7.14 Cessation assistance: telephone- and internet-based interventions

Last updated:  July 2022

Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.14 Cessation assistance: Telephone- and Internet-based interventions. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022. Available from: http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-14-methods-services-and-products-for-quitting-te 

 

Assistance for smokers wanting to quit can feasibly be delivered through many different platforms. Telephone-based interventions are low-cost and high-reach, and internet-based interventions offer enormous potential for further reducing costs and increasing reach in communities with good digital access. Table 7.14.1 summarises findings from major reviews1-3 of the effectiveness of such interventions.

Table 7.14.1 Effectiveness of telephone- and internet-based interventions for smoking cessation

Intervention

Relative effect (95% CI)

Telephone counselling1

 

         Additional proactive calls to callers of quitlines versus control/brief advice on single call

1.38 (1.19 to 1.61); i.e., smokers receiving multiple sessions of proactive counselling were 1.38 times more likely to successfully quit compared with control/brief advice

         Proactive calls to smokers not calling quitlines versus control

1.25 (1.15 to 1.35)

         More intensive (3-5 calls) versus less intensive (one call)^

1.27 (1.12 to 1.44)

Mobile phone interventions2

 

         Text messaging versus minimal support

1.54 (1.19 to 2.00)

         Text messaging + other cessation support versus other cessation support alone

1.59 (1.09 to 2.33)

Internet-based interventions3

 

         Interactive and tailored versus non‐active control^

1.15 (1.01 to 1.30)

         Internet versus active control

0.92 (0.78 to 1.09)

         Internet plus behavioural support versus non‐Internet‐based non‐active control

1.69 (1.30 to 2.18)

         Internet plus behavioural support versus non‐Internet‐based active control

1.00 (0.84 to 1.18)

         Tailored/interactive program versus not tailored/interactive

1.10 (0.99 to 1.22)

         Tailored/interactive messages versus not tailored/interactive^

1.17 (0.97 to 1.41)

Note: High-quality evidence; Moderate-quality evidence; ^Low-quality evidence.
Italics indicate interventions for which there was no benefit over comparison group.

For a discussion of the tailoring and effectiveness of interventions for priority populations, including low-income groups, see Chapter 9, and for interventions targeting pregnant women, see Section 7.11.

7.14.1 Telephone services (Quitlines)

Telephone services can provide information, advice, and behaviour change counselling to smokers interested in quitting, either as a supplement to or substitute for other types of cessation assistance. While face-to-interventions are effective, telephone counselling is cheaper and more widely accessible, and can equally be tailored to the needs of the individual. Telephone services can be proactive, such that the counsellor initiates the call to support a quit attempt or help with relapse prevention, or reactive, such that smokers make the call.4 Telephone-based services can form part of more general services, such as cancer information hotlines.4 They can also be specific to smoking, such as quitlines in the US,5 New Zealand,6 UK,7 Thailand,8 and Australia.9 In Australia, the Quitline™ is a specialised telephone information and counselling service for people interested in smoking cessation, which provides accessible and affordable tailored support and information to smokers wishing to quit. The support can be one-off or extended.10

7.14.1.1 Efficacy of telephone services

A 2019 Cochrane review of telephone counselling for smoking cessation concluded that proactive telephone counselling (which involves outbound calls to engage the tobacco user in ongoing treatment) helps smokers who seek help from quitlines and smokers in other settings1 and a 2020 report from the US Surgeon General similarly concluded that proactive quitline counselling, when provided alone or in combination with cessation medications, increases smoking cessation.11 The Surgeon General further concluded that quitlines are an effective population-based approach to motivate quit attempts and increase smoking cessation.11 The Cochrane review found that telephone counselling appeared to increase the chances of quitting, regardless of whether people were motivated to quit or were receiving other cessation support. Limited evidence suggests interventions offering three to six calls may be more effective than those offering one call only. There were not enough studies on the effect of reactive telephone counselling to draw any conclusions.1

In many jurisdictions in the US, quitlines also provide NRT and in some cases other cessation medications. In Australia, Queensland is the only state to provide free NRT to Quitline callers. Making cessation medication available to callers and promoting its availability increases calls to quitlines and may increase quit rates by providing callers with the optimal combination of cessation counselling plus medications.11 Quitlines can also increase smokeless tobacco abstinence.12

7.14.1.2 The Quitline in Australia

In Australia, each state and territory funds the Quitline service (13 7848 – 13 QUIT) within its own jurisdiction. Administrative arrangements for the service vary from state to state: one operates from a state health contact centre, while the others are contracted to non-government health organisations (Cancer Councils), commercial contact centres or hospital alcohol and drug services.  

