Comparing the New York State Smokers’ Quitline Reach,Services Offered,and Quit Outcomes to 44 Other State Quitlines,2010 to 2015

Abstract

Purpose:

To summarize the reach, services offered, and cessation outcomes of the New York Quitline and compare with other state quitlines.

Design:

Descriptive study.

Setting:

Forty-five US states.

Participants:

State-sponsored tobacco cessation quitlines in 45 US states that provided complete data to the Centers for Disease Control and Prevention’s National Quitline Data Warehouse (NQDW) for 24 quarters over 6 years (2010-Q1 through 2015-Q4).

Intervention:

Telephone quitlines that offer tobacco use cessation services, including counseling, self-help materials, and nicotine replacement therapy (NRT), to smokers at no cost to them.

Measures:

Percentage of adult tobacco users in the state who received counseling and/or free NRT from state quitlines (reach), services offered by state quitlines, and cessation outcomes among quitline clients 7 months after using quitline services.

Analysis:

Reach, services offered, and cessation outcomes for the New York Quitline were compared with similar measures for the other 44 state quitlines with complete NQDW data for all quarters from 2010 through 2015.

Results:

New York’s average annual quitline reach from 2010 through 2015 was 3.0% per year compared to 1.1% per year for the other 44 states examined.

Conclusion:

Although the New York Quitline was open fewer hours per week and offered fewer counseling sessions and a smaller amount of free NRT than most of the other 44 state quitlines, the New York Quitline had similar quit rates to most of those state quitlines.

Keywords

quitlines program reach tobacco use cessation tobacco control

Introduction

According to the Centers for Disease Control and Prevention (CDC), telephone quitlines are a best practice¹ intervention that provide access to evidence-based cessation services at no cost to smokers. All US states maintain and operate state tobacco cessation quitlines that offer a combination of free tobacco use cessation counseling, free nicotine replacement therapy (NRT), web-based services, and mailed self-help materials to tobacco users. Tobacco quitlines have been shown to be effective at increasing tobacco use cessation and are a recommended component of comprehensive state tobacco control programs.^1
-3 Despite having the potential for broad reach, only around 1% of adult smokers in the United States receive services from state quitlines annually.^1,2,4

-7

States typically contract with a quitline service provider to operate and manage their quitline, with several quitline service providers operating state tobacco quitlines for multiple states. The services offered, as well as operational and implementation procedures, although similar, differ by state and by quitline service provider. States typically determine their quitline service offerings and protocols based on state priorities and available resources. The CDC’s Best Practices for Comprehensive Tobacco Control Programs recommends that state quitlines should aim for 90% of the quitline callers to accept counseling services from the quitline.¹ Beyond this CDC recommendation, very little research or guidance is available regarding what services state quitlines should be offering.

The New York State Smokers’ Quitline (New York Quitline) provides individualized telephone counseling, free NRT, a variety of tips and tools, and a Quitsite website with interactive features for tobacco users who want to quit. We conducted a descriptive study of the New York Quitline using available data from CDC’s National Quitline Data Warehouse (NQDW) for 2010 to 2015 to describe quitline reach, services offered, and cessation outcomes. We compare results for New York to 44 other state quitlines with complete NQDW data.

Data and Methods

In 2010, CDC’s Office on Smoking and Health established the NQDW to serve as a national repository of data for state quitlines and provide an infrastructure and a mechanism for ongoing data collection and monitoring. Select NQDW data are published online through CDC’s State Tobacco Activities Tracking and Evaluation (STATE) System website (http://www.cdc.gov/statesystem). We used NQDW data for 2010 to 2015 available on the STATE System website to conduct descriptive analyses of quitline reach, services offered, and cessation outcomes. We restricted our analysis of NQDW data to the 45 states with complete data for 2010 to 2015. We omitted the following 6 states/territories that are missing data for one or more of the NQDW measures we analyzed in one or more quarters from 2010-Q1 through 2015-Q4: District of Columbia, Michigan, Minnesota, New Jersey, North Dakota, and Wyoming.

