7.14 Cessation assistance: telephone- and internet-based interventions

Last updated: October 2016 

Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.14 Cessation assistance: Telephone- and Internet-based interventions. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from: http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-14-methods-services-and-products-for-quitting-te

Assistance to smokers wanting to quit can be delivered through many different platforms. Telephone- and internet-based interventions offer enormous potential for the delivery of low cost and high reach cessation interventions.

7.14.1 Telephone services (Quitlines)

Telephone services can provide information, advice, and support to smokers interested in quitting, either as a supplement to or substitute for other types of cessation assistance. While face-to-interventions are effective, telephone counselling is cheaper and more widely accessible, and can be tailored to the needs of the individual. Telephone services can be proactive, such that the counsellor initiates the call to support a quit attempt or help with relapse prevention, or reactive, such that smokers or their friends or family can make the call.1 Telephone-based services can form part of more general services, such as cancer information hotlines.1 They can also be specific to smoking, such as Quitlines in the US,2 New Zealand,3 UK,4 Thailand,5 and Australia.6 The Quitline is a specialised telephone information and counselling service for people interested in smoking cessation, which provides accessible and affordable tailored support and information to smokers wishing to quit. The support can be one-off or extended.7

7.14.1.1 Efficacy of telephone services

A 2013 Cochrane review of telephone counselling for smoking cessation concluded that proactive telephone counselling helps smokers who seek help from Quitlines. Quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness. There is limited evidence about the optimal number of calls; however, there is some evidence that a higher number of calls provide a greater benefit, with one or two brief calls being less likely to provide a measurable effect. Three or more calls increase the chances of quitting compared to a minimal intervention such as providing standard self-help materials, or brief advice, or compared to pharmacotherapy alone.1

Subsequent international research has also explored the outcomes of Quitline services. A 2014 systematic review concluded that telephone helplines can have a positive effect on tobacco smoking.8 Research in the Netherlands found that Quitline counselling significantly increased self-efficacy to refrain from smoking, avoidance of smoking cues, and acceptance of internal cues to smoking compared to self-help material.9 However, more frequent and greater urges to smoking can predict failure in smoking cessation among Quitline callers.10 Among a sample of smokers who had previously used Quitline counselling, the majority thought their chances of quitting would have improved if they had spoken with the same advisor each call.11 A comparison of the effectiveness of Quitline and internet-based cessation services found that while both increased quit rates, Quitline users more likely to achieve abstinence.12 Proactive telephone counselling also appears to be more effective than self-help resources.13 Follow-up telephone counselling may also help to prevent relapse.14

Combining telephone and Internet-based cessation services may be more effective than using either service alone,15 while adding a text messaging service to a Quitline service does not appear to improve smoking cessation rates beyond those achieved by offering comprehensive Quitline services alone.16 Research in the US, where NRT or pharmacotherapies are available free of charge to all Quitline callers, found that all service types resulted in cessation rates of 40 per cent or greater, regardless of whether cessation products were provided in addition to coaching.17 Another study found that after just one specially designed telephone-based counselling session combined with NRT, about one third of the participants had quit at 7 and 30 days and at 7 months post-intervention.18 Quitlines can also increase smokeless tobacco abstinence.19

7.14.1.2 Increasing reach and usage of telephone services

An important consideration is how best to increase the number of smokers who call the Quitline. Interviews with a diverse sample of smokers in the US found that they largely perceived the Quitline as a last resort, and were generally unwilling to use the service, suggesting the need for marketing that raises awareness of the nature and benefits of Quitlines.20 Receiving advice from a health professional and higher state tobacco program expenditures are associated with higher Quitline awareness and utilisation in the US.21 An analysis of state Quitline data from the US also found that an evidence-based national tobacco education campaign with adequate reach and frequency can lead to substantial increases in Quitline use.2, 22 On a smaller scale, Dutch research study found that intensive Quitline support tailored to smoking parents who were recruited via their children’s primary school was an effective method for helping parents to quit and promoting parenting practices that protect their children from adverse effects of smoking.23 Proactive outreach to smokers that connects them to evidence-based telephone cessation services can increase long-term population-level cessation rates.24 Quitline registries might also be useful for re-engaging relapsed smokers, through inviting past callers back to the service.25

