Trends in Varenicline Use for Tobacco Cessation, and Their Implications.

BACKGROUND: Tobacco use remains a leading cause of death in the U.S. Varenicline is a preferred medication for tobacco cessation, and a prior report in the literature showed its use fell dramatically after the voluntary recall of Chantix (name-brand varenicline) in July 2021. OBJECTIVES: Working with data on prescriptions for varenicline and nicotine-replacement therapy (NRT), we studied use from 2018 to 2023 to determine if varenicline use had recovered or if there had been a compensatory increase in NRT use. METHODS: Data are yearly from state employees and their dependents who were aged >18 years and were health-insurance beneficiaries of the Washington Public Employees Benefits Board from July 2018 through June 2023. Data include numbers of tobacco users and numbers of prescriptions filled. RESULTS: The 5-year prevalence of tobacco use among 224,816 beneficiaries was 4.6%. The percentage of tobacco users who filled a prescription for varenicline fell from highs of 9.5% and 9.6% in the 2018-2019 and 2019-2020 year to lows of 5.3% and 6.4% in the 2021-2022 and 2022-2023 years. For nicotine replacement therapy, prescriptions rose modestly over the 5 years, from 4.5% in 2018-2019 to 6.0% in 2022-2023. DISCUSSION: Varenicline use dropped after the voluntary recall of Chantix by Pfizer in mid-2021 and has not returned to pre-recall levels. CONCLUSION: Pharmacists and other clinicians should address this drop, in addition to addressing longer-term challenges to increasing varenicline use; these include the requirement for a prescription and the black-box warning by the Food and Drug Administration, rescinded in 2016.

Marijuana Use and Adherence to Smoking Cessation Treatment Among Callers to Tobacco Quitlines.

INTRODUCTION: Tobacco kills over half a million adults annually in the United States. Most smokers want to quit, and over 400,000 call state-funded quitlines for help each year. Marijuana use among tobacco users is common and may impede quitting, but co-use rates among quitline callers are unknown. The purpose of our observational study was to describe marijuana use among quitline callers in states with legalized marijuana. METHODS: Participants were 1,059 smokers aged 21 or older from Oregon, Alaska, and Washington, DC, who called quitlines from September through December 2016. Data on quitline callers' demographics, tobacco and marijuana use, and quitline use were collected. We used χ2 and regression analyses to compare marijuana users with nonusers on demographic characteristics and quitline use. RESULT: Among quitline callers in our study, 24% reported using marijuana in the past 30 days: 28.9% in Alaska, 16.7% in Washington, DC, and 25.0% in Oregon (P = .009). Current users, compared with non-users (n = 772), were less likely to be women (48.4% vs 62.0%, respectively, P < .001). Current marijuana users were less likely to be given nicotine replacement therapy (68.4%) than current nonusers (74.1%) (P < .001), but more likely to complete 3 or more counseling calls (P = .005). Of those who used marijuana in the past 30 days, 62.3% used marijuana on 1 to 19 days, 9.0% used on 20 to 29 days, and 28.7% on all 30 days. Among current marijuana users, the percentage who wanted to quit or reduce marijuana use (42.6%) was higher in Alaska (54.6%) and the District of Columbia (56.8%) than in Oregon (37.9%), P = .03. CONCLUSION: One in 4 quitline callers reported past 30-day marijuana use. Given that nearly half (43%) wanted to reduce marijuana use, addressing co-use may be an important addition to quitline treatment. Future studies should assess co-use effects on tobacco cessation outcomes and explore combined treatment or bidirectional referrals between quitlines and marijuana treatment providers.

Anytime is the Right Time: A Content Analysis of Marijuana Ads in Freely Distributed Print Media in Western Washington State, USA.

Background: Cannabis advertisement content in print media has not yet been studied, despite youth high exposure to them. This study analyzes cannabis ads content in two publications in Western Washington State, USA. Methods: Content analysis of 305 cannabis advertisements published in 2017 in two free print publications was performed with support of NVivo software. A deductive approach was utilized, leveraging alcohol advertisement studies' coding frames and adding cannabis-specific codes in an iterative process. Coding was performed using a two-step analytical procedure. Results: Ads depicted the use of cannabis as part of everyday life and coopted mainstream events such as holidays to promote sales. Ads of cannabis products emphasized lifestyles that conveyed enjoyment of time in nature; such as scenes of people sitting by waterfalls, contemplating natural landscapes, paddle boarding, and canoeing. A sizeable proportion of the cannabis ads shared with alcohol ads an emphasis on the personal and social rewards of using these products, rather than product features, such as quality and taste. Conclusions: In WA State, cannabis use ads content tend to focus on solitude and outdoor recreation rather than parties and team sports, a common theme in alcohol ads. While the themes differ from alcohol, marijuana marketing mimics strategies used by alcohol industries, such as promoting the identification of their products with lifestyles and values considered appealing to attract new consumers. Many ads presented content known to appeal to youth, with content designed to elicit responses based on emotions rather than cognition.