Measures

Quitline reach

Quitline reach can be defined and measured in multiple ways. We examined quitline treatment reach, which is defined as the proportion of the target population that receives an evidence-based service from the quitline.^8,9 We calculated annual state quitline treatment reach by dividing the annual number of adult quitline callers who received counseling and/or free NRT from the state quitline by the total number of adult smokers in the state. Quarterly state-level data on the number of adults who received counseling and/or free NRT from their state quitline were obtained from NQDW and summed for each state to create annual totals for 2010 through 2015. We estimated the annual number of current adult cigarette smokers in each state by multiplying annual state-level adult population estimates from the US Census Bureau by the current adult cigarette smoking prevalence in the state. The annual prevalence of current adult cigarette smoking was obtained from CDC’s Behavioral Risk Factor Surveillance System (BRFSS) for 2011 through 2015. The BRFSS current adult cigarette smoking prevalence for 2011 was used to estimate the number of adult cigarette smokers for 2010. The BRFSS methodology changed substantially in 2011, and prevalence estimates from 2011 forward are not comparable with those from previous years.

Quitline services offered

We obtained measures of quitline hours of operation from NQDW and calculated the total number of hours per day that state quitlines are open with counseling services available. We calculated hours separately for Monday to Thursday, Friday, Saturday, and Sunday because the NQDW data showed that state quitlines frequently have different hours on Fridays and weekends. We obtained information on languages in which counseling is offered from NQDW. Indicators for whether states offer free NRT, as well as the specific types of NRT offered, were also obtained from NQDW. Using NQDW measures of eligibility criteria for counseling or free NRT, we identified states that have a minimum age criterion for counseling or free NRT. We also identified states that restrict the provision of counseling services or free NRT to specific subpopulations, such as uninsured callers, underinsured callers whose insurance does not cover cessation treatments, or callers with specific insurance, such as Medicaid, Medicare, or select private health plans. We also obtained measures of the number of counseling sessions and the number of weeks of free NRT per quit attempt offered to all quitline callers who meet basic eligibility requirements from NQDW.

Quitline effectiveness/quit rates

We obtained measures of quitline effectiveness from NQDW data on 7-month follow-up evaluation surveys completed during 2010 and 2011. Follow-up evaluation surveys were administered to a random sample of quitline callers in each state approximately 7 months after they initially contacted the quitline. Eligibility criteria, sampling procedures, and follow-up survey protocols varied across states. In general, participants had to complete at least 1 counseling call via the quitline or receive medication, provide a valid phone number, speak English, be 18 years or older, and consent to the follow-up evaluation. Most follow-up evaluations were conducted by telephone. However, some follow-up evaluation surveys were conducted through a web-based survey. Modes of follow-up data collection varied across states. Seven-month follow-up evaluation data measures include survey sample size, number of survey respondents, survey response rate, and 2 cessation outcome measures: 24-hour quit rate and 30-day quit rate. The 24-hour quit rate is the percentage of survey respondents who reported that they stopped using tobacco for 24 hours or longer, and the 30-day quit rate is the percentage of survey respondents who reported not smoking any cigarettes or using other tobacco products in the past 30 days. The 24-hour quit rate can be interpreted as a measure of quit attempts, and the 30-day quit rate can be interpreted as a measure of longer-term quit success. Both quit outcomes are reported using 2 different calculation methods: a responder rate and an intent-to-treat rate. Responder rates are calculated only among the individuals who completed follow-up evaluation surveys. Seven-month follow-up evaluation surveys have the potential for nonresponse bias because many quitline callers who were unable to quit or who relapsed since contacting the quitline may be significantly less likely to participate in and complete a follow-up evaluation survey. Intent-to-treat quit rates attempt to correct for the potential nonresponse bias of the 7-month follow-up evaluation survey by including individuals who completed 7-month follow-up evaluation surveys and those who were sampled for but did not complete 7-month follow-up evaluation surveys in the calculation. The numerator is the same for the responder rate and intent-to-treat rate, but the denominators differ with the inclusion of individuals who did not complete the evaluation in the intent-to-treat calculation. The responder rate is likely to be an overestimate because of the potential nonresponse bias of the follow-up evaluation survey, and the intent-to-treat rate is likely to be a conservative estimate because of the assumption that all nonresponders failed to make a quit attempt or maintain sustained quitting behaviors.

