Turning Community Feedback into a Culturally Responsive Program for American Indian/Alaska Native Commercial Tobacco Users.

BACKGROUND: American Indian/Alaska Native (AI/AN) cigarette smoking prevalence is disproportionately high, especially in the northern United States. Tailored quitlines are needed to support AI/AN commercial tobacco users with quitting. OBJECTIVES: Obtain community feedback by working with trusted AI/AN partners; genuinely incorporate feedback into program design; collaboratively develop and implement culturally relevant quitline services for Minnesota's AI/AN community. METHODS: Working in partnership, AI/AN community input was gathered, and community partners were engaged to inform the development, training, implementation and monitoring of a tailored program within the existing state quitline. RESULTS: Findings suggest focusing on the commercial tobacco user/coach relationship, increased cultural understanding and program content adaptations could make quitlines more acceptable for AI/AN commercial tobacco users. CONCLUSIONS: The development and launch of the AI Quitline demonstrated the feasibility of collaboration among AI/AN organizations and community members, funders and providers to create a culturally relevant cessation service for AI/AN commercial tobacco users.

Utilizing Reach Ratios to Assess Menthol Cigarette Smoker Enrollment in Quitline Services.

INTRODUCTION: Increasing the reach of evidence-based cessation services is a longstanding public health priority, especially for subgroups who may be most at risk. Little research has examined whether quitlines are reaching menthol cigarette smokers who may have increased difficulty quitting compared with nonmenthol cigarette smokers. This study aims to understand whether quitline services are reaching menthol cigarette smokers. METHODS: The study sample included adult smokers enrolled in Minnesota's quitline program, QUITPLAN Services, between May 2017 and April 2018 (N=10,999). Cigarette smokers were asked about the usual cigarette type (menthol versus nonmenthol). Reach ratios were calculated by dividing the percentage of program enrollees who are menthol smokers by the percentage of Minnesota smokers who are menthol smokers. Differences in demographic, tobacco use, and utilization characteristics between menthol and nonmenthol smokers were assessed using chi-square and t-tests. Analyses were conducted in March 2019. RESULTS: Among QUITPLAN Services enrollees, 30.7% of smokers reported using menthol cigarettes. The reach ratio was 1.12 (95% CI=0.99, 1.25). Menthol smokers were more likely to be younger, be female, be Black/African American, be Hispanic, and live in an urban area than nonmenthol smokers. Although menthol smokers were more likely than nonmenthol smokers to enroll in text messaging, no other significant differences in service utilization were found. CONCLUSIONS: The findings suggest that menthol smokers are proportionately represented among quitline enrollees. State quitlines should assess menthol smoking status at intake and allocate resources to reach and better serve menthol smokers.

Online Versus Telephone Registration: Differences in Quitline Participant Characteristics.

INTRODUCTION: Although 72% of Internet users have searched for health information, online quitline registration is not universally available. In 2014, QUITPLAN Services (Minnesota's quitline) added options (Individual Services: 2-week nicotine-replacement therapy starter kit, text messaging, e-mail messaging, quit guide) to the existing Helpline (telephone counseling, nicotine-replacement therapy, integrated e-mails and texts, quit guide) and online registration for all programs. Demographic and quit outcome differences by registration mode (online versus telephone) and program type (Individual Services versus Helpline) were examined. METHODS: A total of 4 years (March 2014-February 2018) of participants' registration and utilization data (N=55,817) were examined. Data were also studied from subsets of participants who completed the outcome evaluations conducted in 2014 (n=1,127) and 2017 (n=872). Select demographic and program use characteristics and quit outcomes were analyzed by registration method and stratified by program type. Associations between registration mode and quit outcomes were examined within program and adjusted for available covariates using 2017 outcome study data. Data were analyzed in 2019. RESULTS: Overall, 65.8% of participants enrolled online, and 34.2% enrolled by telephone. Helpline participants were more likely to enroll by telephone than Individual Services participants (85.8% vs 25.3%). Younger adults were more likely to enroll online for either program type than older adults (p<0.001). No differences were found in 30-day point prevalence abstinence by registration mode within program after adjusting for covariates. CONCLUSIONS: Online quitline registration has multiple benefits, including engaging younger tobacco users. Moreover, abstinence rates do not differ. Online registration may be particularly appropriate for nontelephone quitline services. Quitlines may wish to add online registration to capitalize on Internet use.

