Never Quit Trying: Reengaging Tobacco Users in Statewide Cessation Services.

CONTEXT: Tobacco dependence is well established as a chronic condition typically requiring numerous quit attempts. Tobacco users are unlikely to return to the same cessation program on their own. OBJECTIVE: This program evaluation examined the effectiveness of using multiple outreach methods to reengage tobacco users in a statewide cessation program at varying time points after their initial program enrollment. DESIGN: Participants were randomized to receive or not receive reengagement outreach. We conducted outreach via phone, e-mail, and/or text (based on methods participants agreed to receive) at 1, 2, or 3 months post-initial engagement. Participants were offered the opportunity to reenroll in QUITPLAN Services. SETTING: Minnesota's QUITPLAN Services PARTICIPANTS:: A total of 3020 tobacco users who enrolled in Minnesota's QUITPLAN Services and either received a 2-week starter kit of nicotine replacement therapy or completed 0-1 QUITPLAN Helpline calls. MAIN OUTCOME MEASURES: We explored group differences in the odds of reengagement (defined as enrolling in a phone cessation program or selecting 2 or more of nicotine replacement therapy starter kit, text messaging, e-mail program, or print materials), contributors to reengagement, and costs. RESULTS: 14.7% in the Reengagement Outreach (RO) group and 3.4% in the Comparison (no outreach) group reengaged. The majority (71%) reengaged during phone outreach. There were no significant differences in reengagement rates by follow-up time period (1, 2, or 3 months). Cost per reengagement was $546, mostly due to one-time setup costs; scaling to 10 000 tobacco users would cost approximately $101 per reengagement. CONCLUSIONS: Conducting proactive outreach through state-funded quitlines is an effective approach to reengaging tobacco users, yielding a 5-fold greater odds of reengagement compared with no outreach. Since most costs were for initial setup, the cost per reengagement would decrease as the outreach population size increases. Such outreach has the potential to foster treatment utilization and quit attempts.

The effect of tobacco cessation on weight gain, obesity, and diabetes risk.

OBJECTIVE: Most smokers gain weight after quitting, and some develop new onset obesity and type 2 diabetes. The purpose of this paper is to synthesize the current science investigating the consequences of tobacco cessation on body weight and diabetes, as well as intervention strategies that minimize or prevent weight gain while still allowing for successful tobacco cessation. METHODS: Systematic reviews and relevant studies that were published since prior reviews were selected. RESULTS: Smoking cessation can cause excessive weight gain in some individuals and can be associated with clinically significant outcomes such as diabetes or obesity onset. Interventions that combine smoking cessation and weight control can be effective for improving cessation and minimizing weight gain but need to be tested in specific populations. CONCLUSIONS: Despite the health benefits of quitting tobacco, post-cessation weight gain and new onset obesity and diabetes are a significant concern. Promising interventions may need to be more widely applied to reduce the consequences of both obesity and tobacco use.

Addressing weight gain in smoking cessation treatment: a randomized controlled trial.

PURPOSE: To evaluate the effectiveness of a cognitive behavioral treatment (CBT) addressing cessation-related weight concerns delivered via a tobacco quitline that does not address weight concerns. DESIGN: Randomized controlled trial, blinded 6-month follow-up. SETTING: The Oklahoma Tobacco Helpline (OKHL). SUBJECTS: All 7998 smokers who called the OKHL were screened; 4240 were eligible; 2000 were randomized to the standard quitline (STD) or the brief version of the CBT weight concerns program (WCP). INTERVENTION: Telephone counseling to help people quit smoking and address concerns about cessation-related weight gain. MEASURES: Demographics, weight, tobacco status, weight concerns, self-efficacy in quitting, and quitting without weight gain. ANALYSIS: Descriptive statistics and logistic regression. RESULTS: Of those randomized, 1002 participants completed the 6-month survey (response rates  =  53.2% for STD, 47% for WCP). Compared with STD, WCP led to reduced weight concerns (p < .01) and less weight gain among quitters (1.8 vs. -3.4 pounds; p  =  .01). Although not significant, participants in the WCP were more likely to report 30-day abstinence (33.3% vs. 36.8%, p  =  .24; intent to treat  =  17.7 vs. 17.3). CONCLUSION: The WCP was successfully delivered via a quitline and resulted in improved attitudes about weight and decreased cessation-related weight gain without harming quit rates. Promotion of a quitline focused on addressing weight in conjunction with quitline treatment for smoking cessation may improve cessation and weight outcomes. Study limitations include use of self-report and survey response.

