Integrating Quitlines into the National
Health Systems
Tim McAfee, MD, MPH
Director, Office on Smoking and Health
Symposium No. 60; World Conference on Tobacco or Health
March 17, 2015, Abu Dhabi, UAE
The findings and conclusions in this presentation are those of the authors and
do not necessarily represent the official position of the Centers for Disease Control and Prevention.
National Center for Chronic Disease Prevention and Health Promotion
Office on Smoking and Health
Outline
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Context
Component of a comprehensive package
Steps
Challenges
Quitlines – Best Practices
 Comprehensive Tobacco Control Strategy
 National Health Systems or Primary Health Care
 Media
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Future
Resources
Noncommunicable Diseases
38M Global
28M LMIC
Deaths
$21.3 Trillion
Losses
$1-3
Person/Year
A Modest Investment in Prevention Could
Have a Major Impact
Source: WHO. Global Status Report on noncommunicable diseases 2014. Geneva: World Health Organization, 2015
Source: WHO Report on the Global Tobacco Epidemic, 2013
Philippines’ Sin Tax Funds Universal
Health Care
 Tobacco & Alcohol Excise
(‘Sin’) Tax, Dec 2012
 Revenue collection from
cigarettes increased by
111% & sales declined by
17% (Jan-Nov 2013)
 Foundation to resource
public health
infrastructure, including
quitlines
Source: Regional Sin Tax Workshop, Manila, Feb 27, 2014, Roberto Iglesias & Kai Kaiser, World Bank, and from the Working Draft of the GTCR background
economics chapter
Tobacco Use Prevalence Among Adults
Source: Global Adult Tobacco Survey (GATS) 2008-2015. http://www.cdc.gov/tobacco/global/gtss/
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Source: Global Adult Tobacco Survey (GATS) 2008-2015. http://www.cdc.gov/tobacco/global/gtss/
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Source: Global Adult Tobacco Survey (GATS) 2008-2015. http://www.cdc.gov/tobacco/global/gtss/
WHO Guidelines: Developing and improving
national toll-free quitline services
10 Step Guide
10 Steps
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1: Identify an expert
2: Undertake needs assessment for a Quitline service
3: Assess place/role of Quitline services within the
national tobacco control strategy
4: Establish goals
5: Determine range of services and utilization rates
6: Strategize to create demand for the Quitline
7: Identify sponsors, funders and oversight agencies
8: Establish a project management/implementation plan
9: Confirm the organization that will deliver services
10: Determine who is accountable for ensuring success
Countries Represented Today
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Argentina
Bulgaria
Egypt
Germany
Hong Kong
India
Iran
UAE
Serbia
Sweden
Organization Profile
Source: Preworkshop Survey, WCTOH, 2015
Challenges
Source: Preworkshop Survey, WCTOH, 2015
Operational Challenges
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Enrollment protocols
Counseling protocols
Quality of service
Hours of operation
Space needs
Telephone requirements
Computer system requirements
Caution
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May take resources away from population policy
strategies
Provides the illusion of benefit if minimally supported
Lowering motivation or creating backlash if poor service
New Zealand’s National Quitline
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Offers free telephone support, low-cost nicotine
replacement therapy, and other resources to all
residents
Use television, radio, and print campaigns, along
with an interactive website and text messaging
service
Registered 44,000 - or 5% of all smokers to make a
quit attempt either by telephone or via the website
in one year
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3 Benefits
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Comprehensive Tobacco Control Programs
Health Care Systems
Media Campaigns
Point #1
TOBACCO CONTROL EFFORTS
Tobacco Use in a Population??
Attempting to quit
All tobacco users
Non-tobacco users
Using some evidence-based support
during quit attempts
Using highly effective
evidence-based support
How Do We Increase Total Long-term Quits
in a Population ??
Increase quit attempts
Sweet spot
Increase use of evidence-based support
during quit attempts
Increase effectiveness
of evidence-based support
Comprehensive Tobacco Control
Prevention
Treatment
Access
Tobacco Product
Regulation
Surveillance
Education
Tax/Price Incentives
Clean Indoor Air Laws
Treatment Access
1.2 Million Fewer people in Turkey
Smoked in 2012 than in 2008
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Source: Global Adult Tobacco Survey (GATS) Turkey 2008-2012. http://www.cdc.gov/tobacco/global/gtss/
Australia’s Smoking Decline 1991-2013
 Steady decline
in smoking
prevalence,
from 24.3% in
1991 to 12.8% in
2013
Source: http://www.health.gov.au/internet/main/publishing.nsf/Content/tobacco-kff
Tobacco Treatment Can Include:
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Health systems support
Healthcare provider training
In-person counseling
Medication availability
Quitline
Web/text support
Benefits of Quitlines to Tobacco Control Programs
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Helps normalize quitting and stimulate quit attempts
Increases overall cessation rate and reduces relapses
Increases support for tobacco control initiatives
Additional Benefits
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Serve as a central resource for direct service and a
portal for community services
Act as a hotline to report violations of smoke-free
legislation
Respond to inquiries regarding tobacco control laws
Provide support to families and friends
Tobacco Industry is Outspending
Prevention Efforts 23:1
30
25
20
15
10
State Tobacco
Revenue
(taxes and settlement
funds)
$25.6
billion
Federal
Cigarette
Tax
Revenues
$15
billion
Tobacco
Industry
Marketing
& Promotion
Spending (2008)
$10.5 billion
Smokeless
Cigarettes
5
0
Total CDCState
Recommended
Tobacco
Spending
Program
Level
Budgets
$3.7
billion
$0.5 billion
Campaign for Tobacco Free Kids, Federal Trade Commission, American Heart Association American Cancer Society, American Lung
Association, SmokeLess States National Tobacco Policy Initiative
Point #2
HEALTH CARE SYSTEMS
A Symbiotic Relationship
Quitlines
Health care
systems
&
Each can help the
other achieve the goal.