Predictors of engagement in post-discharge quitline counseling among hospitalized smokers.

Quitlines provide evidence-based tobacco treatment and multiple calls yield higher quit rates. This study aimed to identify subgroups of smokers with greater quitline engagement following referral during hospitalization. Data were from a randomized clinical trial assessing the effectiveness of fax referral (referral faxed to proactive quitline) versus warm handoff (patient connected to quitline at bedside) (n = 1054). Classification and regression trees analyses evaluated individual and treatment/health system-related variables and their interactions. Among all participants, warm handoff, higher ratings of the tobacco treatment care transition, and being older predicted completing more quitline calls. Among patients enrolled in the quitline, higher transition of care ratings, being older, and use of cessation medication post-discharge predicted completing more calls. Three of the four factors influencing engagement were characteristics of treatment within the hospital (quality of tobacco treatment care transition and referral method) and therapy (use of cessation medications), suggesting potential targets to increase quitline engagement post-discharge.

Drug helplines and adult marijuana users: An assessment in Washington, Colorado, Oregon, and Alaska.

Drug helplines are well-known and widely utilized resources for those seeking help with managing their substance use. Using "secret shoppers," a preliminary assessment of the drug helplines in 4 states was performed. Eleven calls were placed to the helpline staff, where the secret shopper posed as an adult users of marijuana interested in decreasing their marijuana use and asked questions about cannabinoids and methods of marijuana consumption. In 100% of the calls placed, helpline staff had no knowledge about the effects and interactions of marijuana's 2 main components (tetrahydrocannabinol [THC] and cannabidiol [CBD]), neither could they explain the risk differential of smoking, eating, or vaporizing marijuana. In all but one of the calls placed, helpline responders were respectful and empathic. The assessment suggests that drug helplines are equipped with a respectful, empathetic, and nonjudgmental staff who lack important knowledge to best serve those seeking help for marijuana use.

Identifying HIV care enrollees at-risk for cannabis use disorder.

Increased scientific attention given to cannabis in the United States has particular relevance for its domestic HIV care population, given that evidence exists for both cannabis as a therapeutic agent and cannabis use disorder (CUD) as a barrier to antiretroviral medication adherence. It is critical to identify relative risk for CUD among demographic subgroups of HIV patients, as this will inform detection and intervention efforts. A Center For AIDS Research Network of Integrated Clinical Systems cohort (N = 10,652) of HIV-positive adults linked to care at seven United State sites was examined for this purpose. Based on a patient-report instrument with validated diagnostic threshold for CUD, the prevalence of recent cannabis use and corresponding conditional probabilities for CUD were calculated for the aggregate sample and demographic subgroups. Generalized estimating equations then tested models directly examining patient demographic indices as predictors of CUD, while controlling for history and geography. Conditional probability of CUD among cannabis-using patients was 49%, with the highest conditional probabilities among demographic subgroups of young adults and those with non-specified sexual orientation (67-69%) and the lowest conditional probability among females and those 50+ years of age (42% apiece). Similarly, youthful age and male gender emerged as robust multivariate model predictors of CUD. In the context of increasingly lenient policies for use of cannabis as a therapeutic agent for chronic conditions like HIV/AIDS, current study findings offer needed direction in terms of specifying targeted patient groups in HIV care on whom resources for enhanced surveillance and intervention efforts will be most impactful.

Threaten, Distract, and Discredit: Cannabis Industry Rhetoric to Defeat Regulation of High-THC Cannabis Products in Washington State.

