Challenges facing Australian Quitlines

European Network of Quitlines

Amsterdam September 2008

Ian Ferretter

Quitline Manager Victoria, Australia

Acknowledgements

• Australian Quitline Managers Network:Craig Black, Dan Nelson, Shannon Maxwell, Phil Hull, Lyndy Abram, Jason Wells,

Bonnie Travers, Gail Hamilton, Justin Heath, Melissa Seibold.

• Prof Ron Borland VCTC

• Dr Cathy SeganVCTC

• James Balmford VCTC

• Suzie Stillman Quit Victoria

• Ainslie Hannan CCV

Australian Quitlines: Setting the Scene

Quitline 13 QUIT (13 7848)

• National number– Cost of a local call on a landline– 40c for a local call with unlimited time– 0.4 Australian Dollar = 0.23 Euro – Each state and territory funds the Quitline in their own jurisdiction– Each pays a share of the number rental– All callbacks are free of charge– Number and Quitline logo owned by the Cancer Council Victoria

Australian Quitlines

Calls to the Quitline July 2007 to June 2008

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15000

20000

NSW ACT VIC TAS QLD NT SA WA

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Australian Quitlines: Setting the Scene

• Each State and Territory has the responsibility of providing Quitline services for its own jurisdiction

• Variety of models

• Various agencies

Australian Quitlines: Setting the Scene

Jurisdiction Model

Australian Capital Territory Outsourced to NSW

New South Wales and Western Australia

Located in state based Alcohol and Drug Information Services

Tasmania Quit Tasmania

South Australia and Victoria State Cancer Councils

Northern Territory Outsourced to Alcohol and Drug Service in Queensland

Queensland State Government Health Contact Centre

Australian Quitlines: Setting the Scene

• Some Quitline established in high technology call centre type environments

- EG Queensland in the Health Contact Centre

• Others located within smaller organisations, with limited capacity to leverage off of technology

• Victorian Quitline well established, effective, in large organisation, but not up to date technology

Australian Quitlines: Minimum Standard

1.1 The Quitline is answered 24 hours a day, 7 days a week

1.2 A person answers the Quitline number at all times. This could be a call centre agent, a Quitline Counsellor or Quitline reception staff

1.3 Call answered within a maximum of 5 rings

1.4 The Quit Book is readily available and offered to all callers to the Quitline

Australian Quitlines: Minimum Standard

4.1 Counselling available during minimum hours ie. Business hours (0900-1700) plus out of hours as dictated by call demand and determined by each jurisdiction

5.1 A pro-active call-back service is available, which takes the caller through the process of quitting and has a well-structured schedule according to best evidence

Minimum standards cover…

• Opening hours, response times, hold times, answering rate

• Availability and despatch times of Quit Pack

• Access to counsellors, recontact times if counsellors are not immediately available, hours of counselling

• Referral program from health professionals to Quitline

• Tailored assistance for callers with special needs

• Evidence-based counselling content and advice

Minimum standards cover…

• Recruitment (including requirement that counsellors be current non-smokers)

• Counsellor training: initial, ongoing professional development

• Referral to other agencies: cessation services and cessation products

• Collection of data: minimum data set

• Evaluation

Minimum standards development

As part of the development of Minimum Standards the Network of Quitline Managers led the development of protocols for each of the special needs groups:

» Indigenous» Mental Health Conditions» Youth » Pregnancy» Cultural and Linguistic Diversity

Australian Quitlines: Issues

• Distribution of NRT from Quitlines- Only one very limited trial in Australia to date

• New technologies- Quit Coach

- SMS

• Relapse prevention

•Callers with mental health conditions

Australian Quitlines: Issues• NRT (or is it therapeutic nicotine ?)• - The tension between research and the regulations

• - Different regulations for very similar products*Pre-Quit patch

Australian Quitlines: Issues

NRT & Pregnancy• Intermittent dosing products (such as the chewing gum, the

microtab or the inhaler) may be preferable as these usually provide a lower daily dose of nicotine than patches.

• However, patches may be preferred if the woman is suffering from nausea during pregnancy. If patches are used they should be removed before going to bed.

• The use of the above products are also encouraged for

breastfeeding women.

Australian General Practice Guidelines

Two strategies for providing patients with effective cessation assistance:

1. In-practice counselling 2. referral to specialist

support services (Quitlines)

(unless good clinical reason to refer) (where appropriate)

Fax referral to Quitline

RCT: Referral vs in-practice management

Cluster RCT randomisation by GP Practice

45 GPs

30 referral GPs 15 in-practice Quitline triage management

Recruited 1040 smokers Baseline survey and 3 and 12 month surveys

Randomisation successful, no differences in samples

Borland et al, Family Practice, 2008

Help received

• Within practice

• Outside practice: Referral > In-practice– 35% Referral got intensive help

- 30.5% Callback

- 4.4% QuitCoach

Main outcomes

Outcome 12 months:

10 months sustained abstinence

In-practice Referral OR

(95% CI)

Available data: Intention to treat 2.6% 6.5% 2.86

0.9-8.7

Imputing missing as smoking 1.7% 4.3% 3.08

1.0-9.3

NB: Intention-to-treat = all cases in allocated group regardless of help received

Referral

• Results in smokers getting more help– Thus more quit

• Acceptable to smokers– They appreciate it

• Acceptable to health professionals– Fits better into busy schedules– Easy way to do something they know they should– But often don’t

• Just do it!

Can we help quitters embrace a non-smoking lifestyle?

