Why Quitlines Work Shu-Hong Zhu, Ph.D Gary Tedeschi, Ph.D. University of California, San Diego

1. Why Quitlines Work Shu-Hong Zhu, Ph.D Gary Tedeschi, Ph.D. University of California, San Diego NAQC Annual Membership Meeting, Chicago May 2-3, 2005, Chicago

2. Goals of “Why Quitlines Work” Session • Identify the basic hypotheses underlying various quitline service protocols. • Identify rules-of-thumb to guide the design of effective interventions. • Understand how quitlines lend themselves to efforts to achieve a population impact. • Help all of us think more critically and effectively when designing or evaluating a cessation intervention.

3. What Do We Mean by “Quitlines?”

4. What Do We Mean by “Quitline?” • Distribution/referral center/hub • Send self-help materials • Distribute free/discounted NRT • Referral people to existing cessation programs • A place to call when there is a media campaign • Phone counseling center • A few minutes of conversation • Comprehensive reactive counseling • Comprehensive proactive counseling with multiple followups

5. What Do We Mean by “It Works?”

6. What Do We Mean by “It Works?” • A lot people have called (what is a lot?) • Increase the use of service • More people use self-help materials • More people use referred services • More people use NRT • More people use counseling • Increase callers’ chance of quitting • Increase the quitting of smokers in communities where the quitline is advertised

7. The Key Word is “Increase” • A comparison point is always needed • Explicit or implicit (what is a lot?) • Avoid “creative” use of statistics • Not mentioning drop out rate (hypnosis effects) • Minimal data set has done a great job in defining the terms of measure (though the comparison point is not emphasized)

8. Effects of NRT Sent by Quitline • More smokers using NRT, sent by the quitline • More people are quitting Due to more use of NRT Due of more use of counseling • NRT effects look bigger in a non-randomized study than a randomized one

9. Why Do Quitlines Work?

10. Why Do People Change? • They want to • They have to • In reality, do we have more people who changed because they wanted to or because they had to? • If you do not have much of either, then you do not change. • How many of you like to be sick, so you do not have to perform?

11. How to Increase Cessation • Increase the rate of quit attempt • Increase probability of survival of these attempts Q = A x S

12. Follow-Up Evaluation Multiple Counseling Motivate smokers to call Single Counseling Self-Help A Randomized Controlled Trial 3 6 12 Months Source: California Smokers’ Helpline

13. Quit Attempts Quit in 3 Months % Treatment Group 58.8 66.7 66.6 Self-Help Single Counseling Multiple Counseling Source: Zhu et al. (1996), JCCP, 64, 202-211

14. Relapse Curves for 3 Groups Source: Zhu et al. (1996), JCCP, 64, 202-211

15. How do you design a counseling protocol that will affect quits attempt, survival rates or both?

16. 4 Key Considerations • How many sessions? • How should they be scheduled? • What should happen in each session? • How important is matching/tailoring?

17. How Many Sessions? • From a quit attempt standpoint, one session may do the job. • Address the essential elements • Lead to a quit date • From a survival standpoint, multiple sessions can help.

18. How Should They Be Scheduled? • From a recycling standpoint, spread calls over several months. • From a survival standpoint, schedule calls based on the probability of relapse.

19. Relapse-Sensitive Scheduling 100 80 60 40 20 0 Percent abstinent 0 1 3 7 14 30 Days after quitting Source: Zhu & Pierce (1995), Prof. Psych. Res.& Practice, 26, 624-625

20. What Should Happen in Each Session? • Consider non-specific and specific counseling effects.

21. Nonspecific Effects • Rapport • Motivation • Attribution & Self-efficacy • Social support • Hope • Ambivalence & Accountability • Proactivity

22. Proactivity • Addresses client ambivalence • Reduces attrition • Provides social support • Creates accountability

23. Specific Effects • Knowledge • Tobacco & nicotine • Quitting process • Quitting aids

24. Specific Effects (cont.) • Ability to Facilitate Planning (Specific ideas for coping) • Behavioral (e.g., changing habits) • Cognitive (e.g., self-image) • Pharmacological (e.g., NRT)

25. How Important is Tailoring? • Tailoring to group or client? • Yes, but not too many. • Matching client and counselor? • If possible, great. But there are other considerations • Same counselor or different counselor for follow-up? • Yes, but not necessary.

26. What Explains A Quit Rate? Q = aP + bN + cS + dE + eU

27. What Explains A Quit Rate? Q = aP + bN + cS + dE + eU a > b > c

28. What Explains A Quit Rate? Group A • Highly motivated (cardiac patients) • Used self-help materials only • Q = 40% Group B: • Mental health patients • Received multiple counseling + medications • Q = 15%

29. How to Achieve a Population Effect

30. The Biggest Issue: Only 1-2% of Smokers Are Using Quitlines

31. A Conundrum • We want higher utilization • Yet some quitlines have already exceeded their capacity (limited budget) • The National Action Plan recommends a 16% reach, requiring an annual budget of $3.2 B. (not including media budget)

32. One Solution • Quitlines work with other population-based approaches to cessation to increase quit attempts in the population. • Think about overall cessation in terms of how many quit attempts occurring in a given period of time, not how many smokers are trying to quit.

33. Worksite Policy A Quitline in a Population-Based Framework Media Quitline School Programs Provider Advice Source: California Smokers’ Helpline

34. The California Tobacco Control Program 1989$0.25/pack Excise Tax School Programs Local Initiatives Media Program Assistance ` Community Norm Change

35. Mobilizing the Community-Asian Americans and Pacific Islanders- AAPI-Asian Line AAPI-English

36. Why Do People Change?

37. Micro & Macro Tobacco Cessation Interventions • Micro interventions tend to focus on increasing the level of “want to change” • Macro interventions tend to focus on increasing the level of “have to change” • The trick is the turn “have to” to “want to”

38. A Particularly Promising Approach • Second-hand smoke campaign changes the societal norm regarding smoking • We need to create quitting as the norm among the current smokers. • Quitlines, because their centralized operation, are particularly suitable for highly visible large-scale campaign.

39. Thank you!