Engaging Smokeless Tobacco Users in Population-Based Cessation Services: Findings From an Observational Study.

Although telephone quitlines are effective for helping smokeless tobacco (ST) users quit, ST users are underrepresented among quitline participants. After ClearWay MinnesotaSM implemented multiple changes to its quitline service (QUITPLAN® Services), utilization increased dramatically, including by ST users. We examined data from Minnesota and Wisconsin to determine whether these changes were unique to Minnesota. Four years of quitline registration data were analyzed for both states. A significant increase in enrollees reporting any ST use was seen in Minnesota after changes were made to services; no change was seen in Wisconsin. A 2-week starter kit of nicotine replacement therapy and the ability to register for services online were popular among Minnesotans reporting ST use. This study suggests that quitline services can be designed to increase participation by ST users.

Projecting the future impact of past accomplishments in tobacco control.

BACKGROUND: The benefits to adults who quit smoking increase over time as former smokers live longer, healthier lives. Youth who never smoke will benefit for decades. Thus, the long-term population effects of tobacco prevention and control policies may be substantial. Yet they are rarely quantified in evaluations of state tobacco control programmes. METHODS: Using a microsimulation model, we predicted the benefits to Minnesotans from 2018 to 2037 of having reduced cigarette smoking prevalence from 1998 to 2017. We first simulated the health and economic harms of tobacco that would have occurred had smoking prevalence stayed at 1997 levels. The harms produced by that scenario were then compared with harms in scenarios with smoking declining at observed rates from 1998 to 2017 and either expected declines from 2018 to 2037 or a greater decline to 5% prevalence in 2037. RESULTS: With expected smoking prevalence decreases from 2018 to 2037, Minnesotans will experience 12 298 fewer cancers, 72 208 fewer hospitalisations for cardiovascular disease and diabetes, 31 913 fewer respiratory disease hospitalisations, 14 063 fewer smoking-attributable deaths, $10.2 billion less in smoking-attributable medical expenditures and $9.4 billion in productivity gains than if prevalence had stayed at 1997 levels. These gains are two to four times greater than for the previous 20 years, and would be about 15% higher if Minnesota achieves a 5% adult prevalence rate by 2037. CONCLUSIONS: The tobacco control measures implemented from 1998 to 2017 will produce accelerated benefits during 2018-2037 if modest progress in tobacco prevalence rates is maintained.

Perceived harm of menthol cigarettes and quitting behaviors among menthol smokers in Minnesota.

Although overall smoking prevalence in Minnesota has declined, the proportion of current smokers who smoke menthol cigarettes has increased. While studies have examined associations between smokers' perceived risks of smoking and quitting, similar studies on menthol smoking are lacking. This study examined whether perceived harm of menthol cigarettes was associated with menthol smokers' quitting behaviors. Data from the 2018 Minnesota Adult Tobacco Survey were examined. Respondents were categorized as current menthol smokers (n = 200), current nonmenthol smokers (n = 527), or nonsmokers (n = 5324). All were asked four questions to assess their perceptions of menthol cigarettes' harm compared to nonmenthols. Sum scores were calculated (range 0-4); higher scores indicated perceptions of similar or greater harm. Data on menthol smokers' quitting behaviors were analyzed to identify associations between sum scores and quitting behavior. Data were analyzed using Wilcoxon Rank Sum tests and Spearman Rank Correlation tests. Additional analyses examined whether gender, age, race/ethnicity, education or income moderated the association between sum scores and past 12-month quit attempts. Menthol smokers were less likely to answer the harm perception questions correctly than nonmenthol smokers. Among menthol smokers, perceived harm of menthol cigarettes was positively associated with past 12-month quit attempts (p = 0.006), use of counseling/behavioral support (p = 0.012), and number of quit attempts (p = 0.004). No demographic characteristics moderated the association between sum scores and past 12-month quit attempts. Findings suggest that efforts to increase menthol smokers' perceptions of menthol cigarettes' harm may potentially increase quitting behaviors. Understanding this association can inform interventions to increase quit attempts.

