- Email: [email protected]
Enhancing the Effect of Telephone Quitline Counseling Through Proactive Call-Back Counseling
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mutations: a prospective phase II trial. Lancet 2008; 372:719 – 727 Frederiksen B, Koch C, Høiby N. Antibiotic treatment of initial colonization with Pseudomonas aeruginosa postpones chronic infection and prevents deterioration of pulmonary function in cystic fibrosis. Pediatr Pulmonol 1997; 23:330 – 335 Aaron SD, Vandemheen KL, Ferris W, et al. Combination antibiotic susceptibility testing to treat exacerbations of cystic fibrosis associated with multiresistant bacteria: a randomised, double-blind, controlled clinical trial. Lancet 2005; 366:463– 471 Balfour-Lynn IM, Lees B, Hall P, et al. Multicenter randomized controlled trial of withdrawal of inhaled corticosteroids in cystic fibrosis. Am J Respir Crit Care Med 2006; 173:1356 – 1362 Rosenfeld M, Emerson J, Williams-Warren J, et al. Defining a pulmonary exacerbation in cystic fibrosis. J Pediatr 2001; 139:359 –365 Fuchs HJ, Borowitz DS, Christiansen DH, et al. Effect of aerosolized recombinant human DNase on exacerbations of respiratory symptoms and on pulmonary function in patients with cystic fibrosis: the Pulmozyme Study Group. N Engl J Med 1994; 331:637– 642 Elborn JS, Prescott RJ, Stack BH, et al. Elective versus symptomatic antibiotic treatment in cystic fibrosis patients with chronic Pseudomonas infection of the lungs. Thorax 2000; 55:355–358 Al-Aloul M, Miller H, Alapati S, et al. Renal impairment in cystic fibrosis patients due to repeated intravenous aminoglycoside use. Pediatr Pulmonol 2005; 39:15–20 Ring E, Eber E, Erwa W, et al. Urinary N-acetyl--Dglucosaminidase activity in patients with cystic fibrosis on long-term gentamicin inhalation. Arch Dis Child 1998; 78: 540 –543 Turvey SE, Cronin B, Arnold AD, et al. Antibiotic desensitization for the allergic patient: 5 years of experience and practice. Ann Allergy Asthma Immunol 2004; 92:426 – 432 Steinkamp G, Wiedemann B, Rietschel E, et al. Prospective evaluation of emerging bacteria in cystic fibrosis. J Cyst Fibros 2005; 4:41– 48 Klein M, Cohen-Cymberknoh M, Armoni A, et al. 18FDGPET/CT imaging of lungs in patients with cystic fibrosis. Chest 2009; 136:1220 –1228 Johannesson M, Askling J, Montgomery SM, et al. Cancer risk among patients with cystic fibrosis and their first degree relatives. Int J Cancer 2009 [Epub ahead of print]
Enhancing the Effect of Telephone Quitline Counseling Through Proactive Call-Back Counseling issue of CHEST (see page 1229), I nSoodthe andcurrent colleagues report on the outcome of a 1
randomized controlled trial evaluating reactive telephone smoking-cessation counseling compared with the provision of mailed self-help materials on 7-day point prevalence quit rates at up to 12-month follow-up. The authors found no significant differ-
www.chestjournal.org
ences in abstinence rates between the two randomized groups and concluded that supplemental reactive telephone counseling did not provide better smoking-cessation outcomes than the use of self-help educational materials alone. They suggest that reactive telephone counseling, which relies on the smoker to initiate calls to a helpline or quitline for assistance with quitting smoking, may be inadequate possibly due to its infrequent use and recommend that consideration be given to incorporating a call-back counseling approach to reactive telephone counseling. Call-back or proactive counseling involves counselors actively calling smokers who initially contact a smoking-cessation quitline with a call-back schedule tailored to the individual’s needs, including during the preparation process and peak relapse risk periods. The recommendation of Sood and colleagues1 to add call-back or proactive counseling to reactive telephone counseling adds emphasis to similar findings in the current literature on smoking-cessation treatment and quitlines and is consistent with the Public Health Service guidelines,2 which support the efficacy of proactive counseling and, as such, contribute substantially to the field. Telephone counseling services such as those offered by quitlines are recognized as an effective and recommended component of comprehensive tobacco control, providing smoking-cessation services in a convenient and accessible manner, reducing barriers to and potential stigma associated with in-person smoking-cessation programs.3 All 50 states and the District of Columbia have quitlines to assist smokers who want to stop smoking,4 and most state-supported quitlines offer proactive counseling.5 Multiple proactive calls from quitline counselors have been shown to be effective.3,6 Two comprehensive reviews conducted by Stead et al3,6 found that, among smokers who contacted quitlines, those receiving multiple sessions of call-back counseling had significantly higher quit rates compared with those not receiving call-back counseling and those who were mailed materials or were provided brief counseling at the first contact. A dose response was found, with three or more calls increasing the odds of quitting compared with minimal intervention (eg, providing self-help materials, brief advice, or pharmacotherapy alone). These findings suggest that proactive calls from quitline counselors may help smokers who otherwise would not initiate further contact and seek additional assistance. This hypothesis is lent credence by the finding of Zhu and colleagues7 that quit rates can be enhanced by proactive calls in smokers who were invited to make further contact with the quitline but had not done so. The reviewers concluded that proactive telephone counseling CHEST / 136 / 5 / NOVEMBER, 2009
