7.14 Cessation assistance: high reach, tailored or interactive

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7.14.1 Quitlines and callback services

The Quitline is a specialised telephone information and counselling service for people interested in smoking cessation. Quitlines have become a core smoking cessation resource in many countries. They can be effective in helping smokers quit, can help smokers access the most appropriate assistance, can provide one-off or extended support, can be tailored, and are accessible and low cost for the callers.¹ Cessation counselling provided via Australian quitlines involves providing evidence-based information in a single call (reactive) as well as repeated calls from trained counsellors (proactive).

A comprehensive review of telephone counselling services throughout the world concluded that multiple sessions were more effective than single sessions.^2,3 Some studies show that offering free nicotine replacement therapy (NRT) and proactive quitline support results in higher quit rates and similar costs.⁴ Research continues as to the efficacy and cost-effectiveness of reactive versus proactive services and on the benefit of providing NRT in addition to counselling.^5–8 Further research is needed to guide future directions for quitlines, particularly in areas of quality control, cost-efficiency, linkage with web-based interventions and emerging communication technologies, integration with healthcare systems and pharmacotherapy and encouraging and responding to more smokers and a wider range of smokers.^9–14

In Australia each state and territory funds the service within its own jurisdiction. All of the quitlines have a common telephone number (13 7848 – 13 QUIT). Administrative arrangements for the service vary from state to state: some operate from within the state alcohol and drug treatment services and others are based in non-government health organisations contracted to provide the service. All services operate to an agreed set of national minimum standards for such things as the range of services provided, response times for calls, data collection, and the training and qualifications of counsellors.¹⁵ There are also agreed protocols for supporting callers with special needs, such as pregnant smokers, those with mental illness, young people and those from Aboriginal and culturally and linguistically diverse communities. From the beginning of July 2009 to the end of June 2011 there were 185 800 calls to the Quitline throughout Australia.¹⁶

A significant advantage of the Quitline is that it provides equity of access in regard to income, different languages and location. For the price of a local landline telephone call, Quitline provides access to confidential advice, support, courses, self-help resources and telephone counselling for smokers who want to quit. All calls to the Quitline are answered 24 hours a day. In some states and territories counsellors are available 24 hours a day, while in others they are available during the day and evenings, and will return calls to out-of-hours callers during counselling hours. The qualifications and experience of Quitline counsellors ensure that they understand smoking cessation issues and methods and can deliver a supportive and non-judgemental service consistent with national standards and protocols. They must be non- or ex-smokers and usually have tertiary qualifications in psychology, counselling or related fields, followed by induction training in smoking cessation issues and methods, with regular updates. Counsellors systematically record information on smoking history and previous quit attempts. They encourage smokers to set a quit date, and to maximise success by considering evidence-based methods as well as their individual preferences and past history of quitting. They assist callers to deal with issues such as withdrawal symptoms. Callers are encouraged to participate in a program of callbacks.

The effectiveness of the Australian Quitline service has been evaluated in several studies including in 1997/98, after its first year of national promotion as part of the National Tobacco Campaign. Callers rated the Quitline positively: 97% said it was either very or somewhat friendly, 86% helpful, and 82% said they would recommend it to friends. When callers were followed up for 12 months, 29% were found to be quit (point prevalence) although only 6% had been continuously quit over that time.¹⁷

Evaluations of the South Australian and Victorian services show that in South Australia, 88% of the callers sampled had made a quit attempt since their initial call to the Quitline. Of those who had made a quit attempt, 38% were 'stopped' (had ceased smoking) at six-month follow-up. At the 12-month follow up, 96% said they had made a quit attempt, and 38% were stopped at the time of interview. Assuming that those who could not be contacted for follow-up were all smokers, the conservative quit rate estimate would be 20%.¹⁸ In the 2010 Victorian evaluation, 81% of callers were very satisfied and 15% somewhat satisfied with the service received from an advisor; 95% of callers said they would recommend the service to a friend and 89% said they would use the service again in the future if necessary.¹⁸ It is probable that these relatively high rates of cessation reflect the value of the Quitline's assistance, but callers are also likely to be more motivated and prepared than other smokers.

