The Emerging Global Tobacco Treatment Workforce: Characteristics of Tobacco Treatment Specialists Trained in Council-Accredited Training Programs from 2017 to 2019.

Tobacco use is projected to kill 1 billion people in the 21st century. Tobacco Use Disorder (TUD) is one of the most common substance use disorders in the world. Evidence-based treatment of TUD is effective, but treatment accessibility remains very low. A dearth of specially trained clinicians is a significant barrier to treatment accessibility, even within systems of care that implement brief intervention models. The treatment of TUD is becoming more complex and tailoring treatment to address new and traditional tobacco products is needed. The Council for Tobacco Treatment Training Programs (Council) is the accrediting body for Tobacco Treatment Specialist (TTS) training programs. Between 2016 and 2019, n = 7761 trainees completed Council-accredited TTS training programs. Trainees were primarily from North America (92.6%) and the Eastern Mediterranean (6.1%) and were trained via in-person group workshops in medical and academic settings. From 2016 to 2019, the number of Council-accredited training programs increased from 14 to 22 and annual number of trainees increased by 28.5%. Trainees have diverse professional backgrounds and work in diverse settings but were primarily White (69.1%) and female (78.7%) located in North America. Nearly two-thirds intended to implement tobacco treatment services in their setting; two-thirds had been providing tobacco treatment for 1 year or less; and 20% were sent to training by their employers. These findings suggest that the training programs are contributing to the development of a new workforce of TTSs as well as the development of new programmatic tobacco treatment services in diverse settings. Developing strategies to support attendance from demographically and geographically diverse professionals might increase the proportion of trainees from marginalized groups and regions of the world with significant tobacco-related inequities.

The comparative effectiveness of clinic, work-site, phone, and Web-based tobacco treatment programs.

INTRODUCTION: Tobacco treatment programs may be offered in clinical settings, at work-sites, via telephone helplines, or over the Internet. Little comparative data exist regarding the real-world effectiveness of these programs. This paper compares the reach, effectiveness, and costs of these different modes of cessation assistance. METHODS: This is an observational study of cohorts of participants in Minnesota's QUITPLAN programs in 2004. Cessation assistance was provided in person at 9 treatment centers, using group counseling at 68 work-sites, via a telephone helpline, or via the Internet. The main outcomes of the study are enrollment by current smokers, self-reported 30-day abstinence, and cost per quit. Reach was calculated statewide for the helpline and Web site, regionally for the treatment centers, and for the employee population for work-site programs. RESULTS: Enrollment was greatest for the Web site (n = 4,698), followed by the helpline (n = 2,351), treatment centers (n = 616), and work-sites (n = 479). The Web site attracted younger smokers. Smokers at treatment centers had higher levels of nicotine dependence. The helpline reached more socially disadvantaged smokers. Responder 30-day abstinence rates were higher for the helpline (29.3%), treatment centers (25.8%), and work-sites (19.6%) compared with the online program (12.5%). These differences persisted after controlling for baseline differences in participant characteristics and use of pharmacological therapy. The cost per quit was lowest for the Web site program ($291 per quit, 95% CI = $229-$372). DISCUSSION: Treatment center, work-site, helpline, and Web site programs differ in their reach, effectiveness, and estimated cost per quit. Each program plays a part in assisting populations of tobacco users in quitting.

Utilization of smoking cessation informational, interactive, and online community resources as predictors of abstinence: cohort study.

BACKGROUND: The association between greater utilization of Web-assisted tobacco interventions and increased abstinence rates is well recognized. However, there is little information on how utilization of specific website features influences quitting. OBJECTIVE: To determine the association between utilization of informational, interactive, and online community resources (eg. bulletin boards) and abstinence rates, with the broader objective to identify potential strategies for improving outcomes for Web-assisted tobacco interventions. METHODS: In Spring 2004, a cohort of 607 quitplan.com users consented to participate in an evaluation of quitplan.com, a Minnesota branded version of QuitNet.com. We developed utilization measures for different site features: general information, interactive diagnostic tools and quit planning tools, online expert counseling, passive (ie, reading of bulletin boards) and active (ie, public posting) online community engagement, and one-to-one messaging with other virtual community members. Using bivariate, multivariate, and path analyses, we examined the relationship between utilization of specific site features and 30-day abstinence at 6 months. RESULTS: The most commonly used resources were the interactive quit planning tools (used by 77% of site users). Other informational resources (ie, quitting guides) were used more commonly (60% of users) than passive (38%) or active (24%) community features. Online community engagement through one-to-one messaging was low (11%) as was use of online counseling (5%). The 30-day abstinence rate among study participants at 6 months was 9.7% (95% Confidence Interval [CI] 7.3% - 12.1%). In the logistic regression model, neither the demographic data (eg, age, gender, education level, employment, or insurance status) nor the smoking-related data (eg, cigarettes per day, time to first morning cigarette, baseline readiness to quit) nor use of smoking cessation medications entered the model as significant predictors of abstinence. Individuals who used the interactive quit planning tools once, two to three times, or four or more times had an odds of abstinence of 0.65 (95% Confidence Interval [CI] 0.22 - 1.94), 1.87 (95% CI 0.77 - 4.56), and 2.35 (95% CI 1.0 - 5.58), respectively. The use of one-to-one messages (reference = none vs 1 or more) entered the final model as potential predictor for abstinence, though the significance of this measure was marginal (OR = 1.91, 95% CI 0.92 - 3.97, P = .083). In the path analysis, an apparent association between active online community engagement and abstinence was accounted for in large part by increased use of interactive quitting tools and one-to-one messaging. CONCLUSIONS: Use of interactive quitting tools, and perhaps one-to-one messaging with other members of the online community, was associated with increased abstinence rates among quitplan.com users. Designs that facilitate use of these features should be considered.