OBJECTIVE: Washington State legislators have attempted to regulate high delta-9-tetrahydrocannabinol (THC) cannabis to reduce cannabis-related harms. Historically, industry actors of other health-compromising products have influenced governments' adoption of evidence-based regulation policies. A better understanding of the industry rhetoric can be used by public health advocates to develop counterarguments and disseminate alternative narratives that protect the public's health. We analyzed the arguments used by cannabis industry actors opposing regulations to de-incentivize the availability and use of high-THC products in Washington State. METHOD: We analyzed 41 testimonies transcribed from 33 cannabis industry actors in 3 public bill hearings and one legislative work session that occurred between 2020 and 2023. Using a deductive thematic analysis, informed by industry actors' arguments opposing regulation of alcohol, tobacco, and high-sugar beverages, we developed a codebook to analyze and identify themes within cannabis industry rhetorical strategies. RESULTS: We identified three main rhetorical strategies used by cannabis industry actors to oppose THC content regulation: threaten, distract, discredit. The most frequently used rhetorical strategy was threats to economic benefits, public health, and the will of the people. The other two most apparent strategies were distracting from the bill's focus by introducing a tangential topic and discrediting the science that supported regulation of cannabis products with high THC concentration or its advocates. CONCLUSIONS: Cannabis industry actors have leveraged several arguments used by industry actors of other health-compromising products to undermine initiatives to advance public health. They have also adapted rhetoric from other industries to the unique conditions of the cannabis regulatory landscape.

Identifying policy options to regulate high potency cannabis: A multiple stakeholder concept mapping study in Washington State, USA.

BACKGROUND: Cannabis legalization in some U.S.A. states has catapulted the mass production of concentrates, with tetrahydrocannabinol (THC) concentrations ranging from 50-90%. A major public health concern is that these products will increase cannabis-related harms such as use disorders, psychotic symptoms, and accidental poisonings. This paper describes and contextualizes the results of a study requested by the WA State Legislature to understand perspectives of WA stakeholders on the topic. METHODS: Concept Mapping (CM), a mixed-methods research approach that supports people-centered policy decisions was utilized. The goal of the study was to explore stakeholders' concern levels and support of policies to address the availability of high THC cannabis products. For analysis purposes, stakeholders were categorized into three groups: community, professionals, and cannabis advocates. RESULTS: CM generated an inventory of policy ideas for regulating high-potency cannabis from a variety of stakeholders. Notably, stakeholders from community and professional groups supported environmental policy changes such as such as taxation, increasing minimum age for high concentration cannabis products, and advertising prohibition. Meanwhile, cannabis advocates (mostly industry actors) opposed taxation per THC content, proposed lowering taxes, and supported policies with low population impact such as educating parents, teachers, and youth. CONCLUSION: Support for regulating high concentration THC products varied by stakeholder group. Consistent with how other health compromising industries have historically acted, cannabis industry stakeholders rejected regulation of their products. Future studies should explore non-cannabis industry stakeholders' willingness to work towards minimizing the influence of the cannabis industry in policy development processes to assure public health regulations prevail.

Testing a Brief Quitline Intervention for Tobacco Cannabis Co-Users: A Randomized Controlled Pilot Study.

Background: Tobacco cannabis co-use is common and becoming more prevalent. Frequent and heavy users of cannabis may struggle to quit smoking. Quitlines offer free cessation treatment in the United States and 25% of quitline callers may also be cannabis users. The present paper describes a randomized pilot study of a tailored intervention for cannabis and cigarette co-users. The intervention combines the quitline smoking cessation treatment with a motivational enhancement therapy-based cannabis intervention. Methods: The randomized pilot study was conducted within four state-funded quitlines with quitline coaches as interventionists. 102 quitline callers who were cannabis and cigarette co-users were randomized to receive treatment as usual (TAU) or the new Quitline Check-Up (QLCU) intervention. Outcomes were collected 90 days post-randomization. Primary outcomes included feasibility and acceptability of delivering the QLCU in the quitline setting. Secondary outcomes included 7-day point prevalence tobacco abstinence, past 30-day cannabis use, and Cannabis Use Disorder Identification Test scores. Results: Study participants were heavy cannabis users, averaging 25 days of use in the past 30; nearly 70% used at a level considered hazardous. Fidelity ratings indicated coaches were successful at delivering the intervention. Treatment engagement was high for both groups (TAU m = 3.4 calls; QLCU m = 3.6 calls) as was treatment satisfaction. Intent-to-treat quit rates (with survey non-responders classified as smokers) were 28.6% for the TAU control group and 24.5% for the QLCU group (P = .45). Discussion: Hazardous cannabis use rates were high in this sample of tobacco cannabis co-users calling quitlines to quit smoking. The intervention for co-users was acceptable and feasible to deliver. No improvements in tobacco cessation outcomes were observed. Pragmatic intervention development within a real-world clinical setting can streamline the intervention development process. More research is needed on tobacco cannabis co-users and who can benefit from a tailored intervention. Registered: ClinicalTrials.gov NCT04737772, February 4, 2021.

