1. Why Quitlines Work Shu-Hong Zhu, Ph.D Gary Tedeschi, Ph.D. University of California, San Diego NAQC Annual Membership Meeting, Chicago May 2-3, 2005, Chicago

2. Goals of “Why Quitlines Work” Session 1. Identify the basic hypotheses underlying various quitline service protocols. 2. Identify rules-of-thumb to guide the design of effective interventions. 3. Understand how quitlines lend themselves to efforts to achieve a population impact. 4. Help all of us think more critically and effectively when designing or evaluating a cessation intervention.

3. What Do We Mean by “Quitlines?”

4. What Do We Mean by “Quitline?” l Distribution/referral center/hub –Send self-help materials –Distribute free/discounted NRT –Referral people to existing cessation programs l A place to call when there is a media campaign l Phone counseling center –A few minutes of conversation –Comprehensive reactive counseling –Comprehensive proactive counseling with multiple followups

5. What Do We Mean by “It Works?”

6. l A lot people have called (what is a lot?) l Increase the use of service –More people use self-help materials –More people use referred services –More people use NRT –More people use counseling l Increase callers’ chance of quitting l Increase the quitting of smokers in communities where the quitline is advertised

7. The Key Word is “Increase” l A comparison point is always needed –Explicit or implicit (what is a lot?) l Avoid “creative” use of statistics –Not mentioning drop out rate (hypnosis effects) –Minimal data set has done a great job in defining the terms of measure (though the comparison point is not emphasized)

8. Effects of NRT Sent by Quitline l More smokers using NRT, sent by the quitline l More people are quitting Due to more use of NRT Due of more use of counseling l NRT effects look bigger in a non- randomized study than a randomized one

9. Why Do Quitlines Work?

10. Why Do People Change? l They want to l They have to –In reality, do we have more people who changed because they wanted to or because they had to? l If you do not have much of either, then you do not change. –How many of you like to be sick, so you do not have to perform?

11. How to Increase Cessation –Increase the rate of quit attempt –Increase probability of survival of these attempts Q = A x S

12. Motivate smokers to call Multiple Counseling Single Counseling Self-Help A Randomized Controlled Trial Months Follow-Up Evaluation 3612 Source: California Smokers’ Helpline

13. Quit Attempts Source: Zhu et al. (1996), JCCP, 64, 202-211 Self-Help 58.8 66.7 66.6 Treatment Group Quit in 3 Months % Single Counseling Multiple Counseling

14. Relapse Curves for 3 Groups Source: Zhu et al. (1996), JCCP, 64, 202-211

15. How do you design a counseling protocol that will affect quits attempt, survival rates or both?

16. 4 Key Considerations l How many sessions? l How should they be scheduled? l What should happen in each session? l How important is matching/tailoring?

17. How Many Sessions? l From a quit attempt standpoint, one session may do the job. –Address the essential elements –Lead to a quit date l From a survival standpoint, multiple sessions can help.

18. How Should They Be Scheduled? l From a recycling standpoint, spread calls over several months. l From a survival standpoint, schedule calls based on the probability of relapse.

19. Days after quitting Relapse-Sensitive Scheduling Source: Zhu & Pierce (1995), Prof. Psych. Res.& Practice, 26, 624-625 Percent abstinent 3014730 1 100 80 60 40 20 0

20. What Should Happen in Each Session? l Consider non-specific and specific counseling effects.

21. Nonspecific Effects Rapport Motivation Attribution & Self-efficacy Social support Hope Ambivalence & Accountability Proactivity

22. Proactivity l Addresses client ambivalence l Reduces attrition l Provides social support l Creates accountability

23. Specific Effects l Knowledge l Tobacco & nicotine l Quitting process l Quitting aids

24. Specific Effects (cont.) l Ability to Facilitate Planning (Specific ideas for coping) l Behavioral (e.g., changing habits) l Cognitive (e.g., self-image) l Pharmacological (e.g., NRT)

25. How Important is Tailoring? l Tailoring to group or client? –Yes, but not too many. l Matching client and counselor? –If possible, great. But there are other considerations l Same counselor or different counselor for follow-up? –Yes, but not necessary.

26. What Explains A Quit Rate? Q = aP + bN + cS + dE + eU

27. What Explains A Quit Rate? Q = aP + bN + cS + dE + eU a > b > c

28. What Explains A Quit Rate? Group A –Highly motivated (cardiac patients) –Used self-help materials only –Q = 40% Group B: –Mental health patients –Received multiple counseling + medications –Q = 15%

29. How to Achieve a Population Effect

30. The Biggest Issue: Only 1-2% of Smokers Are Using Quitlines

31. A Conundrum A Conundrum l We want higher utilization l Yet some quitlines have already exceeded their capacity (limited budget) l The National Action Plan recommends a 16% reach, requiring an annual budget of $3.2 B. (not including media budget)

32. One Solution l Quitlines work with other population-based approaches to cessation to increase quit attempts in the population. –Think about overall cessation in terms of how many quit attempts occurring in a given period of time, not how many smokers are trying to quit.

33. A Quitline in a Population-Based Framework Worksite Policy Media School Programs Provider Advice Source: California Smokers’ Helpline Quitline

34. The California Tobacco Control Program ` Community Norm Change 1989 $0.25/pack Excise Tax School Programs Local Initiatives Media Program Assistance

35. Mobilizing the Community -Asian Americans and Pacific Islanders- AAPI-English AAPI-Asian Line

36. Why Do People Change?

37. Micro & Macro Tobacco Cessation Interventions l Micro interventions tend to focus on increasing the level of “want to change” l Macro interventions tend to focus on increasing the level of “have to change” l The trick is the turn “have to” to “want to”

38. A Particularly Promising Approach l Second-hand smoke campaign changes the societal norm regarding smoking l We need to create quitting as the norm among the current smokers. l Quitlines, because their centralized operation, are particularly suitable for highly visible large-scale campaign.

39. Thank you!