Health Providers Can Play a Vital Role in Helping
Patients Quit
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Increase patient motivation
Help motivated patients to quit successfully
Drive calls to quitlines
Support tobacco control
Quitlines Help Providers Fulfill Their Role
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Serves as an evidence-based referral
Increases willingness to conduct interventions
Helps increase quit attempts among patients
Provides additional medication usage instruction
Quitlines Revise the Tobacco Intervention Model
1. Ask about tobacco use
(including smoking and
other forms of tobacco)
and document in the
chart.
Ask
Advise
5As
Brief Tobacco
Intervention
Assess
Assist
Arrange
2. Advise patients who use
tobacco to quit. “Quitting
is one of the best things
you can do for your
health.”
3. Assess readiness to quit.
“Have you thought about
quitting tobacco?”
4. Assist the patient in
making a quit attempt
by providing self-help
materials, setting a quit
date, discussing
medications, and
discussing quitting
strategies.
5. Arrange for follow-up
care. Check in with the
patient on quitting
progress and continue to
provide support.
Ask
2As
and R
Advise
Brief Tobacco
Intervention
Refer
1. Ask about tobacco use
(including smoking
and other forms of
tobacco) and
document in the chart.
2. Advise patients who
use tobacco to quit.
“Quitting is one of the
best things you can do
for your health.”
3. Refer to trusted
resources.
Providers and Health Care Systems
Help Quitlines
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Create demand
Provide continuity of care
Offer complementary services
Build credibility
Telemarketing
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Health care systems asking quitlines to call patients
with smoking-related diseases to invite them to join
Used for patients with chronic disease conditions –
diabetes, heart and lung disease
Used for pregnant women
Include integrating quitline services with the HIV and
tuberculosis initiatives
Integration=
Long-term impact
Point #3
MEDIA
Quit
Line
WinWin
Media
Media Campaigns Benefit Quitlines
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Can increase calls
Can decrease the money spent solely on promoting the
quitline
Can demystify and normalize the process of calling a
quitline
Quitlines Benefit Media Campaigns
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Tagging ads increase the acceptability of the message
Australia
http://www.quit.org.au/media/article.aspx?ContentID=mouth-cancer
Brazil
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First country in Latin America to
launch a nationwide Quitline in
2001
First to act on the WHO FCTC
recommendation to put their
Quitline number on the back of
all cigarette packs, with graphic
pictorial health warnings
When Brazil put the telephone
number on cigarette packs, the
Quitline experienced
unprecedented call volumes.
Source: Levy D, de Almeida LM, Szklo A (2012) The Brazil SimSmoke Policy Simulation Model: The Effect of Strong Tobacco Control Policies on Smoking
Prevalence and Smoking-Attributable Deaths in a Middle Income Nation. PLoS Med 9(11): e1001336. doi:10.1371/journal.pmed.1001336
40
United States TIPS Campaign
 $54 million
 Cost <3 days of tobacco industry
spending on marketing & promotion
 300,000-500,000 in years of life saved
 <$200 per year of life saved
United States
“Tips From Former Smokers”
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“Tips” from real people
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Aimed at smokers 18-54
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12 weeks beginning March 19th, 2012
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Reaching almost 90% of 18-54 YOs in the country with a
frequency of 18.6
All ads include a call to action
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 800-QUIT- NOW, www.smokefree.gov, www.cdc.gov/quitting/tips
TIPS Campaigne Created a Demand for Services
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Policy changes
Promotion
A brand identity
Television Ads
Tips videos
Impact Evaluation of the TIPS Campaign
Saw at Least
One Ad
Quit Attempts
Quit at End
of Campaign
Likely to
Quit
Permanently
80% smokers
75% nonsmokers
1.6 million
additional
(12%) more
More than
200,000
100,000
Best Practices

Evidence based guide to help states
establish comprehensive tobacco control
programs.
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Provide integrated programmatic
structure & recommend levels of state
investment.
Total
State and
Community
Interventions
Mass-Reach
Health
Communication
Interventions
Cessation
Interventions
Surveillance
and
Evaluation
Infrastructure,
Administration,
and
Management
Total Level
($ millions)
$3,306.3
$1,071.0
$532.0
$1,271.9
$287.7
$143.7
Per Person
$10.53
$3.41
$1.69
$4.05
$0.92
$0.46
National
Recommended
Investment
Source: Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs - 2014. Atlanta: U.S. 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, 2014.
Innovation and
Integration is the Future
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New clinical approaches
Adapt to evolving policy context
Use intelligent technologies (digital health systems)
Ensure cost efficiencies
Integrate into primary health care/national health
systems
Resources
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CDC Media Campaign Resource Center
Global Dialogue on Stop Smoking
New South Wales Cancer Institute
Quit Victoria
World Lung Foundation
World Health Organization
Quitlines Work Best When Integrated
Into Larger Comprehensive Tobacco
Control Program and National Health
Systems
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: [email protected]
Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
National Center for Chronic Disease Prevention and Health Promotion
Office on Smoking and Health