline research and, in particular, quitline treatment services. As noted previously, communication campaigns can greatly increase quitline use.10HHS. Smoking cessationA report of the Surgeon General. HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2020https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdfGoogle Scholar,34Wilson DK Lorig K Klein WMP Riley W Sweeney AM Christensen A Efficacy and cost-effectiveness of behavioral interventions in nonclinical settings for improving health outcomes.Health Psychol. 2019; 38: 689-700https://doi.org/10.1037/hea0000773Crossref PubMed Scopus (7) Google Scholar An important direction for such campaigns is the targeting of populations that have the highest rates of tobacco use and related harms (e.g., the least educated and those with comorbid psychiatric and substance use diagnoses). Thus, additional targeted communication campaigns would be an important means of addressing widening and refractory tobacco-related disparities. In addition, research shows that increasing the intensity or service provision of quitline treatment can meaningfully enhance effectiveness (e.g., using combination nicotine-replacement therapy instead of monotherapy increases long-term abstinence rates,35Smith SS Keller PA Kobinsky KH et al.Enhancing tobacco quitline effectiveness: identifying a superior pharmacotherapy adjuvant.Nicotine Tob Res. 2013; 15: 718-728https://doi.org/10.1093/ntr/nts186Crossref PubMed Scopus (34) Google Scholar as does using 3 or more counseling calls versus fewer).5Hollis JF McAfee TA Fellows JL Zbikowski SM Stark M Riedlinger K The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline.Tob Control. 2007; 16: i53-i59https://doi.org/10.1136/tc.2006.019794Crossref PubMed Scopus (150) Google Scholar,23Jenssen BP Muthu N Kelly MK et al.Parent eReferral to tobacco quitline: a pragmatic randomized trial in pediatric primary care.Am J Prev Med. 2019; 57: 32-40https://doi.org/10.1016/j.amepre.2019.03.005Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar States, however, have frequently been forced to limit the comprehensiveness of their quitline services, including the number of counseling calls, typically because of budget constraints.36Quitline profiles 2020. North American Quitline Consortium. http://map.naquitline.org/. Accessed 15 April 2020.Google Scholar Quitline treatment pays high health and economic dividends to tobacco users, health insurers, and society at large.34Wilson DK Lorig K Klein WMP Riley W Sweeney AM Christensen A Efficacy and cost-effectiveness of behavioral interventions in nonclinical settings for improving health outcomes.Health Psychol. 2019; 38: 689-700https://doi.org/10.1037/hea0000773Crossref PubMed Scopus (7) Google Scholar Over the past 15 years, countless individuals have sought out this treatment resource, generating more than 10 million quitline calls. Yet, quitlines still reach only about 1% of individuals who smoke in the U.S., which is unfortunate given that the means of increasing quitline reach are known and highly feasible. Quitlines are certainly a resource that merits continued and enhanced support at the national and state levels to bring more evidence-based treatment services to individuals who use tobacco and want to quit. This work was supported by National Cancer Institute grants PO1 CA180945 and R35CA197573 (TBB, MCF). The funder had no role in the interpretation of data, writing the report, or the decision to submit for publication. Both authors contributed to manuscript preparation. Dr. Baker consults with the National Cancer Institute via a contract with ICF International. Dr. Fiore has no conflicts to report. This article is part of a supplement entitled The Role of Quitlines in Tobacco Cessation, which is sponsored by the U.S. Centers for Disease Control and Prevention (CDC), an agency of the U.S. Department of Health and Human Services (HHS), with support from RTI International under contract # 200-2014-61263.