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How do we make quit lines make a difference in lowering smoking rates? How can quit lines be significant to population-based tobacco control?

Posted By Natalia A. Gromov, Sunday, March 11, 2012

Wow! We are already on the fifth question of 20…and this can only mean one thing. Okay, maybe it can mean two things. We are getting closer to the NAQC Conference (call for abstracts open now!) and we are ready to start moving away from questions related to our history and toward questions focused on our future.

To help us make this shift NAQC asked Michael Cummings, PhD, MPHProfessor in the Department of Psychiatry & Behavioral Sciences at the Medical University of South Carolina and former Chairman of the Department of Health Behavior at Roswell Park Cancer Institute how do we make quit lines make a difference in lowering smoking rates? How can quit lines be significant to population-based tobacco control?

"Tobacco control interventions that have the greatest chance of reducing tobacco use in the population are those that reach the most smokers. Highly efficacious interventions that reach only a tiny fraction of the target population will not have a sizeable impact on rates of tobacco use in the population at large. This is one of the reasons that past research has shown that the most potent demand-reducing influences on tobacco use on a population level (albeit relatively weak in terms of efficacy) have been interventions that impact virtually all smokers repeatedly, such as higher taxes on tobacco products, comprehensive advertising bans, pack warnings, mass media campaigns, and smoke-free policies. Similarly, despite the promising evidence on the efficacy of different stop smoking treatments (including quit lines), there is not compelling evidence to support the idea that any of these therapies have dramatically influenced rates of tobacco use in the population at large, mainly because too few smokers use them when they try to quit.

Quit lines have a huge potential to contribute to population based tobacco control efforts, but this potential has not been effectively exploited so far. The challenge for quit lines is how they can expand their recruitment of smokers while also providing a service that effectively helps someone overcome their nicotine addiction. Resource limitations have forced many quit lines to trade off reach against maintaining elements of an effective tobacco cessation intervention. However, as the research evidence suggests reach is a necessary condition for impacting population level tobacco use behaviors. A quit line that reaches only a tiny fraction of the smokers in its catchment area cannot expect to have a measurable impact on smoking rates at the population level, and thus is probably not worth the investment. Quit lines that reach large numbers of smokers in the population at least have a chance to impact smoking rates.

The advantage that quit lines have is the opportunity to engage smokers directly at relatively low costs, capture information about their smoking behaviors, and re-engage with them repeatedly over months, years, and even decades. Relapse is part of the smoking cessation business and we ought to accept it and build this directly into our treatment programs. The fact that most smokers who call a quit line will quit and return back to smoking means our treatments should be offered repeatedly over a longer time frame than is currently the case for most quit lines. Much like the cigarette marketer who continually sends out coupons to a customer in hopes to get them to switch to their brand eventually, quit lines need to think of smokers in the population as their customers and repeatedly interact with them in hopes that some will switch to their "Quit” brand.

In my opinion, quit lines need to stop worrying about delivering the perfect evidenced-based, highly resource intense, cessation intervention each time they interact with a smoker. We would be far better off if quit lines focused more effort on recruiting as many smokers as possible into their service and then designing low cost interventions that track, prompt, and triage smokers to services over many years. Taking advantage of things that prompt smokers to think about changing their smoking behavior such as higher taxes on cigarettes, a new clean indoor air law, new warning labels, and mass media all can motivate smokers to contact a quit line service. The offer of free nicotine patches has also been shown to increase call volume and should not be discounted as a recruitment tool.

Working together state quit lines could make a real dent in the smoking rates in this country if they all focused more attention on recruiting larger numbers of smokers into a national registry of smokers. The national registry could then offer low cost interventions such as online cessation support, e-mail and text messaging and triage those in need of greater support back to state run services. In 10 years there is no reason why 80% or more of smokers in the population could not be recruited into a common database for cessation service delivery. Such a data base would offer an inexpensive way to deliver target messages to smokers to prompt them to change their smoking behavior. Since the vast majority of smokers desire not to smoke anyway, developing this voluntary registry should be feasible.

Quit lines need to evolve to ensure greater relevance to population-based tobacco control which simply means the focus needs to be on recruitment of smokers into a common database. Intervention services need to be tailored to the evolving needs of smokers and designed for low-cost delivery. The metrics by which quit lines are evaluated in the future also need to be changed to emphasize reach and low-cost delivery of services over the current emphasis on short-term cessation outcomes.

What are your thoughts on the quitline community’s role in population-based tobacco control? Has your quitline changed its approach over time in order to increase your reach? Share with us! We want to hear your thoughts!

Tags:  lowering smoking rates  Michael Cummings  population-based tobacco control 

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