Quitlines: Considerations for Future Directions

Christopher M. AndersonCalifornia Smokers’ Helpline

University of California, San Diego

European Network of Quitlines Conference10-11 December 2007 - Rome

The California Smokers’ HelplineBackground

Funded by tobacco taxes In continuous operation by UCSD since

1992 Over 440,000 callers served Annual budget US$4.5 million 45 counselors 6 languages 07:00-21:00 Mon-Fri, 09:00-13:00 Sat Dual mission: service and research

The California Smokers’ HelplineLarge, randomized controlled trials

English & Spanish speaking adults Pregnant smokers Adolescents NRT users Asian language speakers

Current studies Proxy callers Direct marketing Quitline data repository

Quitlines in the U.S.A national network

Federal government provides 1-800-QUIT-NOW to link US quitlines

All 50 states fund quitlines Some national promotion 20+ quitlines operators Friendly but real competition North American Quitline Consortium

facilitates information sharing among US and Canadian quitlines (and now Mexico)

Quitlines in the U.S.Current status

Calls answered live 96 hrs/wk (median) Counseling available 87 hrs/wk (median) 100% provide proactive, multiple

sessions (median goal is 5 sessions) 35% provide pharmacotherapy Median annual budget is US$622,000

(Budget & reach are strongly correlated) Average quitline reaches 1% per year

Considerations for future directions

1. Benchmarking/quality improvement2. Expanding the menu of service

offerings3. Adapting protocols to a wide range of

quitline users4. Funding for growth5. Integrating with health care6. Promoting quit attempts in the larger

population

1. Benchmarking/quality improvementIn a recent survey, NAQC members

were asked: “Describe one significant quality

improvement that you would like to see, either in your own quitline or in quitlines generally. The improvement could be in any area (e.g., service delivery, promotion, funding, contracting, integration with health care, evaluation, etc.)”

1. Benchmarking/quality improvement113 members responded with desired

improvements in the following areas: Service delivery – 47 Evaluation – 29 Integration with health care – 29 Promotion – 24 Funding – 17 Contracting & other – 7(Many respondents mentioned >1)

1. Benchmarking/quality improvementNumber of respondents who were

content with things as they are: 0Main (subjective) findings: NAQC

members… Are excited by their evolving field Want much more from quitlines Are working to make it happen Want to compare notes with colleagues

A proposed framework for qualityThe Quality Assurance Project

Funded by the US Agency for International Development

Focuses on: clients, systems and processes, measurement, and teamwork

Mission is to strengthen quality of health care in developing world

Ideas are broadly applicable

QAP: 9 dimensions of quality

a. Technical performanceb. Access to servicesc. Effectiveness of cared. Efficiency of service deliverye. Interpersonal relationsf. Continuity of servicesg. Safetyh. Physical infrastructurei. Choice

a. Technical performance Does the quitline recruit capable

counselors? Does it provide them with optimal training and continuing education?

Do counselors follow protocol?

b. Access to services Do hours of operation meet the need? Are calls answered live and promptly? Are services provided in callers’

preferred languages? Are there enough counselors to meet

the demand? Is the literacy level of program materials

appropriate to the clientele? Are barriers to pharmacotherapy as low

as possible?

c. Effectiveness of care Are protocols based on the best

available evidence? Are referrals converted to clients? Do

callers opt for counseling? Do those opting for counseling receive it? Do they set a quit date? Do they make a serious quit attempt? Do they maintain long term continuous abstinence?

d. Efficiency of service delivery

Do callers receive immediate service? Is phone tag minimized?

Is counselors’ time spent actively helping clients? Is administrative work streamlined so they can focus on clinical work?

Are the services provided cost-competitive?

e. Interpersonal relations Are callers greeted courteously and

professionally? Do counselors exhibit empathy? Do they

establish and maintain rapport? Do they practice Motivational Interviewing?

Is the rationale for questions and treatment decisions made clear?

Is confidential information protected?

f. Continuity of services Does the quitline move referred patients

seamlessly into treatment? Do referred patients experience the quitline as an extension of their health care?

Is therapeutic rapport maintained and increased over successive sessions?

Does the quitline remember repeat callers? Does it actively re-engage them?

g. Safety Are crisis situations managed so as to

minimize the risk of harm to self or others? (suicide, homicide, child or elder abuse, etc.)

Are contraindications for pharmacotherapy observed?

h. Physical infrastructure Does the quitline have robust telecom

and data systems for managing telecommunications and data collection, management, and retrieval?

Are personnel functions optimally supported by technology?

i. Choice Are clients offered a range of services

including but not limited to counseling? Are clients informed of evidence-based

programs in their local area? Are callers offered counseling either

immediately or at a time of their choosing?

Do counselors facilitate movement rather than dictating a plan of action?

2. Expanding the menu ofservice offerings

Barriers to pharmacotherapy could be reduced

Innovations in telephony may be worth exploring (texting, predictive dialer, IVR, video)

Web-assisted interventions, if shown to be efficacious, may increase reach very cost-effectively

3. Adapting protocols to awide range of quitline users

For certain populations, specialized protocols are warranted (chewers, teens, pregnant, mental health)

Is the same true for all demographically identifiable groups? Perhaps not.

How to handle the many non-registered callers?

Provide abbreviated services for callers with fewer risk factors?

4. Increasing the fundingfor quitlines

Average quitline in the U.S. currently reaches 1% of smokers per year

CDC sets bar at 8% DHHS National Action Plan calls for 16% Much bigger public investment is

needed to achieve a large impact on public health

Promising approach: cost sharing between public and private sectors

5. Integrating quitlines withhealth care

Availability of a quitline can encourage health care providers to address tobacco use in all patients

Proactive enrollment of patients may persuade more providers to refer

Promoting quitlines through health care systems can amplify the effects of a quitline working alone

6. Promoting both aided and unaided quit attempts

Advertising a quitline can spark quitting among callers and non-callers alike

Quitline promotion can also spur nonsmokers to take action

How best to leverage quitline to maximize impact on entire population?

References Anderson CM, Zhu SH. Tobacco quitlines:

looking back and looking ahead. Tob Control 2007; 16(Suppl):i81-86.

Cummins SE, Bailey L, Campbell S, Koon-Kirby C, Zhu SH. Tobacco cessation quitlines in North America: a descriptive study. Tob Control 2007; 16(Suppl):i9-15.

U.S. Agency for International Development. Quality assurance project. Online at http://www.qaproject.org/.

Thank you!

For questions or comments, contact:Chris Anderson

cmanderson@ucsd.edu