Assistance for people wanting to quit smoking can feasibly be delivered through many different platforms. Telephone-based interventions are low-cost and high-reach, and internet-based interventions offer enormous potential for further reducing costs and increasing reach in communities with good digital access. Table 7.14.1 summarises findings from major reviews1-3 of the effectiveness of such interventions.
For a discussion of the tailoring and effectiveness of interventions for priority populations, including low-income groups, see Chapter 9, and for interventions targeting pregnant women, see Section 7.11.
7.14.1 Telephone services (Quitlines)
Telephone services can provide information, advice, and behaviour change counselling to people 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 equally 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 individuals initiate the call.4 Telephone-based services can form part of more general services, such as cancer information hotlines.4 They can also be specific to smoking, such as quitlines in the US,5 New Zealand,6 UK,7 Thailand,8 and Australia.9 In Australia, the Quitline™ is a specialised telephone information and counselling service which provides accessible and affordable tailored support and information for people who smoke and/or vape. The support can be one-off or extended.10
7.14.1.1 Efficacy of telephone services
A 2019 Cochrane review of telephone counselling for smoking cessation concluded that proactive telephone counselling (which involves outbound calls to engage the tobacco user in ongoing treatment) helps people who seek help from quitlines and those in other settings1 and a 2020 report from the US Surgeon General similarly concluded that proactive quitline counselling, when provided alone or in combination with cessation medications, increases smoking cessation.11 The Surgeon General further concluded that quitlines are an effective population-based approach to motivate quit attempts and increase smoking cessation.11 The Cochrane review found that telephone counselling appeared to increase the chances of quitting, regardless of whether people were motivated to quit or were receiving other cessation support. Limited evidence suggests interventions offering three to six calls may be more effective than those offering one call only. There were not enough studies on the effect of reactive telephone counselling to draw any conclusions.1
In many jurisdictions in the US, quitlines also provide nicotine replacement therapy (NRT) and in some cases other cessation medications. In Australia, the Queensland Quitline provides free NRT to callers from priority groups12 and similar programs are being trialled in other states. Making cessation medication available to callers and promoting its availability increases calls to quitlines and may increase quit rates by providing callers with the optimal combination of cessation counselling plus medications.11,13,14 Quitlines can also increase smokeless tobacco abstinence.15
7.14.1.2 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: one operates from a state health contact centre, while the others are contracted to non-government health organisations (Cancer Councils) or commercial contact centres.
A set of National Quitline Minimum Standards16 was developed by Cancer Council Victoria, the owner of the national Quitline telephone and fax numbers and the Quitline trademark, and implemented in 2021. The Minimum Standards set out response times for calls, data collection, and the training and qualifications of counsellors, plus agreed protocols for supporting callers with special needs, such as pregnant people, those with mental illness, young people, and those from Aboriginal and culturally and linguistically diverse communities. In 2024, Version 2 of the Minimum Standards was released after a comprehensive review, broadening Quitline’s scope to include evidence-based clinical support for people who vape17—see Section 18.11 for information on quitlines for vaping cessation. The proportion of people who smoke 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.18 There was also a sustained increase in calls to the Quitline after the introduction of tobacco plain packaging.19
A significant advantage of the Quitline is that it provides equity of access with regard to income, language, and location. Inbound calls to Quitline are charged at standard local or mobile rates, while outbound calls made by Quitline to clients are provided at no cost to the recipient. Quitline offers confidential advice, support, self-help resources, and telephone counselling for people who smoke. Counsellors are never- or ex-smokers and have a minimum qualification in psychology, counselling or related fields, as well as specialist training in smoking cessation according to WHO Training for tobacco quitline counsellors.20 Counsellors provide tailored and evidence-based support throughout all stages of the quitting process, from thinking about quitting through to relapse prevention and maintaining abstinence. Counsellors draw on a range of counselling modalities, such as motivational interviewing and cognitive behaviour therapy. See Section 7.15 for an overview of counselling modalities and their effectiveness for smoking cessation. There are also specific programs for priority populations, such as people living with mental illness (especially depression), people experiencing incarceration, pregnant women and partners, and Aboriginal and Torres Strait Islander peoples.