Intervening to prevent longer-term relapse

2 Tasks of Staying Quit ‘The 2Ts’

1. Learning to effectively deal with cravings and other withdrawal symptoms without relapsing

2. Learning to enjoy and value smokefree lifestyle– Starts when cravings drop to less than daily

– Finding alternative behaviours to replace functions previously served by smoking

– Facing old smoking situations to extinguish habit

– Adopting new self-image by rejecting or growing out of smoker self-image

Study Aim

• Can an extended callback service reduce relapse rates compared to Quit’s standard callback service?

Design:

Randomised controlled trial

CONTROL INTERVENTION

Standard service Extended service

2 Tasks of quitting framing Yes Yes

Pre-quitting callbacks 2 2

Post-quitting callbacks up to 4 up to 10 over 1 month over 3

months

The intervention: extra ‘integration’ callbacks to facilitate becoming a non-smoker•Structured intervention designed to minimise perceived losses associated with quitting

•Starts when standard service ends (around 1 month after quitting) and offered 4-6 callbacks over 2 month period

•Weekly or fortnightly calls with more frequent calls provided around any slip up or relapse crises

•Same counsellors delivered both standard and ‘integration’ callbacks

12 month follow up

Measure/ Sig. Test CONTROL INTERVENTION

% quit (point prevalence) (n=409) 50.0 50.7 p=.88

% never relapsed(still quit from baseline attempt) 27.8 27.7

p=.98

Mean length baseline 63.4 56.7 p=.29

quit attempt (days)

% lost to follow up 41.0 41.8 p=.85

Conclusions

• Extra ‘integration’ callbacks were ineffective in reducing rates of longer-term relapse

• Cannot recommend the program in its current form – no value in a couple of extra sessions beyond 1 month

to assist with 2nd task

Considerations – Why no effect?

• Poor quality intervention unlikely

• Lack of differentiation between control and intervention condition

• Methodological challenges in implementing RCTs of differing counselling protocols

Historical Comparison

1996 2002-04% quit 12mths (point prevalence)

All smokers at recruitment

All offered callback counselling 22% 34%

www.QuitCoach.org.au

• Computer-tailored cessation program

• Assessment leads to tailored advice

• Designed to be used multiple times

– Flexible scheduling

• Strong focus on relapse prevention

• Tailors to increase relevance as well as on issues

• Advice on use of aids

Development and evaluation of a Quitline service for smokers with a history of depression

• Ainslie Hannan; Dr Catherine Segan; Dr Ron Borland; A/Prof Kay Wilhelm; Ian Ferretter; Suzie Stillman; Dr Sunil Bhar and A/Prof David Dunt

Overview

Why depression?

• How we’re evaluating the service

• Features of the service

• Issues and insights arising out of the development and delivery of the tailored service and in the data collection

Why depression?

• Around 1 in 5 people experience depression during their lifetime

• Smokers report more depressive symptoms, more frequent and severe episodes of depression and higher rates of suicidal ideation and suicideWilhelm et al 2006

Depression and smoking cessation

• Smokers with symptoms of depression tend to smoke more and experience more severe withdrawal, including greater negative moodBreslau et al 1994; Wilhelm et al 2004

• Lifetime of symptoms of depression doesn’t predict a failure to quitHitsman et al 2003

• Those with increased depressive symptoms while quitting are more likely to relapseBurgess et al 2002

Depression and smoking cessation

• Around 30% of quitters with symptoms of depression will develop a new episode of depressionGlassman et al 2001; Killen et al 2003

• Chemicals in cigarettes can affect metabolism of some antidepressants e.g. fluvoxamineZevin et al 1999

• Two antidepressants also function as ‘anti craving agents’: bupropion and nortriptylineHughes et al 2003

The Victorian Quitline context

• Almost 1 in 3 Victorian Quitline callers disclose a mental health condition, most commonly depression

• Doctor – Quitline co-management of smoking cessation for people with current mental health conditions

• For callers with a diagnosed history of depression an additional tailored service is offered

Research questions

1. Can a tailored callback service for smokers with symptoms of depression produce comparable quit rates?

2. What factors predict depression recurrence?

3. Does depression predict failure to quit?

4. What do callers think of Doctor-Quitline coordinated care?

Study design

• Prospective study - follow up 3 groups of callers over a 6 month period

• 3 caller groups– Smokers without MHC n=400– Smokers with past depression n=190– Smokers with current depression n=140

• Research interviews– Baseline– 2 months (around end of Quitline service)– 6 months

Service development within a research context

Program enhancement• Counsellor training in the relationship between smoking cessation and

depression.

• The development of counselling guidelines for callers with symptoms of depression that complement Quit Victoria’s mental health policy.

• The development of a joint Quit and beyondblue fact sheet on smoking cessation and depression.

• Continued development of the partnership between Quit and health professionals.

Evaluation of the tailored service• Recruitment May 07 – May 08

• Follow-up surveys until Dec 08

Key features of the additional service• Introduction to

Quitline of the Health Screen Assessment Tool which documents the caller’s physical and mental health

• Tailored callback service focusing on the relationship between smoking, mood and the impact of quitting on mood

• Smoking cessation and mood monitoring and management techniques

• Doctor involvement and resourcing

• Development of quit plan in with the caller’s Doctor

• Letters to doctor reporting on progress

• Specialised resources and activity sheets

Caller responses to the service

• Thankful for greater awareness, normalisation of experience and preparation for mood management

• Initial concern that their history of depression is being assessed before being given smoking cessation advice

Issues and insights

• The need to develop an understanding of the relationship between smoking cessation and depression

• Choose to smoke rather than take medication

• Use of mood management skills for other callers without a history of diagnosed depression

• Considerations when delivering a tailored service within a population service

• The role and acceptance of partnerships

• Resourcing a client centred service

Finally

• Improving cessation rates is not an easy task– But one we need to continue to work on

• Getting more people to use effective services, and, or, aids is somewhat easier– And provides improved outcomes, even in a population not

selected initially by desire to quit