Prepared by: ERDU May 5, 2009 Draft Results from the 2008 NAQC Annual Survey

Overview: The following slides present results from the 2008 NAQC Annual Survey for Survey Workgroup review Any changes or edits recommended will be incorporated into the final presentation to be used at the NAQC Annual Conference in June 2009

Background of Annual Survey Conducted Annually , 2008 –Research Partners: 2008 Evaluation, Research and Development Unit, University of Arizona 2006 Center for Tobacco Research and Intervention, University of Wisconsin 2005 University of California, San Diego 2004 Tobacco Technical Assistance Consortium Informs research and practice Is an iterative process

2008 Annual Survey Methods 63 quitline funders and their service providers were asked to respond: –53 US and Territories quitlines –10 Canadian quitlines Reporting was for Fiscal Year 2008 Web-based completion Winter 2008 Follow-up with quitlines thru January 2009 Data cleaning thru March % response rate

General Service Description All quitlines reported having counseling services available at least five days per week for a minimum of eight hours per day 46 US and 8 Canadian quitlines also offered counseling service on at least one day of the weekend 13 quitlines (12 US, 1 Canadian) reported having live pick-up of incoming calls (may or may not have counseling services available) 24 hours a day, 7 days a week 72% of US and 80% of Canadian quitlines reported closing on holidays

Quitline Services Offered

Existing Cessation Services Separate from the Quitline – US (N=53)

Existing Cessation Services Separate from the Quitline – Canada (N=10)

Language of Counseling Service

US Primary Service Providers The figure below shows the organizations (n=18) that were the primary service provider of counseling services for US quitlines. Percent of Quitlines Reporting Service Provider

Canadian Service Providers The majority of Canadian quitlines (60%) had counseling services provided by the Canadian Cancer Society, Ontario Division Percent of Quitlines Reporting Service Provider

Number of Funding Sources – US (N=53) Number of Quitlines

Number of Funding Sources – Canada (N=10) Number of Quitlines 4 5 1

US Funding Sources Respondents were asked to identify the types of funders that supported their quitlines. The number and percentage of US quitlines reporting each type of funding source is shown in the figure below. *In 2008 the Centers for Disease Control and Prevention provided quitline supplemental funding to all U.S. states and territories but one; data reported here indicate states that used supplemental funding for quitline services (counseling and medications).

Canadian Funding Sources 6 10 Respondents were asked to identify the types of funders that supported their quitlines. The number and percentage of Canadian quitlines reporting each type of funding source is shown in the figure below. 11

US Quitline Budgets Budget Category NMissingMinMaxMedianSum Total 512$100,000$24,538,157$1,000,000$118,587,046 Services 467$85,000$5,711,411$683,944$52,611,933 Medications 2825$16,000$5,000,000$310,024$16,149,797 Evaluation 2528$6,650$1,200,000$75,000$3,131,450 Media 3617$4,000$16,000,000$373,621$43,672,706 Outreach 1637$18,000$1,104,451$133,924$5,110,545

Canadian Quitline Budgets Budget Category NMissingMinMaxMedianSum Total 82$46,230$2,660,500$324,624$6,036,968 Services 82$25,000$1,320,000$221,500$3,080,572 Medications 010 Evaluation 28$50,000$206,000$128,000$256,000 Media 82$7,610$900,000$100,000$1,883,859 Outreach 46$2,246$479,500$44,092$569,931

Spending per Smoker The smoking population was calculated for each state or province using adult population (18+ US BRFSS, 15+ Canada Statcan ) and smoking prevalence (18+ US BRFSS, 15+ Canada CTUMS ) estimates for 2007 The Services and Medications Budget reported per quitline was then divided by the number of smokers in each state/province The mean spending per smoker for US quitlines was $3.33, (median =$1.33), with a range from $0.08 to $24.05 (N=45, N=25 also provided Meds budget) The mean spending per smoker for Canadian quitlines was $0.60, (median =$0.53), with a range from $0.13 to $1.66 (N=8) *Canadian Quitlines reported no Medications Budget so spending per smoker is for Services only CDC Best Practices for Comprehensive Tobacco Control Programs recommends spending of $10.53 per adult smoker ($2.19 per capita – adults) for quitline services and medications*

Relationship Between Service Spending and Utilization Reach CDC calculates that quitlines funded at the recommended level of $10.53 per adult smoker could serve 6% of smokers with counseling, and assumes 85% of those served would accept free NRT (CDC, 2007)