State quitlines and cessation patterns among adults with selected chronic diseases in 15 states, 2005-2008.

INTRODUCTION: The death rate of people who have a chronic disease is lower among former smokers than current smokers. State tobacco cessation quitlines are available for free in every state. The objective of our study was to compare demographic characteristics, use of quitline services, and quit rates among a sample of quitline callers. METHODS: We used data from 15 states on tobacco users aged 18 or older who enrolled with a quitline between October 1, 2005, and May 31, 2008; 9 states also provided data from 7-month follow-up surveys. We used descriptive statistics and logistic regression to compare callers by disease status. RESULTS: Among 195,057 callers, 32.3% reported having 1 or more of the following chronic diseases: 17.7%, asthma; 5.9%, coronary artery disease; 11.1%, chronic obstructive pulmonary disease; and 9.3%, diabetes; 9.0% had 2 or more chronic diseases. Callers who had a chronic disease were older and better educated; more likely to be female, have Medicaid or other health insurance, and have used tobacco for 20 years or more; and less likely to quit smoking (22.3%) at 7 months than callers who had none of these chronic diseases (29.7%). CONCLUSION: About one-third of tobacco users who call state quitlines have a chronic disease, and those who have a chronic disease are less likely to quit using tobacco. Continued efforts are needed to ensure cessation treatments are reaching tobacco users who have a chronic disease and to develop and test ways to increase quit rates among them.

The 2009 US federal cigarette tax increase and quitline utilization in 16 states.

BACKGROUND: On April 1, 2009, the federal cigarette excise tax increased from 39 cents to $1.01 per pack. METHODS: This study describes call volumes to 16 state quitlines, characteristics of callers and cessation outcomes before and after the tax. RESULTS: Calls to the quitlines increased by 23.5% in 2009 and more whites, smokers ≥ 25 years of age, smokers of shorter duration, those with less education, and those who live with smokers called after (versus before) the tax. Quit rates at 7 months did not differ before versus after tax. CONCLUSIONS: Descriptive analyses revealed that the federal excise tax on cigarettes was associated with increased calls to quitlines but multivariate analyses revealed no difference in quit rates. However, more callers at the same quit rate indicates an increase in total number of successful quitters. If revenue obtained from increased taxation on cigarettes is put into cessation treatment, then it is likely future excise taxes would have an even greater effect.

Cost-effectiveness of varenicline and three different behavioral treatment formats for smoking cessation.

There is a lack of evidence of the relative cost-effectiveness of proactive telephone counseling (PTC) and Web-based delivery of smoking cessation services in conjunction with pharmacotherapy. We calculated the differential cost-effectiveness of three behavioral smoking cessation modalities with varenicline treatment in a randomized trial of current smokers from a large health system. Eligible participants were randomized to one of three smoking cessation interventions: Web-based counseling (n=401), PTC (n=402), or combined PTC-Web counseling (n=399). All participants received a standard 12-week course of varenicline. The primary outcome was a 7-day point prevalent nonsmoking at the 6month follow-up. The Web intervention was the least expensive followed by the PTC and PTC-Web groups. Costs per additional 6-month nonsmoker and per additional lifetime quitter were $1,278 and $2,601 for Web, $1,472 and $2,995 for PTC, and $1,617 and $3,291 for PTC-Web. Cost per life-year (LY) and quality-adjusted life-year (QALY) saved were $1,148 and $1,136 for Web, $1,320 and $1,308 for PTC, and $1,450 and $1,437 for PTC-Web. Based on the cost per LY and QALY saved, these interventions are among the most cost-effective life-saving medical treatments. Web, PTC, and combined PTC-Web treatments were all highly cost-effective, with the Web treatment being marginally more cost-effective than the PTC or combined PTC-Web treatments.