An important aspect of the Quitline operation is the proactive callback service. Callers who are intending to quit are encouraged to participate in the program, with the aim of increasing the success rate and reducing relapse over a period of about 12 weeks from the quit date. Once a smoker sets a quit date, a quitline counsellor calls at agreed times to provide information, assistance to deal with barriers, and generally provide encouragement and practical support. Calls are typically scheduled closer together soon after the quit date and then are more widely spaced as the client progresses towards maintenance of their new non-smoker status.

Evaluation of the South Australian callback service at 12-month follow-up showed a higher point prevalence quit rate (47%) than callers who chose not to have the callback service (37%).¹⁸ A similar pattern was found in Victoria, where the benefit was found to be predominantly due to relapse prevention.¹⁹ The findings from these evaluations are in line with a comprehensive review of proactive telephone counselling, which found that it significantly improved quitting outcomes.²

The Quitline has also developed a variety of programs for special purposes, varying from state to state and year to year depending on needs and funding. Examples include programs for people living with mental illness (especially depression), prisoners, pregnant women and partners, and cancer patients.

7.14.2 Internet, emails, phone messages, other electronic

Internet-based programs have the potential to reach large numbers of smokers at relatively low cost and provide great flexibility for time of use. Although smokers may still be slightly less likely to use the Internet than non-smokers, they do have a high level of interest in web-based cessation information and support and find it an acceptable method.^20,21

A good example of a site designed to tailor information to individual needs is the Quit Coach (www.quitcoach.org.au). This is a tailored, internet-delivered smoking cessation advice program supported by Quit Victoria and available as part of the websites of Quit Victoria and the Commonwealth's National Tobacco Campaign. It has been developed to appeal to smokers interested in quitting who do not want the direct personal contact of the Quitline. In order to tailor information to individual smokers, users begin by answering a series of questions about their smoking and quitting experience, background information, self-efficacy, pros and cons of smoking, habitual smoking situations, and stage of change. This information is used to provide relevant advice to support smokers through the process of quitting. Although the internet version has not yet been fully evaluated, the content was developed from an earlier automated system of generating letters that were mailed to smokers after an initial call to the Quitline. That system was found to increase cessation outcomes, especially by preventing relapse.²²

Most users of the Quit Coach use it to make a quit attempt and, for those who continue to use the Quit Coach, to help them stay quit. However the majority of users only visit the site once.²³ The site successfully targets people who are moderately addicted, with users being more likely to be female and younger than smokers in general and quitline callers.²⁴

There is increasing research being conducted as to the effectiveness of web-based smoking cessation interventions. The evidence is inconsistent, but does suggest that the use of interactive quitting tools on a website is related to increased cessation, especially if information is more personalised, intensive and appropriately tailored and users are frequently contacted.^25–33 There is weaker association between cessation and one-to-one messaging with other members of the on-line community.³⁰ Evidence suggests that the degree of user engagement with the program affects the outcome and that engagement is influenced by where the message comes from, how tailored it is and the timing.³⁴

The content, quality and usability of cessation websites vary greatly. Some programs are intensive and provide a number of different contacts to users, and others are more static. Many websites sell cessation-related products but do not provide evidence-based treatment.³⁵ Smoking cessation videos can be found on YouTube but a minority of these are evidence-based and more research is needed to understand the utility of YouTube as a cessation resource.³⁶ Cessation websites have improved since they started to appear but common issues include lack of adherence to evidence-based tobacco treatment guidelines, inaccurate information about pharmacotherapy and sites not taking full advantage of the interactive and tailoring capabilities of the Internet.³⁵ Some programs combine internet (email, web pages) and mobile phone (interactive voice responses, text/SMS) technology, with promising results.^37–41 Combining an enhanced internet program and telephone support appears to be effective.^42,43 Other approaches include using a personal digital assistant (PDA) or an individualised hand-held computer delivered treatment (CDT) to help maintain cessation following a quit attempt, with further research being needed.^44,45 This is an emerging area of research and more studies are warranted into the effectiveness of web-based cessation interventions. One review has identified a number of current methodological issues and suggestions for future research, including isolating the specific effect of the web and of the content of particular web-based programs, small sample sizes, lack of information about participants, lack of comparison with no treatment groups, lack of control for NRT use, high loss to follow-up and lack of information about missing data.²⁵

Future issues to be addressed include developing strategies to overcome barriers to use and encourage repeated use, finding methods of promoting web-based programs to a wider range of smokers and developing research to understand how to maximise the interactive capabilities of the Internet. One study is evaluating the effect of having healthcare providers refer patients to an interactive cessation website by providing the smoker's email. This enables the delivery of automated emails that provide cessation information and encourage the patient to use the website.⁴⁶ Another has suggested that increasing understanding of the persuasive features of web-based behaviour change interventions may help to improve the engagement of users.⁴⁷

Rapidly developing mobile phone technologies, for example mobile phone text messaging/SMS, video messaging and iPhone applications, offer opportunities to engage with smokers wanting to quit, particularly younger adults. The evidence as to the effect of SMS and video messaging on long-term cessation is inconsistent, however some short-term results are positive.^48–51 More rigorous studies are warranted. There is evidence that current iPhone apps for smoking cessation have rarely been developed around evidence-based practices, and usually do not adhere to established guidelines.⁵²

7.14.3 Recruiting smokers to high-efficacy, low-cost services

The overall impact of smoking cessation interventions in reducing smoking prevalence is a product of reach and efficacy. Use of support services such as the Quitline continues to be low relative to their potential.⁵³ Strategies that recruit more smokers to high-efficacy, low-cost services are needed.

Demand for these services is largely a function of how much they are promoted. Mass media campaigns can effectively promote evidence-based quitlines.⁵⁴ In Australia, the national Quitline number was promoted through all National Tobacco Campaign advertising beginning in 1997, including on the end frame of campaign television advertisements. From the onset of the advertising, a causal relationship between campaign television advertising and quitline calls was apparent.^55–57 See Chapter 14 for further information on social marketing campaigns. Campaigns may also promote web-based programs or encourage smokers to use SMS to access support. For example, use of the Quit Coach is related to anti-smoking advertising²⁴ and there is potential for it to be promoted further as a resource for those who have already quit and those who are uncertain.²⁴

Placement of the Quitline number on cigarette packaging is another promotional method that increases awareness of the service and increases the proportion of new callers.⁵⁸

Direct telemarketing of the Quitline service in Australia to smokers has also been trialled with some success. A study in New South Wales found that such cold calling was acceptable to many smokers, especially if it offered subsidised nicotine replacement products as well as the current range of services.⁵⁹ There is evidence that this approach can increase the proportion of smokers using quitline support at a reasonable cost and recruit smokers currently under-represented in quitline populations,^60,61 and that proactive telephone counselling of cold-called smokers initially increases cessation.⁶²

Understanding and addressing the barriers to use of the Quitline by smokers may help to more effectively develop strategies to increase calls, however, more research is warranted to address this issue.⁶³ Barriers to using services include lack of knowledge about the service, people preferring to quit without support and a belief that the service would not be helpful to them personally.^64,59

Enhancing referral links between health professionals, healthcare systems and the quitlines may increase the use of proactive telephone support by smokers.⁶⁵ However, some evidence suggests that the actual enrolment rates into quitline services from faxed referrals is low.⁶⁶ There is some evidence that a pay-for-performance program increases referral to quitline services.⁶⁷

Quitlines offer population access to cessation support, but very few also offer pharmacotherapy. Some studies have found that the addition of free NRT to a quitline is a cost-effective strategy that increases calls and may increase cessation rates.^68–70

Many people search for smoking cessation information online. Online advertising has potential to increase access to evidence-based web and quitline support. Research suggests that compared to traditional recruitment approaches such as billboards, television and radio advertisements, outdoor advertising, direct mail and health professional referral, online advertisements recruits a higher percentage of males, young adults, minority groups, those with lower education levels and more highly addicted smokers.⁷¹

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