How should policymakers regulate the tetrahydrocannabinol content of cannabis products in a legal market?

An increased use of high-potency cannabis products since cannabis legalization in the United States, Canada and elsewhere may increase cannabis-related harm. Policymakers have good reasons for regulating more potent cannabis in ways that minimize harm, using approaches similar to those used to regulate alcohol; namely, banning the sale of high-potency cannabis, setting a cap on tetrahydrocannabinol (THC) content and imposing higher rates of taxes on more potent cannabis products. Given the difficulty that US policymakers have had in regulating cannabis extracts and edibles, governments that are planning to legalize cannabis need to put policies on extracts into enabling legislation and evaluate the impact of these policies on cannabis use and cannabis-related harms.

Trajectories of cigarettes per day during the course of telephone tobacco cessation counseling services: a comparison of missing data models.

INTRODUCTION: Cigarette smoking accounts for approximately 1 in 5 deaths in the United States every year. To combat smoking, a network of telephone-based smoking cessation counseling services or "quitlines" provide smokers in the United States with smoking cessation resources, and several studies have demonstrated the efficacy of quitlines in promoting long-term smoking cessation. Yet, many individuals who enroll in quitlines do not receive all intended calls, and there is a dearth of research on the impact of missing data on the evaluation of quitline outcomes. METHODS: The current study was a secondary analysis of existing data from a commercial telephone smoking cessation counseling service to estimate the trajectories of cigarettes per day among participants (n = 2,041) during the course of the first 5 calls of the quitline program. Numerous missing data models were estimated to assess the degree to which trajectories of cigarettes per day were associated with the propensity for missing data. RESULTS: The results from growth curve models indicated a significant decrease in cigarettes per day during the quitline program, which was predicted from levels of nicotine dependence. The comparison of missing data models indicated that the propensity for missing data was not systematically associated with the trajectories of cigarettes per day after controlling for level of nicotine dependence. CONCLUSIONS: Analyses conducted in the current study provide evidence that the quitline program was effective at reducing cigarettes per day. Researchers are encouraged to examine missing data mechanisms and control for nicotine dependence in studies of smoking cessation treatment outcomes.

Reaching out, inviting back: using Interactive voice response (IVR) technology to recycle relapsed smokers back to Quitline treatment--a randomized controlled trial.

BACKGROUND: Tobacco dependence is a chronic, relapsing condition that typically requires multiple quit attempts and extended treatment. When offered the opportunity, relapsed smokers are interested in recycling back into treatment for a new, assisted quit attempt. This manuscript presents the results of a randomized controlled trial testing the efficacy of interactive voice response (IVR) in recycling low income smokers who had previously used quitline (QL) support back to QL support for a new quit attempt. METHODS: A sample of 2985 previous QL callers were randomized to either receive IVR screening for current smoking (control group) or IVR screening plus an IVR intervention. The IVR intervention consists of automated questions to identify and address barriers to re-cycling in QL support, followed by an offer to be transferred to the QL and reinitiate treatment. Re-enrollment in QL services for both groups was documented. RESULTS: The IVR system successfully reached 715 (23.9%) former QL participants. Of those, 27% (194/715) reported to the IVR system that they had quit smoking and were therefore excluded from the study and analysis. The trial's final sample was composed of 521 current smokers. The re-enrollment rate was 3.3% for the control group and 28.2% for the intervention group (p < .001). Logistic regression results indicated an 11.2 times higher odds for re-enrollment of the intervention group than the control group (p < .001). Results did not vary by gender, race, ethnicity, or level of education, however recycled smokers were older (Mean = 45.2; SD = 11.7) than smokers who declined a new treatment cycle (Mean = 41.8; SD = 13.2); (p = 0.013). The main barriers reported for not engaging in a new treatment cycle were low self-efficacy and lack of interest in quitting. After delivering IVR messages targeting these reported barriers, 32% of the smokers reporting low self-efficacy and 4.8% of those reporting lack of interest in quitting re-engaged in a new QL treatment cycle. CONCLUSION: Proactive IVR outreach is a promising tool to engage low income, relapsed smokers back into a new cycle of treatment. Integration of IVR intervention for recycling smokers with previous QL treatment has the potential to decrease tobacco-related disparities. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01260597.