Adherence to varenicline in the COMPASS smoking cessation intervention trial.

INTRODUCTION: Patient adherence to smoking cessation medications can impact their effectiveness. It is important to understand the extent to which prescribed medications are actually taken by smokers, how this influences smoking cessation outcomes, and what factors may influence adherence. METHODS: Smokers recruited from a large health plan were randomized to receive different modes of cessation counseling in combination with varenicline (Swan, G. E., McClure, J. B., Jack, L. M., Zbikowski, S. M., Javitz, H. S., Catz, S. L., et al. 2010.Behavioral counseling and varenicline treatment for smoking cessation. American Journal of Preventive Medicine, 38, 482-490). One thousand one hundred and sixty-one participants were mailed a 28-day varenicline supply when they set a quit date and were able to request up to two refills from the health plan pharmacy at no cost. Pharmacy fill records were obtained and telephone surveys completed at baseline, 21 days, 12 weeks, and 6 months post target quit date. RESULTS: Good adherence to varenicline (≥80% of days taken) was associated with a twofold increase in 6-month quit rates compared with poor adherence (52% vs. 25%). Smokers were more likely than nonsmokers to stop varenicline early. Purposeful nonadherence was associated with smoking at 12 weeks and was predicted in multivariate analyses by age, gender, adherence self-efficacy, and initial medication side effect severity. CONCLUSIONS: Innovative methods for increasing adherence to smoking cessation medications are needed, particularly early in the quit process. Simple metrics of adherence such as number of days cessation medication is taken can and should be routinely incorporated in effectiveness trials and reported to advance future attempts to understand and reduce nonadherence.

Utilization of services in a randomized trial testing phone- and web-based interventions for smoking cessation.

INTRODUCTION: Phone counseling has become standard for behavioral smoking cessation treatment. Newer options include Web and integrated phone-Web treatment. No prior research, to our knowledge, has systematically compared the effectiveness of these three treatment modalities in a randomized trial. Understanding how utilization varies by mode, the impact of utilization on outcomes, and predictors of utilization across each mode could lead to improved treatments. METHODS: One thousand two hundred and two participants were randomized to phone, Web, or combined phone-Web cessation treatment. Services varied by modality and were tracked using automated systems. All participants received 12 weeks of varenicline, printed guides, an orientation call, and access to a phone supportline. Self-report data were collected at baseline and 6-month follow-up. RESULTS: Overall, participants utilized phone services more often than the Web-based services. Among treatment groups with Web access, a significant proportion logged in only once (37% phone-Web, 41% Web), and those in the phone-Web group logged in less often than those in the Web group (mean = 2.4 vs. 3.7, p = .0001). Use of the phone also was correlated with increased use of the Web. In multivariate analyses, greater use of the phone- or Web-based services was associated with higher cessation rates. Finally, older age and the belief that certain treatments could improve success were consistent predictors of greater utilization across groups. Other predictors varied by treatment group. CONCLUSIONS: Opportunities for enhancing treatment utilization exist, particularly for Web-based programs. Increasing utilization more broadly could result in better overall treatment effectiveness for all intervention modalities.

Behavioral counseling and varenicline treatment for smoking cessation.