7.14.1.3 The Quitline in Australia

In Australia, each state and territory funds the Quitline service (13 7848 – 13 QUIT) within its own jurisdiction. Administrative arrangements for the service vary from state to state: some operate from within the state alcohol and drug treatment services and others are based in non-government health organisations contracted to provide the service. All services operate to an agreed set of national minimum standards for the range of services provided, response times for calls, data collection, and the training and qualifications of counsellors.26 There are also agreed protocols for supporting callers with special needs, such as pregnant smokers, those with mental illness, young people, and those from Aboriginal and culturally and linguistically diverse communities. From the beginning of July 2009 to the end of June 2011 there were 185,800 calls to the Quitline throughout Australia.27 The proportion of smokers who cited the financial burden of smoking as a reason to quit increased dramatically alongside large tobacco tax increases, highlighting the importance of promoting cessation services concurrent with policy change.28 There has also been a sustained increase in calls to the Quitline after the introduction of tobacco plain packaging.29

A significant advantage of the Quitline is that it provides equity of access in regard to income, language, and location. For the price of a local landline telephone call, Quitline provides 24-hour access to confidential advice, support, courses, self-help resources, and telephone counselling for smokers who want to quit. Counsellors are non- or ex-smokers and usually have tertiary qualifications in psychology, counselling or related fields, as well as specialist training in smoking cessation. They provide tailored and evidence-based support throughout all stages of the quitting process, from thinking about quitting through to relapse prevention and maintaining abstinence. There are also specific programs for priority populations, such as people living with mental illness (especially depression), prisoners, pregnant women and partners, and cancer patients.

The Australian Quitline service has been evaluated in several studies including in 1997/98, after its first year of national promotion as part of the National Tobacco Campaign. Callers rated the Quitline positively: 97% said it was either very or somewhat friendly, 86% said it was helpful, and 82% said they would recommend it to friends. When callers were followed up at 12 months, 29% were currently not smoking , although only 6% had been continuously abstinent over that time.30 An evaluation of the South Australian service in 2010 found that 88% of the callers sampled had made a quit attempt since their initial call to the Quitline. Of those who had made a quit attempt, 38% had quit at six-month follow-up. At one year, 96% said they had made a quit attempt, and 38% were abstinent at the time of interview. Assuming that those who could not be contacted for follow-up were all smokers, the conservative quit rate estimate would be 20%.31 In the 2010 Victorian evaluation, 81% of callers were very satisfied and 15% somewhat satisfied with the service received from an advisor; 95% of callers said they would recommend the service to a friend and 89% said they would use the service again in the future if necessary.31 The callback service, whereby counsellors proactively phone users, led to higher quit rates in both states in smokers that used the service compared with those who did not.6, 31

7.14.1.4 Telephone services for high-need groups

A longitudinal evaluation of callers in NSW found that Quitline callers’ tobacco consumption and dependence decreased between 2008 and 2011, but they remained more addicted than the average NSW smoker.28 In regards to Aboriginal and Torres Strait Islander people, South Australian research found that while the proportion of Indigenous and non-Indigenous smokers who registered for the Quitline service was comparable, Indigenous callers received significantly fewer callbacks, were significantly less likely to set a quit date, and were successfully less likely to be successfully quit at 3 months.32

Quit rates among priority population callers to a Quitline suggest that the service is effective when used by high risk and underserved populations.33 However, access to the Quitline can be a hurdle for such groups. A study in the US found that over one-third of low socioeconomic smokers did not have access to a phone they could use to call the Quitline. There were also low levels of knowledge about the Quitline, quitting, and trust in tobacco treatment programs, and mixed feelings about the costs and benefits of quitting; for example, some participants were concerned about getting sick if they quit.34 New Zealand research found that smokers in rural areas were less likely to use the Quitline, suggesting that the service is less effective in reaching rural smokers.35 Quitline callers who report a history of mental health conditions and/or recent emotional challenges also appear to be less likely to successfully quit.36 Among mental health patients, a specialised telephone counselling intervention may be more effective.37

