1. Challenges facing Australian Quitlines European Network of Quitlines Amsterdam September 2008 Ian Ferretter Quitline Manager Victoria, Australia

2. Acknowledgements Australian Quitline Managers Network: Craig Black, Dan Nelson, Shannon Maxwell, Phil Hull, Lyndy Abram, Jason Wells, Bonnie Travers, Gail Hamilton, Justin Heath, Melissa Seibold. Prof Ron BorlandVCTC Dr Cathy SeganVCTC James Balmford VCTC Suzie StillmanQuit Victoria Ainslie Hannan CCV

3. Australian Quitlines: Setting the Scene

4. Quitline 13 QUIT (13 7848) National number –Cost of a local call on a landline –40c for a local call with unlimited time –0.4 Australian Dollar = 0.23 Euro –Each state and territory funds the Quitline in their own jurisdiction –Each pays a share of the number rental –All callbacks are free of charge –Number and Quitline logo owned by the Cancer Council Victoria

5. Australian Quitlines

6. Australian Quitlines: Setting the Scene Each State and Territory has the responsibility of providing Quitline services for its own jurisdiction Variety of models Various agencies

7. Australian Quitlines: Setting the Scene JurisdictionModel Australian Capital TerritoryOutsourced to NSW New South Wales and Western Australia Located in state based Alcohol and Drug Information Services TasmaniaQuit Tasmania South Australia and VictoriaState Cancer Councils Northern TerritoryOutsourced to Alcohol and Drug Service in Queensland QueenslandState Government Health Contact Centre

8. Australian Quitlines: Setting the Scene Some Quitline established in high technology call centre type environments - EG Queensland in the Health Contact Centre Others located within smaller organisations, with limited capacity to leverage off of technology Victorian Quitline well established, effective, in large organisation, but not up to date technology

9. Australian Quitlines: Minimum Standard 1.1 The Quitline is answered 24 hours a day, 7 days a week 1.2 A person answers the Quitline number at all times. This could be a call centre agent, a Quitline Counsellor or Quitline reception staff 1.3 Call answered within a maximum of 5 rings 1.4 The Quit Book is readily available and offered to all callers to the Quitline

10. Australian Quitlines: Minimum Standard 4.1 Counselling available during minimum hours ie. Business hours (0900-1700) plus out of hours as dictated by call demand and determined by each jurisdiction 5.1 A pro-active call-back service is available, which takes the caller through the process of quitting and has a well-structured schedule according to best evidence

11. Minimum standards cover… Opening hours, response times, hold times, answering rate Availability and despatch times of Quit Pack Access to counsellors, recontact times if counsellors are not immediately available, hours of counselling Referral program from health professionals to Quitline Tailored assistance for callers with special needs Evidence-based counselling content and advice

12. Minimum standards cover… Recruitment (including requirement that counsellors be current non-smokers) Counsellor training: initial, ongoing professional development Referral to other agencies: cessation services and cessation products Collection of data: minimum data set Evaluation

13. Minimum standards development As part of the development of Minimum Standards the Network of Quitline Managers led the development of protocols for each of the special needs groups: »Indigenous »Mental Health Conditions »Youth »Pregnancy »Cultural and Linguistic Diversity

14. Australian Quitlines: Issues Distribution of NRT from Quitlines - Only one very limited trial in Australia to date New technologies - Quit Coach - SMS Relapse prevention Callers with mental health conditions

15. Australian Quitlines: Issues NRT (or is it therapeutic nicotine ?) - The tension between research and the regulations - Different regulations for very similar products *Pre-Quit patch

16. Australian Quitlines: Issues NRT & Pregnancy Intermittent dosing products (such as the chewing gum, the microtab or the inhaler) may be preferable as these usually provide a lower daily dose of nicotine than patches. However, patches may be preferred if the woman is suffering from nausea during pregnancy. If patches are used they should be removed before going to bed. The use of the above products are also encouraged for breastfeeding women.

17. Australian General Practice Guidelines Two strategies for providing patients with effective cessation assistance: 1. In-practice counselling 2. referral to specialist support services (Quitlines) (unless good clinical reason to refer)(where appropriate)

18. Fax referral to Quitline

19. RCT: Referral vs in-practice management Cluster RCT randomisation by GP Practice 45 GPs 30 referral GPs 15 in-practice Quitline triage management Recruited 1040 smokers Baseline survey and 3 and 12 month surveys Randomisation successful, no differences in samples Borland et al, Family Practice, 2008

20. Help received Within practice Outside practice: Referral > In-practice –35% Referral got intensive help - 30.5% Callback - 4.4% QuitCoach

21. Main outcomes Outcome 12 months: 10 months sustained abstinence In-practiceReferralOR (95% CI) Available data: Intention to treat2.6%6.5%2.86 0.9-8.7 Imputing missing as smoking1.7%4.3%3.08 1.0-9.3 NB: Intention-to-treat = all cases in allocated group regardless of help received

22. Referral Results in smokers getting more help –Thus more quit Acceptable to smokers –They appreciate it Acceptable to health professionals –Fits better into busy schedules –Easy way to do something they know they should –But often dont Just do it!

