Quitline Treatment Protocols for Users of Non Cigarette Tobacco and Nicotine Containing Products Brittany D. Linde, Jon O. Ebbert, G. Wayne Talcott, Robert C. Klesges PII: DOI: Reference:
S0306-4603(15)00087-8 doi: 10.1016/j.addbeh.2015.02.015 AB 4506
To appear in:
Addictive Behaviors
Please cite this article as: Linde, B.D., Ebbert, J.O., Wayne Talcott, G. & Klesges, R.C., Quitline Treatment Protocols for Users of Non Cigarette Tobacco and Nicotine Containing Products, Addictive Behaviors (2015), doi: 10.1016/j.addbeh.2015.02.015
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
PT
ACCEPTED MANUSCRIPT
RI
Quitline Treatment Protocols for Users of Non Cigarette Tobacco and Nicotine Containing
SC
Products
NU
Brittany D. Linde, PhD1
Jon O. Ebbert, MD, MSc2
MA
G. Wayne Talcott, PhD1
TE
1
D
Robert C. Klesges, PhD1
Department of Preventive Medicine, Center for Population Sciences, University of Tennessee
2
AC CE P
Health Science Center, 66 N Pauline, Suite 467, Memphis, TN 38163 Mayo Clinic, 200 First Street SW, Rochester, MN 55905
Corresponding Author: Jon O. Ebbert, MD, MSc, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Telephone: (507) 266-1944; Facsimile: (507) 266-7900; E-mail: [email protected]
Pages: 10 Number of Tables: 1 Number of Appendices: 1
ACCEPTED MANUSCRIPT Abstract Introduction: Use of non cigarette tobacco and nicotine containing products (TNCP) is
PT
increasing in the US. Telephone tobacco quit lines (QLs) are one of the most widely
RI
disseminated tools for providing cessation services to cigarette smokers, but the range of QL treatment services offered to non cigarette TNCP users needs to be determined.
SC
Methods: We surveyed QLs across 50 US states, Washington D. C, and Guam for the number of
NU
treatment protocols offered, products they were intended to treat, and how telephone counselors triaged patients reporting use of non cigarette TNCPs.
MA
Results: Thirteen organizations provided US QL interventions of which eleven agreed to be interviewed regarding their treatment services (84.6%). Seven of the eleven QL providers
TE
D
(63.6%) used a single intervention protocol adapted to the type of non cigarette TNCP used. Two of the eleven QLs (18.2%) referred hookah users to another provider and one QL (9.1%)
AC CE P
referred electronic cigarette users to third party resources for cessation support; otherwise a single intervention protocol was used for all other TNCP users. Only one QL (9.1%) had a specialized protocol for smokeless tobacco users in addition to a standard protocol for all other callers.
Conclusions: QL providers do not have access to tailored protocols for non cigarette TNCP users, and it remains uncertain whether a common tobacco protocol will be efficacious for these users. Future research should both validate potential common protocols for non-cigarette TNCP users and address the need for and the development of specialized QL interventions for TNCP users to help them quit. Keywords: tobacco, cessation, telephone intervention, quit line, tobacco and nicotine containing products (TNCP)
ACCEPTED MANUSCRIPT Introduction Tobacco and nicotine containing products (TNCP) [e.g. cigarettes, cigars, hookah, e-
PT
cigarettes, and smokeless tobacco (ST)] contribute to the prevalence of total tobacco
RI
consumption (i.e. 26.2% for men and 15.4% for women; Centers for Disease Control, 2014). Unlike the decline in cigarette smoking since the 1950s, the use of non cigarette TNCPs have
SC
remained constant or increased in the last decade (ALA, 2011). Many of these products have
NU
health effects that are believed to be either similar, or potentially worse (e.g., hookah), than cigarette smoking and are a growing public health concern (Centers for Disease Control, 2013;
MA
American Lung Association, 2014a; Grana, Benowitz, & Glantz, 2014; O’Connor, 2012). A wide array of behavioral interventions have been shown to be effective for increasing
TE
D
tobacco abstinence rates in civilian populations, including face-to-face, internet and telephone quit line (QL) interventions (Fiore et al., 2009). One of the most widely validated, adopted, and
AC CE P
disseminated tobacco treatment interventions is the telephone tobacco quit line (QL) (NACQ, 2014). Services offered by QLs include coaching and/or counseling, referrals, mailed materials, training to healthcare providers, web-based services and, in some instances, free medications in the form of nicotine replacement therapy (NRT) (NAQC, 2014). Due to their ability to reach and serve widespread tobacco users, QLs are accessible in all 50 states, Washington D. C., and the U.S. territories (NAQC, 2014). US tobacco QLs received over 1.3 million calls in 2012; this number has increased every year except one since 2005 (NAQC, 2014). Telephone tobacco QLs were initially created to treat cigarette smokers, the leading cause of preventable and premature death in the United States (Anderson & Zhu, 2007; American Lung Association, 2014b). And although telephone QLs are effective methods of delivering evidencebased smoking treatment to large numbers of cigarette users (Stead, Perera, & Lancaster, 2006;
ACCEPTED MANUSCRIPT Fiore et al., 2009) and in some cases ST users (Boyle, Enstad, Asche, Thoele, Sherwood, Severson, et al., 2008; Ebbert, Montori, Erwin, & Stead, 2011), little is known about the range of
PT
services provided to non cigarette TNCP users or if they are effective for cessation. For example,
RI
a recent survey of QL providers reported that 10-30% of QL callers were e-cigarette users, often in addition to other TNCPs (NAQC, 2014b; Vickerman, Carpenter, Altman, Nash, & Zbikowski,
SC
2013). Interestingly, e-cigarette users were less likely to be quit seven months after calling a QL
NU
compared with those who had never tried e-cigarettes (Vickerman et al., 2013). Even without evidence of their effectiveness for the treatment of users of non cigarette TNCPs, many QLs are
MA
encouraging all tobacco users to utilize their cessation treatment services (e.g. Colorado State QuitLine; CDPHE, 2013).
