Increasing the Effectiveness of Tobacco Quitlines
Authors: R. T. Croyle
Journal: JNCI Journal of the National Cancer Institute (2010)

In this issue of the Journal, Toll et al. (1) report results from a randomized trial that compared a theory-based message-framing strategy with standard care in the context of tobacco quitline counseling. Smokers who received a gain-framed counseling intervention that emphasized the benefits of quitting reported statistically significantly more quit attempts and a higher rate of abstinence from smoking at the 2-week follow-up interview. Although the clarity of the study's test of the theoretical model of intervention was weakened by a confounding type of intervention with duration of intervention, the study provides an important contribution to the growing literature concerning quitlines. Most importantly, it demonstrates the feasibility of conducting scientifically and practically important treatment trials within a health services domain that has become a central component of the Nation's tobacco control strategy.

Quitlines emerged in the 1990s as a means of broadening the reach of smoking cessation services, and they now provide services throughout North America, Europe, and parts of Asia (2). Collaboration among the public, private, and nonprofit sectors has facilitated the growth of services and the development of evaluation strategies. In the United States and elsewhere, quitlines have faced an ongoing funding and service paradox. Limited resources have to be allocated between program operations and efforts to promote utilization. Clearly, a quitline that provides outstanding service but is rarely utilized is nearly useless. However, successful advertising that overwhelms the capacity of a quitline can impair the quality of services and discourage those attempting to quit.

In the United States, the National Cancer Institute's Cancer Information Service, state quitlines supported by the Centers for Disease Control and Prevention, and other providers form a network facilitated by the North American Quitline Consortium to provide services to all 50 states (3). The American Legacy Foundation, the American Cancer Society, and the Robert Wood Johnson Foundation have all played key roles in supporting the dissemination of cessation services and the use of evidence-based strategies. In many states and in some cities, quitline counseling has been complemented by the provision of nicotine replacement therapies or other cessation aids (3). Although recommended in a 2004 federal task force report (4), the federal government has yet to launch a national media campaign to increase awareness and utilization of quitlines, so the full potential of these programs has yet to be realized.

Given the urgent need for evidence concerning quitline promotion and intervention strategies, the study by Toll et al. is especially timely. Quitline program directors need more specific evidence concerning the types of counseling strategies that are most effective and how to maximize the use of pharmacotherapies. As new communication technologies are incorporated into quitline services, it will become increasingly important to identify the relative contributions of intervention components through efficacy and effectiveness studies that include cost-effectiveness analyses. Remarkably, little is known about the psychological barriers to calling a quitline (5), and trials have only recently been conducted to establish the efficacy of telephone counseling for smokeless tobacco cessation (6).

In the United States, two important changes in tobacco control policies provide remarkable opportunities to leverage the potential of quitlines to increase population-level cessation rates. Recent increases in federal and state excise taxes on tobacco products serve as important sources of motivation for smokers to quit, and the economic recession may have served to magnify the impact on quitline utilization. Tobacco excise taxes have also served in some states as important sources of funding for quitline programs. The second change is the passage of the Family Smoking Prevention and Tobacco Control Act of 2009, which provided the US Food and Drug Administration with extensive authority to regulate tobacco products and marketing. The implementation of these new authorities will provide tobacco control program directors with opportunities to synergize countermarketing and cessation efforts with the introduction of new warning labels, the disclosure of product ingredients, and the banning of certain product categories, such as flavored cigarettes. Quitlines that prepare for and leverage policy changes can play an important role in disseminating information about the availability of new medications for treating dependence and new information about the harms of tobacco products. In addition, they can serve as an important modality for collecting data to assess short-term trends in product awareness and usage.

Given the generational shift in the use of communication technology, stand-alone quitlines are already a fading anachronism. Many providers integrate Internet and telephone-based services with print materials and medications. Especially for younger smokers, Web 2.0 applications, including social networking services, are already being used, but the evidence concerning their impact remains limited. Given the importance of proactive outreach to both adolescent and adult quitline program participants (7), investigators need to evaluate the growing variety of popular communication modalities. Although preliminary evidence suggests that text messaging is an acceptable modality to reach young smokers (8), the science of tobacco control has struggled to keep pace with the explosion in its use. Evaluations of commercial mobile phone applications are needed, and there are numerous opportunities for collaborations between software developers and tobacco control investigators.

The alarming increase in tobacco use in the developing world has been paralleled by a rapid growth in cell phone access and use. As a result, quitlines will continue to play an essential role in the implementation of tobacco control programs throughout the world. This fact reinforces the relevance and need for research that delineates the processes and mechanisms underlying telephone-based cessation counseling. Because many developing countries will be unable to provide the access to cessation medications that is provided by quitlines in developed countries, communication processes will often be the only avenue for encouraging and facilitating cessation. The next generation of quitline research will need to address the cultural adaptation of quitline counseling and inform its implementation in limited literacy populations. Within the United States, our immediate challenge is to strengthen support for a fragile public health infrastructure that has demonstrated both efficacy and cost-effectiveness. Few technologies have as much potential to increase our reach and translate evidence into prevention both here and abroad.