Relationship Between Media Spending and Utilization Reach

Language of Cessation Materials

Specialized Materials for Special Populations 52 US quitlines (98%) and 4 Canadian quitlines (40%) send specialized materials to special populations. These include:

Specialized Materials for Non-tobacco Users 100% of US and 90% of Canadian quitlines send materials to callers who are not tobacco users or recent quitters. These include:

First Counseling Encounter - US Typical Intake/Enrollment –25 could separate out Intake/Enrollment –Range: 7 to 30 minutes, median =15 minutes Typical Assessment –36 could separate out Assessment –Range: 7 to 45 minutes, median =10 minutes Typical first Counseling session –51 could separate out first Counseling session –Range: 10 to 45 minutes, median =30 minutes

First Counseling Encounter - Canada Typical Intake/Enrollment –2 could separate out Intake/Enrollment –Range: 5 to 25 minutes, median =15 minutes Typical Assessment –9 could separate out Assessment –Range: 4 to 15 minutes, median =5 minutes Typical first Counseling session –10 could separate out first Counseling session –Range: 5 to 45 minutes, median =15 minutes

Median Minutes of First Counseling Encounter – US and Canada Minutes N=25N=2 N=36 N=9 N=10 N=51

Counseling Intervention Protocols Yes Minimum # of sessions Maximum # of sessions Median # of sessions Allow Additional Sessions No Limit to Additional Sessions US (N=53) Canada (N=10) No US (N=53) 24, 5 Canada (N=10) 614 for all Respondents were asked whether their quitline has a counseling protocol that dictates a certain number of sessions. The number who responded yes and a summary of the session protocols are shown in the first three rows below. The last two rows show the number of quitlines that do not dictate a certain number of sessions, and the maximum number of calls allowed for each.

Timing of Counseling Sessions

Major Content Areas of Counseling US (N=53) Canada (N=10) Freq% % Motivation (Effects of nicotine, health risks of continued smoking, medical conditions and concerns) Use of quitting medications (including medication compliance) Development of quit plan Setting a quit date Relapse prevention Self-efficacy (including confidence level monitoring) Withdrawal symptoms Planning—coping strategies for dealing with triggers (alternatives to smoking, conflict management, refusal skills, decision making) History of smoking/quitting behavior (including barriers to quitting) Social support Weight gain Stress management (Relaxation, breathing) Culturally specific information Second hand smoke / environmental tobacco smoke

Specialized Counseling Protocols 94% of US and 90% of Canadian quitlines use specialized counseling protocols for special populations. These include:

Eligibility Criteria for Counseling 87% of US and 60% of Canadian quitlines have eligibility criteria for callers to receive counseling. These include:

Eligibility Criteria for Different Levels of Service 18 US quitlines (34%) and 7 Canadian quitlines (70%) have different eligibility criteria for different levels of service Open-ended responses described eligibility criteria for differing level of service including: –Increased sessions depending on readiness to quit (n=10, US and n=6, Canada) –Increased sessions for pregnant women (n=6, US) –Increased sessions for youth (n=4, US) –Increased sessions for uninsured or Medicaid/Medicare/VA/IHS insured (n=5, US)

Provision of Quitting Medication PatchGumLozengeZybanChantixNasal Spray InhalerANY Meds US (N=53) Provide free medication 70%57%34%7%4%2% 70% Provided discounted meds 9% 6%7%4% 9% Provided voucher to redeem meds 13%11%9%6%7%4% 13% Canada (N=10) Provide free medication 10% Provided discounted meds 10% Provided voucher to redeem meds

Provision of Information about Quitting Medication PatchGumLozengeZybanChantixNasal SprayInhaler US (N=53) Provided info about using meds 98% 94% 81%49% Referred to organization that provides meds 36%34%30%26%23%7% Provided info about accessing meds 28%25%23% 26%19%17% Canada (N=10) Provided info about using meds 100% 90%100% 30%90% Referred to organization that provides meds 20% Provided info about accessing meds 30% 10%20%10% 20%

Free Medication Provision – US Quitlines Free Meds Type # Providing Type of Free Meds N (Providing weeks data) Median # of Weeks Provided Minimum # of Weeks Maximum # of Weeks Patch Gum Lozenge Zyban Chantix2112 Nasal Spray Inhaler11888

US Free Medications Eligibility Criteria Of the 37 US quitlines providing some form of free meds, the following number used eligibility criteria which included: Percent of 37 quitlines with free meds citing each meds eligibility criteria

