Quitlines: Considerations for Future Directions

1. Quitlines:Considerations for Future Directions Christopher M. Anderson California Smokers’ Helpline University of California, San Diego European Network of Quitlines Conference 10-11 December 2007 - Rome

2. The California Smokers’ Helpline Background • 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

3. The California Smokers’ Helpline Large, randomized controlled trials • English & Spanish speaking adults • Pregnant smokers • Adolescents • NRT users • Asian language speakers Current studies • Proxy callers • Direct marketing • Quitline data repository

4. 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)

5. 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

6. Considerations for future directions • Benchmarking/quality improvement • Expanding the menu of service offerings • Adapting protocols to a wide range of quitline users • Funding for growth • Integrating with health care • Promoting quit attempts in the larger population

7. 1. Benchmarking/quality improvement In 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.)”

8. 1. Benchmarking/quality improvement 113 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)

9. 1. Benchmarking/quality improvement Number of respondents who were content with things as they are: 0 Main (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

10. A proposed framework for quality The 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

11. QAP: 9 dimensions of quality • Technical performance • Access to services • Effectiveness of care • Efficiency of service delivery • Interpersonal relations • Continuity of services • Safety • Physical infrastructure • Choice

12. a. Technical performance • Does the quitline recruit capable counselors? Does it provide them with optimal training and continuing education? • Do counselors follow protocol?

13. 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?

14. 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?

15. 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?

16. 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?

17. 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?

18. 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?

19. 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?

20. 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?

21. 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

22. 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?

23. 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

24. 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

25. 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?

26. 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/.

27. Thank you! For questions or comments, contact: Chris Anderson cmanderson@ucsd.edu