The Kids Are Not All Right: E-cigarettes, Cannabis Co-Use, and an Emerging Public Health Crisis--A Commentary on Roberts et al. (2022).

The Roberts et al. commentary highlights the "looming public health emergency" of e-cigarettes and cannabis co-use among young people and the urgency to make deliberate efforts to address dual use now. We agree and want to further elaborate on some of their comments.

Cannabis Industry Marketing Violations in Washington State, 2014-2019.

OBJECTIVE: The purpose of this study was to describe marketing violations from the cannabis industry in Washington State. METHOD: The study team obtained records of all Washington State cannabis marketing violations from October 2014 to September 2015, immediately following the legal cannabis market opening, and May 2017 to July 2019. A code book was developed based on the Washington State regulations related to marijuana advertising. Each marketing violation was coded according to ad characteristics including ad size, location, or type; content; business practices; and lack of mandatory health warnings. RESULTS: A total of 328 violations were analyzed, from 183 different businesses. Marketing violations occurred most frequently in content posted online or directly in front of cannabis stores. Community members were as likely to identify violations as officers from the Washington State Liquor and Cannabis Board (WSLCB), the state agency in charge of regulation and enforcement of cannabis businesses. Very few violations were reported from competing members of the cannabis industry. Violations reported by the community were mostly related to content appealing to minors, whereas WSLCB officers were more likely to identify violations related to ad location in public spaces and ad size. CONCLUSIONS: This study shows the conflict between prevention and profit in the nascent cannabis industry and the importance of community involvement in the regulation of cannabis marketing.

Cannabis-only use in the USA: prevalence, demographics, use patterns, and health indicators.

BACKGROUND: The prevalence of adults who consume cannabis while abstaining from other substances is not known in the USA. This study used nationally representative data to estimate the prevalence and explore the demographic characteristics, cannabis use behaviors, and self-reported health of US adults with past 30-day cannabis-only use, as compared with adults who used cannabis as well as other substances. METHODS: Data came from adults 18 years and older who responded to the 2017 or 2018 National Survey on Drug Use and Health and reported past 30-day cannabis use (n = 12,143). Cannabis-only use was defined as past 30-day cannabis use with no past 30-day use of other substances (alcohol, tobacco, other illicit substances, non-prescribed controlled medications). Weighted frequencies and 95% confidence intervals (CI) were computed for all sociodemographic and cannabis-related variables, overall, and across the two categories of cannabis consumers, stratified by age. RESULTS: The prevalence of past 30-day cannabis-only use among US adults was 0.9% (95% CI: 0.8, 1.0) and varied by age (2.0% of 18-25 years old; 0.7% of 26-49 year olds, and 0.6% of those ≥ 50 years). Among adults with any past 30-day cannabis use, 8.4% (95% CI: 7.6, 9.2; n = 980) reported cannabis-only use. Age was significantly associated with past 30-day cannabis-only use, with adults 18-25 years and 26-49 years having higher odds of cannabis-only use compared with older adults. Past year cannabis dependence was lowest among cannabis-only consumers aged ≥ 50 years (0.2%; 95% CI: 0.1, 0.5) and highest among young adult cannabis and other substance consumers (16.7%; 95% CI: 15.3, 18.2). Past year prevalence of any mental illness was generally similar across cannabis use groups and by age. CONCLUSIONS: The prevalence of adult cannabis-only use in the US is low - most cannabis consumers report using other substances in the past 30 days as well. While cannabis-only use among older adults is rare, it does not appear to be accompanied by a high prevalence of dependence. These findings should guide future research and policymaking.

Cannabis Retail Staff ("Budtenders") Attitudes Towards Cannabis Effects on Health and Experiences Interacting with Consumers - Washington State, USA.

Cannabis legalization in Washington State has increased the availability, consumption, and potency of cannabis products for adults. Public health education promoting safe use for adult consumers has lagged behind these trends. This study assesses the potential of cannabis retail workers (budtenders) to engage in responsible use education with adult consumers at point of sale. Focus groups explored how budtenders perceive their professional role, including educating consumers about cannabis over intoxication, storage, and risks of use before driving and during pregnancy. Transcripts were analyzed to develop a coding scheme, which was then applied with an iterative review by the research team. Budtenders identified three main professional roles: creating a good experience for customers; being compliant with the state law and regulations, and educating customers on products. Budtenders did not believe their job involved discussing use during pregnancy or while driving or safe storage. They prioritized customers' autonomy over education on these topics, and they did not necessarily consider these behaviors to be harmful. Budtenders are committed to keeping minors outside stores and educating consumers on how to avoid over intoxication and exposure to cannabis contaminants. Future research could build on this to develop point-of-sale education to reduce cannabis use risks.