Utilization - Calls Total CallsNMissingMinMaxMedianSum US (N=53) Answered live ,8118,270608,377 Went to voic , ,086 Hung up or abandoned , ,428 Canada (N=10) Answered live ,5651,60050,924 Went to voic Hung up or abandoned

Utilization – Unique Tobacco Users Unique Users Calling for Self NMissingMinMaxMedianSum US (N=53) Total ,8944,847409,902 Smokers ,8274,544317,296 Other Tobacco Users , ,873 Canada (N=10) Total , ,125 Smokers ,2251,6429,458 Other Tobacco Users

Utilization – Received Service Tobacco Users Who Received Service NMissingMinMaxMedianSum US (N=53) Self-help Materials , ,604 Counseling ,0973,065348,880 Canada (N=10) Self-help Materials Counseling 281,5621,6761,6193,238

Utilization Proxy Calls and Proactive Referrals NMissingMinMaxMedianSum US (N=53) Proxy Calls , ,044 Total Proactive Referrals , ,609 Fax Referrals431049, ,156 Other Referrals , ,800 Canada (N=10) Proxy Calls ,660 Total Proactive Referrals 73151,531402,263 Fax Referrals91151,389783,972 Other Referrals ,315

Insurance Status of Callers Insurance TypeNMissingMinMaxMedianSum US (N=53) None ,8031,61892,269 Gov’t Provided (Medicare, Medicaid, etc.) ,1411,33692,674 Private ,4992,065113, US quitlines (85%) reported that they collect information on the insurance status of callers who receive services. The numbers of three types of insurance quitlines collect include:

Staff Training All quitlines train cessation specialists/counselors before they counsel clients. Training includes: US (N=53) Canada (N=10) Training Type NMedian Hours MinMaxNMedian Hours MinMax Classroom training Role playing Call shadowing Online training On their own Other

Supervision of Cessation Counselors All quitlines indicated they had a procedure for supervising cessation counselors. Types of supervision include: US (N=53) Canada (N=10) Supervision TypeN Most common frequency N Group led by clinical supervisor52 Biweekly or weekly 10 As needed Individual meeting with clinical supervisor 52 As needed 10 Quarterly Peer supervision50 As needed 9 Daily Reviewing taped calls52 Biweekly or weekly 10 Quarterly Live call monitoring by supervisor 52 Bimonthly or monthly 10 Semiannually or Yearly

Evaluation 52 US quitlines (98%) and 3 Canadian quitlines (30%) conduct follow-up evaluations Most quitlines have follow-up evaluation conducted internally by; –quitline staff (US n=20; Canada n=1) –staff other than quitline staff (e.g., internal evaluation unit) (US n=20; Canada n=1) Next most commonly cited was evaluation conducted by; –an outside evaluation firm (US n=13; Canada n=1), –an Other source (US n=5) –the Funding Agency (US n=3)

Evaluation The types of evaluation data collected by those quitlines that conduct follow-up evaluations include; –Customer satisfaction: US (94%, 50), Canada (30%, 3) –Staff performance: US (66%, 35), Canada (10%, 1) –Quitting outcome: US (98%, 52), Canada (20%, 2)

Treatment Reach Data provided by quitlines should be put into the context of the size of the smoking population within each state/province by calculating reach Treatment reach is defined as “the proportion of the target population who receive an evidence- based treatment from a quitline” (NAQC, 2009, p 1) Only 2 Canadian quitlines were able to report the number of tobacco users who received service Prevalence estimates available are only for smokers (BRFSS, CTUMS), not all tobacco users As a result, treatment reach can not be adequately calculated at this time However, utilization reach, “the proportion of a population who use a service” (NAQC, 2009, p 2) can be calculated for smokers, at least for the US

Utilization Reach for Smokers The smoking population was calculated for each state or province using adult population (18+ US BRFSS, 15+ Canada Statcan ) and smoking prevalence (18+ US BRFSS, 15+ Canada CTUMS ) estimates for US and 3 Canadian quitlines reported the total number of smokers calling for self during FY08 The mean utilization reach for the 3 Canadian quitlines was 0.44% (median=0.38%) The mean utilization reach for 40 US quitlines was 1.3% (median=0.7%), with a range of 0.1% to 5.2% *Utilization reach could not be calculated for 1 US quitline reporting the number of smokers calling for self because no smoking prevalence data was available for this territory.

For more information on the survey or on NAQC’s data request and review process, please contact; Jessie Saul, Ph.D. Director of Research North American Quitline Consortium 3030 N. Central Ave, Ste 602 Phoenix, AZ Ph: