Telephone Recruitment into a Randomized Controlled Trial of Quitline Support

doi:10.1016/j.amepre.2009.05.022

American Journal of Preventive Medicine

Volume 37, Issue 4, October 2009, Pages 324-329

https://doi.org/10.1016/j.amepre.2009.05.022 Get rights and content

Background

Only 1%–7% of adult smokers use quitlines annually. Active telephone recruitment may increase utilization and enroll new groups of quitline users.

Purpose

This study aimed to (1) determine the proportion of adult daily smokers actively recruited by telephone to quitline support; (2) calculate the cost per smoker recruited; and (3) compare the characteristics of participants to smokers in the New South Wales (NSW, Australia) general population.

Methods

Between September 2005 and April 2007, 1562 adult daily smokers randomly selected from the electronic NSW telephone directory were recruited into an RCT. The proportion of smokers and the cost per smoker recruited were examined. Participants were compared to NSW adult daily smokers from the NSW Population Health Survey and the Centre for Health Research & Psycho-oncology Smoking Community Survey. Analysis was completed in 2008.

Results

More than half (52%) of eligible smokers contacted by telephone were recruited into cessation support. The cost per smoker recruited was AU$71 (US$59). Active telephone recruitment successfully enrolled smokers who are currently under-represented among quitline users. For instance, more than two thirds (68%) of participants were not intending to quit within 1 month. Compared with NSW adult daily smokers, participants were significantly more likely to be older; more highly educated; married/living with partner or divorced/separated; a nonmetropolitan resident; more nicotine dependent; more ready to quit; and have fewer household members. Participants were significantly less likely to live with a smoker than were NSW adult daily smokers.

Conclusions

Active telephone recruitment has the potential to substantially increase the proportion of smokers using quitline services at a reasonable cost. This method also engages smokers currently under-represented in quitline populations.

Introduction

Quitlines provide effective smoking-cessation support.1, 2, 3, 4 Passive recruitment channels requiring smoker-initiated contact with quitlines⁵ are commonly utilized (e.g., mass media6, 7, 8, 9). However, quitlines have also adopted active recruitment channels that involve recruiter-initiated contact with smokers⁵ (e.g., fax referrals10, 11, 12, 13). Only 1%–7% of adult smokers call quitlines each year.7, 9, 14, 15, 16, 17 A much higher proportion must be reached in order for quitlines to have a substantial impact on smoking prevalence. A target of 16% of smokers receiving quitline services annually has been proposed.¹⁸

Active telephone recruitment could potentially increase quitline utilization given that it recruits the largest proportion of smokers,⁵ is acceptable,¹⁹ and re-enrolls more former quitline users.²⁰ For example, 41% of cold-called smokers received quitline services.²¹ The few trials that actively telephoned smokers to offer proactive telephone counseling (i.e., counselor-initiated support)22, 23, 24 found that 38%²² and 67%²⁴ of smokers were receptive. However, smokers who were interested in quitting,²² had young children,²⁴ or who were health maintenance enrolees²³ were targeted. No trial engaged smokers from the entire general population or calculated the cost per smoker recruited.22, 23, 24

Compared with the general smoking population, quitline callers are more likely to be women,14, 16, 25, 26 younger,14, 25, 26 unemployed,14, 26 never married,²⁶ more highly educated,25, 26 more addicted,14, 16, 25, 26 to have previously quit,²⁶ and to be ready to quit within 30 days.²⁵ Active telephone recruitment may increase the reach of quitlines by enrolling currently under-represented smokers.27, 28 Past trials offering proactive telephone counseling to smokers actively recruited by telephone have not assessed their sample's representativeness compared to the general smoking population.22, 23, 24

This study aims to (1) assess the proportion of adult daily smokers from the entire general population enrolled into a proactive telephone counseling trial via active telephone recruitment, (2) calculate the cost per smoker recruited, and (3) determine the representativeness of participants compared to New South Wales (NSW) smokers.

Section snippets

Sample

Recruitment occurred between September 2005 and April 2007. Eligibility criteria were (1) daily tobacco user; (2) aged ≥18 years; (3) NSW, Australia, resident; and (4) English speaker. Nondaily smokers were excluded given fewer in this group wish to quit and receive cessation assistance.²⁹

Procedures

Telephone numbers were randomly selected from the NSW Electronic White Pages telephone directory. An information letter was mailed to households, followed by a telephone call within 2 weeks. At least six

Results

Of 48,014 households selected, 4304 were unreachable. Of 43,710 reached, 40,702 were ineligible. From 3008 eligible households, 939 (31.2%) smokers refused; 502 (16.7%) household members refused; and five (0.2%) interviews were not completed. If smoking status was not identified before the call ended, the household was assumed to contain an eligible smoker. Consequently, the recruitment rate may be underestimated (Figure 1).

Discussion

Approximately half (52%) of eligible smokers were recruited actively by telephone to cessation support. This rate is higher than that in a U.S. trial (38%)²² but lower than that in a Hong Kong trial (67%).²⁴ The Hong Kong trial subjects were parents of young children who had already participated in research²⁴ and thus may have been more motivated to participate than smokers in the general population. The trial recruitment rate (52%) was substantially higher than the 1%–7% of adult smokers using

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Cited by (27)

The Equity Impact of Proactive Outreach to Smokers: Analysis of a Randomized Trial
2018, American Journal of Preventive Medicine
Citation Excerpt :
Traditional smoking-cessation interventions rely on motivated smokers to seek out services. Smokers who independently call quitlines for support41 or volunteer for intervention programs42 are more likely to come from a higher educational background than the general smoking population. By proactively calling smokers, the proactive outreach intervention addressed the fear of being judged, fear of failure, and lack of knowledge43 that may prevent low-SES smokers from seeking assistance.
Population-based smoking-cessation services tend to preferentially benefit high-SES smokers, potentially exacerbating disparities. Interventions that include proactive outreach, telephone counseling, and free or low-cost cessation medications may be more likely to help low-SES smokers quit. This analysis evaluated the role of SES in smokers’ response to a population-based proactive smoking-cessation intervention.
This study, conducted in 2016 and 2017, was a secondary analysis of the Veterans Victory Over Tobacco Study, a multicenter pragmatic RCT of a proactive smoking-cessation intervention conducted from 2009 to 2011. Logistic regression modeling was used to test the effect of income or education level on 6-month prolonged abstinence at 1-year follow-up.
Of the 5,123 eligible, randomized participants, 2,565 (50%) reported their education level and 2,430 (47%) reported their income level. The interactions between education (p=0.07) or income (p=0.74) X treatment arm were not statistically significant at the 0.05 level. The largest effect sizes for the intervention were found among smokers in the lowest education category (≤11th grade), with a quit rate of 17.3% as compared with 5.7% in usual care (OR=3.5, 95% CI=1.4, 8.6) and in the lowest income range (<$10,000), with a quit rate of 18.7% as compared with 9.4% in usual care (OR=2.2, 95% CI=1.2, 4.0).
In a large, multicenter smoking-cessation trial, proactive outreach was associated with higher rates of prolonged abstinence among smokers at all SES levels. Proactive outreach interventions that integrate telephone-based care and facilitated cessation medication access have the potential to reduce socioeconomic disparities in quitting.
This study is registered at www.clinicaltrials.gov NCT00608426.
Just how high-risk are ongoing smokers? Exploring clusters of health risk behaviours among current and ex-smokers
2016, Preventive Medicine
Citation Excerpt :
The sample frame places some limitations on the data in that study participants had participated in a prior cessation trial and therefore would not be representative of all smokers. However, as the participants in the trial were recruited using an active rather than passive recruitment strategy, they were likely to be more representative of smokers than samples recruited to many other cessation trials (Tzelepis et al., 2009). The study response rate (51.3% of prior trial participants), while reasonable given the time elapsed since trial completion, may limit the generalizability of the results to smokers.
There is limited research about the patterns of multiple health risks among smokers, despite the associated increased risk of poor health. This study aimed to identify which risk behaviours were evident in a sample of smokers and ex-smokers who had previously been offered cessation support. A cross-sectional telephone interview in 2013 involved participants from New South Wales, Australia, from the control condition (self-help materials only) of a randomised smoking cessation trial conducted approximately five years earlier. The interview assessed smoking, weight, height, fruit and vegetable intake, physical activity, alcohol intake and depression. Of the 626 eligible participants, 321 were interviewed (consent rate = 85.6%, response rate = 51.3%); 62% were current smokers. Most participants (57%) reported four or five health risk behaviours. Three risk clusters were identified using latent class analysis: i) ‘high risk’ (42% of sample): smokers, overweight, inadequate intake of fruit and vegetables and low levels of physical activity; ii) ‘lower risk non-depressed’ (22% of sample): adequate physical activity and an absence of depression; and iii) ‘lower risk, low alcohol’ (36% of sample): low alcohol consumption, overweight and depressed. Males and current smokers were more likely to be ‘high risk’, while women and ex-smokers were more likely to be members of the ‘lower risk, low alcohol’ cluster. Those who continue to smoke have multiple additional health risks; as do ex-smokers in the ‘lower risk, low alcohol’ cluster. Achieving good health outcomes for these sizeable groups will require tailored, intensive or case-management approaches which can address multiple health risk behaviours.
Improving the continuity of smoking cessation care delivered by quitline services
2015, Patient Education and Counseling
Citation Excerpt :
Another limitation of this study is that it measured intended use rather than behaviour. However our previous work found that when smokers were proactively offered quitline support, uptake (52%) [37] exceeded prior reports of intended use (46%) [38]. Furthermore, reported use of NRT (78–89%) when provided via international quitline services [27,30] although similar, exceeded the intended use of subsidised NRT reported by smokers (75%) in the current study.
This study identified smokers’ intended use of new quitline features aimed at improving smoking cessation such as having the same quitline advisor for each call, longer-term telephone counselling and provision of additional cessation treatments.
Smokers who had previously used quitline counselling completed a computer-assisted telephone interview examining intended use of potential quitline enhancements.
The majority of smokers (61.1%) thought their chances of quitting would have increased a lot/moderately if they had the same quitline advisor for each call. Most smokers reported likely use of longer-term quitline telephone support after a failed (58.3%) or successful (60%) quit attempt. Smokers were likely to use quitline support long-term (mean = 9.9 months). Most smokers would be likely to use free or subsidised nicotine replacement therapy (NRT) (74.9%) if offered by quitlines. Younger smokers had greater odds of being likely to use text messages, whereas less educated smokers had greater odds of being likely to use free or subsidised NRT.
Smokers appear interested in quitlines offering longer-term telephone support, increased continuity of care and additional effective quitting strategies.
Quitlines could adopt a stepped care model that involves increasingly intensive treatments and extended telephone counselling delivered by the same quitline advisor.
Acceptability of proactive telephone recruitment to a telephone support service to encourage healthy eating, physical activity and weight loss
2012, Australian and New Zealand Journal of Public Health
Telephone survey methods: implications of the increasing mobile‐only population for public health research
2011, Australian and New Zealand Journal of Public Health
Barriers and facilitators to the uptake of online and telephone services targeting health risk behaviours among vocational education students: A qualitative study
2021, International Journal of Environmental Research and Public Health