BACKGROUND: Smoking remains the primary preventable cause of death and illness in the U.S. Effective, convenient treatment programs are needed to reduce smoking prevalence. PURPOSE: This study compared the effectiveness of three modalities of a behavioral smoking-cessation program in smokers using varenicline. METHODS: Current treatment-seeking smokers (n=1202) were recruited from a large healthcare organization between October 2006 and October 2007. Eligible participants were randomized to one of three smoking-cessation interventions: web-based counseling (n=401); proactive telephone-based counseling (PTC; n=402); or combined PTC and web counseling (n=399). All participants received a standard 12-week FDA-approved course of varenicline. Self-report determined the primary outcomes (7-day point prevalent abstinence at 3- and 6-month follow-ups); the number of days varenicline was taken; and treatment-related symptoms. Behavioral measures determined utilization of both the web- and Phone-based counseling. RESULTS: Intent-to-treat analyses revealed relatively high percentages of abstinence at 3 months (38.9%, 48.5%, 43.4%) and at 6 months (30.7%, 34.3%, 33.8%) for the web, PTC, and PTC-web groups, respectively. The PTC group had a significantly higher percentage of abstinence than the web group at 3 months (OR=1.48, 95% CI=1.12, 1.96), but no between-group differences in abstinence outcomes were seen at 6 months. CONCLUSIONS: Phone counseling had greater treatment advantage for early cessation and appeared to increase medication adherence, but the absence of differences at 6 months suggests that any of the interventions hold promise when used in conjunction with varenicline.

Smoking outcome by psychiatric history after behavioral and varenicline treatment.

Treatment outcomes were compared across smokers enrolled in the COMPASS cessation trial with (positive psychiatric history [PH+], n = 271) and without (PH-, n = 271) a diagnosis of PH based on medical record evidence of anxiety, depression, psychotic disorder, or bipolar disorder. Everyone received behavioral counseling plus varenicline and was followed for 6 months post quit date. PH+ smokers took varenicline for fewer days on average (59.4 vs. 68.5, p < or = .01) but did not differ in their use of behavioral treatment. PH+ smokers were more likely to report anxiety and depression, but side-effect intensity ratings did not differ after adjusting for multiple comparisons. Overall, all side effects were rated as moderate intensity or less. Groups had similar 30-day abstinence rates at 6 months (31.5% PH+ vs. 35.4% PH-, p = .35). In sum, having a psychiatric diagnosis in this trial did not predict worse treatment outcome or worse treatment side effects.

Using free patches to improve reach of the Oregon Quit Line.

For 2 1/2 months, the Oregon Tobacco Quit Line (ORQL) offered a free 2-week starter kit of nicotine patches to all callers. The promotional plan, utilizing Roger's Diffusion of Innovation theory, targeted health plans, local policy makers, media sources, and referral sources, such as healthcare providers. Word-of-mouth advertising was also encouraged using a free patch card, which could be handed out to tobacco users. Six weeks prior to the public launch, information about the initiative was disseminated by e-mailing and sending letters to public and private sector partners. Call volume to the ORQL was monitored 6 months prior to the Free Patch Initiative and immediately following the launch. Demographic characteristics of callers pre- and postinitiative were compared using ORQL data. A media firm tracked earned media generated by the initiative. The Initiative generated free "earned" media attention, increased calls to the ORQL by 12-fold, and reached 1.3% of the smoking population within a 3-month period. Offering a short course of free NRT is an effective way to promote the use of quitlines.

Mood, side-effects and smoking outcomes among persons with and without probable lifetime depression taking varenicline.

BACKGROUND: Varenicline may be associated with greater mood disturbance and side-effects among smokers with psychiatric history, but empirical evidence is limited. Differential treatment effectiveness by psychiatric history may also exist. OBJECTIVE: To compare mood, prevalence and intensity of treatment side-effects, and abstinence among people with a probable history of major depression (DH+) or not (DH-) who took varenicline and received behavioral smoking cessation treatment. DESIGN: Smokers participated in a randomized behavioral intervention effectiveness trial. Treatment side-effects and outcomes were compared between DH+ and DH- participants (n = 1,117) at 21 [corrected] days and 3 months after the target quit date. PARTICIPANTS: Smokers recruited from a large regional health plan. MEASUREMENTS: Change in stress and depression scores, prevalence and intensity of treatment side-effects, and abstinence rates. RESULTS: All side-effects averaged moderate intensity or less and were similar across DH groups, except DH+'s endorsed slightly worse confusion, nausea (adjusted P = 0.04) and trouble sleeping (adjusted P = 0.008) at 21 days. Depression and stress scores declined in both DH groups and an equal proportion of each evidenced new/worsening depressive symptoms. Despite few differences in symptom intensity, more DH+ participants reported recent tension/agitation, irritability/anger, confusion, and depression at 21 days (adjusted P < 0.05), and depression and anxiety (adjusted P < 0.01) at three months. Nonsmoking rates did not differ by DH group at follow-up. CONCLUSION: While some group differences were noted, DH+ smokers did not report qualitatively worse neuropsychiatric symptoms, more new/worsening mood disturbance, or differential abstinence rates compared to DH- smokers.