A set of National Quitline Minimum Standards13 was developed by Cancer Council Victoria, the owner of the national quitline telephone and fax numbers and the Quitline trademark, and implemented in 2021. The Minimum Standards set out response times for calls, data collection, and the training and qualifications of counsellors, plus 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.

The proportion of smokers who cited the financial burden of smoking as a reason to quit increased dramatically alongside large tobacco tax increases, highlighting the importance of promoting cessation services concurrent with policy change.14 There was also a sustained increase in calls to the Quitline after the introduction of tobacco plain packaging.15

A significant advantage of the Quitline is that it provides equity of access with regard to income, language, and location. For the price of a local landline telephone call, Quitline provides access to confidential advice, support, self-help resources, and telephone counselling for smokers who want to quit.  Counsellors are never- or ex-smokers and have a minimum qualification in psychology, counselling or related fields, as well as specialist training in smoking cessation according to WHO Training for tobacco quitline counsellors.16 Counsellors provide tailored and evidence-based support throughout all stages of the quitting process, from thinking about quitting through to relapse prevention and maintaining abstinence. There are also specific programs for priority populations, such as people living with mental illness (especially depression), people experiencing incarceration, pregnant women and partners, and Aboriginal and Torres Strait Islander peoples.

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% said it was helpful, and 82% said they would recommend it to friends. When callers were followed up at 12 months, 29% were currently not smoking, although only 6% had been continuously abstinent over that time.17 An evaluation of the South Australian service in 2010 found that 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% had quit at six-month follow-up. At one year, 96% said they had made a quit attempt, and 38% were abstinent 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 The Australian Quitline callback service, whereby counsellors proactively phone users, led to higher quit rates in both states in smokers that used the service compared with those who did not.9 ,18

Economic evaluations of the Quitline in Australia have also concluded that they are highly cost-effective—see Section 17.4.3.2.

7.14.1.3 Telephone services for high-need groups

Quit rates among priority population callers to a quitline suggest that the service can be effective when used by high-risk and underserved populations.19 However, a recent review found that most studies examining the effectiveness of quitlines do not reflect these populations, leading to gaps in the evidence.20 Further, access to the quitline can be a hurdle for such groups. A study in the US found that over one-third of low socioeconomic smokers did not have access to a phone they could use to call the quitline. There were also low levels of knowledge about the quitline, quitting, and trust in tobacco treatment programs, and mixed feelings about the costs and benefits of quitting; for example, some participants were concerned about getting sick if they quit.21 New Zealand research found that smokers in rural areas were less likely to use the quitline, suggesting that the service is less effective in reaching rural smokers.22 In Australia however, low socioeconomic status smokers appear to be just as or more likely to contact the Quitline—see Section 9.9. A longitudinal evaluation of callers in NSW found that Quitline callers’ tobacco consumption and dependence decreased between 2008 and 2011, but they remained more addicted than the average NSW smoker,14 suggesting that they may need more intensive or extended support. US research also suggests that more intensive quitline support may be helpful for smokers with lower education levels.23

Quitline callers who report a history of mental health conditions and/or recent emotional challenges also appear to be less likely to successfully quit.24 Among smokers with mental health conditions, a specialised telephone counselling intervention may increase engagement in treatment,25 , 26 and may be more effective.27 There is also the potential for cessation interventions to be paired with additional behavioural interventions, such as treatment for depression.26

South Australian research found that while the proportion of Aboriginal and Torres Strait Islander and non-Indigenous smokers who registered for the Quitline service was comparable, Aboriginal and Torres Strait Islander callers received significantly fewer callbacks, were significantly less likely to set a quit date, and were significantly less likely to be successfully quit at three months.28 The Australian Government’s Tackling Indigenous Smoking Initiative includes funding to enhance existing Quitline services—see Section 8.13.5 for an overview of this program, and Section 8.10.4 for a summary of the effectiveness of quitlines for Aboriginal and Torres Strait Islander peoples.

7.14.2 Text messaging (SMS) services

Mobile phones are used widely and are well integrated into the daily lives of many people, particularly young adults. Mobile phones are increasingly being used by health services, for example for appointment reminders, to promote preventative activities, for medication adherence, and to self-manage chronic disorders. Recent years have also seen the increasing use of mobile phones for smoking cessation support, particularly as an adjunct to existing programs such as quitlines. In the US in 2017, 55% of state tobacco quitlines provided interactive text messaging.29 Mobile phone-based cessation interventions are widely and easily accessible. They can also serve as a distraction from cravings, and provide social support.30 Text messaging interventions generally send messages that are grounded in social cognitive behavioural theories, such as behavioural change techniques and individually tailored messages based on demographic information.31

The US Surgeon General concluded in 2020 that services providing short text messages about quitting are independently effective in increasing smoking cessation, particularly if they are interactive or tailored to individual text responses.11 A 2019 Cochrane review similarly found that text messaging programs may be effective in supporting people to quit, increasing quit rates by 50% to 60%,2 and a 2021 Cochrane review examining behavioural interventions for cessation concluded that there is moderate‐certainty evidence that text message interventions are beneficial.32 An earlier review concluded that the advantages of mobile phones for cessation interventions include low cost, better reach, increased interaction between researcher and participants, and easier as well as faster way to send tailored and personalised messages.33 Additional meta-analyses have similarly supported the efficacy of mobile phone- and text-based interventions for smoking cessation.34-39

Despite their promise, further research is needed to more fully understand the most effective elements of text-messaging interventions. Studies to date have had substantial variation in key features of the interventions, including frequency of messages per day and per week; length of programs; use of unidirectional versus bidirectional messages; and message content. Variations in study design, such as the endpoint used for measuring abstinence, have also presented a challenge when interpreting findings. Nonetheless, the overall evidence supports the efficacy of text-based cessation interventions.11

7.14.3 Smartphone applications (apps)

Smartphones, by incorporating computer operating systems and enabling internet access, have substantially broadened the functionality of mobile phones. Recent years have seen the proliferation of health and wellness apps, including those that support smoking cessation. Smartphones apps have the potential to overcome limitations of website and text messaging interventions, whilst maintaining all of their benefits. Specifically, smartphone apps could boost user engagement—an important predictor of cessation—through incorporating these important features: (1) available at arm's reach, (2) visually-engaging design, (3) video and audio capabilities, (4) unrestricted text capabilities, (5) access without phone or internet connection, (6) immediate access to intervention content, (7) optimised to smartphone screen size, (8) content sharable via social media, and (9) tracking progress at any time.40 However, despite showing promise,41 ,42 a Cochrane review in 2019,2 the US Surgeon General’s report in 2020,11 and several review papers43-45 have all concluded that there is currently inadequate evidence to determine the effectiveness of smartphone apps for smoking cessation.

Despite their potential advantages, the quality of cessation apps can vary substantially. A content analysis of smartphone apps to assess how ‘smart’ they actually found that while users value tailored feedback, many apps fall short in this area, and are limited in their capabilities.46 Smoking cessation app users also cite the importance of personalisation, support, functionality, and credibility.47 Several analyses have found that most apps do not adhere to clinical guidelines on smoking cessation,48 such as incorporating elements of evidence-based therapies such as CBT.49 ,50 The highest quality apps combine both information and several assistive functions (e.g., the provision of several of the ‘5As’).51 The addition of a supportive ‘chatbot’ (an AI-driven computer program that has conversations with the user) to a cessation app appears to increase engagement and may increase cessation.52 ,53 An AI-based app combined with usual care (i.e., pharmacotherapy plus behavioural support) may also increase abstinence beyond usual care alone.54 ,55 While most apps rely on participant self-report, wearable sensors (i.e., armbands/smartwatch) offer great potential to provide automatic feedback and objective verification of smoking status; however, most of these are still in the early stages of development.56 ,57

A 2015 study in New Zealand that ranked smartphone apps for smoking cessation by their quality found that most did not perform particularly well. The highest scoring app was produced by the Australian National Preventive Health Agency, called "Quit Now: My QuitBuddy".58 Another review of apps available in Australia identified only six that were ‘high quality’ in 2017: SF28; HPB I Quit; My QuitBuddy; QuitStart; SmartQuit; and SmokeFree Baby.59 A 2021 review found wide variation in the methods, design and types of participants included in studies examining smartphone apps for cessation, and called for greater consistency and larger trials of such interventions.43 In 2022 the World Health Organization launched a smoking cessation app, ‘Quit Tobacco App’.60 Although apps are more commonly used by younger smokers, Australian research has found that My QuitBuddy may promote cessation among older Australians who are willing to use it.61 Health professionals may wish to recommend the highest quality apps in conjunction with existing evidence-based methods,58 including face-to-face support.62 One review noted that although evidence-based apps are available, they are difficult to find among the many apps that are identified through app store searches.63 Problematic apps that are likely ineffective appear to have a large market share.51