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.21 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 people who smoked, the conservative quit rate estimate would be 20%.22 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.22 The Australian Quitline callback service, whereby counsellors proactively phone users, led to higher quit rates in both states among people who smoke that used the service compared with those who did not.9,22
Economic evaluations of the Quitline in Australia have also concluded that they are highly cost-effective—see Section 17.4.2.7.
7.14.1.3 Telephone services for high-need groups
Quit rates among priority population callers to a quitline suggest that the service can be effective when used by high-risk and underserved populations.23 However, a 2022 review found that most studies examining the effectiveness of quitlines do not reflect these populations, leading to gaps in the evidence.24 Further, access to the quitline can be a hurdle for such groups. A 2015 study in the US found 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.25 New Zealand research found that people living in rural areas who were less likely to use the quitline.26 In Australia however, people who smoke who live in low socioeconomic status areas appear to be just as or more likely to contact the Quitline—see Section 9.9. 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 person who smokes,18 suggesting that they may need more intensive or extended support. US research also suggests that more intensive quitline support may be helpful for people with lower education levels.27
Two in five (40% of) Quitlines callers report having a current mental health condition, according to an analysis of the NSW Quitline. Callers with a mental health condition on average had higher nicotine dependency and made more quit attempts prior to engaging with the service, compared to those without mental health conditions.28 Callers with a mental health conditions tend to engage with quitlines more frequently and for longer durations, and are also more likely to utilise supplementary supports such as text message and email services, and free NRT.28,29 While desire to quit and likelihood of making a quit attempt is similar,28 callers who report a history of mental health conditions and/or recent emotional challenges appear to be less likely to successfully quit.30 Aspecialised telephone counselling intervention may increase engagement in treatment for people with mental health conditions,31,32 and may be more effective.33 There is also the potential for cessation interventions to be paired with additional behavioural interventions, such as treatment for depression.32 A trial of a tailored Quitline intervention and combination NRT for individuals receiving support for mental health conditions in Victoria showed promising improvements in short-term abstinence compared to brief advice.14 See Section 9A.3 for more information on smoking among people with mental health conditions and effectiveness of cessation inventions.
The Australian Government’s Tackling Indigenous Smoking (TIS) Initiative includes funding to enhance existing Quitline services—see Section 8.13.5 for an overview of this program. Between 2016 and 2020, over 12,000 Aboriginal and Torres Strait Islander people used the Quitline, with the majority residing in TIS areas.34 South Australian research found that while the proportion of Aboriginal and Torres Strait Islander and non-Indigenous people who smoke who registered for the Quitline service was comparable, Aboriginal and Torres Strait Islander callers received significantly fewer callbacks, were significantly less likely to set a quit date, and were significantly less likely to be successfully quit at three months.35 See Section 8.10.4 for a summary of the effectiveness of quitlines for Aboriginal and Torres Strait Islander peoples.
A US study found people with low incomes who smoke were interested in digital cessation services in addition to quitlines including mobile apps, personalised web programs and online chat with quit coaches.36
7.14.2 Text messaging services
Mobile phones are used widely and are well integrated into the daily lives of many people, particularly young adults. Short Message Services (SMS) through people’s 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 text messaging for smoking cessation support, particularly as an adjunct to existing programs such as quitlines. In the US in 2017, 55% of state tobacco quitlines provided interactive text messaging.37 Mobile phone-based cessation interventions are widely and easily accessible. 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
The US Surgeon General concluded in 2020 that services providing short text messages about quitting are independently effective in increasing smoking cessation, particularly if they are interactive or tailored to individual text responses.11 A 2019 Cochrane review similarly found that text messaging programs may be effective in supporting people to quit, increasing quit rates by 50% to 60%,2 and a 2021 Cochrane review examining behavioural interventions for cessation concluded that there is moderate‐certainty evidence that text message interventions are beneficial.40 An earlier 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.41 Additional meta-analyses have similarly supported the efficacy of mobile phone- and text-based interventions for smoking cessation42-49 and cessation specifically among young people50.
