Referring Smokers to Quitlines



Telephone-based programs to encourage and support quitting smoking—known as “quitlines”—have been established as effective both clinically and in the “real world.” However, quitlines rely on smokers calling in for them to work. Researchers from the Tobacco Cessation and Prevention Program and the Massachusetts Department of Public Health, both in Boston, say being referred to quitlines by their health care providers might help even more smokers quit.

The researchers collected data for 2,737 provider-referred and 530 self-referred smokers from the Massachusetts Smokers’ Helpline, which offers evidence-based proactive telephone counseling sessions, nicotine replacement therapy (NRT), and self-help materials. They then examined differences in demographics, service utilization, and quit outcomes. The primary outcome was quit status at the 6- to 8-month follow-up.

Twenty percent of provider-referred clients quit smoking; 26% of self-referred clients quit. Provider-referred smokers who used the quitline services had higher odds of quitting, compared with those who used methods not including a quitline. However, the provider-referral model was limited by lower enrollment, lower use, and poorer outcomes compared with self-referred services. Patients aged 18 to 34 years and those aged > 65 years had the best chances of quitting and staying smoke-free. Patients referred from private practices were more likely to quit than were those referred from a hospital.

Provider-referred smokers who read the self-help materials had 1.2 times the odds of quitting compared with those who didn’t. Using any amount of the 2-week supply of NRT doubled the odds of quitting. Clients who used a combination of counseling and NRT had the greatest success, with more than triple the chances of quitting, compared with clients who did neither.

Self-referred smokers also had good results, although not usually as quickly as provider-referred smokers, who saw significantly improved outcomes after 3 counseling sessions. It took 4 sessions for the self-referred smokers to see the same results.

Readiness to quit was an important predictor of success. Tobacco dependence also predicted quitting success. Clients in both groups who could wait > 30 minutes before smoking their first cigarette had better luck than did those who had to smoke immediately after waking.

The researchers suggest some ways to improve the provider-referred model. One is to offer more support for smokers from lower socioeconomic levels. According to other research, those smokers may need more treatment content and access to more intensive pharmacotherapy, the researchers say.

It might also help all quitline clients, they add, to minimize the wait time between referral and actual provision of service. Longer wait times can “increase the room for ambivalence for any smoker,” they note, “but may be especially detrimental for provider-referred smokers who are less ready to make a quit attempt.”

And what is the provider’s role in assessing patient readiness to quit and preparing patients for the quitline services? In reality, the researchers say, not all patients have received an evidence-based intervention or are ready to quit when they are enrolled. Moreover, many are lost in the callback process. Using 3 callback attempts, the Massachusetts quitline only reaches 40% of their potential quitters. Upping the callback rate to 5 attempts raises the reach slightly, to 50%. That shows the need, the researchers say, for better and more frequent provider training, outreach, feedback reporting, clinical champions on site, and systems support.

Song G, Landau AS, Gorin TJ, Keithly L. Am J Prev Med. 2014;47(4):392-402.
doi: 10.1016/j.amepre.2014.05.043.

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