Telephone Support to Stop Smoking: Telephone Support to Stop Smoking: RCT investigating support of differing RCT investigating support of differing

intensities & the option of ‘no cost’ intensities & the option of ‘no cost’ nicotine replacement therapynicotine replacement therapy

Linda BauldLinda BauldUniversity of StirlingUniversity of Stirling

Tim ColemanTim ColemanUniversity of Nottingham, UKUniversity of Nottingham, UK

Graeme DochertyGraeme DochertyUniversity of Nottingham, UKUniversity of Nottingham, UK

and colleaguesand colleagues

Background Smoking remains a public health problem

but cessation interventions are effective. Many countries operate telephone quit

lines as a source of support for smokers who want to quit

They are a cost-effective approach to smoking cessation with the potential to reach significant numbers of smokers.

Finding optimal methods of providing effective cessation interventions via quitlines will increase their effectiveness.

Background In mainly US studies, ‘proactive’ (repeated

calls from cessation advisor to client) appears more effective than ‘reactive’ counselling (i.e. responding only to smokers’ calls).

RCT offering NRT (USA)Hollis 2007 – free NRT offer increased quit rates by around 30%

PORTSSS trial rationale: find optimal methods to improve quit rates NRT or no NRT ? Standard or more intensive telephone support?

Efficacy of Telephone Support

In 2006 a Cochrane Review examined the efficacy of telephone counselling for smoking cessation by examining the findings of 48 trials.

Proactive support increased the odds of long term cessation (OR = 1.41, 95%CI 1.27-1.57).

Efficacy of Telephone Support

The review concluded (Stead, Perera and Lancaster, 2006):Proactive telephone counselling helps smokers interested in quitting. There is evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increases the odds of quitting compared to a minimal intervention such as providing standard self-help materials, brief advice, or compared to pharmacotherapy alone. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness.

Reactive or Proactive Telephone Support

Most of the trials in the Cochrane review were of PROACTIVE telephone support.

Reactive: Provision of information to support

quit with brief counselling, usually call initiated by smoker

Proactive Repeated, sequenced calls made by

counsellors to smokers. Proactive telephone support achieves

approx. 1.4 times higher quit rates.

Telephone Support Compared:

4 week estimates

0%

10%

20%

30%

40%

50%

60%

70%

80%

No medication NRT Bupropion Varenicline

No support

Individual BS

Group BS

Telephone

Source: estimates provided by Paul Aveyard for NHS stop smoking service and monitoring guidance

Telephone Support in the UK

In the UK, the management and delivery of quitlines varies between the four home countries

There are two main forms of telephone support available for smokers who want to quit in England

The NHS Smoking Helpline (delivered by The Listening Company who also deliver ‘Smokeline’ in Scotland)

Quit (who provide a range of services)

Telephone Support in England

The NHS Smoking Helpline delivers a number of different types of support to smokers

One of these is the ‘Together Programme’, which is a largely reactive form of telephone support consisting of a relatively large number of calls supported by written material, emails and texts. ‘Together’ was the focus of this study.

Together Programme•Developed in 2003, based on Prochaska Behavioural Change Model

•Timing/frequency of interventions was as follows:

Communication Received Description Mail Email

SMS Callback

1 - 6 weeks before Preparation X      

1 week before Countdown       X

3 days before Countdown   X X  

2 days before Survival X      

Stop Date Good luck   X X X

2 days after Motivational       X

1 week after Motivational   X X  

3 weeks after Motivational   X X X

1 month after How’s it going? X X X  

3 months after Maintenance X X X  

12 months after Anniversary   X X  

Ad hoc Relapse X      

MethodsMethods Two by two parallel group RCTTwo by two parallel group RCT Sample: callers of the English national Sample: callers of the English national

quitline seeking help to stopquitline seeking help to stop February 2009 – January 2010. 16 years or February 2009 – January 2010. 16 years or

over; Not pregnant; Need to agree to quit over; Not pregnant; Need to agree to quit datedate

Four treatment groups:Four treatment groups: Standard; Standard + NRT offerStandard; Standard + NRT offer More intensive; More intensive + NRT More intensive; More intensive + NRT

offeroffer

Recruitment and Recruitment and randomisationrandomisation

StandardN = 648

More Intensiven = 648

Standard + NRT N = 647

More Intensive +NRTn = 648

N = 5355 offered enrolment

n = 2728 refused

N = 2627 agreed

N = 56 withdrew after randomisationITT analysis n = 2591

Technical difficulties – not randomised n = 36

Results – type of supportResults – type of support

Comparison of proactive and usual Comparison of proactive and usual care groupscare groupsProactive

groups(n=1295)

Usual care groups(n=1296)

Unadjusted OR* (95% CI)

6 month quit rate (self report)

6 month quit rate (CO validated)

18.2%

7.7%

19.6%

8.3%

.91 (0.75, 1.11)

.93 (0.70, 1.23)

* Similar figures obtained when adjusted for age, sex, SES and HSI

There was no interaction between interventions

Results – NRTResults – NRT

Comparison of NRT and no NRT Comparison of NRT and no NRT groupsgroupsNo NRT

groups(n=1296)

NRT groups(n=1295)

Unadjusted OR* (95% CI)

6 month quit rate (self report)

6 month quit rate (CO validated)

20.1%

9.4%

17.7%

6.5%

.85 (0.70, 1.04)

.67 (0.50, 0.90)

* Similar figures obtained when adjusted for age, sex, SES and HSI

There was no interaction between interventions

No NRT groups more likely to No NRT groups more likely to use non-trial cessation use non-trial cessation

support?support?Therapy No NRT

groupsn = 1296

NRT groupsN = 1295

NRT without prescription

222 (17.1) 276 (21.3)

NRT from health professional

254 (19.6) 225 (17.4)

Zyban 17 (1.3) 20 (1.5)

Champix 101 (7.8) 64 (4.9)

NHS SSS group

72 (5.6) 53 (4.1)

NHS 1:1 118 (9.1) 103 (8.0)

Other quitline 20 (1.5) 20 (1.5)

ConclusionsConclusions1. Offering ‘proactive’ telephone support

via the NHS smoking helpline is no more effective than offering more ‘reactive’ support (usual care)

2.2. Unless study specific reasons exist, Unless study specific reasons exist, more intensive behavioural support via more intensive behavioural support via a quitline not good use of resources in a quitline not good use of resources in countries where cessation countries where cessation interventions are freely availableinterventions are freely available

ConclusionsConclusions1.1. Offering free NRT no more effective Offering free NRT no more effective

than not offering NRTthan not offering NRT

2.2. Was this because those Was this because those notnot given NRT given NRT vouchers made more use of NHS vouchers made more use of NHS interventions?interventions?

3.3. Unless study specific reasons exist, Unless study specific reasons exist, offering NRT via a quitline not good offering NRT via a quitline not good use of resources in countries where use of resources in countries where cessation interventions freely availablecessation interventions freely available

Acknowledgements

•Funder: Department of Health (England)•Essentia Ltd (now the Listening Group) – counsellors•Credit care systems - databases•University of Nottingham Clinical Trials Unit (data file preparation)

Thank YouThank You

Linda.bauld@stir.ac.uLinda.bauld@stir.ac.ukk