1199
helps smokers who are interested in quitting smoking and that call-back counseling enhances their success of quitting. The importance of enhancing the effect of telephone counseling offered by quitlines through proactive call-back counseling is highlighted by evidence8 supporting the cost-effectiveness of intensive telephone-counseling protocols. A review9 found that, from a population perspective, proactive telephone counseling was the most cost-effective intervention as a first-line approach for smoking cessation. In addition, adding proactive telephone counseling to pharmacotherapy was found to increase the effectiveness of pharmacotherapy at a low incremental cost, and therefore this combination could be a very costeffective strategy. The authors concluded that the low cost of proactive counseling along with the tremendous health-care cost savings associated with successful smoking cessation make investment in proactive telephone counseling programs a particularly cost-effective strategy. Despite their effectiveness, quitline utilization is relatively low, with approximately 1% of the US population of smokers accessing this service.5 Physicians and other health-care providers can be important partners in promoting the use of quitlines and proactive telephone counseling, as they often serve as a first contact with smokers and can provide both motivation and referral to quitline counseling. Indeed, proactive counseling is recommended as an adjunct to less intensive intervention such as physician advice.2 Certainly for those patients in whom smoking-related illnesses such as COPD and cardiovascular disease have already been diagnosed, smoking cessation is of paramount importance, reducing the number of subsequent coronary events and mortality among patients with cardiovascular disease, and is the only treatment that has been shown to slow the progression of COPD.10,11 One strategy for increasing the utilization of quitline services and proactive counseling has been the establishment of fax-referral protocols that encourage health-care providers to enroll their patients in proactive quitline programs at the point of health-care service contact. Many states have linked their quitlines with healthcare providers and settings through fax referrals, and this trend is increasing, with 34 quitlines reporting receipt of fax referrals as of 2006.4,12 However, little research has been conducted to systematically evaluate such programs. The article by Sood and colleagues1 advances the field by underscoring the need to evaluate strategies to enhance and maximize the utilization of existing, effective smokingcessation telephone counseling offered through quit1200
lines, including the use of proactive, call-back counseling and linking quitlines to health-care systems and providers. Lori Pbert, PhD Worcester, MA Affiliations: Dr. Pbert is Associate Professor of Medicine, Director, Center for Tobacco Treatment Research and Training, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School. Financial/nonfinancial disclosures: The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Lori Pbert, PhD, Center for Tobacco Treatment Research and Training, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655; e-mail: [email protected] © 2009 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/ misc/reprints.xhtml). DOI: 10.1378/chest.09-1081
References 1 Sood A, Andoh J, Verhulst S, et al. “Real-world” effectiveness of reactive telephone counseling for smoking cessation: a randomized controlled trial. Chest 2009; 136:1229 – 1236 2 Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Rockville, MD: US Department of Health and Human Services, Public Health Service, 2008 3 Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database Syst Rev (database online). Issue 3, 2006 4 North American Quitline Consortium. Quitline facts. Available at: http://www.naquitline.org/?page⫽quitlinefacts. Accessed September 10, 2009 5 Cummins SE, Bailey L, Campbell S, et al. Tobacco cessation quitlines in North America: a descriptive study. Tob Control 2007; 16(suppl):i9 –i15 6 Stead LF, Perera R, Lancaster T. A systematic review of interventions for smokers who contact quitlines. Tob Control 2007; 16:(suppl):i3–i8 7 Zhu SH, Anderson CM, Tedeschi GJ, et al. Evidence of real-world effectiveness of a telephone quitline for smokers. N Engl J Med 2002; 347:1087–1093 8 Hollis JF, McAfee TA, Fellows JL, et al. The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline. Tob Control 2007; 16(suppl):i53–i59 9 Shearer J, Shanahan M. Cost effectiveness analysis of smoking cessation interventions. Aust N Z J Public Health 2006; 30:428 – 434 10 Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet 2006; 19368:647– 658 11 US Department of Health and Human Services. The health consequences of smoking: a report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004 12 Perry RJ, Keller PA, Fraser D, et al. Fax to quit: a model for delivery of tobacco cessation services to Wisconsin residents. Wisconsin Med J 2005; 104:37– 40, 44 Editorials