7.14.2 Text messaging (SMS) services

Mobile phones are widely used and are now well integrated into the daily lives of many people, particularly young adults. Mobile phones are increasingly being used by health services, for example for appointment reminders, to promote preventative activities, for medication adherence, and to self-manage chronic disorders. Recent years have also seen the increasing use of mobile phones for smoking cessation support, particularly as an adjunct to existing programs such as the Quitline. Mobile phone-based cessation interventions are widely and easily accessible, and can be tailored to the individual smoker. They can also serve as a distraction from cravings, and provide social support.38 Text messaging interventions generally send messages that are grounded in social cognitive behavioural theories, such as behavioural change techniques and individually tailored messages based on demographic information.39

A systematic review concluded that the advantages of mobile phones for cessation interventions include low cost, better reach, increased interaction between researcher and participants, and easier as well as faster way to send tailored and personalised messages.40 A meta-analysis of SMS text message-based interventions for smoking cessation published in 2015 found that quit rates for the text messaging intervention group were 35% higher compared to the control group.41 A 2016 Cochrane of the effectiveness of mobile phone-based interventions for quitting concluded that the current evidence supports a beneficial impact of mobile phone-based interventions on six-month cessation outcomes. The interventions were predominantly text messaging-based.38 Two additional meta-analyses published in 2016 similarly support the efficacy of mobile phone- and text-based interventions for smoking cessation.42, 43

Researchers have also examined usage patterns and individual differences among users of mobile phone-based interventions. An examination of the use of a text messaging intervention in Australia found that while some users complied fully with the requirement to report any changes in their quit status, even among those who did not, many found the intervention to be very helpful, suggesting that it is not essential for the message to fully align with the person’s current smoking behaviour.44 A study of users in the US and the UK concluded that short and low-effort communications, such as text messaging, might be useful for smokers with low motivation to quit.45 Smokers report that text messaging interventions provide emotional support and reinforcement at temporally appropriate moments.46 One study found that Interactive text messaging via the ‘WhatsApp’ messaging service was effective in reducing relapse, and this was attributed to enhanced discussion and social support.47 Text messaging is also effective among adolescents,48 and tailoring and higher frequency of text messages increases quit rates among young smokers.49 Among another sample of adolescents, readiness to stop smoking (an important predictor of cessation) mediated the effects of the intervention on smoking for those with fewer friends smoking, but not for those with more friends smoking, highlighting the importance of peer-focused interventions for young people.50

Integrating proactive messaging that promotes pharmacotherapy options can increase utilisation of cessation medications.51 Australian researchers recently explored whether receiving text messages that provide advice, motivational reminders, and support can promote change in unhealthy lifestyle behaviours among patients with coronary heart disease. Participants in the intervention group received four text messages per week with messages such as, “Don't forget physical activity is good for you! It reduces your risk of diabetes, heart attack and stroke”, in addition to usual care. Those in the intervention group experienced a greater improvement in cardiovascular disease risk factors, including a significant reduction in smoking, compared with those who received usual care alone.52 Researchers in the UK have adapted a tailored SMS cessation service (MiQuit) in order to test its feasibility and uptake in routine antenatal care settings. They found that the service, which was a low-intensity, cheap cessation intervention promoted at very low cost, resulted in a small but potentially meaningful rate of uptake by pregnant smokers.53

7.14.3 Smartphone applications (apps)

Smartphones, by incorporating computer operating systems and enabling Internet access, have substantially broadened the functionality of mobile phones. At the time of the 2012 Cochrane review of mobile phone-based interventions, there were no published studies on smartphone apps designed to help people quit.54 However, recent years have seen the proliferation of health and wellness apps, including those that support smoking cessation. Smartphones apps have the potential to overcome limitations of website and text messaging interventions, whilst maintaining all of their benefits. Specifically, smartphone apps can boost user engagement—an important predictor of cessation—through incorporating these important features: (1) available at arm's reach, (2) visually-engaging design, (3) video and audio capabilities, (4) unrestricted text capabilities, (5) access without phone or internet connection, (6) immediate access to intervention content, (7) optimised to smartphone screen size, (8) content sharable via social media, and (9) tracking progress at anytime.55