Analysis

We conducted a descriptive analysis of state quitline reach, services offered, and quit rates for the 45 states with complete NQDW data for 2010 to 2015. We present trends in annual quitline treatment reach for 2010 to 2015. We also created a descriptive profile of the services offered by state quitlines based on the following NQDW data measures: hours of operation, eligibility criteria for counseling, amount of counseling offered, free NRT offered, eligibility criteria for free NRT, and amount of free NRT offered. We based the quitline services profiles on the most recent NQDW information available on the STATE System website at the time of our analysis (2015-Q4) for the 45 states included in our analysis. The eligibility criteria for counseling and free NRT, as well as the amount of counseling and free NRT offered, presented in our quitline services profiles are for the base amount offered to all callers who meet minimum eligibility criteria. Some quitlines provide additional counseling sessions or extra weeks of free NRT to specific groups of callers, beyond the base amount offered to all eligible quitline callers. We did not analyze, and do not report in this article, any information on additional counseling or free NRT offered to specific groups of callers. For free NRT, we only examined the number of weeks offered to quitline callers per quit attempt. Many state quitlines allow callers to go through the program and receive free NRT multiple times per year. Because NQDW data on the number of times callers could receive free NRT from the quitline in a year were not consistently available across states, we only examined the number of weeks of free NRT that are offered to callers per quit attempt (ie, each time a caller goes through the program).

For the descriptive analysis of 7-month follow-up evaluation data for 2010 and 2011, we further restricted the data to 32 of the 45 states included in the overall analysis. Thirteen of the 45 states included in the overall analysis were omitted from the follow-up data analysis due to missing data. Five states (Arizona, California, Illinois, Tennessee, and West Virginia) were missing data on the survey sample size, making it impossible to calculate intent-to-treat quit rates for these states. Another 5 states (Alaska, Kentucky, New Hampshire, Rhode Island, and Utah) were missing data on the 24-hour quit rate, which is important to our analysis. We present descriptive data from the 7-month follow-up data on the sample size, number of survey respondents, survey response rate, 24-hour quit rates, and 30-day quit rates.

We present descriptive data specifically for the New York Quitline and compare results for New York to the other states included in our analysis. We also ranked states from highest to lowest in terms of reach, services offered, and quit rates and report New York’s rank for each of these measures. For the quitline services profiles, we also report the number of states with a higher amount, the same amount, and a lower amount of services than New York.

Results

Quitline Reach

Figure 1 presents annual trends in New York Quitline reach and the average state reach for the 44 other states that reported complete data to CDC’s NQDW for 2010 through 2015. New York’s average annual quitline reach from 2010 to 2015 was 3.0% per year, ranging from a low of 2.3% in 2015 to a high of 3.6% in 2010. Over this same period, the average annual state quitline reach for the 44 other states included in our analysis was 1.1% per year, ranging from a low of 1.0% in 2015 to a high of 1.2% in 2012.

Figure 1.

Annual quitline reach for New York and 44 other states: 2010 to 2015. Note. Data are calculated from the state-reported quarterly data on the number of tobacco users who received counseling and/or free nicotine replacement therapy (NRT) from their state quitline. Data are from Centers for Disease Control and Prevention’s (CDC) National Quitline Data Warehouse (NQDW) Quitline Services Survey for 2010-Q1 through 2015-Q4 that are published online through CDC’s State Tobacco Activities Tracking and Evaluation (STATE) System website (http://www.cdc.gov/statesystem). Data are for 45 states that reported complete data to NQDW for all quarters from 2010 through 2015. The following 6 states/territories are excluded from this analysis because of missing data for one or more quarters from 2010-Q1 through 2015-Q4: District of Columbia, Michigan, Minnesota, New Jersey, North Dakota, and Wyoming. The labels for average state reach for the 44 comparison states also present the minimum and maximum state reach across those 44 states.