Using the chronic care model to address tobacco in health care delivery organizations: a pilot experience in Washington state.

This article describes a Washington State-based Systems Change Pilot Project in which the chronic care model and the model for improvement were used as tools to promote tobacco cessation-related changes within a health care system. Three diverse sites participated in the pilot. Site teams tailored plan-do-study-act tests to site circumstances, addressing current resources and barriers to implementing change. Teams tested system changes that incorporated tobacco use documentation into the routine health services provided. Findings from this pilot suggest that (a) even simple changes with minimal disruption of services can make a difference in improving documentation of tobacco use status; (b) changes to routine practices of health organizations may not be sustainable if ongoing quality assurance mechanisms are not developed; and (c) systems implemented for other disease states within the same organization or patient population are not instinctively applied to tobacco, because of a multitude of factors.

Understanding the intergenerational transmission of substance use and problem behavior: Implications for future research and preventive interventions.

The Constitution of the Iroquois Nation states that we should "look and listen for the welfare of the whole people and have always in view not only the present, but also the coming generations." The excellent intergenerational longitudinal studies represented here help us better understand patterns of behaviors across generations. Collectively, these studies provide a pathway for future research on contexts and trends in substance use, research on age of onset among early generations, and research related to epigenetics to improve prevention interventions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A Taxonomy of Consumers' Perspectives on the Function of Cannabis in Their Lives: A Qualitative Study in WA State, USA.

US state-level policy often divides legal cannabis use into medical and recreational categories. However, research suggests medical and non-medical cannabis consumption often overlaps and consumers' relationship with cannabis may change. This study aimed to understand cannabis consumption from the perspective of consumers. Focus group participants shared their perspectives on motivations, settings, and contexts for consumption. A three-category taxonomy of cannabis consumption emerged from the data - Casual, intentional, and therapeutic. Within each category, there is potential for high- and low-risk behaviors. In the casual group, participants rarely purchased cannabis and only partook if it was freely available. Participants in the intentional group were knowledgeable about the effects produced by different strains, THC levels, and product types, and were frequently self-aware. In the therapeutic group, participants consumed cannabis for physical or mental health conditions. Our findings suggest the medical/non-medical dichotomy used in policy development, clinical care, and research may not reflect how regular consumers perceive the function of cannabis in their lives. Our findings suggest more research is needed to identify cannabis' role in improving quality of life, when it increases behavioral risk, and the intersection of cannabis and disability.

Telephone-based tobacco-cessation treatment: re-enrollment among diverse groups.

BACKGROUND: Telephone quitlines are utilized by diverse individuals and represent an effective tobacco-cessation modality. Quitlines allow tobacco users to seek support for multiple quit attempts. Little is known about how frequently tobacco users take advantage of this opportunity. No studies have been conducted to determine how communication strategies affect quitline re-enrollments. This study aimed to determine the rates of quitline re-enrollment and to compare the responses of people of varying racial/ethnic identities to invitations utilizing different communication strategies. DESIGN: Four-cell RCT. SETTING/ PARTICIPANTS: Random sample of 2400 tobacco users who enrolled into services during 2006, with oversampling of ethnic populations. INTERVENTION: Between November 2006 and January 2007, participants received either no invitation to re-enroll or were invited to re-enroll into services via a letter, a letter with ethnic-specific content, or a letter and a telephone call. MAIN OUTCOME MEASURES: Re-enrollment into quitline services. RESULTS: Analysis of the 252 days prior to the intervention resulted in a spontaneous re-enrollment rate of 0.54% per 30 days. Recruitment using mailers did not significantly change this rate; the addition of telephone calls increased re-enrollment to 6.93% per 30 days. No significant differences were found among the subpopulations studied. Invalid addresses (16%); invalid telephone numbers (29.1%); and the inability to reach subjects after five call attempts (37.9%) were barriers to recruitment. CONCLUSIONS: For those who have previously called quitlines for help, proactive re-enrollment can be one way to initiate a new quit attempt after relapse. This study has shown that it is feasible to re-enroll former quitline participants, making the test of effectiveness the next logical step.