Reducing Tobacco Use and Secondhand Smoke Exposure: Quitline Interventions
Task Force Finding
The Community Preventive Services Task Force recommends quitline interventions, particularly proactive quitlines (i.e. those that offer follow-up counseling calls), based on strong evidence of effectiveness in increasing tobacco cessation among clients interested in quitting. Evidence was considered strong based on findings from 71 trials of proactive telephone counseling when provided alone or in combination with additional interventions.
Three interventions effective at increasing use of quitlines are:
- Mass-reach health communication interventions that combine cessation messages with a quitline number
- Provision of free evidence-based tobacco cessation medications for quitline clients interested in quitting
- Quitline referral interventions for health care systems and providers
Evidence also indicates that quitlines can help to expand the use of evidence-based services by tobacco users in populations that historically have had the most limited access to and use of evidence-based tobacco cessation treatments.
Read the full Task Force Finding and Rationale Statement for more detailed information on the finding, including implementation issues, potential benefits and harms, and evidence gaps.
Quitlines use the telephone to provide evidence-based behavioral counseling and support to help tobacco users who want to quit. Counseling is provided by trained cessation specialists who follow standardized protocols that may include several sessions delivered over one or more months.
Quitline counseling is widely accessible, convenient to use, and generally provided at no cost to users. Content may be adapted for specific populations, and tailored for individual clients. Counseling may be:
- Reactive (tobacco user or recent quitter initiates contacts), or
- Proactive (tobacco user or cessation specialist makes initial contact, and the cessation specialist schedules follow-up calls).
Quitlines may provide additional interventions such as mailed self-help materials, integrated web-based and text-messaging support, and evidence-based, FDA-approved medications for tobacco cessation (Fiore et al., 2008).
About the Systematic Review
The Task Force finding on quitline effectiveness is based on evidence from a systematic review published in 2013 (Stead et al., 77 studies, search period through June 2013). Results from the review were converted into Community Guide metrics and additional analyses were performed to determine whether intervention effectiveness diminishes with longer follow-up. This finding updates and replaces the 2000 Task Force finding on Multicomponent Interventions that Include Telephone Support.
Evidence of effectiveness for quitline promotional efforts is based on a systematic review of 49 studies (search period through July 2012). Three promotional efforts to increase calls to quitlines were evaluated, including mass-reach health communication interventions (23 studies), provision of free cessation medications (12 studies), and quitline referral systems (14 studies).
The systematic reviews were conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to reducing tobacco use and secondhand smoke exposure.
Seventy-seven studies were included in the review. Of these, 71 studies evaluated effectiveness of proactive telephone counseling.
- Quitlines available to the general public
- Tobacco cessation: median absolute percentage point increase of 3.1 percentage points (Interquartile interval [IQI]: 0.5 to 3.3 percentage points; 12 studies)
- Quitlines for callers recruited from clinical or research settings
- Tobacco cessation: median absolute percentage point increase of 1.7 percentage points (IQI:0.0 to 8.5 percentage points; 51 studies)
- The remaining 8 studies used different outcome measures which could not be compared.
Six studies evaluated effectiveness of reactive telephone counseling.
- Different counseling approaches showed inconsistent effects on cessation (3 studies).
- Providing a quitline number to tobacco users showed inconsistent effects on cessation (3 studies).
To supplement findings on quitline effectiveness, the Task Force considered additional evidence from 49 studies that evaluated interventions to promote quitline use.
- Mass-reach health communication interventions that used messages tagged with the quitline number were evaluated in 23 studies.
- Quitline call volume: median relative increase of 132% (IQI: 39% to 379%; 11 studies)
- Tobacco cessation rates among quitline callers: mean absolute percentage point increase of 4.2 percentage points compared with callers who were not exposed to media messages (3.0 percentage points and 5.3 percentage points; 2 studies)
- Increases in campaign intensity resulted in increases in quitline call volume (12 studies).
- Quitline promotions offering free evidence-based tobacco cessation medications (primarily nicotine replacement therapy) to callers were evaluated in 12 studies.