From 2010 through 2015, New York’s quitline reach was consistently one of the highest in the country and substantially exceeded the average state quitline reach for the 44 other states in our analysis (Table 1). New York’s annual quitline reach ranked between second and fourth highest among all 45 states in our analysis, and New York’s annual state quitline reach was an average of 2.7 times higher than the average annual reach across the other 44 states. Annual quitline reach varied widely across states from 2010 through 2015, ranging from 0.1% to 4.6% (see Table 1). The average annual difference between the state with the highest quitline reach and the state with the lowest quitline reach was 3.8% from 2010 through 2015.

Table 1.

Annual Quitline Reach for New York and 44 Other States: 2010 to 2015.^a

Year	Number of States Reporting	New York			Other States (n = 44)
Year	Number of States Reporting	Reach	Reach Rank	Ratio: New York Reach/Average State Reach	Average State Reach	Minimum State Reach	Maximum State Reach
2010	45	3.6%	2	3.2	1.1%	0.1%	4.5%
2011	45	2.9%	4	2.6	1.1%	0.1%	4.6%
2012	45	3.1%	4	2.5	1.2%	0.2%	3.7%
2013	45	2.7%	4	2.4	1.1%	0.2%	3.9%
2014	45	3.4%	2	3.1	1.1%	0.1%	3.8%
2015	45	2.3%	4	2.2	1.0%	0.1%	2.8%

^aData are from Centers for Disease Control and Prevention’s (CDC) National Quitline Data Warehouse (NQDW) Quitline Services Survey for 2010-Q1 through 2015-Q4 published online through CDC’s State Tobacco Activities Tracking and Evaluation (STATE) System website (http://www.cdc.gov/statesystem). Data are calculated from state-reported quarterly data on the number of tobacco users who received counseling and/or free nicotine replacement therapy (NRT) from their state quitline. Data are for 45 states that reported complete data to NQDW for all quarters from 2010 through 2015. The following 6 states/territories are excluded from this analysis because of missing data for one or more quarters from 2010-Q1 through 2015-Q4: District of Columbia, Michigan, Minnesota, New Jersey, North Dakota, and Wyoming.

Quitline Services Offered

Table 2 presents a descriptive profile of the quitline services (hours of operation, counseling services provided, and provision of free NRT) offered by the New York Quitline and the 44 comparison state quitlines. The New York Quitline’s hours of operation when counseling services are available are from 9 am to 9 pm EST, Monday through Thursday (12 hours per day), and from 9 am to 5 pm EST, Friday through Sunday (8 hours per day). The other 44 states included in our analysis were open longer than New York, with counseling services available an average of approximately 20 hours per day during the week (Monday to Friday) and nearly 19 hours per day on the weekends (Saturday and Sunday). All 45 of the states we analyzed offered quitline counseling services in both English and Spanish. New York and 39 of the 44 comparison states also offered quitline counseling services in a variety of other languages.

Table 2.