The impact of a free nicotine patch starter kit on quit rates in a state quit line.

All states offer telephone quit lines but they are under-used in part because of the costs associated with promotion. Offering nicotine replacement therapy (NRT) as well as behavioral counseling can increase treatment participation and abstinence rates, but is expensive. Offering less than a full NRT 8-week course can also generate calls to the quit line but less is known about its impact on program outcomes. In October 2004, Oregon--a state with over 3 million people, 500,000 smokers, and a state-funded quit line--introduced the Free Patch Initiative: a free 2-week introductory supply of NRT with phone counseling offered to all callers. We examined the impact of this intervention among insured callers. Most (97.2%) requested free patches, 86.2% used them, and 47.2% obtained additional patches on their own. Six-month outcome data were obtained from insured quit line participants before (n = 268) and after (n = 614) the Initiative launched. Compared with pre-Initiative controls, Free Patch participants were more satisfied with the quit line (84.8% vs. 89.8%; p = .04) and had higher 7-day quit rates using the assumption that eligible nonrespondents are smokers (9.3% vs. 17.0%, OR = 2.0; 95% CI 1.4-2.8) and using respondent only analysis (19% vs. 33.6%, OR = 2.15; 95% CI 1.52-3.04). Offering a free direct mail starter pack of NRT along with telephone counseling is an effective, cost-sharing method for promoting quit line use, enhancing participant satisfaction, and increasing the reach and effectiveness of quit lines among quit line callers with health insurance.

Prevalence of Weight Concerns and Obesity Among Smokers Calling a Quitline.

BACKGROUND: Cessation-related weight gain and weight concerns are common among smokers and have a negative impact on quitting. Obese smokers tend to gain more than the average amount of weight and also have lower quit rates. This article describes the prevalence of obesity and weight concerns among smokers calling a state quitline in the United States. RESULTS: Among 3972 smokers using a state quitline, 33.3% were obese, 30.2% overweight, 33.3% normal weight and 3.2% underweight; a total of 60.6% were concerned about cessation-related weight gain. Compared with non-obese callers, obese callers were more likely to be female, Hispanic, non-White and heavier smokers. CONCLUSIONS: This is the first study to report data on body weight and weight concerns of smokers calling a national quitline. Given the lower quit rates among obese and weight-concerned smokers, and the burden of smoking and obesity, there is an opportunity to develop new treatment approaches for this at-risk population.

Weight Gain After Quitting: Attitudes, Beliefs and Counselling Strategies of Cessation Counsellors.

Postcessation weight gain is common and a frequent cause of relapse. Although interventions to address weight gain and weight gain concerns exist, the experience of telephone cessation coun- sellors in addressing weight concerns is unknown. We surveyed 134 cessation counsellors providing quitlines for 30 states regarding their experiences and attitudes about how to address weight gain concerns among smokers trying to quit. Counsellors estimated they discuss weight in 40% of their calls, primarily discussing concerns about gaining weight. Counsellors estimated that smokers gain about 4.1 kg after quitting and about 48% gain more than 2.3 kg. Most counsellors believed that exercise, education about weight gain and preparing smokers for weight gain would help people quit, which is consistent with current science. A total of 51% of counsellors believed that dieting while quitting would reduce weight gain and only 35% correctly identified that dieting reduces a smokers' ability to quit. Some counsellors believed they needed more training in weight management and may need to be reassured that they are currently following treatment guidelines when confronted with smokers who have concerns about postcessation weight gain.