The 20-year impact of tobacco price and tobacco control expenditure increases in Minnesota, 1998-2017.

INTRODUCTION: Tobacco control programs and policies reduce tobacco use and prevent health and economic harms. The majority of tobacco control programs and policies in the United States are implemented at local and state levels. Yet the literature on state-level initiatives reports a limited set of outcomes. To facilitate decision-making that is increasingly focused on costs, we provide estimates of a broader set of measures of the impact of tobacco control policy, including smoking prevalence, disease events, deaths, medical costs, productivity and tobacco tax revenues, using the experience of Minnesota as an example. METHODS: Using the HealthPartners Institute's ModelHealth™: Tobacco MN microsimulation, we assessed the impact of the stream of tobacco control expenditures and cigarette price increases from 1998 to 2017. We simulated 1.3 million individuals representative of the Minnesota population. RESULTS: The simulation estimated that increased expenditures on tobacco control above 1997 levels prevented 38,400 cancer, cardiovascular, diabetes and respiratory disease events and 4,100 deaths over 20 years. Increased prices prevented 14,600 additional events and 1,700 additional deaths. Both the net increase in tax revenues and the reduction in medical costs were greater than the additional investments in tobacco control. CONCLUSION: Combined, the policies address both short-term and long-term goals to reduce the harms of tobacco by helping adults who wish to quit smoking and deterring youth from starting to smoke. States can pay for initial investments in tobacco control through tax increases and recoup those investments through reduced expenditures on medical care.

Replicating state Quitline innovations to increase reach: findings from three states.

BACKGROUND: Reaching tobacco users is a persistent challenge for quitlines. In 2014, ClearWay MinnesotaSM changed its quitline services and media campaign, and observed substantial increases in reach and strong quit outcomes. Oklahoma and Florida implemented the same changes in 2015 and 2016. We examined whether the strategies used in Minnesota could be replicated with similar results. METHODS: We conducted a cross-sectional observational study of Minnesota's QUITPLAN® Services, the Oklahoma Tobacco Helpline, and Florida's Quit Your Way program. Each program offers free quitline services to their state's residents. For each state, data were compared for 1 year prior to service changes to 1 year after services changed and promotions began. Registration and program utilization data from 21,918 (Minnesota); 64,584 (Oklahoma); and 141,209 (Florida) program enrollees were analyzed. Additionally, outcome study data from 1542 (Minnesota); 3377 (Oklahoma); and 3444 (Florida) program enrollees were analyzed. We examined treatment reach, satisfaction, 24-h quit attempts, 30-day point prevalence abstinence rates, select demographic characteristics, registration mode (post period only), and estimated number of quitters. Data were analyzed using χ2 analyses and t-tests. RESULTS: Treatment reach rates increased by 50.62% in Oklahoma, 66.88% in Florida, and 480.56% in Minnesota. Significant increases in the estimated number of quitters were seen, ranging from + 42.75% to + 435.90%. Statistically significant changes in other variables (satisfaction, 24-h quit attempts, 30-day point prevalence abstinence rates, gender, and race) varied by state. During the post period, participants' method of registration differed. Online enrollment percentages ranged from 19.44% (Oklahoma), to 54.34% (Florida), to 70.80% (Minnesota). In Oklahoma, 71.63% of participants enrolled by phone, while 40.71% of Florida participants and 26.98% of Minnesota participants enrolled by phone. Fax or electronic referrals comprised 8.92% (Oklahoma), 4.95% (Florida), and 2.22% (Minnesota) of program enrollees, respectively. CONCLUSIONS: Changing quitline services and implementing a new media campaign increased treatment reach and the estimated number of participants who quit smoking in three states. Quitline funders and tobacco control program managers may wish to consider approaches such as these to increase quitline utilization and population health impact.

