National Quitline Research Articles

Helping Smokers Quit: Understanding the Barriers to Utilization of Smoking Cessation Services

Counseling smokers to quit smoking and providing them with pharmaceutical cessation aides are among the most beneficial and cost-effective interventions that clinicians can offer patients. Yet assistance with quitting is not universally covered by health plans or offered by all clinicians. Analysis of stakeholders' perspectives and interests can identify the barriers to more widespread provision of cessation services and suggest strategies for the public policy agenda to advance smoking cessation. Review of literature and discussions with representatives of stakeholders. All stakeholders-health plans, employers, clinicians, smokers, and the government-face barriers to broader smoking cessation activities. These range from health plans' perceiving that covering counseling and pharmacotherapy will increase costs without producing commensurate health care savings, to clinicians' feeling unprepared and uncompensated for counseling. Like other preventive measures aimed at behavior, efforts directed at smoking cessation have marginal status among health care interventions. State governments can help correct this status by increasing Medicaid coverage of treatment and expanding coverage for state employees. The federal government can promote the adoption of six initiatives recommended by a government subcommittee on cessation: set up a national quit line, develop a media campaign to encourage cessation, include cessation benefits in all federally funded insurance plans, create a research infrastructure to improve cessation rates, develop a clinician training agenda, and create a fund to increase cessation activities through a new $2 per pack cigarette excise tax. Both the federal and state governments can increase cessation by adopting policies such as the higher cigarette tax and laws prohibiting smoking in workplaces and public places. Public policy efforts should assume greater social responsibility for smoking cessation, including more aggressive leadership at the state and federal levels, as well as through advocacy, public health, and clinician organizations.

Acceptability of Tobacco Cessation Interventions in the Pediatric Emergency Department

To assess the acceptability to parents and staff of providing a brief tobacco cessation intervention incorporating the first 2 A's of the Clinical Practice Guideline on Treating Tobacco Use and Dependence (Ask and Advise) + fax referral to a state tobacco quitline from the emergency department (ED) of a large children's hospital. Data were collected from a written survey of (1) parental smokers accompanying their children to a pediatric ED who consented and were randomized to participate in a tobacco cessation intervention and (2) medical doctors (MDs) or nurse practitioners (NPs) caring for their child. Acceptability of the intervention was measured on a 5-point Likert scale ranging from "strongly agree" to "strongly disagree." Of the 1643 parental subjects that were screened to participate in this study, 557 (33.9%) were smokers, 240 of whom were enrolled in the intervention group and a total of 215 (90%) completed the survey. A total of 230 (100%) of the MDs/NPs approached completed the survey. Of the 215 parental subjects in the intervention group, 212 (98.6%) and 208 (96.7%) agreed that the intervention provided them with "useful information" and "easy to understand" advice, respectively. Most parental subjects agreed that the advice given was sufficient and met their needs (n = 208, 96.7%) and that the study length was "just right" (n = 206, 95.8%). On a rating scale of 1 to 10, the mean (SD) rating of the study was 9.1 (1.3). Of the MDs/NPs participating in this survey, 224 (97.4%) and 206 (89.6%) agreed that the "ED is a good place to screen parents for tobacco use" and that the "ED is a good place to give advice about tobacco cessation," respectively. In addition, 202 (87.8%) and 196 (85.2%) reported that they felt comfortable giving tobacco cessation advice to parents or referring parents to the national quitline, respectively. Only 7 (3%) felt that the study interfered with patient care. An ED tobacco cessation intervention using the 2 A's + Quitline referral had excellent acceptability in this study of parents and staff of pediatric patients. The use of the pediatric ED as a venue to providing tobacco cessation counseling to a population with a high prevalence of parental smokers warrants further consideration.

Treatment of Tobacco Dependence

Cigarette smoking continues to cause substantial death and disability, but more than 1 in 5 adults smoke despite the desire among most smokers to stop and the availability of effective treatments. A systematic process to identify all smokers is crucial. Because tobacco dependence is characterized by relapses and remissions, clinicians should be ready to engage smokers and reengage relapsed smokers with options for new medication strategies and additional counseling resources.

PL1-02: Smoking Cessation and Lung Cancer

PL1-02: Smoking Cessation and Lung Cancer

A new national smokefree law increased calls to a national quitline

BackgroundA law making all indoor workplaces including bars and restaurants smokefree became operational in New Zealand in December 2004. New Zealand has a national free-phone Quitline Service which has been operational since 1999. Previous work has shown that the number of calls to the Quitline are influenced by marketing of the service through media campaigns. We set out to investigate if the smokefree law increased calls to the Quitline.MethodsFor 24 months prior to the law, and 12 months after the law, data were collected on: (i) Quitline caller registrations and the issuing of nicotine replacement therapy (NRT) vouchers by the Quitline Service; (ii) expenditure on Quitline-related television advertising; (iii) expenditure on other smokefree television advertising; and (iv) print media coverage of smoking in major New Zealand newspapers. These data were inputs to a time series analysis using a Box-Jenkins transfer function model. This used the law change as the intervention variable, with the response series being the monthly Quitline caller rates and monthly first time NRT voucher issue rates.ResultsThe monthly rates of Quitline caller registrations and NRT voucher issues were observed to increase in the months after the law change. The increase in both these outcomes was even greater when considered in terms of per level of Quitline advertising expenditure (though these patterns may have partly reflected marked reductions in advertising expenditure at the time of the law change and hence are of limited validity).In the more robust time series analyses, the law change (intervention variable) had a significant effect (p = 0.025) on increasing the monthly caller registration rate in December 2004. This was after adjusting for the possible effects of Quitline advertising expenditure, print media coverage, and other smoking-related advertising expenditure.ConclusionThe new national smokefree law resulted in increased quitting-related behaviour. This would suggest there is an extra opportunity for health agencies to promote quitting at such times.