23. Can we help quitters embrace a non- smoking lifestyle? Intervening to prevent longer-term relapse

24. 2 Tasks of Staying Quit The 2Ts 1. Learning to effectively deal with cravings and other withdrawal symptoms without relapsing 2. Learning to enjoy and value smokefree lifestyle –Starts when cravings drop to less than daily –Finding alternative behaviours to replace functions previously served by smoking –Facing old smoking situations to extinguish habit –Adopting new self-image by rejecting or growing out of smoker self-image

25. Study Aim Can an extended callback service reduce relapse rates compared to Quits standard callback service?

26. Design: Randomised controlled trial CONTROL INTERVENTION Standard service Extended service 2 Tasks of quitting framing Yes Yes Pre-quitting callbacks 2 2 Post-quitting callbacks up to 4 up to 10 over 1 month over 3 months

27. The intervention: extra integration callbacks to facilitate becoming a non-smoker Structured intervention designed to minimise perceived losses associated with quitting Starts when standard service ends (around 1 month after quitting) and offered 4-6 callbacks over 2 month period Weekly or fortnightly calls with more frequent calls provided around any slip up or relapse crises Same counsellors delivered both standard and integration callbacks

28. 12 month follow up Measure/ Sig. Test CONTROL INTERVENTION % quit (point prevalence) (n=409) 50.0 50.7 p=.88 % never relapsed (still quit from baseline attempt) 27.8 27.7 p=.98 Mean length baseline 63.4 56.7 p=.29 quit attempt (days) % lost to follow up 41.0 41.8 p=.85

29. Conclusions Extra integration callbacks were ineffective in reducing rates of longer-term relapse Cannot recommend the program in its current form – no value in a couple of extra sessions beyond 1 month to assist with 2 nd task

30. Considerations – Why no effect? Poor quality intervention unlikely Lack of differentiation between control and intervention condition Methodological challenges in implementing RCTs of differing counselling protocols

31. Historical Comparison 1996 2002-04 % quit 12mths (point prevalence) All smokers at recruitment All offered callback counselling 22% 34%

32. www.QuitCoach.org.au Computer-tailored cessation program Assessment leads to tailored advice Designed to be used multiple times –Flexible scheduling Strong focus on relapse prevention Tailors to increase relevance as well as on issues Advice on use of aids

33. Development and evaluation of a Quitline service for smokers with a history of depression Ainslie Hannan; Dr Catherine Segan; Dr Ron Borland; A/Prof Kay Wilhelm; Ian Ferretter; Suzie Stillman; Dr Sunil Bhar and A/Prof David Dunt

34. Overview Why depression? How were evaluating the service Features of the service Issues and insights arising out of the development and delivery of the tailored service and in the data collection

35. Why depression? Around 1 in 5 people experience depression during their lifetime Smokers report more depressive symptoms, more frequent and severe episodes of depression and higher rates of suicidal ideation and suicide Wilhelm et al 2006

36. Depression and smoking cessation Smokers with symptoms of depression tend to smoke more and experience more severe withdrawal, including greater negative mood Breslau et al 1994; Wilhelm et al 2004 Lifetime of symptoms of depression doesnt predict a failure to quit Hitsman et al 2003 Those with increased depressive symptoms while quitting are more likely to relapse Burgess et al 2002

37. Depression and smoking cessation Around 30% of quitters with symptoms of depression will develop a new episode of depression Glassman et al 2001; Killen et al 2003 Chemicals in cigarettes can affect metabolism of some antidepressants e.g. fluvoxamine Zevin et al 1999 Two antidepressants also function as anti craving agents: bupropion and nortriptyline Hughes et al 2003

38. The Victorian Quitline context Almost 1 in 3 Victorian Quitline callers disclose a mental health condition, most commonly depression Doctor – Quitline co-management of smoking cessation for people with current mental health conditions For callers with a diagnosed history of depression an additional tailored service is offered

39. Research questions 1.Can a tailored callback service for smokers with symptoms of depression produce comparable quit rates? 2.What factors predict depression recurrence? 3.Does depression predict failure to quit? 4.What do callers think of Doctor-Quitline coordinated care?

40. Study design Prospective study - follow up 3 groups of callers over a 6 month period 3 caller groups –Smokers without MHC n=400 –Smokers with past depression n=190 –Smokers with current depression n=140 Research interviews –Baseline –2 months (around end of Quitline service) –6 months

41. Service development within a research context Program enhancement Counsellor training in the relationship between smoking cessation and depression. The development of counselling guidelines for callers with symptoms of depression that complement Quit Victorias mental health policy. The development of a joint Quit and beyondblue fact sheet on smoking cessation and depression. Continued development of the partnership between Quit and health professionals. Evaluation of the tailored service Recruitment May 07 – May 08 Follow-up surveys until Dec 08

42. Key features of the additional service Introduction to Quitline of the Health Screen Assessment Tool which documents the callers physical and mental health

43. Tailored callback service focusing on the relationship between smoking, mood and the impact of quitting on mood Smoking cessation and mood monitoring and management techniques Doctor involvement and resourcing Development of quit plan in with the callers Doctor Letters to doctor reporting on progress Specialised resources and activity sheets

44. Caller responses to the service Thankful for greater awareness, normalisation of experience and preparation for mood management Initial concern that their history of depression is being assessed before being given smoking cessation advice

45. Issues and insights The need to develop an understanding of the relationship between smoking cessation and depression Choose to smoke rather than take medication Use of mood management skills for other callers without a history of diagnosed depression Considerations when delivering a tailored service within a population service The role and acceptance of partnerships Resourcing a client centred service

46. Finally Improving cessation rates is not an easy task –But one we need to continue to work on Getting more people to use effective services, and, or, aids is somewhat easier –And provides improved outcomes, even in a population not selected initially by desire to quit