Despite their promise, further research is needed to more fully understand the most effective elements of text-messaging interventions. Studies to date have had substantial variation in key features of the interventions, including frequency of messages per day and per week; length of programs; use of unidirectional versus bidirectional messages; and message content. Variations in study design, such as the endpoint used for measuring abstinence, have also presented a challenge when interpreting findings. Nonetheless, the overall evidence supports the efficacy of text-based cessation interventions.11
7.14.3 Smartphone applications (apps)
Smartphones, by incorporating computer operating systems and enabling internet access, have substantially broadened the functionality of mobile phones. Recent years have seen the proliferation of health and wellness applications (‘apps’), including those that support smoking cessation. Smartphone apps have the potential to overcome limitations of website and text messaging interventions, while maintaining all of their benefits. Specifically, smartphone apps could 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 any time.51 However, despite showing promise,52,53 a Cochrane review in 2019,2 the US Surgeon General’s report in 2020,11 and several review papers54-57 have all concluded that there is currently inadequate evidence to determine the effectiveness of smartphone apps for smoking cessation. Though a meta-analysis has found that smartphone apps in combination with pharmacotherapy had a greater effect on smoking abstinence rates compared to pharmacotherapy alone.58
Despite their potential advantages, the quality of cessation apps can vary substantially. A content analysis of smartphone apps to assess how ‘smart’ they actually are found that while users value tailored feedback, many apps fall short in this area, and are limited in their capabilities.59 Smoking cessation app users also cite the importance of personalisation, support, functionality, and credibility.60 A meta-analysis found that mobile based interventions that had personalised or interactive features were associated with moderate increases in cessation.48 Several analyses have found that most apps do not adhere to clinical guidelines on smoking cessation,61 such as incorporating elements of evidence-based support or therapies such as CBT.62-64 The highest quality apps combine both information and several assistive functions (for example, the provision of several of the ‘5As’).65
A 2015 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".66 Another review of apps available in Australia identified only six that were ‘high quality’ in 2017: SF28; HPB I Quit; My QuitBuddy; QuitStart; SmartQuit; and SmokeFree Baby.67 A 2021 review found wide variation in the methods, design and types of participants included in studies examining smartphone apps for cessation, and called for greater consistency and larger trials of such interventions.54 In 2022 the World Health Organization launched a smoking cessation app, ‘Quit Tobacco App’.68 Although apps are more commonly used by younger people who smoke, Australian research has found that My QuitBuddy may promote cessation among older Australians who are willing to use it.69 Health professionals may wish to recommend the highest quality apps in conjunction with existing evidence-based methods,66 including face-to-face support.70 One review noted that although evidence-based apps are available, they are difficult to find among the many apps that are identified through app store searches.71 Problematic apps that are likely ineffective appear to have a large market share.65
7.14.3.1 Ecological momentary interventions
Ecological momentary interventions (EMIs), which use mobile technology to assess real-time experiences, cravings and thoughts during daily life and deliver tailored and contextually relevant support as needed, also show promise. Some EMI interventions use wearable sensors (i.e. armbands/smartwatch) to provide automatic feedback and objective verification of smoking status; however, most of these are still in the early stages of development.72,73 A 2023 meta-analysis of studies exploring the efficacy of EMIs found higher rates of smoking abstinence among those using them compared to participants in control groups.74
7.14.4 Chatbots
Chatbots, also known as conversational agents, are digital tools designed to simulate real-time human conversation. They use programmed rules or artificial intelligence to understand messages, respond to questions, and carry out tasks within a chat-like interface. Chatbots can deliver personalised support that is continuous, accessible and scalable for a large number of users.75 Reviews have found promising evidence that chatbots may aid smoking cessation though more research is needed to determine their efficacy.76,77 One study found that an AI-based app combined with usual care (i.e. pharmacotherapy plus behavioural support) may also increase abstinence beyond usual care alone.78,79 Users of chatbots expressed preferences for greater control over the pace of chatbot interventions and interaction (for example, preferred to interact with the agents at their own pace and in their own words rather than using pre-defined keywords).76
7.14.5 Internet-based interventions
As of 2025, there were an estimated 6 billion active internet users worldwide (74 per cent of the global population).80 The Internet offers enormous potential for the delivery of low-cost and high-reach cessation interventions.81 ‘Quit smoking’ is a popular online search term,82 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.81 An analysis of the Smokefree.gov initiative in the US found that use has grown over time, with 7–8 million people accessing its web- and mobile-based resources in 2018.37