7.14.4 Internet-based interventions

As of April 2022, there were an estimated five billion active internet users worldwide (63 per cent of the global population).64 The Internet offers enormous potential for the delivery of low-cost and high-reach cessation interventions.65 ‘Quit smoking’ is a popular online search term,66 and online treatment programs, being convenient, anonymous, and accessible 24 hours a day, are able to overcome barriers that commonly prevent people from accessing existing cessation services. They may also be more effective in reaching young people than more traditional services.65  An analysis of the Smokefree.gov initiative in the US found that use has grown over time, with 7–8 million people accessing its web- and mobile-based resources in 2018.29

The US Surgeon General concluded in 2020 that Internet-based interventions increase smoking cessation and can be more effective when they contain behaviour change techniques and interactive components.11 A Cochrane review published in 2017 also found that internet programs that were interactive and tailored to individual responses led to higher quit rates than usual care or written self‐help at six months or longer.3 Additional reviews similarly support the effectiveness of internet-based interventions for increasing the odds of successful cessation.38 ,67-72 A 2019 meta-analysis found that internet-based interventions that included goals and planning, social support, natural consequences, comparison of outcomes, reward and threat, or regulation were more effective in the short and long terms, when compared with study arms that did not include such behaviour change techniques.71 Support via live chat appears to be a helpful addition to cessation websites.73 ,74

Despite their great potential, Internet-based cessation interventions have several limitations. People of higher socioeconomic position may have greater access and usage of online health information;75 users of online cessation services are generally younger, healthier smokers of higher socioeconomic status.76 The Cochrane review noted that the effectiveness of such interventions in younger smokers is unknown.3 Although there are a large number of smoking cessation websites, not all provide an intervention, or if they do, it may not be evidence-based.65 Such websites also vary in quality and credibility, ranging from the comprehensive and well researched to sites set up by tobacco manufacturers. There is some evidence that people using the Internet for smoking cessation information often do not access research-based sites.77 However, as internet-based interventions have grown more sophisticated, incorporating better website design and improved functionality, the efficacy of such interventions has substantially improved.11

Quit Coach (www.quitcoach.org.au) is a tailored, internet-delivered smoking cessation advice program supported by Quit Victoria. Most users of the Quit Coach use it to support 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.78 The site successfully targets people who are moderately addicted, with users being more likely to be female, younger, and users of the Quitline.79

7.14.4.1 Social media

Social media sites, such as Facebook and Twitter, are immensely popular among young adults, and with their potential for wider reach and greater engagement are increasingly being used in health-related research and interventions.80 Two reviews of social media interventions for smoking cessation concluded that while such interventions hold promise, and are feasible and acceptable, more research is needed to examine their effectiveness.81 ,82 One suggested that additional efforts are needed to determine effective strategies to promote user engagement in social media interventions as well as to investigate which type of engagement leads to sustained smoking cessation. Different age groups and segments of the population have preferences for different social media platforms, and such preferences change over time. Therefore, future studies should aim to be translatable to other platforms as well as identify how different elements—such as group size and baseline characteristics, length and type of engagement, and tailored content—contribute to the effectiveness of social media interventions.82

Most recently, a 2021 review of the effectiveness of using social media for smoking cessation concluded that such interventions have demonstrable potential to: recruit and retain smokers online; deliver cessation interventions; collect clinically meaningful cessation outcomes; and help smokers to successfully quit or prevent relapse. The use of incentives appeared to be helpful in decreasing attrition rates. The review examined interventions that used both existing popular social networking platforms (e.g. Facebook, WhatsApp, Twitter) and those that used individually designed interactive platforms (e.g. MyLastDip, iQuit system, Quitxt system), and found no significant differences in their effectiveness. The authors therefore suggest embedding smoking cessation interventions within existing social media platforms, due to the low cost and a large number of existing users.83