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Brief reportTelephone Recruitment into a Randomized Controlled Trial of Quitline Support

Background

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Sample

Procedures

Results

Discussion

Am J Prev Med

Prev Med

Am J Prev Med

Am J Med Sci

Am J Prev Med

Public Health

Telephone counselling for smoking cessation

Cochrane Database Syst Rev

Proactive telephone counseling as an adjunct to minimal intervention for smoking cessation: a meta-analysis

Health Educ Res

Treating tobacco use and dependence: 2008 update

Effectiveness and cost effectiveness of television, radio and print advertisements in promoting the New York smokers' quitline

Tob Control

Uptake and effectiveness of the Australian telephone Quitline service in the context of a mass media campaign

Tob Control

A centralised telephone service for tobacco cessation: the California experience

Tob Control

Increasing reach of quitline services in a U.S. state with comprehensive tobacco treatment

Tob Control

Fax to quit: a model for delivery of tobacco cessation services to Wisconsin residents

Wis Med J

Feasibility, acceptability, and cost of referring surgical patients for postdischarge cessation support from a quitline

Nicotine Tob Res

In-practice management versus quitline referral for enhancing smoking cessation in general practice: a cluster randomized trial

Fam Pract

Effectiveness of antismoking telephone helpline: follow up survey

Br Med J

Impact of a telephone helpline for smokers who called during a mass media campaign

Tob Control

Tobacco cessation quitlines in North America: a descriptive study

Tob Control

Brief report
Telephone Recruitment into a Randomized Controlled Trial of Quitline Support