Smoking cessation interventions including behavioral and pharmacological components have been demonstrated to be both effective and cost-effective. Although there is a high prevalence of smoking and smoking-related disorders among veterans who use VA medical centers for health care, rates of identification of tobacco use and provision of brief and/or intensive smoking cessation services are suboptimal. Telephone outreach (TO) may serve to increase access to counseling and medications to assist smoking cessation. From the standpoint of health systems, TO provides the opportunity for centralized oversight and quality assurance, economy of scale, and dissemination strategies that are practical to implement. At the provider level, TO addresses barriers to delivery of services such as limited time and skills. From the standpoint of the smoker, attractions of TO include accessibility, convenience, and privacy.
The objectives of the study are to: 1) determine if TO increases successful quitting among veterans who smoke, compared to the distribution of written self-help materials; and 2) determine the cost-effectiveness of TO for smoking cessation for veterans who smoke.
The study involved a population-based sample of veterans in VISN 13 who use one of the five Network VAMCs for primary care. 838 smokers were recruited, enrolled and randomly assigned to 1) written self-help materials + TO, or 2) written self-help materials alone. The behavioral intervention protocol included follow-up calls scheduled in a relapse-sensitive fashion. Use of nicotine replacement therapy (NRT) was encouraged, and prescriptions facilitated. Data was collected at baseline, 3 months, and 12 months by telephone. Information on demographic characteristics, medical and mental health histories, smoking history, intervention, and use of clinical services for smoking cessation was included. Cost data will be calculated from administrative databases, and will include 1) written materials, 2) counseling (personnel time, equipment, space), and 3) medications. The primary outcome was 6 months of prolonged abstinence from smoking, measured 12 months following intervention. Secondary analyses evaluated 3 month and 12 month point prevalent abstinence from smoking, quit attempts, and a formal cost-effectiveness analysis that will include total costs, total and marginal effects and cost-effectiveness ratios (average cost/quit and average cost/marginal quit) for TO and SH interventions.
Enrollment and follow-up are complete. 68,903 letters were mailed to primary care patients at participating medical centers. 1807 individuals called the study toll-free number. Of these callers, 1265 were current smokers. Of current smokers, 988 (78%) were eligible for the study. Of eligible smokers, 838 (84%) agreed to participate in this study and were enrolled and randomized. The response rates for the 3 and 12-month follow-ups were 91% and 87% respectively. There were no differences in baseline characteristics between groups. Subjects in the telephone care group reported significantly higher rates of abstinence for both long and short terms measures of smoking cessation. 53 of 418 (12.7%) individuals in the telephone care group were abstinent for 6 or more months at the 12-month follow-up compared with 17 of 420 (4.1%) in the standard care group (OR=3.44 [1.95-6.05], p<0.001). At 3-month follow-up, 164 of 418 (39.2%) individuals in the telephone care group reported 7-day abstinence compared to 42 of 420 (10%) individuals in the standard care group (OR=5.81 [4.00-8.45], p-value<0.001). Receipt of smoking cessation counseling was significantly higher in the TO group compared to the UC group at both 3 and 12-months. In the TO group the total duration of intervention phone contact averaged 123.1 + 71.3 minutes and the median number of calls per subject was 7. Use of smoking cessation pharmacotherapy was also significantly higher in the telephone care group compared to the standard care group. At 3 months, 86% of TO and 30% of UC subjects reported any use of smoking cessation medications (nicotine patch, nicotine gum, bupropion SR) (OR=14.64 [10.15-21.13], p-value<0.001). At 12 months, 89% of TO and 48% of UC subjects reported any use of pharmacotherapy (OR=8.85 [6.04-12.97], p-value<0.001).
This study tested an innovative, efficient intervention that proved to be effective at recruiting smokers to treatment and improving short and long term rates of abstinence. The promising results suggest that a regional or national quitline service to provide smoking cessation treatment to veterans should be made available. The intervention is likely to be attractive to health system administrators, providers, and patients.
- An LC, Zhu SH, Nelson DB, Arikian NJ, Nugent S, Partin MR, Joseph AM. Benefits of telephone care over primary care for smoking cessation: a randomized trial. Archives of internal medicine. 2006 Mar 13; 166(5):536-42.
HSR&D or QUERI Articles
- Joseph AM, An LC. Telephone care for smoking cessation in the Department of Veterans Affairs. VA in the Vanguard: Building on Success in Smoking Cessation. 2004 Oct 1; 207-217.