- Quitline call volume: median relative percent increase of 396% (IQI: 134% to 1132%; 9 studies)
- Tobacco cessation rates among quitline callers: median absolute percentage point increase of 9.8 percentage points compared with callers who were not offered nicotine replacement therapy (IQI: 7.4 to 15.7 percentage points; 11 studies)
- Health system-based quitline referral interventions (e.g., provider referrals) were evaluated in 14 studies..
- Rather than examine overall changes in quitline call volume, most of these studies found increases in the number of quitline referrals from participating clinical settings. In one study from Wisconsin, fax referrals accounted for 30% of the 12,000 annual quitline callers (Perry et al. 2005).
- Tobacco cessation rates for referred tobacco users: median absolute percentage point increase of 2.4 percentage points compared with non-referred tobacco users (IQI: 1.6 to 12.0 percentage points; 8 studies).
- All of the included studies were randomized controlled trials and assessed self-reported (47 studies) or biochemically verified (26 studies) cessation outcomes 6 months or more after the intervention.
- Fifty-three of the 72 included studies were conducted in the United States; the remaining studies were conducted in Australia, Canada, Germany, Hong Kong, Norway, Spain, and the United Kingdom.
- Although most included studies collected information about age, gender, race/ethnicity, and socioeconomic status (SES), cessation outcomes were not generally analyzed on these client characteristics.
- The Task Force finding should be applicable to the tobacco users in the U.S. who are interested in quitting and either call quitlines themselves or are recruited to participate.
Twenty-seven studies were included in the economic review. Twelve studies provided 13 estimates of cost-effectiveness measurements of different quitline services. All monetary values from studies are reported in 2013 U.S. dollars.
- Cost-effectiveness of providing quitline counseling and cessation information: median estimate of $2,358 per quality-adjusted life year (QALY) saved (IQI: $1,761 to $3,156 per QALY; 6 studies)
- Cost-effectiveness of adding cessation medications to existing quitline services: median estimate $849 per QALY saved (IQI $369 to $2,426 per QALY; 6 studies)
- Cost-effectiveness of providing a combination of quitline counseling, nicotine replacement therapy (NRT), and media promotion: $5,965 per QALY saved (1 study)
Estimates of cost-effectiveness were assessed in comparison to a conservative threshold of $50,000 per QALY saved. Overall, the economic evidence indicates that quitline services are cost-effective across a range of different treatments and promotional approaches.
Considerations for Implementation
- Quitline services are available to most tobacco users in the United States through a national state portal (1-800-QUIT-NOW). There is some variation in the treatments offered; some state services do not include proactive counseling.
- Obstacles to quitline use may include clients' lack of awareness about the services available, uncertainties about service costs, concerns about confidentiality, and barriers related to language and cultural issues.
- Quitline use and benefits are likely to be amplified when provided as part of a comprehensive approach to tobacco control and prevention and coordinated with other national, state, and local interventions (CDC, 2007).
- Analytic Framework [PDF - 104 kB]
- Evidence Gaps
- Summary Evidence Tables
- Mass-Reach Health Communication Interventions to Promote Quitline Use [PDF - 455 kB]
- Quitline Promotions Offering Free Evidence-Based Tobacco Cessation Medications [PDF - 345 kB]
- Provider Referral to Promote Quitline Use [PDF - 354 kB]
- Included Studies
- Search Strategy
Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe to be notified when we post these publications or other materials. See our library for previous Community Guide publications on this and other topics.
Community Guide News
- Quitlines, Lower Treatment Cost, and Mass Communication Help People Stop Tobacco Use
Developed by The Community Guide in collaboration with CDC's Office on Smoking and Health
More promotional materials for Community Guide reviews about Reducing Tobacco Use and Secondhand Smoke Exposure.
Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs-2007 [PDF - 1.35 MB] . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; October 2007.
Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.
Perry RJ, Keller PA, Fraser D, Fiore MC. Fax to quit: a model for delivery of tobacco cessation services to Wisconsin residents. Wisconsin Medical Journal 2005;104(4):37-40.
Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD002850. DOI: 10.1002/14651858.CD002850.pub2.
The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.
The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: quitline interventions. www.thecommunityguide.org/tobacco/quitlines.html. Last updated: MM/DD/YYYY.
Review completed: August 2012
- Page last reviewed: November 18, 2015
- Page last updated: November 18, 2015
- Content source: The Guide to Community Preventive Services