Financial incentives and proactive calling for reducing barriers to tobacco treatment among socioeconomically disadvantaged women: A factorial randomized trial.

Improved strategies and scalable interventions to engage low-socioeconomic status (SES) smokers in tobacco treatment are needed. We tested an intervention designed to connect low-SES smokers to treatment services, implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (Sage) in 2017; the trial was designed to last 3 months (July through October). Participants were female smokers who were 250% below the federal poverty level (randomized N = 3723; analyzed N = 3365). Using a factorial design, participants were randomized to six intervention groups consisting of a proactive call (no call vs call) and/or a financial incentive offered for being connected to treatment services ($0 vs $10 vs $20). Simple randomization was conducted using Stata v.13. All individuals received direct mail. Participants and staff were blinded to allocation. The outcome was connection via phone to QUITPLAN Services®, Minnesota's population-based cessation services. Groups that received $10 or $20 incentives had higher odds of treatment engagement compared to the no incentive group [respectively, OR = 1.94; 95% CI (1.19-3.14); OR = 2.18; 95% CI (1.36-3.51)]. Individuals that received proactive calls had higher odds of treatment engagement compared to individuals not called [OR = 1.59; 95% CI (1.11-2.29)]. Economic evaluation revealed that the $10 incentive, no call group had the best cost-benefit ratio compared to the no incentive, no call group. Direct mail with moderate incentives or proactive calling can successfully encourage connections to population-based tobacco treatment services among low-SES smokers. The intervention could be disseminated to similar programs serving low-SES populations. This trial is registered at ClinicalTrials.gov (NCT03760107).

Creating Culturally-Specific and Community-Specific Approaches to Linking Low Socioeconomic Smokers to Cessation Services.

While smoking has declined, rates remain alarmingly high for people of low socioeconomic status. Funding community-based organizations to link low socioeconomic status smokers to cessation services holds promise for reaching this population. This approach also shows potential for elevating addressing tobacco use as a priority within these organizations.

Support person interventions to increase use of quitline services among racially diverse low-income smokers: A pilot study.

INTRODUCTION: Social support from nonsmokers may have a role in prompting smokers to use evidence-based cessation treatment. Prior studies found that an intervention for nonsmoking support persons (SPs) was effective for promoting smokers' use of free, state quitline services. This pilot study adapted and assessed feasibility of this intervention for a racially diverse, low-income population. METHODS: Single group, non-randomized design enrolling SP-smoker dyads with low income status enrolled in one of three study "waves" of 10 pairs each. Participants were recruited using flyers and in-person outreach methods. The SP intervention included a 1-session coaching call and written materials; study waves 2 and 3 also included text messaging and a monetary incentive for smokers who used quitline services. Using content analysis, the intervention was iteratively adapted based on SP feedback. Baseline measures assessed socio-demographics, dyad and tobacco use characteristics. Follow-up assessments were conducted among SPs at 1-month follow-up and among smokers at 3-months follow-up. Feasibility indicators were recruitment, retention, and SP intervention acceptability and adherence. Secondary outcomes were smokers' use of any quitline service verified by quitline staff and 7-day, point prevalence, biochemically verified smoking abstinence at 3 months. RESULTS: Recruitment of 30 dyads was feasible; in-person recruitment methods were the most successful. SPs who completed follow-up assessments found the intervention acceptable, suggesting only minor content modifications, and they perceived the quitline information as novel. But the study had some feasibility challenges (e.g., SP coaching call completion: 60% and SP study retention: 53%). At 3 months, 2 smokers (7%) had used any quitline service and 13% were biochemically confirmed smoking abstinent. CONCLUSIONS: This pilot study demonstrated feasibility of recruiting SP-smoker dyads from diverse, low-income communities. While the intervention was well received, its delivery was not feasible in this population. Results suggest that further consumer adaptation of the intervention is needed among both SPs and smokers.

Impact and Effectiveness of a Stand-Alone NRT Starter Kit in a Statewide Tobacco Cessation Program.