The US Surgeon General concluded in 2020 that Internet-based interventions increase smoking cessation and can be more effective when they contain behaviour change techniques and interactive components.11 A Cochrane review published in 2017 also found that internet programs that were interactive and tailored to individual responses led to higher quit rates than usual care or written self‐help at six months or longer.3 Additional reviews similarly support the effectiveness of internet-based interventions for increasing the odds of successful cessation.46,83-88 A 2019 meta-analysis found that internet-based interventions that included goals and planning, social support, natural consequences, comparison of outcomes, reward and threat, or regulation were more effective in the short and long terms, when compared with study arms that did not include such behaviour change techniques.87 Support via live chat appears to be a helpful addition to cessation websites.89,90
Despite their great potential, Internet-based cessation interventions have several limitations. People of higher socioeconomic position may have greater access and usage of online health information;91 users of online cessation services are generally younger, healthier and with higher socioeconomic status.92 The Cochrane review noted that the effectiveness of such interventions in youngerpeople who smoke is unknown.3 Although there are a large number of smoking cessation websites, not all provide an intervention, or if they do, it may not be evidence-based.81 Such websites also vary in quality and credibility, ranging from the 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.93 However, as internet-based interventions have grown more sophisticated, incorporating better website design and improved functionality, the efficacy of such interventions has substantially improved.11
7.14.5.1 Social media
Social media is 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.94 Two reviews of social media interventions for smoking cessation concluded that while such interventions hold promise, and are feasible and acceptable, more research is needed to examine their effectiveness.95,96 One suggested that additional efforts are needed to determine effective strategies to promote user engagement in social media interventions as well as to investigate which type of engagement leads to sustained smoking cessation. Different age groups and segments of the population have preferences for different social media platforms, and such preferences change over time. Therefore, future studies should aim to be translatable to other platforms as well as identify how different elements—such as group size and baseline characteristics, length and type of engagement, and tailored content—contribute to the effectiveness of social media interventions.96
Most recently, a 2021 review of the effectiveness of using social media for smoking cessation concluded that such interventions have demonstrable potential to: recruit and retain people who smoke online; deliver cessation interventions; collect clinically meaningful cessation outcomes; and help people to successfully quit or prevent relapse. The use of incentives appeared to be helpful in decreasing attrition rates. The review examined interventions that used both existing popular social networking platforms (e.g. Facebook, WhatsApp, Twitter) and those that used individually designed interactive platforms (e.g. MyLastDip, iQuit system, Quitxt system), and found no significant differences in their effectiveness. The authors therefore suggest embedding smoking cessation interventions within existing social media platforms, due to the low cost and a large number of existing users.97
7.14.5.2 Video calling
The delivery of healthcare interventions via video conferencing technology, such as Skype or Zoom, has the potential to increase the provision of healthcare and specialist services to people who may otherwise have limited access to such care. Although real-time video counselling for smoking cessation offers great promise, a 2019 Cochrane review found that more evidence is needed to support such a strategy.98 However, a 2020 review concluded that video counselling appears to be equally effective as telephone counselling in promoting smoking cessation.99 A 2023 network meta-analysis found moderate certainty evidence that video counselling is associated with higher rates of 7-day point abstinence prevalence compared to brief advice.100 Results from Australian studies showed that people who smoke in rural and remote areas generally find video counselling for cessation acceptable and helpful,101 and that it may increase medium-term cessation rates.102
7.14.6 Increasing use of telephone and digital support
The overall impact of smoking cessation interventions in reducing smoking prevalence is a product of the intervention’s reach and its efficacy. Use of support services such as the quitline continues to be low relative to their potential.103,104 An examination of quitline use in 31 countries found that among people who had tried to quit, use ranged from 0% in Cameroon and Egypt to 4.4% in the Philippines.105 In Australia in 2022–23, about 2% of people who smoke reported that they had contacted the Quitline.106 Strategies that recruit more people who smoke to high-efficacy, low-cost services such as telephone- and internet-based interventions may help to increase the number of people who successfully quit, particularly among groups who have disproportionately high smoking rates.107