Quitline Services Offered by New York and 44 Other States: 2010 to 2015.^a

Hours of Operation
Day of Week	New York		Other States (n = 44)				NY Rank
	Daily Hours	Hours per Day	Hours per Day: Mean (Min-Max)	Compared to NY^b
	Daily Hours	Hours per Day	Hours per Day: Mean (Min-Max)	More Hours	Same Hours	Fewer Hours
Monday to Thursday	9 am to 9 pm EST	12	20.2 (12-24)	42	2	0	43 (tied)
Friday	9 am to 5 pm EST	8	20.2 (12-24)	44	0	0	45
Saturday	9 am to 5 pm EST	8	19.3 (0-24)	41	1	2	42 (tied)
Sunday	9 am to 5 pm EST	8	18.9 (0-24)	39	1	4	40 (tied)
Counseling Offered
Eligibility Criteria for Counseling	Minimum Age Required to Receive Counseling		Minimum Age: Mean (Min-Max)		Counseling Only Offered to Specific Subpopulations
New York	No		No minimum age		No
Other states (n = 44)	35 states (80%)		14 (11-18)		1 state (2%)
	New York		Other States (n = 44)
				Compared to New York^c: n (%)
Number of Counseling Sessions Offered to Callers	Number of Sessions		Number of Sessions: Mean (Min-Max)	More Sessions	Same Sessions	Fewer Sessions	NY Rank^c
Counseling Sessions	2		4 (1-8)^d	38 (86%)	0 (0%)	6 (14%)	39
Free Nicotine Replacement Therapy (NRT) Offered
Area	Any Free NRT Offered		Nicotine Patches Only	Multiple Forms of NRT (patch, gum, lozenge)		Patches Only Offered to Specific Subpopulations
New York	Yes		Yes	No		No
Other States (n = 44)	41 states (93%)		5 states (11%)	36 states (82%)		14 states (34%)
	New York	Other States (n = 41)
				Compared to NY^c: n (%)
Amount of Free NRT Offered to Callers	Number of Weeks	Number of Weeks: Mean (Min-Max)		More Weeks	Same Weeks	Fewer Weeks	NY Rank^c
Weeks per quit attempt	2	5 (2-12)		16 (39%)	11 (27%)	14 (34%)	17 (tied)

^bBased on the total number of hours the quitline is open and has counseling services available per day. States that have more hours per day do not necessarily open earlier and/or close later. States that have the same number of hours per day do not necessarily have the same hours of operation (ie, opening time and closing time).

^cFor ranking and comparison purposes, states that restrict provision of counseling services or free NRT to specific subpopulations are classified as providing a lower amount of counseling and/or free NRT than states that do not restrict the provision of quitline services to specific subpopulations, regardless of the number of counseling sessions offered to quitline callers or the number of weeks of free NRT offered to callers per quit attempt.

^dTwo states offer unlimited sessions. Unlimited sessions excluded from these calculations (mean, min, max).

The New York Quitline provides counseling services to all callers who are ready to make a quit attempt in the next 30 days and does not have a minimum age requirement for receiving counseling. The New York Quitline also does not restrict counseling services to specific subpopulations or groups of tobacco users (see Table 2). By comparison, 80% of the other 44 states that we analyzed (35 states) have a minimum age requirement (on average, aged 14 or older) to receive counseling through the state quitline. Seven states only provide counseling services to callers aged 18 or older (data not shown). Only 1 of the 45 states that we examined restricted counseling services to specific subpopulations (only nonprivate insurance callers; data not shown). The New York Quitline offers 2 counseling sessions to all eligible callers, compared to an average of 4 counseling sessions across the other 44 states included in our analysis; 2 states offer unlimited counseling sessions to quitline callers (see Table 2). New York was ranked 39 of the 45 states included in our analysis in the number of counseling sessions offered to eligible quitline callers.

New York, and 41 of the 44 comparison states (93%), offered some form of free NRT to eligible quitline callers. The New York Quitline as well as 5 of the 44 comparison states (11%) only offer free nicotine patches to eligible callers. Among the 44 comparison states, 36 (82%) states offer multiple forms of NRT to callers (eg, nicotine patches, gum, lozenges), 36 (82%) states offer free nicotine gum, and 25 states (57%) offer free nicotine lozenges to eligible callers.

