The free patch initiative was a highly cost effective programme for increasing the reach and effectiveness of the Oregon quitline. Compared to paid media promotion for a single telephone counselling session, shifting media promotion resources to fund a free NRT offer doubled the number of registered callers. The number of quitters increased fourfold and the cost per quit fell more than $2688.
The annual free patch initiative reached an estimated 2.6% of Oregon's 532
000 smokers, excluding the initial roll‐out period, while 1.2% of smokers registered for service during the pre‐initiative period. These results correspond to reach estimates of 0.5%–5% achieved by other state quitlines offering free NRT while maintaining their paid media campaigns.9,10,11,12
Over 3% of Maine smokers call the quitline annually using clinic outreach to promote the free NRT offer.10
In 2003, the New York State quitline offered 2–6 weeks of free NRT to callers from selected areas of the state and used earned media publicity to promote the programme. Call volumes increased in all areas and overwhelmed limited NRT supplies, thus limiting reach to <1% in most of the state.12
About 5% of New York City smokers called the quitline over a six week period.9
The Minnesota quitline added free NRT to its multisession counselling protocol in 2002 with its existing paid media.11
Call volumes increased fourfold.
Providing two weeks of free NRT for Oregon quitline callers nearly doubled intent to treat quit rates at six months compared to no NRT. Other quitline studies report similar benefits. Thirty‐day abstinence was 22.5% for Maine smokers who received six weeks of NRT and multisession counselling compared to 12.3% of callers with counselling only.10
Twenty per cent of NYC callers receiving NRT and a single follow‐up call were not smoking after six months.9
In Minnesota, quit rates increased from 10% to about 18% with free NRT.11
Cost and cost effectiveness data for the free patch initiative were similar to economic evaluations of free NRT offers. Maine's intervention cost $1344 per quit.10
In Minnesota, costs per quit were $1362 for the no NRT programme and $1934 for the free NRT programme.11
Intervention cost per quit for New York's free NRT offer was under $500.9,12
However, our study was the first to include quitline promotion costs as part of the analysis. We estimated that annual paid media costs were $215 per registered tobacco user for the pre‐initiative programme and less than $4 per caller during the free patch initiative.
By substituting free NRT for paid media expenditures, TPEP was able to dramatically reduce the average cost per quit. However, the free NRT prompted more calls and increased the total annual cost of the programme somewhat. The result was a small but positive incremental cost per quit compared to the pre‐initiative programme. This study showed using scarce programme resources to fund free NRT instead of paid media promotion was a good value even for the worst case scenario. Costs/LYS were less than the $1000–$5000 per LYS typical for other tobacco interventions and substantially below other commonly available preventive services (for example, mammography).2,25,26
This study has several limitations. The short follow‐up period did not allow us to assess longer term quit rates and costs. The relatively low response rate to the six‐month survey may also have influenced the accuracy of the quit rates, since all non‐responders were assumed to be treatment failures. A higher response rate would have likely improved cost effectiveness, since some of those not reached may have quit. We excluded the initial period of the campaign when the bulk of the free NRT was actually distributed, assuming that this level of call volume would not be sustained in an ongoing free patch programme. However, this likely underestimated the effect free NRT could provide. We did not biochemically confirm smoking status at follow‐up. However, evidence suggests false reporting is minimal for low intensity interventions with no face to face contact.27,28
We assumed a sustainable quitline promotion programme would require periodic paid media advertising. We do not know how calling rates may vary over time. We also do not know the effectiveness of a month long media campaign conducted once or twice a year. However, we expect declining marginal benefits in terms of call volume from increased media spending. We are sceptical that a paid media campaign can match the call volumes achieved by the free patch initiative.
We were unable to capture any quits that may have been caused solely by viewing the media campaigns. Zhu and others have proposed that an important benefit of quitlines is their enhancement of quit attempts in the larger population regardless of whether people actually call for help.29
However, this effect has only been measured in one instance30
and it is not clear how large an effect, if any, is produced. In addition, it is unclear whether this collateral benefit is best achieved via mass media, healthcare provider promotion, word of mouth, or all three. The availability of free patches and the much cheaper healthcare provider promotion may increase healthcare provider and word of mouth cessation activity more than mass media.
Though not part of this analysis, initiative participants reported spending more for additional cessation products ($27.39, range $23.50–$31.30), primarily for additional patches and bupropion, than pre‐initiative callers ($12.04, range $8.35–$15.73). Only 10 study participants (<0.5%) reported obtaining additional NRT that was partially covered by health insurance, even though the free patch initiative aimed to increase use of covered cessation services.
The CEA results were influenced by the large increase in number of calls generated by the earned media promotion strategy compared to paid media. That difference raises the possibility of TPEP using paid media to increase the number of annual calls to the same level achieved by the earned media and free NRT offer. We looked at how much this strategy would cost, its effect on quitting and how these results compared to the earned media approach of the free patch initiative. We answered these questions by multiplying the average paid media cost per call and quit rate for the pre‐initiative programme by 13
646 callers. Assuming paid TV/radio ads had a constant effect on quitline calls (that is, $215 per registration call) TPEP would spend $4.2 million on paid advertising and cessation counselling for 13
646 callers. Of these callers, we estimated that 1119 would quit. Thus, we estimated that the free patch initiative (even with two months of paid media) could save TPEP nearly $2 million and help 1023 more people quit than if they had increased call volumes using only paid media.
As in other states, extensive earned media coverage of the quitline's free patch offer generated a large initial call volume during the initial roll‐out of the initiative. We expect this was a one‐time phenomenon. In the future, media outlets can include the availability of free quitline services as part of news reports about tobacco control policies, the impacts of tobacco use and benefits of quitting. We expect future call volumes will depend largely on TPEP's continued efforts to promote the quitline among healthcare providers, insurers and public health agencies.
Overall, the free patch initiative appears to have been a very effective and cost effective programme that dramatically increased the number of quitters among Oregon quitline callers. This study shows that expanding cessation services to include medications can substantially increase the reach and effectiveness of state funded quitline services. Given persistent resource limitations, state tobacco control programme managers should consider reallocating portions of their media promotion budget to cover medications.
What this paper adds
- Some state funded telephone tobacco quitlines offer free NRT to tobacco users registering for service. In these instances, free NRT has been added to the existing quitline promotion activities that include paid TV and radio advertising. In 2004, Oregon became the first state to promote quitline services with a strategy that combined a free NRT offer and earned (unpaid) media.
- This study demonstrates that shifting expenditures from media promotion to an NRT offer is a highly cost effective tobacco control strategy for state programmes.