7.14.4.2 Video calling

The delivery of healthcare interventions via video conferencing technology, such as Skype or Zoom, has the potential to increase the provision of healthcare and specialist services to people who may otherwise have limited access to such care. Although real-time video counselling for smoking cessation offers great promise, a 2019 Cochrane review found that more evidence is needed to support such a strategy.84 However, a 2020 review concluded that video counselling appears to be equally effective as telephone counselling in promoting smoking cessation.85 Results from Australian studies showed that smokers in rural and remote areas generally find video counselling for cessation acceptable and helpful,86 and that it may increase medium-term cessation rates.87  

7.14.5 Increasing smokers’ use of telephone- and internet-based services

The overall impact of smoking cessation interventions in reducing smoking prevalence is a product of the intervention’s reach and its efficacy. Use of support services such as the quitline continues to be low relative to their potential.88 ,89 An examination of quitline use in 31 countries found that among smokers who had tried to quit, use ranged from 0% in Cameroon and Egypt to 4.4% in the Philippines.90 In Australia in 2019, about 2% of smokers reported that they had contacted the Quitline.91 Strategies that recruit more smokers to high-efficacy, low-cost services such as telephone- and internet-based interventions may help to increase the number of smokers who successfully quit, particularly among groups who have disproportionately high smoking rates.92

Demand for these services is largely a function of how much they are promoted. Mass media campaigns can effectively promote evidence-based quitlines,7 with the US Surgeon General concluding in 2020 that mass media campaigns increase the number of calls to quitlines and increase smoking cessation.11 In the US, an evidence-based national tobacco education campaign substantially increased quitline use.5 ,93 Utilising different types of media when promoting quitline, such as TV and radio, may also allow for effective targeting of specific subgroups of smokers.94 Research in the US also found that higher state tobacco program expenditures are associated with higher quitline awareness and utilisation.95 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. This promotion led to a significant increase in calls to the Quitline.96-98 Increased spending on (and therefore greater levels of public exposure to) antismoking campaigns appears to be as effective in prompting additional calls to the Quitline in lower, compared to higher, SES groups.99  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, anti-smoking advertising is also related to increased use of the Quit Coach.79 In Sweden, tobacco control policies such as health warnings, mass media campaigns, smokefree restaurants and tax increases have been associated with increased calls to quitlines.100

Placement of the Quitline number on cigarette packaging is another form of promotion that increases awareness of the service and the proportion of new callers.101 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 cold calling was acceptable to many smokers, especially if it offered subsidised NRT.102 This approach is a cost-effective way of increasing the proportion of smokers using quitline support and recruiting smokers currently under-represented in Quitline populations,103 ,104 as well as increasing rates of cessation.105 Quitline registries can also be used to re-engage relapsed smokers, through inviting past callers back to the service.106

Understanding and addressing the barriers to use of the quitline by smokers may help to more effectively develop strategies to increase calls.107 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.102 ,108 Smokers often report being unwilling to use the service, and view it as a last resort.109 Among low socioeconomic smokers, lack of access to a phone and low levels of knowledge about quitting can hinder use of the quitline,21 and the service may also be less effective in reaching rural smokers.22

Enhancing relationships between health professionals, healthcare systems and quitlines may increase referrals and the use of proactive telephone support by smokers.110 Health system implementation of an eReferral to Quitline can also increase reach and effectiveness.111-113 “10,000 Lives” is a regional smoking cessation initiative launched by Central Queensland Hospital and Health Service in 2017 that focused on maximising the use of existing cessation services, and researchers found that it increased referral to and use of the Quitline.114 There is some evidence that a pay-for-performance program (whereby healthcare professionals receive financial rewards for making referrals) increases referral to quitline services.115 Receiving advice from a health professional is related to higher quitline awareness and utilisation in the US.95 Engaging a non-smoking support person, through conducting phone intervention for family members and friends, may also increase treatment enrolment among smokers.116 Proactive outreach to smokers that connects them to evidence-based telephone cessation services can increase cessation rates.117 Quitline registries might also be useful for re-engaging relapsed smokers, through inviting past callers back to the service.106

Quitlines offer population access to cessation support, but in Australia, only Queensland also offers pharmacotherapy in the form of 12 weeks of free NRT. 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.11 ,118-120 Many people search for smoking cessation information online. Online advertising has potential to increase smokers’ use of evidence-based web and quitline support. Research suggests that compared to traditional recruitment approaches, online advertisements recruit a higher percentage of males, young adults, minority groups, those with lower education levels and more highly addicted smokers.121 One study in the US found that allowing online quitline registration and offering a range of services (such as telephone counselling, text messages, emails, and NRT) was particularly helpful for engaging younger smokers.122

 

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References 

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