Survey results showed that state and provincial quitlines in North America share common elements of practice including core service activities and commitment to quality assurance. Results revealed variations among the quitlines regarding funding, services and utilisation. Differences among quitlines may reflect specific contexts of given tobacco control programmes (for example, budget constraints), the pursuit of new ideas (for example, internet based intervention) or variations in implementation (for example, number of counselling sessions). Examination of these commonalities and differences reveals knowledge gaps and may further quitline evolution and impact.
One commonality is that almost all state and provincial quitlines endorsed the use of multisession, proactive counselling. This treatment protocol has the strongest evidence base; proactive counselling is the key feature of the protocols tested in experimental studies and proved effective.1,2,3,4,20
The adoption of multisession, proactive counselling by the many different funders and service providers is clearly a successful case of disseminating research results to practice.1,2,3,4
Single session counselling (when it adheres to a comprehensive protocol) has also been proved to be effective, and most quitlines offered this service as well.4
Counselling was universally characterised as addressing motivation, use of quit aids, planning and coping strategies, setting a quit date, and development of skills to prevent relapse. Despite the general agreement on counselling content, it remains unclear exactly what transpires in each quitline's counselling sessions. With few exceptions,19,21
quitline operators have not detailed their counselling protocols in public documents. An additional issue hampering accurate comparison of interventions is that implementation of a protocol often deviates from the intended intervention. For example, two quitlines may adopt the same standardised protocol, with the same number of proactive follow‐up sessions prescribed, and yet differ in the average number of follow‐up sessions delivered. Deviations from the intended intervention might arise as a result of differences in staffing levels or in persistence of counsellors attempting to reach smokers who miss appointments. In short, the actual delivery of counselling may deviate from a stated standardised protocol in many important ways, leaving a significant knowledge gap in quitline operation. The quitline community (through NAQC) has embraced the standardisation of intake data through its recommended minimal data set.22
It would likewise be useful to work towards a consistent format for documenting the delivery of counselling.
Most quitlines appear to have quality control built into their operations. Quality of service starts with training, and the survey results indicate that most quitlines provide lengthy training before counselling staff begin taking clients. Most quitlines augment the standard didactic classroom hours with additional modalities of learning such as role playing and shadowing, providing opportunities to develop the nuances of counselling. Supervision ranges from daily, informal peer contacts or weekly groups to quarterly, individual supervision sessions. Most quitlines also have formal continuing education programmes to ensure that counsellors stay up to date on developments in tobacco control. This considerable investment in counsellor training and supervision allows quitlines to be staffed by para‐professionals and professional counsellors alike.14
Most quitlines continuously assess quality of work through evaluation of clients' quitting outcomes. Whereas details of evaluation procedures differ across quitlines (another place where standardised reporting would be useful), the policy of ongoing outcome evaluation is prudent because treatment effects in real world application of clinically proved intervention protocols may not equate with effects observed in clinical studies. For example, the treatment effect may decay over time as counsellors drift from the rigour of the intervention delivered in the clinical trials. Emphasis on continuous performance assessment keeps programmes accountable and ensures the ongoing effectiveness of the intervention.
Quitlines provide extensive coverage across area, time and language. This is economically feasible because quitlines are centralised operations: a few counsellors on duty can cover a large geographic area and several different languages. It is interesting to note that compared to unpublished data from the 2002 quitline survey,11
the hours of operation for quitlines in North America in 2005 have increased, as have the numbers of quitlines providing counselling “in language” without the use of a translation service. These positive trends reflect quitline operators' efforts to increase accessibility and thereby improve service.
Survey results show that quitlines are largely supported by state and provincial funding, with additional federal monies. On average 1% of smokers in the United States utilised quitlines in the fiscal year 2004–5, although utilisation rates ranged from 0.01% to 4.3%. As figure 1 shows, quitline utilisation rates were directly related to funding levels. Interestingly, however, some quitlines with lower levels of funding managed to reach greater proportions of smokers. The current survey did not examine the important topic of quitline promotion. Although it is well known that mass media have been the major channel of promotion for quitlines,23,24,25
more studies on various promotional strategies and their effectiveness are needed.26
Variations in practice naturally arise among entities that differ from one another in terms of geographic areas covered, populations served and structure (for example, medical centre/university based, commercial enterprises, etc). These variations are important in two ways. Firstly, they provide the contextual information necessary to make sense of data provided by each quitline. Secondly, they represent alternate approaches that can fuel future research. One example is the use of eligibility criteria for providing counselling. Some quitlines counsel only smokers who are ready to quit—that is, they reserve the most intensive and costly intervention for clients who state a desire to take action. Restricting eligibility affects the context in which clients receive the counselling intervention and thereby affects the absolute quit rates. Knowing whether counselling is restricted, and to whom, is important in assessing data on success rates, especially if the data are being used to compare service providers.14
At the same time, the use of readiness to quit as a criterion for counselling is consistent with the evidence base, since most randomised trials of quitlines have recruited smokers who were ready to quit. The alternate approach would be to counsel all callers, regardless of their stated readiness to take action. Whether quitlines should allocate counselling resources according to readiness to change (which is more like a stepped care approach) or counsel every smoker without regard to readiness is still an open question whose answer has both scientific and practical implications.
Variations can reveal values underlying decisions about scope of practice, resource allocation, and services beyond the current evidence base. One example is the provision of free cessation medications. In 2004–5, one third of US quitlines reported providing nicotine replacement therapy (NRT), and another 20% provided vouchers or discounts. Both medication and telephone counselling are effective; providing both permits “one‐stop shopping” and decreases barriers to quitting. Offering free medication has been shown to markedly increase the number of smokers calling the quitline.27,28,29
Given these advantages, it is somewhat surprising that only one third of US quitlines provide this service. One issue may involve whether provision of medications falls within quitlines' scope of work or is the responsibility of health plans. Public funding for tobacco control is limited, and many quitlines opt to reserve their resources for counselling. Several service providers are conducting studies to examine issues (for example, cost) associated with providing free medication via quitline.30
Another promising direction is the use of internet based interventions. Only about half of quitlines use the internet to provide cessation information, and fewer still offer such components as chat rooms or interactive counselling. Given the internet's potential for reaching very large numbers of smokers, the use of internet interventions and the integration with telephone counselling are promising areas of exploration. Several quitline operators are currently conducting studies of internet based interventions31
to provide stronger empirical evidence of efficacy.
Some limitations of the survey itself need to be acknowledged. Although this survey provided more specific data than have previous surveys,11,12
results are still limited by respondents' interpretations, and there were questions left blank by respondents. We have identified in the tables the effective sample size for each question. Despite those limitations, the overall data patterns clearly show where quitlines share common practices and where they diverge. However, the survey did not examine reasons for variations. This leaves us to raise questions and speculate about implications.
It should be mentioned that the unit of analysis in reporting results is the quitline. As a result, descriptions are weighted towards the practices of the nine organisations that provide service to multiple states or provinces. Changes in the number of service providers would inevitably affect the variability of practice. One result of the limited variability is greater consistency across quitlines in areas such as quality control or adherence to a minimal data set for screening and evaluation.22