A study that took place over one year in Australia, the UK, and the US concluded that a smartphone app was able to reach smokers across the three countries that were not seeking professional help, but were ready to quit within the next 30 days.56 US research found that delivering acceptance and commitment therapy (ACT) via a smartphone app was feasible and showed higher engagement and promising quit rates compared to an app that followed US Clinical Practice Guidelines.55 Another study found that including elements of both ACT and traditional cognitive behavioural therapy (CBT) in a cessation app was appealing to users and was associated with successful quitting.57 Interviews with users of an app revealed that tips for coping were more commonly used than distractions to cope with cravings, because they helped solidify the quit attempt and provided opportunities to connect with other users.58

As with other types of interventions, apps may need to be tailored to better reach and engage priority populations. A recent study explored characteristics of high and low users of a smoking cessation mobile phone app (SmartQuit), and found that lower education, heavier smoking, and depression predicted lower use of the app. Women, those with lower education, and heavier smokers had lower utilisation of several features of the app likely to predict smoking cessation. The authors suggest that increasing engagement with these groups could improve the effectiveness of the app in promoting cessation.59 Another recent study explored the experiences of people with serious mental illness using a cessation app. Data showed that participants found the app difficult to use and that they needed considerable guidance, while interviews highlighted the importance of breaking down "cessation" into smaller steps and using a reward system.60

Despite their advantages, the quality of cessation apps can vary substantially. A content analysis of how ‘smart’ smartphone apps are found that while users value tailored feedback, many apps fall short in this area, and are limited in their capabilities. However, many smokers are open to using such apps, so this represents an important area for future development.61 Another analysis found that most apps to not adhere to clinical guidelines on smoking cessation.62 A study in New Zealand that ranked smartphone apps for smoking cessation by their quality found that most did not perform particularly well. The highest scoring app was produced by the Australian National Preventive Health Agency, called "Quit Now: My QuitBuddy". The researchers highlight that more evidence is needed to support the effectiveness of smartphone apps, but that health professionals may wish to recommend the highest quality apps in conjunction with existing evidence-based methods.63

7.14.4 Internet-based interventions

In 2015, it was estimated that there were 3.17 billion Internet users worldwide.64 The Internet offers enormous potential for the delivery of low cost and high reach cessation interventions.65 “Quit smoking” is a popular online search term,66 and online treatment programs, being convenient, anonymous, and accessible 24 hours a day, are able to overcome barriers that commonly prevent people from accessing existing cessation services. They may also be more effective in reaching young people than more traditional services.65 A review of technology-based interventions for college students concluded that there is great potential for such interventions to reach large numbers of students, many who may not identify themselves as smokers or seek traditional methods for treatment.67 Print materials that are tailored for the individual are more effective than non-tailored ones,68 and interventions on the Internet can be highly personalised to mimic one-to-one counselling.65

Despite their great potential, there are several limitations of Internet-based cessation interventions. Although there are a large number of smoking cessation websites, not all provide an intervention, or of those that do, it may not be evidence-based.65 Such websites also vary in quality and credibility, ranging from being comprehensive and well researched to sites set up by tobacco manufacturers. There is some evidence that people using the Internet for smoking cessation information often do not access research-based sites.69 People of higher socioeconomic position may also have greater access and usage of online health information compared to those from lower socioeconomic groups.70

Some evidence suggests that Internet-based cessation interventions are as effective as smoking cessation therapies or groups, but are much less costly in terms of time and money.71 A meta-analysis of randomised controlled trials72 and a systematic review,73 both published in 2009, concluded that Internet-based smoking cessation programs can be effective in aiding quitting. A 2012 systematic review and network meta-analysis concluded that computer and other electronic aids increase the likelihood of cessation compared with no intervention or generic self-help materials, but the effect is small. Such interventions are likely to be highly cost-effective.74 A 2013 Cochrane review concluded that some Internet-based interventions can assist smoking cessation at six months or longer, particularly those which are interactive and tailored to individuals. However, results from studies that compared Internet interventions with usual care or self-help were mixed and at risk of bias.65 A subsequent systematic review and meta-analysis published in 2016 concluded that internet interventions are more effective than other broad reach cessation interventions, such as print materials, and are equivalent to other well-supported treatments such as telephone and face-to-face counselling.75

