After two days of celebration and reflection in Kansas City with over 150 of our quitline colleagues, it only seems fitting to close this series of blog posts, Celebrating 20 Years of Quitline History with 20 Questions About our Future, with a laser-like focus on the ultimate reason we all do this work: to help people quit tobacco. To help us do that, NAQC asked David Abrams, PhD, Executive Director of The Schroeder Institute for Tobacco Research and Policy Studies for his thoughts on THE POTENTIAL OF QUITLINES AND CESSATION SERVICES TO DECREASE TOBACCO USE PREVALENCE IN THIS DECADE. Here is what Dr. Abrams had to say.

There is a great potential to save lives, reduce preventable death and disability burden, and save hundreds of millions to billions of dollars in health care expenses over the next decade. As has been stated by many leaders many times before, making this potential a reality is a matter of putting what we know into practice and policy in a coordinated fashion. This challenge is what myself and others have called "systems integration.” By systems integration I refer to the need for: (a) strong unwavering political will to support comprehensive tobacco control; (b) putting in place aligned incentives and resources at every level of the system - individual, group, organizational, community, state and national; and (c) full implementation of evidence-based tobacco control that is comprehensive, has continuity of coordinated care, and includes supportive policies at every level of health care and public health service delivery. Thus systems integration is "arguably the single most critical missing ingredient”, referred to in the Institute of Medicine’s (2007) recommendations for "Ending The Tobacco Problem: A Blueprint For The Nation” ^1,3 and outlined in the Department of Health and Human Services’ government-wide coordinated effort, "Tobacco Control Strategic Plan for the Nation” (November, 2010).

The preservation of both the Affordable Care Act by the Supreme Court and hopefully of some of the prevention fund, contain resources and an extraordinary opportunity to achieve dramatic gains in cessation if they are not eviscerated. These resources must be fought for and preserved with all our might. Already they have been eroded and threaten our goals if we are to achieve the unrealized potential for significant reductions in population tobacco use prevalence.

Another dream for the future is to address the huge connection between tobacco use disparities and general health disparities. The disparity gap in smoking prevalence is huge and may be widening. Lower socioeconomic status smokers, those with mental health or substance abuse disorders and other vulnerable populations including racial and ethnic minorities, Native Americans, LGBT, and others, continue to smoke at rates that exceed 30% and can be as high as 70-85%, whereas many higher SES groups smoke at rates that are under 10%. Tobacco use disparities are a very strong driver of health disparities and thus eliminating tobacco use will go a long way to eliminating health disparities in our nation. In the next decade our intervention programs must do a better job of reaching, treating and supporting those at disproportionate risk. We must stop blaming the victims (calling them hard to reach, hard to treat, unmotivated, non-adherent or non- compliant with treatment recommendations). If we are to make a difference in the next decade we must take full responsibility for finding ways to reach and treat all our smokers with accessible and affordable evidence-based interventions at every level of society.

Clearly, to significantly accelerate the stalled reduction in tobacco use prevalence and eliminate the devastating deaths, disease burden and cost to society, requires having interventions with both broad reach and with levels of intensity and tailoring that can be matched to the needs of different groups in a stepped care model.² This dream of a plausible and possible future has been around for decades and perhaps it can indeed be realized in the coming decade. This would clearly make a huge difference in health impact and reducing the snails pace, slow rates of reduction in population prevalence that we have seen in the last decade, hovering around 20%.

Evidence-based interventions like quitlines and other proven brief and self-help interventions (used by health professionals, such as the three or five A’s, and Internet programs) are cost-efficient, have capacity to be scalable to reach and serve large numbers of consumers and can be combined or used together. They also must be able to adjust relatively fast in response to changing consumer demand. These valuable moderate intensity resources, that lie in the "sweet spot” between more intensive and more costly interventions and very minimal, less costly but less effective materials (e.g., educational brochures left on tables in worksites or doctors’ offices) are essential, central drivers of any future hope to make a significant impact at the population level in the next decade. Making a difference at the population level requires large numbers of users to stop and remain non-users. But once a user is driven to a moderate intensity intervention, additional challenges exist to boosting future sustained cessation rates. These moderate to low intensity programs are good, but of course can be improved in terms of treatment efficacy and especially in addressing relapse prevention, which is still very high in almost all forms of treatment of addictions and is a great challenge for the future.

Quitlines and evidence-based Internet programs are at the heart of this capacity to make a difference at the population level, are increasingly integrated, and employ cognitive-behavioral, pharmacological and social support as core components. Evidence is mounting that combined quitline and Internet programs can make a very cost efficient impact on population health if fully implemented at capacity. A recent study of Internet and combined Internet plus quitline counseling indicated 30-day point prevalence abstinence rates at 18-months follow up of 17 to almost 20 percent.⁹ If scaled up to national capacity such a program might ideally reach 10 million smokers each year producing almost 2 million new ex-smokers.