The New York Quitline offers free nicotine patches to medically eligible quitline callers aged 18 or older and does not restrict the provision of free nicotine patches to specific subpopulations. Fourteen (34%) states restrict the provision of free nicotine patches through their state quitline to specific subpopulations. The most common restriction on the provision of free nicotine patches is insurance status, with many of those states only offering free nicotine patches to uninsured callers, underinsured callers who do not have insurance coverage for NRT, or Medicaid-insured callers. We assessed whether states have a minimum age criterion for free NRT, but we do not present those results because all state quitlines either require callers to be at least 18 years of age or require a prescription from a physician for callers younger than 18 years to receive free NRT from the quitline. The New York Quitline offers 2 weeks of free nicotine patches per quit attempt to eligible quitline callers. Across the 44 comparison states, the average number of weeks of free nicotine patches per quit attempt offered to eligible quitline callers was 5 weeks per quit attempt. New York was ranked 17 of the 45 states included in our analysis in the number of weeks of free nicotine patches per quit attempt offered to quitline callers. Although New York provides the fewest weeks of free nicotine patches per quit attempt to eligible quitline callers among the 45 states that we examined, 14 states restrict the provision of free nicotine patches to specific subpopulations, usually based on insurance status, and 3 states do not offer any free NRT to their quitline callers. We did not examine the eligibility criteria, or amount offered, for nicotine gum or lozenges, since New York does not offer those forms of NRT to quitline callers.

Quitline Effectiveness/Quit Rates

Table 3 presents descriptive information from the 7-month follow-up evaluation surveys conducted in 2010 to 2011 by 32 states with complete data. In 2010 to 2011, New York conducted 7-month follow-up evaluation surveys with a random sample of 5074 quitline callers, and 2626 of those quitline callers completed a 7-month follow-up evaluation survey for a survey response rate of 51.8%. Among the 32 states for which complete 7-month follow-up evaluation data were available, New York had the third highest follow-up survey response rate. The average follow-up survey response rate for the other 31 states we analyzed was 37% and ranged from 8.1% to 65.1% (see Table 3).

Table 3.

Seven-Month Follow-up Evaluation Survey Results for New York and 31 Other States, 2010 to 2011.^a

Statistic	Follow-Up Sample Size	Completed Follow-Up Survey	Response Rate	24-Hour Quit Attempt		30-Day Quit Rate
Statistic	Follow-Up Sample Size	Completed Follow-Up Survey	Response Rate	Responder Rate	Intent-to- Treat Rate	Responder Rate	Intent-to-Treat Rate
New York	5074	2626	51.8%	91.3%	47.2%	25.6%	13.2%
New York rank	6	3	3	1	2	22	7
Other States (n = 31)
Average	3486	1118	37.0%	76.6%	29.3%	29.0%	10.7%
Minimum	1251	400	8.1%	35.0%	5.9%	21.9%	2.7%
Maximum	11 108	3623	65.1%	89.9%	56.9%	48.7%	27.7%

^aData are from Centers for Disease Control and Prevention’s (CDC) National Quitline Data Warehouse (NQDW) Seven-Month Follow-Up Evaluation Survey data published online through CDC’s State Tobacco Activities Tracking and Evaluation (STATE) System website (http://www.cdc.gov/statesystem). Data are for 32 states that reported complete 7-month follow-up evaluation data for all measures to NQDW. The following 19 states/territories were excluded from our analysis due to missing data: Alaska, Arizona, California, Colorado, District of Columbia, Georgia, Illinois, Kentucky, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, North Dakota, Rhode Island, Tennessee, Utah, West Virginia, and Wyoming.

The 24-hour quit rate measure from the 7-month follow-up evaluation survey is a measure of whether quitline callers made quit attempts lasting 24 hours or longer at some point between initially contacting the quitline and the date when the 7-month follow-up evaluation was conducted. Nearly, all the New York Quitline callers who completed 7-month follow-up evaluations (91.3%) reported making a quit attempt lasting 24 hours or longer at some point after contacting the quitline. When using the intent-to-treat approach, the 24-hour quit rate for New York was 47.2%. Comparing New York’s 24-hour quit rates to the other 31 states with complete 7-month follow-up evaluation data, New York had the highest 24-hour quit rate among follow-up survey respondents and the second highest 24-hour quit attempt rate based on the intent-to-treat approach (see Table 3).