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12 13 14 15
mutations: a prospective phase II trial. Lancet 2008; 372:719 – 727 Frederiksen B, Koch C, Høiby N. Antibiotic treatment of initial colonization with Pseudomonas aeruginosa postpones chronic infection and prevents deterioration of pulmonary function in cystic fibrosis. Pediatr Pulmonol 1997; 23:330 – 335 Aaron SD, Vandemheen KL, Ferris W, et al. Combination antibiotic susceptibility testing to treat exacerbations of cystic fibrosis associated with multiresistant bacteria: a randomised, double-blind, controlled clinical trial. Lancet 2005; 366:463– 471 Balfour-Lynn IM, Lees B, Hall P, et al. Multicenter randomized controlled trial of withdrawal of inhaled corticosteroids in cystic fibrosis. Am J Respir Crit Care Med 2006; 173:1356 – 1362 Rosenfeld M, Emerson J, Williams-Warren J, et al. Defining a pulmonary exacerbation in cystic fibrosis. J Pediatr 2001; 139:359 –365 Fuchs HJ, Borowitz DS, Christiansen DH, et al. Effect of aerosolized recombinant human DNase on exacerbations of respiratory symptoms and on pulmonary function in patients with cystic fibrosis: the Pulmozyme Study Group. N Engl J Med 1994; 331:637– 642 Elborn JS, Prescott RJ, Stack BH, et al. Elective versus symptomatic antibiotic treatment in cystic fibrosis patients with chronic Pseudomonas infection of the lungs. Thorax 2000; 55:355–358 Al-Aloul M, Miller H, Alapati S, et al. Renal impairment in cystic fibrosis patients due to repeated intravenous aminoglycoside use. Pediatr Pulmonol 2005; 39:15–20 Ring E, Eber E, Erwa W, et al. Urinary N-acetyl--Dglucosaminidase activity in patients with cystic fibrosis on long-term gentamicin inhalation. Arch Dis Child 1998; 78: 540 –543 Turvey SE, Cronin B, Arnold AD, et al. Antibiotic desensitization for the allergic patient: 5 years of experience and practice. Ann Allergy Asthma Immunol 2004; 92:426 – 432 Steinkamp G, Wiedemann B, Rietschel E, et al. Prospective evaluation of emerging bacteria in cystic fibrosis. J Cyst Fibros 2005; 4:41– 48 Klein M, Cohen-Cymberknoh M, Armoni A, et al. 18FDGPET/CT imaging of lungs in patients with cystic fibrosis. Chest 2009; 136:1220 –1228 Johannesson M, Askling J, Montgomery SM, et al. Cancer risk among patients with cystic fibrosis and their first degree relatives. Int J Cancer 2009 [Epub ahead of print]
Enhancing the Effect of Telephone Quitline Counseling Through Proactive Call-Back Counseling issue of CHEST (see page 1229), I nSoodthe andcurrent colleagues report on the outcome of a 1
randomized controlled trial evaluating reactive telephone smoking-cessation counseling compared with the provision of mailed self-help materials on 7-day point prevalence quit rates at up to 12-month follow-up. The authors found no significant differ-
www.chestjournal.org
ences in abstinence rates between the two randomized groups and concluded that supplemental reactive telephone counseling did not provide better smoking-cessation outcomes than the use of self-help educational materials alone. They suggest that reactive telephone counseling, which relies on the smoker to initiate calls to a helpline or quitline for assistance with quitting smoking, may be inadequate possibly due to its infrequent use and recommend that consideration be given to incorporating a call-back counseling approach to reactive telephone counseling. Call-back or proactive counseling involves counselors actively calling smokers who initially contact a smoking-cessation quitline with a call-back schedule tailored to the individual’s needs, including during the preparation process and peak relapse risk periods. The recommendation of Sood and colleagues1 to add call-back or proactive counseling to reactive telephone counseling adds emphasis to similar findings in the current literature on smoking-cessation treatment and quitlines and is consistent with the Public Health Service guidelines,2 which support the efficacy of proactive counseling and, as such, contribute substantially to the field. Telephone counseling services such as those offered by quitlines are recognized as an effective and recommended component of comprehensive tobacco control, providing smoking-cessation services in a convenient and accessible manner, reducing barriers to and potential stigma associated with in-person smoking-cessation programs.3 All 50 states and the District of Columbia have quitlines to assist smokers who want to stop smoking,4 and most state-supported quitlines offer proactive counseling.5 Multiple proactive calls from quitline counselors have been shown to be effective.3,6 Two comprehensive reviews conducted by Stead et al3,6 found that, among smokers who contacted quitlines, those receiving multiple sessions of call-back counseling had significantly higher quit rates compared with those not receiving call-back counseling and those who were mailed materials or were provided brief counseling at the first contact. A dose response was found, with three or more calls increasing the odds of quitting compared with minimal intervention (eg, providing self-help materials, brief advice, or pharmacotherapy alone). These findings suggest that proactive calls from quitline counselors may help smokers who otherwise would not initiate further contact and seek additional assistance. This hypothesis is lent credence by the finding of Zhu and colleagues7 that quit rates can be enhanced by proactive calls in smokers who were invited to make further contact with the quitline but had not done so. The reviewers concluded that proactive telephone counseling CHEST / 136 / 5 / NOVEMBER, 2009