Demand for these services is largely a function of how much they are promoted. Mass media campaigns can effectively promote evidence-based quitlines,7 with the US Surgeon General concluding in 2020 that mass media campaigns increase the number of calls to quitlines and increase smoking cessation.11 In the US, an evidence-based national tobacco education campaign substantially increased quitline use.5,108 Utilising different types of media when promoting quitline, such as TV and radio, may also allow for effective targeting of specific subgroups of people who smoke.109 Research in the US also found that higher state tobacco program expenditures are associated with higher quitline awareness and utilisation.110 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.111-113 Increased spending on (and therefore greater levels of public exposure to) antismoking campaigns appears to be as effective in prompting additional calls to the Quitline in lower, compared to higher, SES groups.114 See Chapter 14 for further information on social marketing campaigns. Campaigns may also promote web-based programs or encourage people who smoke to use SMS to access support. For example, anti-smoking advertising is also related to increased use of an Australian online cessation program, Quit Coach.115 In Sweden, tobacco control policies such as health warnings, mass media campaigns, smokefree restaurants and tax increases have been associated with increased calls to quitlines.116 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.117
Direct telemarketing of the Quitline service in Australia to people who smoke has also been trialled with some success. A study in New South Wales found that cold calling was acceptable to many people who smoke, especially if it offered subsidised NRT.118 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,119,120 as well as increasing rates of cessation.121 Quitline registries can also be used to re-engage relapsed smokers, through inviting past callers back to the service.122 A US study found that invitations to re-engage with a quitline service were more effective when sent by mail rather than by automated telephone calls, particularly when delivered soon (e.g. 3 months) after previous enrolment. 123
Understanding and addressing the barriers to use of the quitline by smokers may help to more effectively develop strategies to increase calls.124 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.118,125 Smokers often report being unwilling to use the service, and view it as a last resort.126 Among low socioeconomic smokers, lack of access to a phone and low levels of knowledge about quitting can hinder use of the quitline,25 and the service may also be less effective in reaching rural smokers.26
Enhancing relationships between health professionals, healthcare systems and quitlines may increase referrals and the use of proactive telephone support by smokers.127 Health system implementation of an eReferral to Quitline can also increase reach and effectiveness.128-131 “10,000 Lives” is a regional smoking cessation initiative launched by Central Queensland Hospital and Health Service in 2017 that focused on maximising the use of existing cessation services, and researchers found that it greatly increased referral to and use of the Quitline, and cessation.132,133 There is some evidence that a pay-for-performance program (whereby healthcare professionals receive financial rewards for making referrals) increases referral to quitline services.134 Receiving advice from a health professional is related to higher quitline awareness and utilisation in the US.110 Engaging a non-smoking support person, through conducting phone intervention for family members and friends, may also increase treatment enrolment among people who smoke.135 Proactive outreach to people who smoke that connects them to telephone cessation services can increase cessation rates.136
As previously mentioned, Quitlines in a few Australian jurisdictions offer free NRT to callers from priority populations. Several studies have found that the addition of free NRT to a quitline is a cost-effective strategy that increases enrolment, calls and may increase cessation rates.11,13,14,137-139 For example, a trial of an ‘Outback Quit Pack’ intervention in rural, regional and remote regions of NSW which included mailed-out combination NRT and a proactive referral to Quitline led to high rates of Quitline call completion.140
Financial incentives for participation may also increase use of quitlines and internet-based interventions. US-state based trials found that offering financial incentives was associated with increased enrolment, engagement and re-engagement in phone‑ and text‑based support programs, and smoking cessation.123,141,142 See Section 7.17 for further information on financial incentives and rewards for promoting cessation.
Many people search for smoking cessation information online. Online advertising has potential to increase use of evidence-based web and quitline support. Research suggests that compared to traditional recruitment approaches, online advertisements recruit a higher percentage of males, young adults, minority groups, those with lower education levels and more highly addicted.143 One study in the US found that allowing online quitline registration and offering a range of services (such as telephone counselling, text messages, emails, and NRT) was particularly helpful for engaging younger people who smoke.144 The ‘Outback Quit Pack’ trial also found that social media advertising was more effective than mailed out invitations for recruiting participants.140
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References
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