1. ENQ conference Rome, 10/11 December 2007 Marc Willemsen, Sander Bot, Regina van der Meer Which types of smokers get which service?

3. STUDIES (Cost-)effectiveness of quitlines Treatment / service characteristics of callers Quitline tel. on cigaret packs -> call volumes HELP campaign -> call volumes

4. The 9 Participating Quit Lines Denmark Germany Ireland Italy The Netherlands Norway Portugal United Kingdom France STOP-Line Counselling German Cancer Research Unit The National Smokers Quitline Lega Italiana per la lotte contro iI tumo STIVORO Directorate for Health and Social Affairs Instituto Nacional de Cardiologia Preventiva) QUIT UK Insititut National de Prévention et d’Education pour la Santé

5. ESCHER Objectives Develop an evidence base for European quitlines Collect basic data that are usefull for all countries involved and are of interest to the EU Strengthen the position of the quitlines Take advantage of natural variation between countries (compare quitlines in natural settings)

6. Which smokers get the most effective treatment from quitlines?

7. Type of treatment Literature sent Booklets or leaflets on quitting Basic information Objective / neutral information about facts, consequences of stopping smoking, craving etc. (quick call) Specific information Objective / neutral information about cessation methods (pharmacotherapy), referral to outside services or referral to health professional Advice Recommendations on how to quit smoking, eg., what would be the best method to quit or recommendation to see health professional Counselling Caller-centred and person-tailored, in-depth, motivational interaction

8. Hypotheses 1. Heavy smokers more likely to receive counselling + get specific info on pharmacotherapy 2. Lower educated callers more likely to receive counselling, less likely to receive brief advice or written materials 3. Callers in action stage more likely to get counselling or advice, less likely to be referred to outside help 4. Referred callers more likely to get counselling

9. Method In each country, during a period of 12 months (February 2005 – April 2006) up to 500 smokers were recruited. Subjects: “every caller who calls for telephone support for smoking cessation”. Data collected by the counsellors during the first contact (intake). Logistic regression, controlling for country. Method = enter 7 services. Check country x treatment interactions.

10. Country Number of respondents Denmark 425 France 619 Germany 180 Ireland 494 Italy 520 Netherlands 493 Norway 534 Portugal 123 United Kingdom 500 Total3.888

11. Services provided to callers

12. DMFRGEIRITNENOPTUKALL Literature sent 7.151.953.978.331.7-71.087.860.046.0 Basic info 76.766.167.272.945.655.083.781.343.264.0 Advice 27.171.643.988.737.32.081.386.235.2 51.3 Specific Info Pharma 48.0 74.061.151.19.432.551.561.133.045.0 Referral outside 10.81.117.24.362.38.75.814.627.216.9 Referral Health prof. 4.014.420.614.816.53.916.959.313.414.2 Counselling 6.1187.470.091.560.051.994.880.577.876.2

13. DMFRGEIRITNENOPTUKALL % low educated 26.135.925.422.133.227.920.836.138.529.3 % heavy smoker 55.546.448.948.546.358.039.347.246.348.3 % action stage 32.033.023.338.511.331.441.432.535.831.8 Copied tel. nr. from cig. pack 27.830.7---12.018.7--22.5 Referral by health prof. 14.113.6-6.13.814.011.64.912.010.1

14. Heavy smokers (HSI >=3) No association with counselling (contrary to hypothesis) (75% vs. 78%; ns) More likely to get information about pharmacotherapy (OR=1.27; 95%CI=1.10-1.47) (hypothesis confirmed) More often referred to a health professional (OR=1.32; 95CI=1.08- 1.60). Consistent across 9 quitlines

15. Low education callers Not more likely to receive counselling (hypothesis rejected) No relationship with receiving brief advice or written materials. (hypothesis rejected).

16. Low educated More information on pharmacotherapy (OR=1.18; 95%CI =1.01-1.38) Consistent across 9 quitlines

17. Low educated: shorter calls Percentage having a ‘long call’ (>20 minutes)

18. Action stage More likely: Advice 1 Counselling 2 (Hypothesis confirmed) 1 French, German, Irish quitlines; 2 Italian, Dutch quitlines

19. Action stage Less likely: Referral to outside help 3 (hypothesis confirmed) Referral to health professional 4 3 Danish, German, Italian, Portuguese, English quitlines; 4 Irish, Portuguese

20. How were callers referred to the quitline?

21. Callers referred by a health professional compared to other referrals Heavy smokers (53% vs 43%) Low educated (35% vs 29%)

22. Callers referred by a health professional More likely get counselling (hypothesis confirmed) (81% vs 74%) More likely information on pharmacotherapy (50% vs 38%) Less likely brief advice (48% vs 54%) and literature (41% vs 49%)  All quitlines, except Danish, French, English (in these countries: more likely to be further referred to medical professional: 38% vs 10%).

23. Conclusions The most effective quitline service (counselling) was provided to higher educated smokers, callers in action stage of change, and callers who were referred by a health professional. Callers who were referred by a health professional more likely to be low educated and heavy smoker Although many low educated callers received information about pharmacotherapy, low educated smokers came of badly in terms of counselling (less likely + shorter calls).

24. Conclusions In contrast to the US and Australia, in these nine European quitlines, only 10% of contacts were referrals from health care providers. European quitlines should be better integrated into the health care system.

25. Thanks for your attention! Contact: mc.willemsen@stivoro.nlmc.willemsen@stivoro.nl