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Tobacco QuitlinesNational Cancer Advisory Board Meeting

February 6, 2008

Shu-Hong ZhuUniversity of California, San Diego

What is a Quitline?

• Telephone counseling for tobacco cessation– Accessible (for

smokers)– Easy to be

proactive (for interventionists)

0102030405060708090

% re

ceiv

ed c

ouns

elin

g

Reactive Proactive

Source: Zhu et al. (2002), NEJM, 347, 1087-1093.

Proactive Counseling Cuts Attrition in Half

What is a Quitline?

• Telephone counseling for tobacco cessation– Key features: accessibility & reactivity

• Centralized operation– Multi-lingual services and extended hours– Large volume

• Strong implications for research & dissemination

• Potential for integrated service– with new technology– with other cancer prevention endeavors

A Very Brief History of U.S. Quitlines

• 1980s NCI Cancer Information Service• 1992 First state quitline in the US

– California Smokers’ Helpline• 1992 First large HMO quitline

– GHC/Free & Clear Inc. (It now runs about 20 state quitlines)• 2003 ICSH Subcommittee recommendation:

“Launch a national quitline network.”• 2004 NCI-CIS coordinates telecommunication system for

national quitline network, while CDC provides funding to states – National Network = NCI, CDC, states, and NAQC

Statewide Quitline No Statewide Quitline

AZ

WY

ORID

MT

UTNV

WA

CA

TX

AROK

ND

LA

KS

IANE

SD

CO

NM

MO

MN

TN

AL

KY

OH

MS

MI

IN

GA

FL

PA

ME

NY

WV VA

NC

SC

VT

CT

D.C.

RI

NJ

MDDE

NHMA

IL

WI

AK

HI

State Quitlines in 1992


AZ

WY

ORID

MT

UTNV

WA

CA

TX

AROK

ND

LA

KS

IANE

SD

CO

NM

MO

MN

TN

AL

KY

OH

MS

MI

IN

GA

FL

PA

ME

NY

WV VA

NC

SC

VT

CT

D.C.

RI

NJ

MDDE

NHMA

IL

WI

AK

HI



AZ

WY

ORID

MT

UTNV

WA

CA

TX

AROK

ND

LA

KS

IANE

SD

CO

NM

MO

MN

TN

AL

KY

OH

MS

MI

IN

GA

FL

PA

ME

NY

WV VA

NC

SC

VT

CT

D.C.

RI

NJ

MDDE

NHMA

IL

WI

AK

HI


Source: CDC Office on Smoking and Health (http://www.NAQC.org).

AZ

WY

ORID

MT

UTNV

WA

CA

TX

AROK

ND

LA

KS

IANE

SD

CO

NM

MO

MN

TN

AL

KY

OH

MS

MI

IN

GA

FL

PA

ME

NY

WV VA

NC

SC

VT

CT

D.C.

RI

NJ

MDDE

NHMA

IL

WI

AK

HI

Quitline Coverage (In English) With 1-800-QUIT-NOW

A World Map of Quitlines, 2007

Source: Anderson & Zhu (2007) Tobacco Control.

The U.S. State Quitlines

• The state quitlines collectively serve about 400,000 smokers per year

• The 1-800-QUIT-NOW calls had passed one million by the end of 2007

California Smokers’ Helpline

• The first state quitline• Testing multiple protocols in randomized

trials• Reaching underserved populations• Active in both research and dissemination

Motivate smokers

to call

MultipleCounseling

SingleCounseling

Self-Help

Months

Follow-Up Evaluation

3 6 12

The 1st Randomized Controlled Trial

Source: Zhu, Stretch, et al. (1996), J Consult Clin Psychol, 64, 202-211.

0

20

40

60

80

100

0 30 60 90 120 150 180 210 240 270 300 330 360

Days after quitting

Perc

ent a

bstin

ent

Multiple CounselingSingle CounselingSelf-Help

Source: Zhu, Stretch, et al. (1996), J Consult Clin Psychol, 64, 202-211.

Relapse Curves for 3 Groups

California Smokers’ Helpline (cont.)

• The randomized trials – Adult smokers, Study 1 (N=3000)– Adult smokers, Study 2 (N=3000)– NRT users (adults) (N=3000)– Teen smokers (N=1400)– Pregnant smokers (N=1200)– Asian-speaking smokers (N= 2100)

• Trials are large and study samples diverse

NRT (n=98)

TC (n=13)

1.74 (1.64, 1.86)

1.56 (1.38, 1.77)

385

1100

Odds Ratio (95%CI) Average Sample Size per Trial

Based on Cochrane review data, quitline studies average 700 more subjects per study than NRT trials.

Efficacy of Telephone Counseling and NRT COCHRANE REVIEW:

Source: Cochrane Review 2004, Zhu & Anderson (2006).