1199
helps smokers who are interested in quitting smoking and that call-back counseling enhances their success of quitting. The importance of enhancing the effect of telephone counseling offered by quitlines through proactive call-back counseling is highlighted by evidence8 supporting the cost-effectiveness of intensive telephone-counseling protocols. A review9 found that, from a population perspective, proactive telephone counseling was the most cost-effective intervention as a first-line approach for smoking cessation. In addition, adding proactive telephone counseling to pharmacotherapy was found to increase the effectiveness of pharmacotherapy at a low incremental cost, and therefore this combination could be a very costeffective strategy. The authors concluded that the low cost of proactive counseling along with the tremendous health-care cost savings associated with successful smoking cessation make investment in proactive telephone counseling programs a particularly cost-effective strategy. Despite their effectiveness, quitline utilization is relatively low, with approximately 1% of the US population of smokers accessing this service.5 Physicians and other health-care providers can be important partners in promoting the use of quitlines and proactive telephone counseling, as they often serve as a first contact with smokers and can provide both motivation and referral to quitline counseling. Indeed, proactive counseling is recommended as an adjunct to less intensive intervention such as physician advice.2 Certainly for those patients in whom smoking-related illnesses such as COPD and cardiovascular disease have already been diagnosed, smoking cessation is of paramount importance, reducing the number of subsequent coronary events and mortality among patients with cardiovascular disease, and is the only treatment that has been shown to slow the progression of COPD.10,11 One strategy for increasing the utilization of quitline services and proactive counseling has been the establishment of fax-referral protocols that encourage health-care providers to enroll their patients in proactive quitline programs at the point of health-care service contact. Many states have linked their quitlines with healthcare providers and settings through fax referrals, and this trend is increasing, with 34 quitlines reporting receipt of fax referrals as of 2006.4,12 However, little research has been conducted to systematically evaluate such programs. The article by Sood and colleagues1 advances the field by underscoring the need to evaluate strategies to enhance and maximize the utilization of existing, effective smokingcessation telephone counseling offered through quit1200
lines, including the use of proactive, call-back counseling and linking quitlines to health-care systems and providers. Lori Pbert, PhD Worcester, MA Affiliations: Dr. Pbert is Associate Professor of Medicine, Director, Center for Tobacco Treatment Research and Training, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School. Financial/nonfinancial disclosures: The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Lori Pbert, PhD, Center for Tobacco Treatment Research and Training, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655; e-mail: [email protected] © 2009 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/ misc/reprints.xhtml). DOI: 10.1378/chest.09-1081
References 1 Sood A, Andoh J, Verhulst S, et al. “Real-world” effectiveness of reactive telephone counseling for smoking cessation: a randomized controlled trial. Chest 2009; 136:1229 – 1236 2 Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Rockville, MD: US Department of Health and Human Services, Public Health Service, 2008 3 Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database Syst Rev (database online). Issue 3, 2006 4 North American Quitline Consortium. Quitline facts. Available at: http://www.naquitline.org/?page⫽quitlinefacts. Accessed September 10, 2009 5 Cummins SE, Bailey L, Campbell S, et al. Tobacco cessation quitlines in North America: a descriptive study. Tob Control 2007; 16(suppl):i9 –i15 6 Stead LF, Perera R, Lancaster T. A systematic review of interventions for smokers who contact quitlines. Tob Control 2007; 16:(suppl):i3–i8 7 Zhu SH, Anderson CM, Tedeschi GJ, et al. Evidence of real-world effectiveness of a telephone quitline for smokers. N Engl J Med 2002; 347:1087–1093 8 Hollis JF, McAfee TA, Fellows JL, et al. The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline. Tob Control 2007; 16(suppl):i53–i59 9 Shearer J, Shanahan M. Cost effectiveness analysis of smoking cessation interventions. Aust N Z J Public Health 2006; 30:428 – 434 10 Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet 2006; 19368:647– 658 11 US Department of Health and Human Services. The health consequences of smoking: a report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004 12 Perry RJ, Keller PA, Fraser D, et al. Fax to quit: a model for delivery of tobacco cessation services to Wisconsin residents. Wisconsin Med J 2005; 104:37– 40, 44 Editorials