Treatment utilisation, smoking self-efficacy, and social support are important factors in the relationship between Internet and telephone treatment and smoking abstinence.76 Internet-based group contingency management, whereby small teams of smokers must collectively meet abstinence goals to receive financial rewards, appears to be effective in increasing smoking abstinence.77 Internet-based contingency management for individuals may also promote higher rates of short-term abstinence, while other online features such as feedback, frequent monitoring, and goals appear to reduce smoking over the longer term.78 Internet-based interventions may also be useful for preventing smoking among young people. A randomised controlled trial in the Netherlands concluded that a computer-tailored smoking prevention programs are a promising way of preventing smoking initiation among adolescents for at least 6 months, in particular among those 14-16 years.79

Users of online cessation services are generally younger, healthier smokers of higher socioeconomic status.80 Tailoring materials to the smokers’ reading level may support cessation among disadvantaged groups; a study in the UK fond that an easy reading version of computer-tailored smoking cessation advice was better perceived than the standard version, and appeared to have a small, but promising effect in smokers with a lower literacy level.81 A randomised controlled trial that tested an interactive internet-based intervention designed with particular attention directed to people with low socioeconomic status found that it was more effective than an information-only website in smokers of low, but not high, socioeconomic status.82 Another study that used a specially developed novel, web-based, motivational, decision-support system for disadvantaged smokers found that it increased initiation into cessation treatment and abstinence rates.83 Tailored, video-based messages might also be effective in increasing abstinence rates for smokers with diverse education levels.84 In comparing tailored digital interventions, a Dutch study has found that a video-based computer-tailored intervention was more effective in obtaining substantial long-term abstinence than a text-based version and a brief generic text advice.85 Such interventions are also cost-effective.86

Quit Coach (www.quitcoach.org.au) is a tailored, internet-delivered smoking cessation advice program supported by Quit Victoria. Most users of the Quit Coach use it to support a quit attempt and, for those who continue to use the Quit Coach, to help them stay quit. However the majority of users only visit the site once.87 The site successfully targets people who are moderately addicted, with users being more likely to be female, younger, and users of the Quitline.88

7.14.4.1 Social media

Social media sites, such as Facebook and Twitter, are immensely popular among young adults, and with their potential for wider reach and greater engagement are increasingly being used in health-related research and interventions.89 A study that examined a Twitter-based intervention for smoking cessation found combining traditional online social support with daily auto-messages that encourage high-quality interactions showed promise for smoking cessation. The more that people tweeted about a quit date, using nicotine patches, countering roadblocks, utilising self-rewards, believing in themselves and feeling pride, the more likely they were to remain smoke-free.90 A content analysis found that a higher frequency of tweets that included socioemotional support and encouragement was significantly associated with higher number of followers.91 The NHS have also recently run a trial whereby unsolicited messages were sent to users on Twitter who mentioned their smoking habits, giving tips on how to quit and directing them to a smoking helpline.92

Facebook has good potential to be an accessible, low-cost platform for engaging young adults to think about the reasons for their tobacco use, the benefits of quitting or reducing, and the best strategies for tobacco reduction.93 Encouraging participation via frequent moderator posts can increase community engagement with and reach of Facebook pages.94 An analysis of the Facebook page of an evidence-based cessation intervention for young adults in Canada found that the majority of posts aimed to either support smoking cessation or to market the intervention. Seven subthemes of support were identified: encouraging cessation, group stimulation, management of cravings, promoting social support, denormalising smoking, providing health information, and exposing tobacco industry tactics.95 Facebook is also a useful, cost-effective source for recruiting young adult smokers for cessation studies.89