PURPOSE: To examine 2-week nicotine replacement therapy (NRT) starter kit quit outcomes and predictors and the impact of adding this new service on treatment reach. DESIGN: Observational study of a 1-year cohort of QUITPLAN Services enrollees using registration and utilization data and follow-up outcome survey data of a subset of enrollees who received NRT starter kits. SETTING: ClearWay Minnesota's QUITPLAN Services provides a quit line that is available to uninsured and underinsured Minnesotans and NRT starter kits (a free 2-week supply of patches, gum, or lozenges) that are available to all Minnesota tobacco users. PARTICIPANTS: A total of 15 536 adult QUITPLAN Services enrollees and 818 seven-month follow-up survey NRT starter kit respondents. MEASURES: Treatment reach for all services and tobacco quit outcomes and predictors for starter kit recipients. ANALYSIS: Descriptive analyses, χ2 analyses, and logistic regression. RESULTS: Treatment reach increased 3-fold after adding the 2-week NRT starter kit service option to QUITPLAN Services compared to the prior year (1.86% vs 0.59%). Among all participants enrolling in QUITPLAN services during a 1-year period, 83.8% (13 026/15 536) registered for a starter kit. Among starter kit respondents, 25.6% reported being quit for 30 days at the 7-month follow-up. After controlling for other factors, using all NRT and selecting more cessation services predicted quitting. CONCLUSION: An NRT starter kit brought more tobacco users to QUITPLAN services, demonstrating interest in cessation services separate from phone counseling. The starter kit produced high quit rates, comparable to the quit line in the same time period. Cessation service providers may want to consider introducing starter kits to reach more tobacco users and ultimately improve population health.

Changing patterns in E-cigarette use among Minnesota adults between 2014 and 2018.

Minnesota has observed declining combustible tobacco use and a large increase in e-cigarette use among youth and young adults. Less is known about adult e-cigarette users' frequency of use, smoking status, use of flavors, and demographic differences. The Minnesota Adult Tobacco Survey (MATS) is a cross-sectional, random digit-dial telephone survey representative of Minnesotans aged 18 and over. MATS measured e-cigarette use in 2014 (N = 9304) and 2018 (N = 6065). In 2018, 6.0% of adult Minnesotans used an e-cigarette in the past 30 days; this was unchanged from 2014 (5.9%). While past 30-day e-cigarette use declined for current smokers (2014: 27.3%; 2018: 16.1% p < 0.001), it increased for never smokers (2014: 1.2%; 2018: 4.4% p < 0.001) and 18-24-year-olds (2014: 12.8%; 2018: 21.9% p = 0.001). Daily e-cigarette use increased from 2014 to 2018 for current smokers (p = 0.001), 25-44-year-olds (p < 0.001), females (p = 0.001), and those with a high-school education (p = 0.006). Among e-cigarette users in 2018, use of flavored e-cigarettes was associated with smoking status (p = 0.041), age (p < 0.001), and using e-cigarettes to quit smoking (p = 0.011). E-cigarettes appeal primarily to younger adults. Of concern are increases in never smokers initiating e-cigarette use, increasing their exposure to nicotine, addiction, and the risk of future combustible tobacco use. Simultaneously, fewer smokers are using e-cigarettes but those who do are using them more frequently. Use of flavored e-cigarettes was common and correlated with interest in quitting combustible cigarettes. These findings can inform recent calls for additional tobacco control policy and programs aimed at reducing e-cigarette use.

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.

Tobacco User Characteristics and Outcomes Related to Intensity of Quitline Program Use: Results From Minnesota and Pennsylvania.

