Tobacco Use Cessation: The Effectiveness of Quit Lines

Archived page from Summer 2001

Tobacco Use Cessation:
The Effectiveness of Quit Lines

An estimated 70 percent of the current 47 million smokers in the United States want to quit, but only 2.5 percent per year succeed. Smokers who quit smoking before age 50 cut in half their risk of dying in the next 15 years. Healthy People 2010, a compilation of national health objectives, includes the following objectives concerning smoking cessation:

• Smoking rates among adults will need to decrease from 24 percent to 12 percent;

• Youth rates will need to decrease from 35 percent to 21 percent; and

• The percentage of women smokers who quit during pregnancy must increase from 14 percent to 30 percent.

Nationwide, medical care costs attributable to smoking (or smoking-related disease) have been estimated by the Centers for Disease Control and Prevention (CDC) to be more than $50 billion annually. In addition, they estimate the value of lost earnings and loss of productivity to be at least another $47 billion each year. The cost savings from reduced tobacco use resulting from moderately priced, effective smoking cessation interventions would more than pay for themselves within three to four years according to the CDC. One smoker who successfully quits reduces the anticipated medical costs associated with heart attack and stroke by an estimated $47 in the first year and $853 during the next seven years.

Tobacco Control Programs Are Effective

Tobacco control programs are continuously evaluated to substantiate funding allocations. The CDC reports that interventions such as physicians advising their patients to quit smoking can produce cessation rates of 5 percent to 10 percent per year. More intensive interventions, such as the combination of behavioral counseling and pharmacologic treatment, can produce 20 percent to 25 percent quit rates in one year. Self-help interventions, although inconsistent in their success rates, can be delivered easily to smokers who want to quit on their own. Proactive telephone counseling may significantly increase their effectiveness.

Methods to Quit Smoking

"Cold turkey," the patch, cutting down, support group, buddy system, acupuncture, nicotine gum, other tobacco products, hypnosis and telephone counseling are the variety of methods people use to stop smoking.

During telephone counseling, a counselor discusses how to quit smoking. The counselor listens to the caller and they collaborate to devise a plan specific to personal needs. Telephone counseling is one-on-one, private and free.

Brief advice from a primary care physician during a routine consultation is effective in increasing the number of smokers stopping for at least six months. Self-help interventions (generic pre-printed written materials giving advice about ways to quit) provided without personal support have a small effect on quit rates. Their impact is smaller and less certain than face-to-face interventions. Telephone calls from a counselor may be more effective than self-help materials alone.

Reactive approaches - telephone help lines or crisis lines - are amenable to promotional campaigns. While difficult to evaluate, they appear to be effective and useful as a public intervention for large populations. Proactive phone counseling has shown significant short-term (three to six month) effects, and some have shown substantial long-term effects.

Quit lines (or telephone support lines) appeared most effective when used as the sole intervention or when augmenting programs initiated in hospital settings. Telephone support can include the use of trained counselors, health care providers or taped messages in single or multiple sessions. The Task Force on Community Preventive Services, an independent, non-federal task force funded by federal agencies and the Robert Wood Johnson Foundation, strongly recommends multicomponent cessation interventions that include telephone support. Additionally, the task force is responsible for developing The Guide to Community Preventive Services that addresses various health topics important to communities, public health agencies and health care systems.

Quit lines overcome many of the barriers to traditional smoking cessation classes as they are free to the caller, require no transportation and are available at the smoker's convenience. Quit lines bring services to smokers in rural areas where there may be few resources, and they can be tailored to diverse language and cultural needs. Separate quit line numbers have been established and self-help materials tailored for spit tobacco, youth, ethnic minorities, pregnant women or other vulnerable populations.

Tobacco cessation programs complement other tobacco control approaches (such as taxation, public information campaigns, advertising bans, smoke-free places, etc.) which tend to decrease the social acceptance of smoking behavior, increase tobacco users' motivation to quit, encourage them to make an attempt to do so and help maintain quitters' abstinence. Treatment of tobacco dependence also complements approaches such as banning the use of misleading labeling on tobacco products, for example, 'light' and 'mild,' which have deceptively dissuaded smokers from quitting and have, therefore, been in competition with treatment.

"Everyone in the state who has a telephone or who can get to one has access to the Helpline's free services. No other single cessation program can match the ability of its tollfree telephone lines to reach into every community in the state." The California Smokers' Helpline: A Case Study

Federal Guidelines

In June 2000, the U.S. Public Health Service released updated guidelines on treating tobacco use and dependence aimed at practicing clinicians. The tobacco cessation guideline was developed by a consortium and builds on a smoking cessation guideline first issued by the government in 1996. Updates from the 1996 guidelines include:

• Stronger evidence of the association between counseling intensity and successful treatment.

