Tobacco Cessation Quitlines: An Evolving Mainstay for an Enduring Cessation Support Infrastructure

Abstract

Although U.S. cigarette smoking prevalence is the lowest it has been in more than a half century,1Creamer MR Wang TW Babb S et al.Tobacco product use and cessation indicators among adults - United States, 2018.MMWR Morb Mortal Wkly Rep. 2019; 68: 1013-1019https://doi.org/10.15585/mmwr.mm6845a2Crossref PubMed Scopus (286) Google Scholar the human and financial toll remains unacceptably high. Cigarette smoking is the leading cause of preventable death and disease and, each year, is responsible for >480,000 deaths in the U.S.2HHSThe health consequences of smoking—50 years of progress: a 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, GA2014https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdfDate accessed: October 23, 2020Google Scholar About 34 million U.S. adults currently smoke cigarettes, and smoking-related death and disease cost the nation >$300 billion each year.2HHSThe health consequences of smoking—50 years of progress: a 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, GA2014https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdfDate accessed: October 23, 2020Google Scholar,3Xu X Bishop EE Kennedy SM Simpson SA Pechacek TF Annual healthcare spending attributable to cigarette smoking: an update.Am J Prev Med. 2015; 48: 326-333https://doi.org/10.1016/j.amepre.2014.10.012Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar Importantly, marked disparities with regard to smoking persist across population groups, with disproportionately higher burden among American Indian and Alaska Natives; lesbian, gay, and bisexual adults; people of lower SES; and those with behavioral health conditions.4HHSSmoking cessation: a 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.pdfDate accessed: October 23, 2020Google Scholar Decades of evidence demonstrate that cigarette smoking harms nearly every organ of the body.2HHSThe health consequences of smoking—50 years of progress: a 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, GA2014https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdfDate accessed: October 23, 2020Google Scholar It causes cancer, heart disease, stroke, lung disease, type 2 diabetes, and other adverse health conditions. In addition, smoking during pregnancy increases the risk of maternal health complications, premature and low-weight birth, and sudden infant death syndrome. The health risks posed by smoking remain a concern and a priority for the Centers for Disease Control and Prevention (CDC) and the broader tobacco control field. The tobacco product landscape also continues to evolve. As a result, concerns exist regarding health implications that may result from the use of emerging tobacco products, including e-cigarettes, heated tobacco products, and nicotine pouches, especially among youth and young adults. Although a robust body of science has documented the health risks of cigarette smoking, more research is needed to improve the collective understanding of these emerging tobacco products. On January 23, 2020, the U.S. Surgeon General issued a report on smoking cessation.4HHSSmoking cessation: a 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.pdfDate accessed: October 23, 2020Google Scholar This is the first Surgeon General's report in 30 years to solely focus on this topic. Although previous reports documented how smoking can increase the risk of various diseases, the 2020 report is the first to comprehensively detail how smoking cessation can reduce the risk of disease. Quitting smoking reduces the risk of premature death, improves health, and enhances the quality of life. Quitting smoking lowers the risk for 12 types of cancer, cardiovascular disease, chronic obstructive pulmonary disease, and adverse reproductive health outcomes. Quitting smoking can also reduce the financial burden for individuals who smoke, for public and private healthcare systems, and for society as a whole. Tobacco dependence is a chronic, relapsing condition that often requires repeated treatment and long-term support.4HHSSmoking cessation: a 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.pdfDate accessed: October 23, 2020Google Scholar Quitting tobacco is difficult but possible, and the likelihood of successfully quitting is higher when individuals have access to and use proven treatments that are safe and effective. As detailed in the 2020 Surgeon General's report, we know what works. Behavioral counseling and the use of U.S. Food and Drug Administration–approved cessation medication can increase a person's chances of quitting smoking, especially when used in combination. Quitlines provide access to known and effective cessation interventions to help people quit tobacco use. Research shows that proactive quitline counseling, when provided alone or in combination with cessation medications, increases smoking cessation.4HHSSmoking cessation: a 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.pdfDate accessed: October 23, 2020Google Scholar Quitlines can also serve as a starting point for individuals to access cessation medications to help with their quit journey. In this special issue, Fiore and Baker5Fiore MC, Baker TB. Ten million calls and counting: progress and promise of tobacco quitlines in the U.S. Am J Prev Med. 2021;60(3S2):S103–S106.Google Scholar showcase how quitlines can serve as an important treatment extender within the context of healthcare settings, providing a bridge between patients who want to quit and providing cessation support to help them achieve success. In their introduction to this special issue, Glover-Kudon and Gates6Glover-Kudon RM, Gates EF. The role of quitlines in tobacco cessation: an introduction. Am J Prev Med. 2021;60(3S2):S99–S102.Google Scholar presented the 4 themes around which this special issue is organized: quitlines’ reach ensures access to cessation services for individuals seeking to quit tobacco, quitlines can adapt to expand existing services to incorporate new or modified components, quitlines can be tailored to develop and modify existing services to address the needs of certain populations, and quitlines can also innovate and develop new services to promote cessation. Quitlines’ reach can be enhanced through campaigns that educate and promote quitline services to individuals seeking quit assistance. Zhang et al.7Zhang L, Rodes R, Mann N, et al. Differences in quitline registrants’ characteristics during national radio versus television antismoking campaigns. Am J Prev Med. 2021;60(3S2):S107–S112.Google Scholar assess the differences in demographic characteristics of callers who heard about the quitline from different types of media (radio and TV) during brief national nicotine-replacement therapy promotions included as part of CDC's Tips From Former Smokers® campaign. In addition, quitlines can be effectively linked to the electronic health record. Baker et al.8Baker 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 demonstrate