The Minnesota QUITPLAN Helpline collaborates with seven major health plans in Minnesota to provide statewide access to telephone counselling. At the time of this study, these health plans insured approximately 90% of the state population.14
The helpline attempts to transfer callers with insurance to their health plan for services. However, individuals with insurance who cannot identify their specific plan or who do not wish to be transferred are still eligible to receive assistance directly from the QUITPLAN Helpline.
MPAAT contracted with Free & Clear, Inc (Seattle, Washington) to provide QUITPLAN services. QUITPLAN callers choose between a one‐call comprehensive session or a multiple‐session programme that includes four additional proactive calls. Interventions are grounded in social cognitive theory15
and incorporate motivational interviewing16
and cognitive‐behavioural counselling techniques.2
Participants learn problem solving and coping skills and are encouraged to use evidence‐based behavioural strategies (that is, acquiring social support, avoiding high risk situations, etc) with specific approaches tailored to the individual needs of each caller. The efficacy of the Free & Clear programme has been demonstrated in prior randomised trials.17,18
On 3 September 2002 the helpline began offering nicotine patches or gum to callers who enrolled in QUITPLAN's multi‐session programme. For those who enrolled in multi‐session counselling, NRT was recommended for callers who smoked five or more cigarettes per day, planned to quit within 30 days, were age 18 or older, and did not have contraindications to the use of NRT (such as pregnancy, prior sensitivity, chest pain, etc). Eligible callers were mailed an eight‐week supply of nicotine patch or gum with the starting dose determined by their baseline level of tobacco use.
At the time when NRT was introduced, there were few changes in other policy or social–environmental factors in Minnesota that might have influenced helpline call volume.19
There was no change in the price of cigarettes nor were there any changes in city, county, or state restrictions on smoking in public places. MPAAT's media efforts to encourage cessation ($1.5 million annually) were also unchanged in the period before versus after the introduction of NRT. Specifically, no paid media announced the addition of NRT to helpline services. The addition of NRT to the helpline was reported by major news outlets, including a front‐page story in the state's largest newspaper.
MPAAT contracts with Professional Data Analysts, Inc to evaluate the QUITPLAN Helpline. The evaluation plan is shown in fig 1. Data sources include programme registration information (demographic characteristics and initial readiness to quit), helpline administrative records (counselling, delivery of medications, costs), and phone surveys administered two weeks (tobacco use history) and six months (quit attempts, use of medications, cessation outcomes) after registration. Information from the 2003 Minnesota Adult Tobacco Survey, a statewide phone survey (response rate 56.4%, 18% prevalence of tobacco use, n
1368 current smokers identified), allow for comparison of characteristics of helpline callers with the general population of smokers in Minnesota.
Figure 1Evaluation plan.
Consecutive callers to the helpline were selected to be part of evaluation cohorts if the caller (1) requested counselling services (that is, not calling on behalf of others or seeking information only—73% of all callers) and was (2) age 18 or older (over 99% of all callers). To account for possible seasonality in call volume and abstinence rates, cohorts were selected at predetermined periods throughout the calendar year. Four cohorts (n
670) were selected in the year before the introduction of NRT (September 2001 to August 2002) and two cohorts (n
596) in the nine months after the introduction of NRT (September 2002 to May 2003). Callers who were transferred to their health plan are excluded (n
247 pre‐NRT, n
174 post‐NRT) because it was considered the responsibility of health plans to evaluate their services for their own members. Of those callers who received QUITPLAN services, some are excluded because the time window for completion of their six‐month survey (beginning two weeks before and ending four weeks after the six‐month anniversary of programme enrolment) closed before any attempts were made to contact these individuals (n
5 pre‐NRT, n
24 post‐NRT). Also excluded are individuals who asked not to be contacted for the six‐month follow‐up (n
7 pre‐NRT, n
1 post‐NRT). To determine quit rates, we excluded callers who reported they had already stopped smoking at the time of registration (n
31 pre‐NRT, n
24 post‐NRT). This leaves 380 callers in the pre‐NRT sample and 373 in the post‐NRT sample for evaluation of cessation outcomes. For these remaining cohort members, a minimum of seven attempts was made to complete follow‐up phone surveys at two weeks and again at six months.
The primary cessation outcome is self‐reported abstinence from all tobacco products for 30 days or longer on the six‐month follow‐up survey. Secondary outcomes include seven‐day point prevalence abstinence at six months and the number of quit attempts. Process measures include use of pharmacological therapy and receipt of phone counselling. Abstinence rates are presented both among survey respondents and as determined by intention‐to‐treat with all non‐respondents considered to be continuing smokers.
Programme impact is determined by calculating the number of new ex‐smokers per month among QUITPLAN callers. To exclude the one‐time effects of high initial response to the availability of NRT, we compared the period from January to May in the year before and after the introduction of NRT. Cost per caller and cost per quit are determined from the perspective of the funding agency based upon actual programme costs in US$. MPAAT costs are determined on a per caller basis under the contract in place at the time with Free & Clear. Pre‐NRT, these costs are determined by the number of individuals who receive single or multi‐session counselling. Post‐NRT, MPAAT costs include both the cost of providing phone counselling and the cost of providing free NRT. MPAAT media expenditures (unchanged pre‐NRT versus post‐NRT) are not included because media efforts promoted cessation in general and did not specifically mention the availability of NRT from the helpline.
Analysis for this study was performed by Professional Data Analysts, Inc using SPSS 13.0. Comparison of caller characteristics pre‐NRT versus post‐NRT was performed using χ2
for categorical variables and t test or non‐parametric tests for continuous variables. Comparison of abstinence outcomes was performed using χ2
tests. To examine possible reasons for changes in abstinence following the addition of NRT, we examined the odds of 30‐day abstinence post‐NRT versus pre‐NRT using three logistic regression models. The first model presents the unadjusted odds of 30‐day abstinence. The second model examines the odds of 30‐day abstinence after adjusting for potential differences in the baseline characteristics of callers. Baseline characteristics included in this model (age, gender, education, readiness to quit, tobacco use history) were selected a priori based upon their predictive value in prior studies.20,21,22,23,24,25,26
The third model examines the odds of abstinence after controlling for caller characteristics and use of cessation services (one‐call versus multi‐session counselling, use of medications). All tests for level of significance are two‐tailed.
This study was reviewed by the University of Minnesota's Institutional Review Board and determined to be exempt under federal guidelines 45 CFR 46.101 (b) for existing data.