CONTEXT: Tobacco users in all 50 states have access to quitline telephone counseling and cessation medications. While studies show multiple calls relate to quit success, most participants do not complete a full call series. To date, quitline program use studies have analyzed single factors-such as number of calls or counseling minutes. OBJECTIVE: This study combines multiple factors of quitline program use across 2 states to describe how participants use a 5-call program; assess whether intensity of program use is associated with participant subgroups; and assess whether key outcomes (quitting, satisfaction) are associated with intensity. DESIGN, SETTING, AND PARTICIPANTS: This observational study examines data for quitline participants in Minnesota (n = 2844) and Pennsylvania (n = 14 359) in 2011 and 2012. A subset of participants was surveyed 7 months after registration to assess key outcomes (response rates: Minnesota 65%; Pennsylvania 60%). MAIN OUTCOME MEASURES: Quitline utilization data were used to identify program use variables: nicotine replacement therapy provision, number of counseling calls, number of counseling minutes, days from first to last counseling call, and days from registration to first counseling call. Ten program use groups were created using all 5 program use variables, from lowest (1) to highest (10) intensity. RESULTS: Results were similar for both states. Only 11% of Minnesota and 8% of Pennsylvania participants completed all 5 calls. Intensity of quitline program use was associated with several participant characteristics including health conditions and age. Both quit status and program satisfaction were associated with program use intensity. Quit rates peaked in group 9, participants who received the full 5-call program. CONCLUSIONS: Quitlines should focus on engaging participants in multiple calls to improve quit outcomes. In addition, it is important to leverage multiple program use factors for a fuller understanding of how quitline participants use a program.

Increasing reach by offering choices: Results from an innovative model for statewide services for smoking cessation.

Although state quitlines provide free telephone counseling and often include nicotine replacement therapy (NRT), reach remains limited (1-2% in most states). More needs to be done to engage all smokers in the quitting process. A possible strategy is to offer choices of cessation services through quitlines and to reduce registration barriers. In March 2014, ClearWay MinnesotaSM implemented a new model for QUITPLAN® Services, the state's population-wide cessation services. Tobacco users could choose the QUITPLAN® Helpline or one or more Individual QUITPLAN® Services (NRT starter kit, text messaging, email program, or quit guide). The program website was redesigned, online enrollment was added, and a new advertising campaign was created and launched. In 2014-2015, we evaluated whether these changes increased reach. We also assessed quit attempts, quit outcomes, predictors of 30-day abstinence, and average cost per quit via a seven-month follow-up survey. Between March 2014-February 2015, 15,861 unique tobacco users registered, which was a 169% increase over calendar year 2013. The majority of participants made a quit attempt (83.7%). Thirty-day point prevalence abstinence rates (responder rates) were 26.1% for QUITPLAN Services overall, 29.6% for the QUITPLAN Helpline, and 25.5% for Individual QUITPLAN Services. Several variables predicted quit outcomes, including receiving only one call from the Helpline and using both the Helpline and the NRT starter kit. Providing greater choice of cessation services and reducing registration barriers have the potential to engage more tobacco users, foster more quit attempts, and ultimately lead to long-term cessation and reductions in prevalence.

Seizing an opportunity: increasing use of cessation services following a tobacco tax increase.

BACKGROUND: Tobacco tax increases are associated with increases in quitline calls and reductions in smoking prevalence. In 2013, ClearWay Minnesota(SM) conducted a six-week media campaign promoting QUITPLAN® Services (QUITPLAN Helpline and quitplan.com) to leverage the state's tax increase. The purpose of this study was to ascertain the association of the tax increase and media campaign on call volumes, web visits, and enrollments in QUITPLAN Services. METHODS: In this observational study, call volume, web visits, enrollments, and participant characteristics were analyzed for the periods June-August 2012 and June-August 2013. Enrollment data and information about media campaigns were analyzed using multivariate regression analysis to determine the association of the tax increase on QUITPLAN Services while controlling for media. RESULTS: There was a 160% increase in total combined calls and web visits, and an 81% increase in enrollments in QUITPLAN Services. Helpline call volumes and enrollments declined back to prior year levels approximately six weeks after the tax increase. Visits to and enrollments in quitplan.com also declined, but increased again in mid-August. The tax increase and media explained over 70% of variation in enrollments in the QUITPLAN Helpline, with media explaining 34% of the variance and the tax increase explaining an additional 36.1% of this variance. However, media explained 64% of the variance in quitplan.com enrollments, and the tax increase explained an additional 7.6% of this variance. CONCLUSIONS: Since tax increases occur infrequently, these policy changes must be fully leveraged as quickly as possible to help reduce prevalence.