0

10

20

30

40

50

60

0 30 60 90 120 150 180Days after quitting

Perc

enta

ge s

till a

bstin

ent

AA--High IntensityOthers—High Intensity

AA--Low IntensityOthers—Low Intensity

Outcomes for African-Americans & Others, Averaged Over 5 Clinical Trials Done by Helpline

Source: Unpublished data from the California Smokers’ Helpline (Zhu et al. 2008)

6.88.2

6.57.5

9.1

14.1

8.911.2

13.215.2

02468

1012141618

1992-1994 1995-1997 1998-2000 2001-2003 2004-2006

Perc

ent A

fric

an-A

mer

ican

% of Calif. Smokers % of Helpline Callers

African-American Representation Among California Daily Smokers & Among Helpline Callers

Source: Unpublished data from the California Smokers’ Helpline (Zhu et al. 2008)

Representation of Ethnic Minorities Among Helpline Callers Compared to California Smokers

10.8

13.5

6.2

3.1

16.1

7.6

2.0

15.8

0

5

10

15

20

Hispanic African American Asian/Pacific Islander American Indian

Perc

ent

CA SmokersHelpline Callers

Source: CA Health Interview Surveys, 2001, 2003, and 2005, and CA Smokers’ Helpline, 5/1999-7/2007.

Population-level data are estimates based on the aggregated survey results for daily smokers. Helpline data do not include proxy callers

California Smokers’ Helpline (cont.)

• Upcoming research– Smokers with co-

morbidity (e.g., depression)

– Proactive recruitment– Telephone + Web-

based intervention (New NCI trial)

– Nonsmokers as an extension of the quitline

7

25

0

5

10

15

20

25

30

% M

DD b

y PHQ

-9

Smokers at Large Helpline Callers

Smokers with Depression

Source: Zhu et al. (2008) Unpublished paper.

ASK about tobacco USE

ADVISE tobacco users to QUIT

ASSESS readiness to make a QUIT attempt

ASSIST with the QUIT ATTEMPT

ARRANGE FOLLOW-UP care

The 5 A’s

Source: Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

Ask

AdviseHCP Office

Quitline

Telephone Counseling, Starting in the Health Care Provider’s Office

HCP Advises Patients to Call

(N=1555)Quitline

Proactively Calls

Y

Smokers Call as Instructed

3%

N

31%

N

24%

Y

45%

Reach Smokers?

Proactive Recruitment: Pregnant Smokers

Do Smokers Accept Counseling?

Source: Unpublished data, California Smokers’ Helpline

A Study of Asian American Smokers:A Design With Dissemination in Mind

• Key question: – Will “talk therapy” work for the less acculturated Asian

smokers (defined as preferring Asian languages)?• Big challenge:

– There are so many Asian languages• Solution:

– A single protocol: translated and back translated• Design

– Test it on 3 different languages in a single study– Sufficient sample for each language group (700 each)

One Protocol Developed in English

Chinese Koreans Vietnamese

Self-Help Counseling Self-Help Counseling Self-Help Counseling

Asian-Speaking Smokers

A Design With Dissemination in Mind

• Logic:– If the protocol is proven effective in each of the three

languages, then there is some confidence in disseminating it to other Asian languages, without testing it in all the individual languages

• Role for federal agency in dissemination?– NCI, CDC, others?

• Reason: With a few exceptions, most U.S. states do not perceive Asian-language quitlines as cost-efficient

The Response of Nonsmokers

to Quitline Promotion

0

5

10

15

20

25

30

35

40

English-speaking

Whites(n=213041)

English-speaking Blacks

(n=42554)

English-speakingAmericanIndians(n=9649)

English-speakingHispanics(n=30441)

Spanish-speakingHispanics(n=25157)

English-speaking Asians

(n=10781)

Asian-language-speaking

Asians(n=17487)

Language/Ethnic Groups

%C

alls

Mad

e B

y Pr

oxie

s

Proxy Calls By Language/Ethnic Group (Aug. 1992—Sept. 2005)

Source: Zhu et al. (2006). Tobacco Control.

Studies with Nonsmokers as Interventionists

• There is a tendency to professionalize in every field– e.g., Certification of cessation counselors

• Quitlines have taken a different approach– Emphasize ongoing evaluation of program effectiveness, instead

of emphasizing individual counselors’ certification, training, etc.• Harnessing the spontaneous efforts of nonsmokers can

dramatically increase the reach of quitlines– Especially important for groups such as Latinos and Asian

Americans, who are less likely to seek formal help• Capitalizing on nonsmokers’ willingness to help smokers

is another step toward making quitlines an integral part of a population-based approach to tobacco cessation

Worksite Policy

Media

School Programs

ProviderAdvice

Quitline

A Quitline in a Population-Based Framework

Source: California Smokers’ Helpline.

Conclusions

• Quitlines are an accessible & effective cessation service

• Quitlines reach underserved populations• Quitlines can be leveraged to achieve

greater population effects– State tobacco control programs– Healthcare systems (chronic disease

management)

Funding Acknowledgments

• CDPH Tobacco Control Section– # 90-10961, 92-15416, 96-27049, 00-90605

• CCFC # 05-45834• UC-TRDRP

– 7IT-0072, 8RT-0103, 9RT-0205, 11RT-0096, – 13RT-0023

• NCI – P01-CA72092, R01 CA104573

• P30 CA 23100-22S4

Thank [email protected]

tobacco quitlines - nci dea - home page · 0 10 20 30 40 50 60 70 80 90 % received counseling...

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