The 30-day quit rate measure from the 7-month follow-up evaluation survey is a measure of whether the respondent has used any tobacco at all in the past 30 days, assessed at the time the 7-month follow-up evaluation is completed. This measure can be assessed as a measure of longer-term quit success and is one of the longest measures of sustained quitting success available for quitline callers. Among New York Quitline callers who completed 7-month follow-up evaluation surveys, 25.6% reported not using any tobacco in the past 30 days at the time they completed their follow-up evaluation. When using an intent-to-treat approach, the 30-day quit rate for New York drops to 13.2%. Compared to the other 31 states with complete 7-month follow-up evaluation data, New York ranked 22nd in 30-day quit rate assessed among survey respondents. Based on the intent-to-treat approach to measuring 30-day quit rates, New York had the seventh highest 30-day quit rate among the 32 states that we analyzed. This difference is largely attributable to New York having a much higher 7-month follow-up response rate than many of the comparison states.

Discussion

This study presents descriptive results of the reach, services offered, and cessation outcomes for the New York Quitline and compares data for New York with data from other state quitlines. From 2010 through 2015, the New York Quitline had consistently higher reach than most other states, offered similar services like most other state quitlines but at a lower intensity, and had comparable quit rates to most other states. Annual quitline reach from 2010 through 2015 ranged from 2.3% to 3.6% for New York, which was consistently one of the highest among the 45 states that we examined; specifically, New York’s annual quitline reach ranked from second to fourth highest and was an average of 2.7 times higher than the average state reach among the 44 comparison states. The eligibility criteria for receiving counseling services or free NRT from the New York Quitline were similar to most of the comparison state quitlines. We found some differences in services offered by the New York Quitline and other state quitlines. The New York Quitline is open fewer hours per day than almost all the other 44 states that we examined, offers fewer counseling sessions than most other state quitlines, and was near the middle of the states we examined in the amount of free NRT offered to eligible quitline callers. Per capita funding for the New York Quitline is also lower than the national average per capita funding for state quitlines.¹⁰ The cessation outcomes in 2010 to 2011 for the New York Quitline compare favorably to the other 31 states with complete quitline cessation outcomes data. The intent-to-treat measures of 24-hour quit attempts and 30-day quit rates for the New York Quitline were the second and seventh highest, respectively, among the 32 states with complete quitline cessation outcome data.

Many states make decisions regarding their quitline service offerings based on available resources. States that restrict counseling or free NRT to specific subpopulations, or choose not to offer free NRT at all, often make such decisions based more on a lack of available resources than on evidence-based guidelines. The level of quitline services offered may be related to quitline effectiveness (eg, quit rates). Data for New York show that offering fewer counseling sessions, and a generally lower amount of free NRT, than the other 44 comparison states did not appear to have negative consequences on cessation outcomes, such as 24-hour quit attempts or 30-day quit rates. Previous research has shown that quitline callers complete an average of fewer than 3 counseling sessions, regardless of how many counseling calls they are offered, and that the average number of quitline counseling calls completed is typically considerably smaller than the maximum number offered.^11,12 Thus, the number of counseling calls offered by state quitlines may not be a good proxy for the amount of counseling being delivered to quitline callers. As such, quitline callers in New York may be receiving amounts of counseling similar to other states, although other state quitlines offer callers a greater number of counseling sessions than New York.

Quitline reach is largely driven by mass media promotion, referrals from health-care providers and other health systems infrastructure, and word of mouth from family and friends. Past exposure to and use of quitlines may also influence reach. Many quitline callers are repeat callers who have used the program before. The tobacco control environment in the state (eg, higher cigarette excise taxes) may also increase interest in quitting, which in turn may result in increased quitline use. Promotion of state quitlines has been shown to increase awareness and use of quitlines.^3,13,14

New York has consistently and successfully used mass media to promote the quitline and prompt smokers to contact the quitline. Previous research has shown that, from 2003 to 2009, paid mass media implemented by the New York Tobacco Control Program that promoted the New York Quitline resulted in an increase in calls and a decrease in statewide adult smoking prevalence.¹⁵ The New York Tobacco Control Program has also made health systems change a priority and is working to integrate the New York Quitline into New York’s larger health-care system. Specific health system priorities for the New York Quitline relate to referring patients back to providers who referred to the quitline, helping smokers negotiate smoking cessation insurance benefits, and being a resource to health system organizations looking to improve delivery of cessation services to their enrollees. Successful referral networks and practices may also account for New York’s relatively high quitline reach.