Facilitators of health systems change for tobacco dependence treatment: a qualitative study of stakeholders' perceptions.

BACKGROUND: Health systems play key roles in identifying tobacco users and providing evidence-based care to help them quit. Health systems change - changes to health care processes, policies and financing - has potential to build capacity within these systems to address tobacco use. In 2010, ClearWay MinnesotaSM piloted a health systems change funding initiative, providing resources and technical assistance to four health care systems. This paper presents findings from a process evaluation, describing key stakeholders' views on whether changes to how health systems treat tobacco use resulted from this initiative and what may have facilitated those changes. METHODS: A process evaluation was conducted by an independent evaluation firm. A qualitative case study approach provided understanding of systems change efforts. Interviews were conducted with key informants representing the health systems, funder and technical assistance providers. Core documents were reviewed and compared to thematic analysis from the interviews. Results were triangulated with existing literature to check for convergence or divergence. A cross-case analysis of the findings was conducted in which themes were compared and contrasted. RESULTS: All systems created and implemented well-defined written tobacco use screening, documentation and treatment referral protocols for every patient at every visit. Three implemented systematic follow-up procedures for patients referred to treatment, and three also implemented changes to electronic health records systems to facilitate screening, referral and reporting. Fax referral to quitline services was implemented or enhanced by two systems. Elements that facilitated successful systems changes included capitalizing on environmental changes, ensuring participation and support at all organizational levels, using technology, establishing ongoing training and continuous quality improvement mechanisms and leveraging external funding and technical assistance. CONCLUSIONS: This evaluation demonstrates that health systems can implement substantial changes to facilitate routine treatment of tobacco dependence in a relatively short timeframe. Implementing best practices like these, including increased emphasis on the implementation and use of electronic health record systems and healthcare quality measures, is increasingly important given the changing health care environment. Lessons learned from this project can be resources for states and health systems likely to implement similar systems changes.

Enhancing tobacco quitline effectiveness: identifying a superior pharmacotherapy adjuvant.

INTRODUCTION: Telephone tobacco quitlines are effective and are widely used, with more than 500,000 U.S. callers in 2010. This study investigated the clinical effectiveness and cost-effectiveness of 3 different quitline enhancements: combination nicotine replacement therapy (NRT), longer duration of NRT, and counseling to increase NRT adherence. METHODS: In this study, 987 quitline callers were randomized to a combination of quitline treatments in a 2 × 2 × 2 factorial design: NRT duration (2 vs. 6 weeks), NRT type (nicotine patch only vs. patch plus nicotine gum), and standard 4-call counseling (SC) versus SC plus medication adherence counseling (MAC). The primary outcome was 7-day point-prevalence abstinence (PPA) at 6 months postquit in intention-to-treat (ITT) analyses. RESULTS: Combination NRT for 6 weeks yielded the highest 6-month PPA rate (51.6%) compared with 2 weeks of nicotine patch (38.4%), odds ratios [OR] = 1.71 (95% confidence interval [CI]:1.20-2.45). A similar result was found for 2 weeks of combination NRT (48.2%), OR = 1.49 (95% CI: 1.04-2.14) but not for 6 weeks of nicotine patch alone (46.2%), OR = 1.38 (95% CI: 0.96-1.97). The MAC intervention effect was nonsignificant. Cost analyses showed that the 2-week combination NRT group had the lowest cost per quit ($442 vs. $464 for 2-week patch only, $505 for 6-week patch only, and $675 for 6-week combination NRT). CONCLUSIONS: Combination NRT for 2 or 6 weeks increased 6-month abstinence rates by 10% and 13%, respectively, over rates produced by 2 weeks of nicotine patch when offered with quitline counseling. A 10% improvement would potentially yield an additional 50,000 quitters annually, assuming 500,000 callers to U.S. quitlines per year.