The fidelity outcomes from this study suggest that quitlines can train their staff to deliver gain-framed counseling in a consistent fashion. Smokers who spoke with a specialist who received the gained-framed training and ongoing supervision had slightly better smoking cessation outcomes than those who spoke with a specialist who received standard-care training and ongoing supervision. Moreover, there were no differences in callers’ ratings of satisfaction with NYSSQL services between the study groups, and specialists’ ratings of satisfaction were not negatively affected as well. Although the findings from this study need to be replicated and validated by the NYSSQL and other quitlines, they support the hypothesis that quitlines can improve their services by implementing relatively straightforward training programs for telephone staff. Future studies should explore the application of different counseling techniques that might boost cessation outcomes by using rigorous procedures to monitor treatment fidelity (30
). For instance, although virtually all quitlines use some type of motivational interviewing or cognitive behavioral counseling strategies (11
), the effectiveness of these techniques in a quitline setting has not been tested empirically.
In this study, consistent with previous findings (25
) from our smoking cessation clinical trial testing message framing to augment bupropion SR, we observed an initial statistically significant increase in quit rates at 2 weeks but this difference was no longer statistically significant at the 3-month follow-up. In accordance with our hypotheses, we found a statistically significant increase in positive health expectancies over time for callers in the gain-framed group, indicating that the gain-framed intervention did, in fact, affect smokers’ expectations about quitting in the intended manner.
The fact that the difference in quit rates at 3 months was no longer statistically significant might be explained by the low intensity of the gain-framed intervention. To ensure that the study was truly translational, the gain-framed counseling intervention conformed to the brief nature of the NYSSQL standard-care interventions, but this brevity might have attenuated our results. Multiple messages may be necessary for longer-term impact (46
). Our use of the dichotomous primary smoking cessation outcomes (ie, yes or no at 2 weeks and 3 months) should also be considered as a possible measurement constraint. Several of our previous studies (25
) that showed a benefit of gain-framed messages used continuous variables as primary or secondary endpoints. For instance, Schneider et al. (26
) found a decrease in number of cigarettes smoked among participants who were exposed to gain-framed messages, and Steward et al. (28
) found higher intentions to quit among participants who received gain-framed messages. Toll et al. (25
) found that time to first cigarette was more sensitive to message-framing effects than the primary cessation outcomes, both of which were categorical. Indeed, we found that our continuous secondary outcome of expectancy ratings showed statistically significant differences favoring the gain-framed counseling. Given the brevity of quitline calls and the pressure to have very brief assessments, we did not include a more comprehensive continuous outcome, such as time to first cigarette. Consequently, future quitline studies should consider including brief measures of time to first cigarette. Although it may not be possible to use a time-intensive calendar method, such as the timeline follow back in which every day of smoking is documented (47
), callers could be asked the date of their first cigarette, so that time to first cigarette could be calculated.
The initial advantage that we found for gain-framed smoking cessation messages might be prolonged in a real-world setting with additional electronic interventions implemented at multiple time points (eg, biweekly or monthly follow-up text messaging or telephone calls). This type of intervention would allow for further research on more intensive gain-framed messaging without disrupting the actual operations of the NYSSQL or other quitlines. Additionally, by standardizing message delivery, the intervention could provide more consistent, and perhaps higher quality, counseling than is available in some settings (48
). Recent research conducted on automated delivery of smoking cessation services appears to be promising. For instance, it has been found that text messaging (49
), interactive voice response (51
), and some combination of these services (52
) improve rates of quitting. Thus, we suggest that future studies should attempt to improve on the short-term advantage found in this study by adding some type of automated system that delivers gain-framed smoking cessation messages. This addition may prove to be a cost-effective alternative to hiring additional staff.
A recent review (53
) suggests that for nicotine replacement therapy to have the greatest impact on tobacco control and public health, increases in quit attempts and nicotine replacement therapy adherence are needed. Thus, it is encouraging that callers who received the gain-framed intervention were more likely to make a quit attempt. However, consistent with our previous message framing and bupropion study (25
), in which targeted gain-framed statements aimed at medication use did not improve adherence with bupropion, we found that gain-framed statements that specifically targeted nicotine replacement therapy use did not result in improved nicotine replacement therapy adherence for those in the gain-framed counseling group. Thus, now there are two studies [(25
) and this study] showing no relationship between message framing and adherence to smoking cessation medication.
The specialists in the gain-framed group provided 2.5 minutes of additional counseling on average compared with those in the standard-care group. Previous research on number of minutes of smoking cessation counseling has been mixed, with one meta-analysis reporting a benefit for longer interactions (54
) and another reporting no effect (55
). Whether or not the increases in quit rates that we found in this study are attributable to an increase in counseling minutes or to gain-framed messaging, researchers and policy makers need to weigh whether the additional time required for gain-framed counseling is worth the small increases in quit rates observed in this study. Although the 10% advantage in quit rates found at 2 weeks had diminished to a little less than 2% at 3 months, some have argued that even a 2% advantage would be clinically meaningful (56
), especially in the context of a large-scale cessation program. Of course, the goal of interventions should be to achieve the highest quit rates possible for the most meaningful health gains (eg, additional years of life).
The study has several strengths. These include random assignment of specialists to gain-framed or standard-care counseling groups; robust attention controls for counseling intervention; and specialist supervision across counseling groups, large sample size, and translatability of findings.
The study has several potential limitations. The limitations include in addition to the low intensity of the gain-framed intervention and use of dichotomous primary smoking outcomes, different levels of supervision (ie, individual supervision for the gain-framed counseling group and group supervision for the standard-care counseling group) and low follow-up rates. However, the follow-up rates that we observed are consistent with many large-scale rigorous quitline studies conducted by our group (36
) and others (11
). The callers who enrolled in this study, compared with those who declined, were more likely to be female, higher educated, and white and to have smoked more cigarettes for a longer time period. Hence, generalizability is limited to callers who have similar characteristics. The fact that gain-framed counseling specialists spent approximately 2.5 minutes longer per call than standard-care counseling specialists, a statistically significant difference, might account for the differences in smoking cessation effects between the two groups. However, as described above, results for minutes per session from meta-analyses have been mixed (54
). Finally, consistent with the standard in the field of smoking cessation research, no adjustments were made because of multiple comparisons (32
The fidelity outcomes from this study should encourage quitlines to test novel counseling strategies for their ability to increase smoking cessation rates and, thus, prevent cancer. Furthermore, gain-framed statements appear to be somewhat beneficial in enhancing short-term smoking cessation and other secondary outcomes, such as quit attempts and positive health expectancies. A higher rate of long-term smoking cessation was not obtained for callers who received the gain-framed intervention compared with the standard-care intervention. Given that long-term cessation is necessary to prevent cancer-related mortality and other tobacco-induced diseases, future translational research should investigate how to extend the short-term effects that we observed in this study to long-term increases in smoking cessation rates.