Policies that encourage cessation can dramatically increase reach, such as raising taxes, enforcement of indoor air laws and media campaigns. After the federal tax on tobacco increased by $0.62 in April 2009, many quitlines experienced a surge in call volume; nationally, over 550,000 calls were received through 800-QUIT-NOW in the first five months of 2009 compared to 592,000 in the 2008 calendar year.⁴ More recently, CDC’s national tobacco education campaign yielded about 200,000 additional calls to state quitlines over a 12-week period.⁵

For some users who are unable to sustain tobacco-free lifestyles, more intensive, costly and specialized stepped up care programs are also needed. Such intensive programs will have more limited reach, but may also be integrated with health care and public health services to provide highly specialized care, for example in the context of hospital inpatient and outpatient treatments for medical conditions that are exacerbated by tobacco use behavior (e.g. cancer, cardiovascular, pulmonary disease and many others), mental health and substance abuse disorders and clinics that serve the under- or uninsured and those who find it difficult to access state-of-the-science programs. Such intensive programs can also partner with quitlines and Internet programs, providing additional support and ability to prevent relapse as needed and at times when access to an inpatient, outpatient, primary care office or community program is not possible.

The bottom line is that several forces ideally should come together in a coordinated fashion to optimize reductions in smoking prevalence, reinvigorating the slowed rate of reduction in smoking prevalence of the past decade. To increase impact at the population level, it is a matter of reach multiplied by the effectiveness of treatment for those reached in a cost efficient manner.^2,3 Quitlines play a central role in this equation as they are capable of cost-efficient delivery. Increasingly their integration with other modes of intervention such as health care and worksite settings, the Internet, over-the-counter pharmacotherapy, smart phones, and new applications such as text messaging and interactive voice response make quitlines the backbone of an increasing array of efficient and cost-effective modes of access and delivery.

It is quite complicated to decide how best to allocate resources to optimize these goals and computer simulation modeling can help us examine several "what if” scenarios to help us allocate resources. Such programs have increased in sophistication in recent years and have also been improved because we have better data to use as inputs and predict transitions. One such model, SimSmoke, developed by Dr. David Levy has been around for over two decades now and has been used across the world to examine how policies and interventions at different levels of reach, efficacy and cost efficiency, can be combined to accelerate population prevalence reduction. In a series of simulation studies of plausible futures, models that include ideal implementation of comprehensive interventions and policies might boost the stalled reductions in population prevalence in surprisingly optimistic ways if fully implemented.^6,7 We have shown that reaching a Healthy People goal of 12% smoking prevalence could be achieved before 2020 by boosting the number of smokers who make quit attempts and by increasing the impact of quitlines and other cessation services.^3,8 Increasing the number of people that make quit attempts, encouraging those who fail to make more frequent quit attempts without delay, and reducing relapse rates among those that do make an attempt, are three critical ways that the SimSmoke modeling shows to dramatically boost future reductions in smoking prevalence and the concomitant deaths, disease burden and dollar costs in our nation.

Putting everything we know into practice and policy in an integrated system of comprehensive interventions and policies can make a dramatic difference in the next decade. The question is, can we create the political will to make the right thing to do the easy thing to do, from a social justice perspective?

References

1. Abrams DB. Comprehensive smoking cessation policy for all smokers: systems integration to save lives and money. In: Bonnie RJ, Stratton K, Wallace RB, (eds). Ending the tobacco problem: a blueprint for the nation. Institute of Medicine. Washington: The National Academies Press, 2007.

2. Abrams DB, Orleans CT, Niaura RS, Goldstein MG, Prochaska JO, Velicer W. Integrating individual and public health perspectives for treatment of tobacco: A combined stepped care and matching model. Ann Behav Med. 1996 Fall;18(4):290-304.

3. Abrams DB, Graham AL, Levy DT, Mabry PL, Orleans CT. Boosting Population Quits Through Evidence-Based Cessation Treatment and Policy. Am J Prev Med. 2010 Mar;38(3 Suppl):S351-63. PMID: 20176308.

4. Bailey L. Opening Plenary. NAQC Annual Conference. June 8, 2009. Accessed August 6, 2012 online at http://www.naquitline.org/resource/resmgr/2009_conference_materials/openingplenary.pdf.

5. Centers for Disease Control and Prevention press release. June 14, 2012. Landmark ad campaign yields almost 200,000 more calls to state quitlines after 12 weeks. Accessed August 6, 2012 online http://www.cdc.gov/media/releases/2012/p0614_smoking_quitlines.html/.

6. Levy DT, Mabry PL, Graham AL, Abrams DB, Orleans CT. Modeling the impact of smoking cessation treatment policies on quit rates. Am J Prev Med 2010;38(3S):S364 –S372.

7. Levy DT, Mabry PL, Graham AL, Orleans CT, Abrams DB. Reaching Healthy People 2010

by 2013: a SimSmoke simulation. Am J Prev Med 2010;38(3S):S373–S381.

8. Levy, DT, Graham AL, Mabry PL, Orleans CT, Abrams, DB. Exploring Scenarios to Dramatically Reduce Smoking Prevalence: A Simulation Model of the Three-Part Cessation Process. Am J Public Health. 2010 Jul; 100(7):1253-9. Epub 2010 May 13. PMID: 20466969.

9. Graham AL, Cobb NK, Papandonatos GD, Moreno JL, Kang H, Tinkelman DG, Bock BC, Niaura RS, Abrams DB. A Randomized Trial of Internet and Telephone Treatment for Smoking Cessation. Arch Intern Med. 2011 Jan 10; 171(1):46-53.