This study is the largest to date of the effectiveness and cost effectiveness of alternative tobacco quitline services and policies. One‐year abstinence rates increased when quitline callers were offered: (1) free NRT patches shipped by mail; and/or (2) more intensive counselling with follow‐up calls. These effects for NRT and follow‐up counselling calls are consistent with meta‐analyses for research conducted in other settings.7,8,15,16
Callers were also more satisfied with the quitline when they were offered NRT and/or additional follow‐up counselling support. Customer satisfaction is important because of its relevance to word of mouth advertising and because policy makers often use this measure to evaluate the performance of quitlines.
The added costs of additional counselling and NRT were offset by their increased effectiveness and all conditions were highly cost effective enhancements to brief no NRT. While the cost per incremental quit was about $200 less for moderate no NRT ($1912) compared to either moderate NRT ($2109) or intensive NRT ($2112), moderate no NRT yielded a lower quit rate (14% vs 20% and 21%, respectively). Overall, the differences in incremental cost effectiveness across the five enhanced treatment conditions were modest and policy makers should focus more on other important attributes of the interventions, such as overall quit rates achieved, client satisfaction and their potential to attract more smokers to quitlines. Others have found that short term offers of NRT resulted in marked spikes in quitline calls.40,41,42,43,44
If this effect persists, states could choose to reduce advertising and instead provide more intensive and effective cessation services.
The literature generally supports a dose‐response relation between level of service provision and successful quitting, but our primary intent to treat analyses found that the difference between the moderate (that is, two‐call) and intensive (up to five‐call) protocols was modest. This finding was probably due to the small difference in the number of calls actually completed in the moderate versus intensive conditions (1.7–2.0 vs 2.5–2.9 calls completed). This small difference is surprising because, with a similar quitline protocol in a non‐research context, over 48
000 callers completed an average of 3.8 calls.45
Programme planners should do all they can to encourage callers to complete the full regimen of calls (for example, provide incentives and review counselling protocols to see if language needs to be changed to more strongly emphasise the importance of completing the entire protocol).
Our response rate at 12 months was modest (69%), though fairly typical for low contact studies in community settings. Our primary outcome assumed that those with missing outcomes were still smoking. Because controversy remains about how to handle missing data in smoking trials,37,46
we compared our primary intent to treat method to two different multiple imputation approaches. When we used multiple imputation methods to replace all missing outcomes, we found that the effect for the intensive intervention remained strong, the odds ratio for NRT was substantially reduced (though still significant) and the effect for the moderate intervention became non‐significant. Multiple imputation strategies, however, are considered appropriate only when “missingness” is unrelated to outcome. This assumption may be more appropriate for those with invalid phone and address information than for those who chose not to respond to repeated messages and mailings. When we imputed values only for those with invalid phone and address information and counted “passive refusers” as smokers, results were similar to our primary intent to treat approach.
Strengths of this study include the large sample size and the opportunity to compare the effects of six alternative treatment regimens among the large portion (77%) of eligible OTQL callers who consented. The high recruitment rate and naturalistic context of the study increase the external validity and policy relevance of the findings. We tested the range of services typically offered by state quitlines and provide data by which to judge the effectiveness and cost effectiveness of alternative approaches.
A potential limitation is that our outcome relied on self reported abstinence. Although biochemical confirmation of abstinence is appropriate and necessary in some intervention settings, we47
have argued against the need for biochemical validation in adult population based studies with no face to face contact. In these settings, the proportion of self reported quitters who test positive for cotinine is low and generally equal for treatment and control subjects;47
and the compliance with saliva collection procedures is poor (50‐60% at best), especially across a large geographic area like Oregon.
Another potential limitation is that we did not obtain quit data beyond one year. Because differences in quit rates converged somewhat between six months and 12 months, it is possible that treatment effects would have diminished further by two years and beyond. Quit rates could also diverge, as has been seen in some studies,26
owing to repeated quit attempts in treatment groups. The reduced effect size between six months and 12 months also suggests that we need to study increasing booster sessions or repeating the intervention for those who relapse. A recent VA study suggests almost two thirds of relapsers are interested in trying again with behavioural and pharmacological support in the next 30 days.51
Another limitation is that we could not use a placebo NRT in this effectiveness trial of a politically sensitive statewide service and thus the NRT effect may, in part, be due to expectancy effects. Also, effect sizes may have been reduced by contamination if some controls acquired NRT on their own or if some subjects who were mailed NRT did not use it. From a policy perspective, however, state decision makers may care less about the mechanisms and more about the total impact (and costs) of policies that include an NRT offer versus no offer.
The Department of Health and Human Services in collaboration with the states has created a national network of quitlines4
that can route anyone in the United States who calls a single number (1–800‐QUITNOW) to their local state quitline. Health plans and employers are increasingly promoting similar services, sometimes coordinating closely with the state‐level efforts.52
As a result, many physicians are routinely referring interested patients to quitlines for more extensive tobacco cessation support than can be offered during a short office visit.53
Our data show that offering follow‐up counselling and medications through a quitline cost effectively increased patient satisfaction and doubled the overall quit rate.
What this paper adds
- Several large studies, a recent Cochrane review and the US clinical practice guideline for tobacco have all concluded that telephone quitlines increase quit rates. Because telephone quitlines are convenient to access and are often provided free of charge, they have the potential to serve a broader and more diverse group of tobacco users than traditional group programmes. Quitlines vary widely in terms of the services they offer, however, and few routinely offer multisession counselling and pharmacological aids to most callers. Randomised trials of the relative effectiveness and cost effectiveness of different protocols are limited.
- This randomised trial showed that one‐year abstinence rates increased when quitline callers were offered: (1) free NRT patches shipped by mail; and/or (2) more intensive counselling with follow‐up calls. Callers were also more satisfied with the quitline when they were offered NRT and/or additional support. The added costs of additional counselling and NRT were offset by their increased effectiveness and all conditions were highly cost effective enhancements to brief counselling without NRT.