Evidence of Declining Nicotine Dependency in New Callers to a National Quitline

AbstractObjective: To look for evidence of changing nicotine dependency self-reported by new callers to a national quitline in New Zealand between 2001 and 2005. Methods: Levels of self-reported nicotine dependence of new callers were compared across 5 years to determine changes over time. Results: Statistically significant decreases were found in all 3 measures of nicotine dependence over the 5-year period: time to first cigarette (7.9% decline for smoking within 30 minutes of waking), intensity of inhalation (36.8% decline for ‘heavy’ inhalation), and number of cigarettes per day (29.8% decline for 21+ cigarettes per day). Conclusions: The results showed the proportion of callers with high nicotine dependency remains large but decreased continuously during the 5-year period. A decline of highly nicotine dependent callers to the Quitline may indirectly suggest an increased proportion of hard-core smokers in the overall smoking population as this group tends to be less likely to consider quitting smoking. However, the results may also suggest that the overall smoking population was less nicotine dependent in 2005, than it was in 2001, or that the Quitline has become less appealing to heavily nicotine dependent smokers.

Tobacco Control Interventions in the Emergency Department: A Joint Statement of Emergency Medicine Organizations

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

Tobacco Control Interventions in the Emergency Department: A Joint Statement of Emergency Medicine Organizations

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

A National Survey of the Acceptability of Quitlines to Help Parents Quit Smoking

Provision of telephone smoking cessation counseling can increase the rate of quitting smoking. The US Public Health Service recently helped to establish a free national quitline enrollment service. No previous surveys have assessed the acceptability to parents of enrollment in quitline counseling in the context of their child's health care visits. Therefore, the objective of this study was to assess acceptability to parents of enrollment in quitline counseling and to compare that with the reported rate of actually being enrolled in any smoking cessation counseling outside the office in the context of the child's health care visit. Data were collected by a national random-digit-dial telephone survey of households from September to November 2004. The sample is weighted by race and gender on the basis of the current US Census to be representative of the US population. Of 3615 eligible respondents contacted, 3011 (83.3%) completed surveys; 958 (31.8%) who completed the survey were parents with children under the age of 18 years. Of these parents, 187 (19.7%) were self-identified smokers. Of the parents who smoked, 113 (64.2%) said that they would accept enrollment in a telephone cessation program if the child's doctor offered it to them. In contrast, of the 122 smoking parents who accompanied their child to the doctor in the past year, only 11 (9%) had any counseling recommended to them, and only 1 (0.8%) was actually enrolled. These results did not vary by parent age, gender, race, or child age. When interacting with parents who smoke, child health care providers have low rates of referring and enrolling parents in any services related to smoking. Enrollment in quitlines would be acceptable to the majority of parents in the context of their child's health care visit. Tobacco control efforts in the child health care setting should include implementation of office systems that can facilitate enrollment of parental smokers in telephone quitlines.

Are non-responders in a quitline evaluation more likely to be smokers?

BackgroundIn evaluation of smoking cessation programs including surveys and clinical trials the tradition has been to treat non-responders as smokers. The aim of this paper is to assess smoking behaviour of non-responders in an evaluation of the Swedish national tobacco cessation quitline a nation-wide, free of charge service.MethodsA telephone interview survey with a sample of people not participating in the original follow-up. The study population comprised callers to the Swedish quitline who had consented to participate in a 12 month follow-up but had failed to respond. A sample of 84 (18% of all non-responders) was included. The main outcome measures were self-reported smoking behaviour at the time of the interview and at the time of the routine follow-up. Also, reasons for not responding to the original follow-up questionnaire were assessed. For statistical comparison between groups we used Fischer's exact test, odds ratios (OR) and 95% confidence intervals (CI) on proportions and OR.ResultsThirty-nine percent reported to have been smoke-free at the time they received the original questionnaire compared with 31% of responders in the original study population. The two most common reasons stated for not having returned the original questionnaire was claiming that they had returned it (35%) and that they had not received the questionnaire (20%). Non-responders were somewhat younger and were to a higher degree smoke-free when they first called the quitline.ConclusionTreating non-responders as smokers in smoking cessation research may underestimate the true effect of cessation treatment.

Preventing 3 Million Premature Deaths and Helping 5 Million Smokers Quit: A National Action Plan for Tobacco Cessation

In August 2002, the Subcommittee on Cessation of the Interagency Committee on Smoking and Health (ICSH) was charged with developing recommendations to substantially increase rates of tobacco cessation in the United States. The subcommittee's report, A National Action Plan for Tobacco Cessation, outlines 10 recommendations for reducing premature morbidity and mortality by helping millions of Americans stop using tobacco. The plan includes both evidence-based, population-wide strategies designed to promote cessation (e.g., a national quitline network) and a Smokers' Health Fund to finance the programs (through a 2 US dollar per pack excise tax increase). The subcommittee report was presented to the ICSH (February 11, 2003), which unanimously endorsed sending it to Secretary Thompson for his consideration. In this article, we summarize the national action plan.

Generating Quitline calls during Australia’s National Tobacco Campaign: effects of television advertisement execution and programme placement

Objective: The study sought to measure the relative efficiency of different television advertisements and types of television programmes in which advertisements were placed, in generating calls to Australia’s national Quitline....

Uptake and effectiveness of the Australian telephone Quitline service in the context of a mass media campaign

Objectives: Since June 1997, Australia has run its first nationally coordinated mass media anti-smoking campaign, with all States collaborating to offer a standard Quitline service. An overview of the Australian...