Tobacco Use: Quitline Interventions

Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) 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 60 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.

The full CPSTF Finding and Rationale Statement and supporting documents Tobacco Use: Quitline Interventions are available in The Community Guide Collection on CDC Stacks.

Intervention

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 CPSTF 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 CPSTF 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 CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to reducing tobacco use and secondhand smoke exposure.

Study Characteristics

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, sex, race/ethnicity, and socioeconomic status (SES), cessation outcomes were not generally analyzed on these client characteristics

Summary of Results

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)

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
- 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)

Summary of Economic Evidence

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.

Applicability

The CPSTF 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.

Evidence Gaps

Intervention Design:

Few studies provided information to evaluate the effectiveness of reactive telephone counseling. Since this service format is common, additional studies should examine the effectiveness of single-session counseling when delivered reactively.
Studies should examine the relative and combined effectiveness of quitline services and cessation services provided through other digital media formats (like automated text messages on mobile phones, or web-based social support).

Quitline Promotion:

Only a minority of tobacco users make use of quitline services despite evidence demonstrating effectiveness at population level. Hence, additional research is needed to increase quitline awareness both population-wide and in high-risk populations, including groups with high rates of tobacco use and tobacco-related diseases or limited access to health care and evidence-based cessation treatments.

Intervention Evaluation:

Studies could attempt to measure or model the impact of quitline services on tobacco-related morbidity and mortality.

Economic Evaluation:

Future economic studies should include the combined costs for both quitline promotion and quitline services.
Additional studies should examine the economic costs and outcomes of quitline referral systems.

Implementation Considerations and Resources

Quitline services are available to most tobacco users in the United States through 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)

Crosswalks

Find programs from the Evidence-Based Cancer Control Programs (EBCCP) website that align with this systematic review. (What is EBCCP?)

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.