Although New York’s quitline reach is relatively high, compared to the other 44 comparison states in our analysis, overall state quitline reach remains low nationwide. Future work is needed to better understand the determinants of quitline reach and to determine what mechanisms, such as additional promotional efforts or system change efforts in health and nonhealth systems, might be effective at increasing quitline reach. Although additional, or more intensive, quitline services likely do not influence reach, the services offered by quitlines may affect quit outcomes among those who use quitline services. Additional research is also needed to determine whether quit outcomes are influenced by variations in quitline services provided.

Limitations

This study has several limitations. First, because of missing data, we were only able to analyze quitline reach and services offered for 45 states and we were only able to assess 7-month follow-up evaluation survey data for 32 states. Second, annual reach may be overestimated because it was calculated based on quarterly counts of the unique number of tobacco users who received counseling and/or free NRT from their state quitline. If tobacco users enrolled in and received services from their state quitline in more than one-quarter during a calendar year, then our estimates of annual reach are overstated. However, because this is an issue with the data design, and all states complete the same quarterly survey, this issue should be uniform across all states included in our analysis. Third, our descriptive profiles of the services offered by state quitlines are only based on one point in time (2015-Q4); therefore, our results may not fully reflect the differences in quitline services between New York and the comparison states because of changes in state quitline service offerings that may have occurred over the study period. A fourth limitation is that quitline reach across states may be affected by differences in the population of smokers across states with respect to age, sex, income, and other demographics or characteristics of smokers. If New York’s adult smoking population contains a higher proportion of smokers who are likely to use quitline services than other states, then New York’s quitline will tend to be higher, all else being equal. Finally, the 7-month follow-up evaluation survey data were collected using different sampling and implementation protocols, as well as different data collection modes, which limits the comparability of quit rates across states. Differences in quit rates from 7-month follow-up evaluations across states may be influenced by the mode of follow-up data collection as well as differences in the distribution of quitline clients by age, sex, and income and other characteristics across states. Available follow-up evaluation data do not allow us to stratify quit outcomes or control for differences by mode of follow-up data collection or demographics and characteristics of quitline clients. The 7-month follow-up evaluation survey is also inherently subject to nonresponse bias because individuals who were unable to quit or who relapsed after quitting are less likely to complete a survey. We attempted to control for nonresponse bias by including an intent-to-treat quit rates in our analysis.

So What? Implications for Health Promotion Practitioners and Researchers

What is already known on this topic?

Telephone quitlines offer tobacco use cessation services, including counseling, self-help materials, and sometimes nicotine replacement therapy, to smokers at no cost to them. Quitlines exist in all US states. Previous research has demonstrated that quitlines are effective at increasing tobacco use cessation. Annually, about 1% of adult smokers in the United States use telephone quitlines with substantial variation in quitline utilization across states

What does this article add?

This study extends and updates existing data on quitline reach, utilization, and effectiveness. This study also provides a descriptive profile of the different services offered by state telephone quitlines. Finally, this study highlights the variation in quitline service offerings across states as well as the variation in quitline reach, utilization, and effectiveness across states

What are the implications for health promotion practice or research?

This study highlights that the services offered by quitlines vary widely across states. There is very little research or guidance available regarding what specific services state telephone quitlines should be offering. This study provides information which may be useful for developing guidance or best practices regarding what services state quitlines should be offering to callers.

Footnotes

Acknowledgments

The findings and conclusions in the paper are those of the authors and do not necessarily represent the views of the New York State Department of Health.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the New York State Department of Health (contract number C028511).

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