Research in Canada examined the effectiveness of a social media campaign called “Break it off”, on young adults’ rates of smoking cessation. It uses a “break-up” metaphor, comparing quitting smoking with ending a romantic relationship. The campaign’s website guides users through the stages of ending their relationship with smoking: getting it over with, staying split up, and moving on with life. The site educates users about established quit methods, and allows them to share their experiences on social media (e.g., announcing their “break-up” on Facebook). Another key feature is a smartphone app that provided instant support during specific trigger points. Users of the campaign had significantly higher 7- and 30-day quit rates than those who used a helpline, and were more likely to have made a quit attempt, indicating that a multi-component digital and social media campaign offers a promising opportunity to promote smoking cessation.96

Although social media represents a promising platform for cessation interventions among young people, studies have often struggled with low participation or engagement. Researchers in the US found that tailoring intervention content to the person’s stage of readiness to quit may promote higher engagement; participants not ready to quit in the next 30 days (in Precontemplation or Contemplation) engaged most when prompted to think about the pros and cons of behaviour change, while those in the Preparation stage engaged most when posts increased awareness about smoking and smoking cessation.97 The reach of social media sites may also need strengthening. An analysis in the US concluded that the current reach of state tobacco control program social media sites is low and most are not promoting existing cessation services or capitalizing on social media's interactive potential.98

7.14.5 Increasing smokers’ use of telephone- and internet-based services

The overall impact of smoking cessation interventions in reducing smoking prevalence is a product of the interventions’ reach and efficacy. Use of support services such as the Quitline continues to be low relative to their potential.99 Strategies that recruit more smokers to high-efficacy, low-cost services such as telephone- and internet-based interventions may help to increase the number of smokers who successfully quit.

Demand for these services is largely a function of how much they are promoted. Mass media campaigns can effectively promote evidence-based Quitlines.4 In the US, an evidence-based national tobacco education campaign substantially increased Quitline use.2, 22 In Australia, the national Quitline number was promoted through all National Tobacco Campaign advertising beginning in 1997, including on the end frame of campaign television advertisements. This promotion led to a significant increase in calls to the Quitline.100-102 See Chapter 14 for further information on social marketing campaigns. Campaigns may also promote web-based programs or encourage smokers to use SMS to access support. For example, anti-smoking advertising is also related to increased use of the Quit Coach.88

Placement of the Quitline number on cigarette packaging is another form of promotion that increases awareness of the service and the proportion of new callers.103 Direct telemarketing of the Quitline service in Australia to smokers has also been trialled with some success. A study in New South Wales found that cold calling was acceptable to many smokers, especially if it offered subsidised nicotine replacement products.104 This approach is a cost-effective way of increasing the proportion of smokers using Quitline support and recruiting smokers currently under-represented in Quitline populations,105, 106 as well as increasing rates of cessation.107 Quitline registries can also be used to re-engage relapsed smokers, through inviting past callers back to the service.25

Understanding and addressing the barriers to use of the Quitline by smokers may help to more effectively develop strategies to increase calls.108 Barriers to using services include lack of knowledge about the service, people preferring to quit without support, and a belief that the service would not be helpful to them personally.104, 109 Smokers often report being unwilling to use the service, and view it as a last resort.20 Among low socioeconomic smokers, lack of access to a phone and low levels of knowledge about quitting can hinder use of the Quitline,34 and the service may also be less effective in reaching rural smokers.35

Enhancing relationships between health professionals, healthcare systems and the Quitlines may increase referrals and the use of proactive telephone support by smokers.110 There is some evidence that a pay-for-performance program (whereby healthcare professionals receive financial rewards for making referrals) increases referral to Quitline services.111 Receiving advice from a health professional is related to higher Quitline awareness and utilisation in the US.21

Quitlines offer population access to cessation support, but very few also offer pharmacotherapy. Some studies have found that the addition of free NRT to a quitline is a cost-effective strategy that increases calls and may increase cessation rates.112-114

Many people search for smoking cessation information online. Online advertising has potential to increase smokers’ use of evidence-based web and Quitline support. Research suggests that compared to traditional recruitment approaches, online advertisements recruits a higher percentage of males, young adults, minority groups, those with lower education levels and more highly addicted smokers.115

Recent news and research

For recent news items and research on this topic, click here (Last updated June 2018)     

 

References

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