Expanding access to nicotine replacement therapy through Minnesota's QUITLINE partnership.

BACKGROUND: Partnerships can expand the reach and effectiveness of quitlines while conserving limited tobacco control dollars. OBJECTIVE: To describe how the addition of free nicotine replacement therapy (NRT) to the "QUITPLAN Helpline" in Minnesota influenced triage and transfer to health plan quitlines and how efforts taken to re-establish balance in the partnership expanded population based access to NRT. METHODS: NRT provision began in September 2002. Call volumes, transfer rates and ClearWay Minnesota dollars spent serving health plan members were examined from May 2001 through November 2005. The process by which health plan quitlines began providing NRT as a result of the addition of NRT to the QUITPLAN Helpline in September 2002 was explored through interviews with health plan representatives. RESULTS: Following the addition of NRT to the QUITPLAN Helpline, the percentage of health plan members transferred to their health plans decreased because callers were resisting transfer to their health plans for telephone counselling that did not include NRT. Transfer rates eventually returned to pre-NRT levels following sequential implementation of scripting changes, transfer requirements and collection of health plan identification numbers. These changes reduced ClearWay Minnesota dollars spent on providing services to insured Minnesotans. Through the partnership, all Minnesotans currently have access to both telephone counselling and NRT either at no or low cost. CONCLUSIONS: Minnesota's partnership has effectively expanded access to NRT through quitlines. The increased use of partnerships for providing quitline services may be effective in broadening population access while conserving limited tobacco control dollars for those without cessation benefits.

Increased reach and effectiveness of a statewide tobacco quitline after the addition of access to free nicotine replacement therapy.

BACKGROUND: Tobacco users receiving behavioural and pharmacological assistance are more likely to quit. Although telephone quitlines provide population access to counselling, few offer pharmacotherapy. OBJECTIVE: To assess change in cessation rates and programme impact after the addition of free nicotine replacement therapy (NRT) to statewide quitline services. DESIGN, SETTING, PARTICIPANTS: An observational study of cohorts of callers to the Minnesota QUITPLAN(SM) Helpline before (n = 380) and after (n = 373) the addition of access to free NRT. INTERVENTION: Mailing of NRT (patch or gum) to callers enrolling in multi-session counselling. MAIN OUTCOME MEASURE: Thirty-day abstinence six months after programme registration. RESULTS: The number of callers increased from 155 (SD 75) to 679 (180) per month pre-NRT to post-NRT (difference 524, 95% confidence interval (CI) 323 to 725). Post-NRT, the proportion of callers enrolling in multi-session counselling (23.4% v 90.1%, difference 66.6%, 95% CI 60.8% to 71.6%) and using pharmacotherapy (46.8% v 86.8%, difference 40.0%, 95% CI 31.3% to 47.9%) increased. Thirty-day abstinence at six months increased from 10.0% pre-NRT to 18.2% post-NRT (difference 8.2%, 95% CI 3.1% to 13.4%). Post-NRT the average number of new ex-smokers per month among registrants increased from 15.5 to 123.6 (difference 108.1, 95% CI 61.1 to 155.0). The cost per quit pre-NRT was 1362 dollars (SD 207 dollars). The cost per quit post-NRT was 1934 dollars (215 dollars) suggesting a possible increase in cost per quit (difference 572 dollars, 95% CI -12 dollars to 1157 dollars). CONCLUSION: The addition of free NRT to a state quitline is followed by increases in participation and abstinence rates resulting in an eightfold increase in programme impact. These findings support the addition of access to pharmacological therapy as part of state quitline services.

Outcomes and cost-effectiveness of two nicotine replacement treatment delivery models for a tobacco quitline.

Many tobacco cessation quitlines provide nicotine replacement therapy (NRT) in the U.S. but consensus is lacking regarding the best shipping protocol or NRT amounts. We evaluated the impact of the Minnesota QUITPLAN(®) Helpline's shift from distributing NRT using a single eight-week shipment to a two-shipment protocol. For this observational study, the eight week single-shipment cohort (n = 247) received eight weeks of NRT (patches or gum) at once, while the split-shipment cohort (n = 160) received five weeks of NRT (n = 94), followed by an additional three weeks of NRT if callers continued with counseling (n = 66). Patient satisfaction, retention, quit rates, and cost associated with the three groups were compared. A higher proportion of those receiving eight weeks of NRT, whether in one or two shipments, reported that the helpline was "very helpful" (77.2% of the single-shipment group; 81.1% of the two-shipment group) than those receiving five weeks of NRT (57.8% of the one-shipment group) (p = 0.004). Callers in the eight week two-shipment group completed significantly more calls (3.0) than callers in the five week one-shipment group (2.4) or eight week single-shipment group (1.7) (p < 0.001). Using both responder and intent-to-treat calculations, there were no significant differences in 30-day point prevalence abstinence at seven months among the three protocol groups even when controlling for demographic and tobacco use characteristics, and treatment group protocol. The mean cost per caller was greater for the single-shipment phase than the split-shipment phase ($350 vs. $326) due to the savings associated with not sending a second shipment to some participants. Assuming no difference in abstinence rates resulting from the protocol change, cost-per-quit was lowest for the five week one-shipment group ($1,155), and lower for the combined split-shipment cohort ($1,242) than for the single-shipment cohort ($1,350). Results of this evaluation indicate that while satisfaction rates increase among those receiving more counseling and NRT, quit rates do not, even when controlling for demographic and tobacco use characteristics.