Background: Quitlines have become an integral part of tobacco control efforts in the United States and Canada. The demonstrated efficacy and the convenience of telephone based counselling have led to the fast adoption of quitlines, to the point of near universal access in North America. However, information on how these quitlines operate in actual practice is not often readily available. Objectives: This study describes quitline practice in North America and examines commonalities and differences across quitlines. It will serve as a source of reference for practitioners and researchers, with the aim of furthering service quality and promoting continued innovation. Design: A self administered questionnaire survey of large, publicly funded quitlines in the United States and Canada. A total of 52 US quitlines and 10 Canadian quitlines participated. Descriptive statistics are provided regarding quitline operational structures, clinical services, quality assurance procedures, funding sources and utilisation rates. Results: Clinical services for the 62 state/provincial quitlines are supplied by a total of 26 service providers. Nine providers operate multiple quitlines, creating greater consistency in operation than would otherwise be expected. Most quitlines offer services over extended hours (mean 96 hours/week) and have multiple language capabilities. Most (98%) use proactive multisession counselling-a key feature of protocols tested in previous experimental trials. Almost all quitlines have extensive training programmes (.60 hours) for counselling staff, and over 70% conduct regular evaluation of outcomes. About half of quitlines use the internet to provide cessation information. A little over a third of US quitlines distribute free cessation medications to eligible callers. The average utilisation rate of the US state quitlines in the 2004-5 fiscal year was about 1.0% across states, with a strong correlation between the funding level of the quitlines and the smokers' utilisation of them (r = 0.74, p,0.001). Conclusions: Quitlines in North America display core commonalities: they have adopted the principles of multisession proactive counselling and they conduct regular outcome evaluation. Yet variations, tested and untested, exist. Standardised reporting procedures would be of benefit to the field. Shared discussion of the rationale behind variations can inform future decision making for all North American quitlines.

SummaryBackgroundResults of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.MethodsFOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762.FindingsBetween Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839–1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26–6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38–2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months.InterpretationFluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function.FundingUK Stroke Association and NIHR Health Technology Assessment Programme.

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Objectives:This paper discusses the development of a minimal dataset (MDS) for tobacco cessation quitlines across North America. The goal was to create a standardised instrument and protocol that would allow for comparisons and pooling of data across quitlines for evaluation and research purposes. Principles of utilisation focused evaluation were followed to achieve consensus across diverse stakeholder groups in two countries.Methods:The North American Quitline Consortium (NAQC) assembled a working group with representatives from quitline service providers, funders, evaluators and researchers from Canada and the United States. An extensive, iterative consultation process over two years led to consensus on the evaluation domains, indicators and specific items. Descriptive information on quitline service models, data collection protocols and methodological issues were addressed.Results:The resulting minimal dataset (MDS) includes 15 items collected from eligible callers at intake and eight items collected from smokers participating in evaluation. Recommendations for selecting evaluation participants, length of follow-up and repeat callers were developed. Full MDS questions and technical documents are available on the NAQC website.Conclusion:Adoption and implementation of the MDS occurred in the majority of North American quitlines by the end of 2006. Key success factors included a focus on utility and feasibility, a commitment to meeting multiple and varied needs, sensitivity to situational factors and investment in working interactively with stakeholders. The creation and implementation of a MDS across two countries is an important “first” in tobacco control which will help speed the creation of practice based evidence and facilitate practice based research.

Introduction Smokers are asking health practitioners for guidance about using e-cigarettes as an aid to quitting. Several studies have surveyed physicians. However, in North America many smokers seek help from telephone quitlines rather than physicians. The objective of the current study was to assess quitline counselors' perceptions of e-cigarettes and what they tell callers about these products. Methods An online cross-sectional survey, conducted in 2014 with 418 quitline counselors in the U.S. and Canada, measured perceptions of e-cigarettes: (1) as quitting aids; (2) safety; (3) professional guidance given/organizational guidance received; (4) regulation. The response rate was 90.1%. Analyses included calculating standard errors and 95% confidence intervals around summary statistic. Results Nearly 70% of counselors believed that e-cigarettes are not effective quitting aids. Most believed e-cigarettes are addictive (87%) and that secondhand exposure to vapor is harmful (71%). Counselors reported that callers ask for advice about e-cigarettes, but few counselors recommended e-cigarettes (4%). Counselors (97%) reported being instructed by quitline employers to explain to clients that e-cigarettes are not FDA-approved; 74% were told to recommend approved quitting aids instead. Most counselors (>87%) believed e-cigarettes should be regulated like cigarettes in terms of advertising, taxation, access by minors, and use in public places. Conclusions Quitline counselors view e-cigarettes as ineffective quitting aids, potentially dangerous, and in need of greater regulations. Counselors can influence how treatment seekers view e-cigarettes, therefore it is imperative that quitlines stay abreast of emerging data and communicate about these products in ways that best serve clients.