1. The Cost-Efficient Quitline: Considerations for Funders Christopher Anderson

2. The California Smokers’ Helpline Run by UCSD Cancer Center First statewide quitline, supported since 1992 by Calif. Dept. of Health Services 350,000+ registered callers Ongoing research mission: building the evidence base for effective cessation

3. First Things First Cost-efficiency assumes an effect; if no effect, cost-efficiency = 0. Quitting that would have happened anyway is not part of the effect. Cost-efficiency can be framed in terms of: I. Delivery of a clinical service II. Impact on public health

4. I. Cost-efficiency in the Context of Service Delivery How many quit as a direct result of the service? How much does that service cost?

5. Can Quitline Providers Increase Their Cost-Efficiency? Yes! They can: Improve their protocols (Are they validated, or similar to ones that are validated?) Tighten their quality assurance procedures. Decrease their costs (e.g., by making sensible use of automation). Increase their productivity (e.g., by removing idle time).

6. How Can Funders Support Cost-Efficient Quitline Operations? They can: Negotiate solid Quality Improvement Plans, addressing all of the above. Hold vendors accountable & reward progress. Avoid feast-or-famine marketing. To the extent possible, avoid feast-or-famine funding, too.

7. Basic Service Models 1. Brief, reactive service Focus is on broad reach; quitline supports the promotional campaign; may include NRT give- aways Generates buzz, earned media Spikes in call volume can be hard to handle May be difficult to sustain over long term Little evidence of efficacy

8. Basic Service Models 2. Single-session counseling Focus is on planning a successful quit attempt May be reactive or proactive More challenging to operationalize than brief, reactive counseling The counseling itself may build positive word-of- mouth (i.e., not just the items being given away) Some evidence of efficacy

9. Basic Service Models 3. Multi-session, proactive counseling Focus is on comprehensive behavioral service, covering planning and relapse prevention Most challenging model to operationalize May result in highest caller satisfaction and most positive word-of-mouth Strongest evidence of efficacy Costliest model; may be less cost-efficient than single-session counseling

10. Regardless of Service Model: “Live answer” rate is extremely important. Barriers can easily thwart ambivalent callers Each call is generated at some cost Others will pay attention to the live answer rate: health care providers, local program people, hostile legislators 90-95% is very decent

11. II. Cost-efficiency in the Context of Improving the Public Health What is achieved as an indirect result of the service?

12. What Indirect Results Should Quitline Funders Aim For? Positive PR, a friendly face for the tobacco control program Synergy with other program components Norm change around smoking and quitting Increased “volunteer” efforts by HCP’s and others More unaided (“free”) quit attempts Reduced prevalence of tobacco use

13. A Refreshing Problem in Tobacco Cessation Quitlines are effective, intuitive, and easy to promote. Unlike many group programs, they are not plagued by low utilization. In fact, demand can easily (and often does) outstrip supply.

14. How Do We Deal With This Refreshing Problem? We want to make resources go as far as possible to make a real difference. So we need to think comprehensively: Attend to the operational details that determine clinical impact. Attend to the quitline’s connections to the larger tobacco control effort, to strive for a population impact.

15. Thank you!