• Additional effective strategies including telephone counseling and counseling that helps smokers enlist support outside the treatment context.

• More options for drug treatment strategies. Further information also is available on the efficacy of combinations of nicotine replacement therapies and pharmacotherapies that are obtained over-the-counter.

• Strong evidence that smoking cessation treatments are cost-effective relative to other routinely reimbursed medical interventions (e.g., mammography screening).

Despite such strong evidence supporting the efficacy of counseling and treatment, health plans typically do not cover cessation services. Less than half of state Medicaid programs provide reimbursement for smoking cessation services with coverage ranging from state to state. Medicare excludes coverage completely. There is currently no federal legislation that provides states with minimum benefit requirements for cessation treatment, therefore it is not
surprising that there is a wide variation among states in their cessation benefits.

In April 2001, a letter was issued from the U.S. Office of Personnel Management's Office of Insurance Programs. The letter specified the proposed benefit and rate changes for federal employees health benefits plans. Changes included:

• Encouraging plans to follow the Pubic Health Service's guidelines for smoking cessation benefits.

• Covering primary care visits for tobacco cessation with the standard office visit co-payment.

• Covering individual or group counseling for tobacco cessation with no co-payment.

• Covering prescriptions for all FDA-approved medications for tobacco cessation with the usual pharmacy co-payments.

State Examples

California's comprehensive tobacco control program has received national attention for its successes. In 10 years, the smoking rate has dropped from 26.7 percent in 1988 to 18.4 percent. In November 1988, California voters approved the California Tobacco Tax and Health Promotion Act (Proposition 99), which increased the state surtax on cigarettes by 25 cents per pack (and an equivalent amount on other tobacco products). Tobacco tax revenues fund tobacco-related disease research, health education against tobacco and health care for medically indigent families.

The California Smokers' Helpline has been in operation since 1992 and has served more than 100,000 smokers. Helpline services are funded by the California Department of Health Services. Individuals who call the helpline get a choice of services including: self-help materials, a referral list of other programs and one-on-one telephone counseling. The helpline is available in English, Spanish, Korean, Vietnamese and Cantonese/Mandarin as well as a separate line for the hearing impaired. There is an additional helpline for smokeless tobacco users.

In 1995, Arizona voters passed the Tobacco Tax and Health Care Act (Proposition 200) increasing the state sales tax on tobacco products to fund health care for the medically needy, medically indigent and low income children; tobacco education and prevention; and tobacco related research. Twenty-three percent of the tax revenue funds the Tobacco Education and Prevention Program. The Arizona Smokers' Helpline was launched in 1995. It offers brief interventions and basic information to anonymous "questions only" clients. Brief interventions, active community referrals and mailed bilingual self-help materials go to "self-help only" clients. Intensive interventions, mailed bilingual self-help materials and ongoing telephone counseling for up to a year is offered to "counseling + self-help" clients. A unique aspect of this helpline is the focus on the Native American community.

The West Virginia Public Employees Insurance Agency insures one out of every nine West Virginians. The agency began a policy to promote tobacco cessation, including the development of a cessation quitline, after noting that a high proportion of subscribers were smokers. With more than 26,000 calls since the quitline was initiated, three out of every five tobacco users have received cessation services. Pregnant smokers are given the highest priority for pharmaceuticals and counseling. The agency has since adjusted its new policies to promote more use of cessation services including differential premiums and pharmaceutical reimbursement. The Medicaid Program of West Virginia is working with the agency to offer this quitline service to its population. Future plans involve expanding the quitline to the uninsured population.

Resources

Susan J. Curry, Michael C. Fiore and Marguerite E. Burns. Community Level Tobacco Interventions: Perspectives of Managed Care. American Journal of Preventive Medicine, 20, 2S. 2001; 6-7.

The Task Force on Community Preventive Services. Guide to Community Preventive Services. Systematic Reviews and Evidence-based Recommendations. Atlanta, Ga., November 2000.

California Department of Health Services. Tobacco Control Section. The California Smokers' Helpline: a case study. Sacramento, Calif., May 2000.

U.S. Public Health Service. Treating Tobacco Use and Dependence-A Systems Approach. A Guide for Health Care Administrators, Insurers, Managed Care Organizations, and Purchasers. Washington, D.C., November 2000.

Center for Disease Prevention & Epidemiology. Oregon Health Division. CD Summary: Tobacco Prevention: It's Working on Many Levels. Portland, Ore., January 2001.

Robert Wood Johnson Foundation. Substance Abuse. The Nation's Number One Health Problem. Princeton, N.J., 2001.

National Governors Association. NGA Center for Best Practices. Preventing Maternal Smoking. Washington, D.C., August 2001.