how transitioning from a fax-to-quit to an electronic health record–based referral process increased quitline referrals for patients who used tobacco, and as highlighted by Ahluwalia et al.,9Ahluwalia IB, Tripp AL, Dean AK, et al. Tobacco smoking cessation and quitline use among adults aged ≥15 years in 31 countries: findings from the Global Adult Tobacco Survey. Am J Prev Med. 2021;60(3S2):S128–S135.Google Scholar the expansive reach of quitlines is relevant not only domestically but also internationally. Quitlines can be adapted to engage a more expansive cohort of individuals seeking to quit tobacco use. Keller and colleagues10Keller PA, Lachter RB, Lien RK, Klein J. Online versus telephone registration: differences in quitline participant characteristics. Am J Prev Med. 2021;60(3S2):S136–S141Google Scholar highlight how expanding quitline registration to include an online option can engage younger individuals who use tobacco and want to quit. Vickerman et al.11Vickerman KA, Carpenter KM, Raskob MK, Nash CM, Vargas-Belcher RA, Beebe LA. Vaping and e-cigarettes within the evolving tobacco quitline landscape. Am J Prev Med. 2021;60(3S2):S142–S153.Google Scholar provide insight on the opportunities that exist to better leverage quitlines to respond to the youth e-cigarette use epidemic. In detailing quitline practices that currently exist related to e-cigarette use assessment, treatment, and evaluation, Vickerman and colleagues also demonstrate how quitline data can meaningfully inform cessation research and evaluation of emerging tobacco products. Quitlines’ service delivery can be tailored to optimize treatment support for certain communities. Through tailored services, quitlines can work to address and reduce tobacco-related disparities that persist and move us toward greater health equity. For example, Morris et al.12Morris CD, Lukowski AV, Vargas-Belcher RA, Ylioja TE, Nash CM, Bailey LA. Quitline programs tailored for mental health: initial outcomes and feasibility. Am J Prev Med. 2021;60(3S2):S163–S171.Google Scholar highlight how quitline services can be personalized to specifically support cessation among people with mental health conditions. Quitlines are a ready vehicle for innovation. Prutzman and colleagues13Prutzman YM, Wiseman KP, Grady MA, et al. Using digital technologies to reach tobacco users who want to quit: evidence from the National Cancer Institute's Smokefree.gov initiative. Am J Prev Med. 2021;60(3S2):S172–S184.Google Scholar showcase how quitlines can maximize the use of the Internet and mobile technologies to establish a multimodal suite of digital interventions to assist individuals in their tobacco quit attempts. Efforts developed in response to the growth of smartphone ownership and greater broadband access can optimize the use of newer communications modalities to support cessation. Tracing the advances made and the evolution of quitlines over time provides a glimpse into the immense potential they hold to continue to modernize cessation support into the future. Much has changed in the world since the first state quitline began in California in 1992 and since the establishment of the national network of tobacco cessation quitlines in 2004,14Anderson CM Zhu SH Tobacco quitlines: looking back and looking ahead.Tob Control. 2007; 16: i81-i86https://doi.org/10.1136/tc.2007.020701Crossref PubMed Scopus (101) Google Scholar which is jointly supported by the National Cancer Institute and CDC. Policies and social norms have changed such that smoking is now prohibited in places such as airplanes and much less common nationwide in public areas such as worksites, restaurants, and bars. As new technology has emerged, we now connect with others using the Internet and smartphones. The tobacco product landscape also has changed, with new and emerging products such as e-cigarettes, heated tobacco products, and nicotine pouches having entered the marketplace. Despite all these changes, quitlines remain relevant and critical. Contributing to the sustained success of quitlines has been their ability to undergo their own changes throughout time. CDC has been pleased to partner with quitlines over the years, in part, by providing funding to equip state quitlines to strengthen their infrastructure, enhance supports, and test new strategies to improve service delivery. CDC's ongoing commitment also extends to supporting the National Quitline Data Warehouse. As a national repository composed of data on services, utilization, and successes from 54 quitlines, the National Quitline Data Warehouse is essential for evaluation and to inform continuous program improvement. Included in the 2020 Surgeon General's report are the latest scientific findings to help guide the course forward to improve smoking cessation. The report notes that increasing quit rates among those who smoke requires several strategies to increase the appeal and reach of existing evidence-based interventions,4HHSSmoking cessation: a 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.pdfDate accessed: October 23, 2020Google Scholar such as expanding treatment targets, leveraging technology to enhance treatment initiation and sustained engagement among those who use tobacco, and accelerating the integration of cessation services across multiple platforms and healthcare systems. The articles included in this special issue show how quitlines already have helped our nation move in these directions. It is important to ensure that this momentum continues. We must pursue innovative ways to promote the value of quitlines. We need to apply even greater creativity in improving quitline service delivery to adapt and personalize our efforts. We must enhance the support we provide to individuals, regardless of what tobacco products they are using and wherever they are in their quit journey. We need to pay close attention to public health data to inform our cessation efforts, especially data that identify where disparities exist to hone our strategies accordingly. We need to keep abreast of opportunities as new technology and communication tools emerge to create a comprehensive and complementary suite of quit support modalities available to individuals, and as novel and promising quitline strategies are implemented in the field, it is critical that we test and evaluate their effectiveness and share these findings widely to keep us moving forward. Continued advancements in tobacco cessation are not automatic but need foresight, leadership, and resources to propel them forward. Quitlines cannot succeed in isolation, and it is therefore incumbent on the tobacco control field as a whole to carry this momentum forward. Advances in tobacco cessation could not and will not be accomplished without quitlines and the unique services they provide. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention (CDC) or the U.S. Department of Health and Human Services (HHS). No financial disclosures were reported by the authors of this paper. 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.