The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline

Abstract

Objectives: State and national tobacco quitlines have expanded rapidly and offer a range of services. We examined the effectiveness and cost effectiveness of offering callers single session versus multisession counselling, with or without free nicotine patches. Methods: This 362 randomised trial included 4614 Oregon tobacco quitline callers and compared brief (one 15-minute call), moderate (one 30-minute call and a follow-up call) and intensive (five proactive calls) intervention protocols, with or without offers of free nicotine patches (nicotine replacement therapy, NRT). Blinded staff assessed tobacco use by phone at 12 months. Results: Abstinence odds ratios were significant for moderate (OR = 1.22, CI = 1.01 to 1.48) and intensive (OR = 1.29, CI = 1.07 to 1.56) intervention, and for NRT (OR = 1.58, CI = 1.35 to 1.85). Intent to treat quit rates were as follows: brief no NRT (12%); brief NRT (17%); moderate no NRT (14%); moderate NRT (20%); intensive no NRT (14%); and intensive NRT (21%). Relative to brief no NRT, the added costs for each additional quit was $2467 for brief NRT, $1912 for moderate no NRT, $2109 for moderate NRT, $2641 for intensive no NRT, and $2112 for intensive NRT. Conclusion: Offering free NRT and multisession telephone support within a state tobacco quitline led to higher quit rates, and similar costs per incremental quit, than less intensive protocols.T he past decade has produced a dramatic nationwide dissemination of a new form of behavioural therapy. In 1999, only four states (Oregon, Arizona, California, and Massachusetts) provided centralised telephone support services (quitlines) and none offered free nicotine replacement therapy (NRT). By 2005, all states in the United States, all provinces of Canada, Australia, New Zealand and many countries in the European Union and elsewhere had established quitlines. [1][2][3] Services range from information, counselling, and referral in a single call to multisession counselling with proactive followup. [4][5][6] More than 18 states currently provide NRT to some or all callers. 1 Cessation medications, including nicotine replacement, 7 8 bupropion, 9 and varenicline, 10-12 all increase success rates. Proactive, multiple session telephone counselling 7 13-16 also improves outcomes, and the efficacy of cessation quitlines has been confirmed in statewide programmes 17-19 serving large and diverse populations. 4 6 20 21 The US clinical practice guideline for tobacco concluded that both medications and quitlines are effective. 7 Proactive quitlines provide support over multiple contacts, but are more convenient than group counselling and are often provided free of charge. These features allow quitlines to attract more and more diverse, tobacco users than do group programmes. 22 The efficacy and broad reach of quitlines create a potentially large population impact.Few randomised trials have assessed the relative effectiveness and cost effectiveness of alternative quitline services. Borland 23 and Zhu 24 found that adding follow-up calls to an init...

Randomized Trial of Telephone-Delivered Acceptance and Commitment Therapy Versus Cognitive Behavioral Therapy for Smoking Cessation: A Pilot Study

“…All counselors were bachelors or masters-level providers with at least 3 years of general counseling experience, consistent with prior QL (Hollis et al, 2007;Stead et al, 2013) and ACT intervention trials (Dahl, Wilson, & Nilsson, 2004;Forman et al, 2007;Lappalainen et al, 2007). Counselors completed at least 100 hr of training in the treatment approach that they delivered and, prior to beginning as a study counselor, demonstrated acceptable adherence to the intervention protocol using standardized rating procedures.…”

“…The estimate of the number of calls completed was 3.5 (SD = 1.3) for ACT (Bricker et al, 2010) and 2.3 (SD = 1.6) for CBT (Hollis et al, 2007). Based on these estimates, there was 80% power to detect a significant difference in number of completed calls (60 per arm).…”

“…Independent ratings of audio recordings of all telephone counseling calls showed that intervention delivery was highly competent (M = 4.81, SD = 0.39, on a 1-5 scale) (SchimmelBristow et al, 2012). The study provided four initial receptivity and efficacy results: (a) Average number of calls completed (i.e., 3.5) was higher than the widely used traditional CBT QL intervention (i.e., 2.3; Hollis et al, 2007); (b) 93% said the intervention was useful for quitting smoking; (c) from baseline to posttreatment, there was an increase in acceptance of physical cravings, emotions, and thoughts that cue smoking, consistent with ACT's theory-based mechanism of change; (d) in intent-to-treat analyses, 29% had not smoked at all in the past 12 months at 12 months posttreatment.…”

“…Alere is the largest provider of telephone smoking cessation interventions in the United States, currently operating QLs for 28 states and numerous large health insurers and companies. This intervention met our criteria for a comparison intervention because (a) it follows Agency for Healthcare Research and Quality (AHRQ) clinical practice guidelines for smoking cessation (Fiore et al, 2008); (b) it has demonstrated efficacy (Bush et al, 2012;Hollis et al, 2007;Swan et al, 2003); (c) its traditional CBT approach is mediated by psychological processes that are different from those of ACT, providing a rigorous test of the hypothesized mediator (Forman et al, 2007;Hayes et al, 1999); and (d) the intervention is equal in length to the ACT intervention. Sessions focus on assisting participants to develop a quit plan and teaching skills in the avoidance of triggers through techniques such as distraction, stimulus control, and changing the content of thoughts about smoking.…”

“…Interrater agreement was high and did not differ by arm (proportion of positive agreement = 0.91 for CBT; 0.99 for ACT; proportion of negative agreement = 0.00 for CBT; 0.00 for ACT). ACT calls were rated using the ACT Adherence Raters' Manual (modified from Gifford et al, 2004Gifford et al, , 2011, whereas CBT calls were rated using the Alere Call Quality Management Tool used in multiple NIH-funded trials (Bush et al, 2012;Hollis et al, 2007;Swan et al, 2003).…”