TE
D
In order to determine how QLs address non cigarette TNCP users, we conducted a survey of US tobacco QLs to determine the number and type of intervention protocols available, the
AC CE P
types of tobacco products they are intended to treat, and how each caller is handled (by product type) when they seek assistance from the QL. This study will inform future studies of QL intervention protocols and treatment plans for TNCP users. Methods
Contact information for each telephone quit line (QL) provider was collected from the NAQC website (see http://map.naquitline.org/reports/operators/ for a list of current providers). Initial contact with the service provider aided in the search for individuals associated with detailed implementation of tobacco intervention protocols. No demographic information was collected from the QL respondent. Verbal consent was granted by the qualified representative (typically a program manager, director, or supervisor) prior to the questionnaire being administered. All questionnaires were completed between June 2014 and July 2014. The
ACCEPTED MANUSCRIPT Wilford Hall Ambulatory Surgical Center Institutional Review Board (FWH20140079E) approved the execution of this exempt study.
PT
The questionnaire began with an overview of the purpose of the study followed with
RI
questions specific to the intervention protocols. We inquired about: 1) the existence and number of all treatment protocols; 2) the tobacco products the protocols were intended to treat; and 3) the
SC
procedures implemented when a non cigarette user calls in to the QL. Appendix 1 presents the
NU
survey questions in detail. Results
MA
We identified thirteen QL service providers who were contracted to deliver services. One QL was undergoing reorganization (QL personnel could not be reached to complete the survey)
TE
D
and another QL point-of-contact could not be reached after multiple attempts. Thus, 11 QL providers (84.6%) completing the survey. Four of the eleven providers (36.4%) delivered
AC CE P
services to multiple states/districts/territories. The remaining seven providers (63.6%) operated a single state QL. No state was represented by more than one service provider. Every QL service provider who participated in the survey (n = 11, 100.0%) had at least one established tobacco cessation intervention protocol (i.e. a plan for treatment with specific procedures/language used) that was followed when someone called the QL for cessation assistance (Table 1). Seven out of eleven providers (63.6%) treated every caller the same; they treated callers with the only protocol available and adapted it to the product being used (e.g. the word ―cigarette‖ was replaced with ―hookah‖ or ―cigar‖ as needed). Three out of eleven service providers (27.3%) referred participants to a variety of third party resources (i.e. not provided by the QL website or counselor; e.g. websites, downloadable materials, or mailed pamphlets; NAQC, 2014b) if they used hookah or e-cigarettes; any other non cigarette TNCP user was
ACCEPTED MANUSCRIPT treated with the standard protocol and adapted it to the product being used. Only one provider used a specialized telephone intervention protocol (9.1%) for one of the non cigarette TNCPs on
PT
our questionnaire; the specialized intervention was created and implemented for smokeless
RI
tobacco (ST) users. This specialized ST protocol used unique language and modified procedures during the behavioral component of the treatment intervention in conjunction with the provision
SC
of dedicated printed materials. This protocol was applied in addition to a standardized protocol
NU
used for all other TNCPs. Discussion
MA
The current study surveyed telephone tobacco QL providers in the United States. Most of the QLs (63.6%) adapted a single standardized intervention protocol for all non cigarette
TE
D
TNCP users who called in for assistance. Only one QL (9.1%) had a tailored treatment for any form of non cigarette TNCP user; in this case, ST users were treated with a unique intervention
AC CE P
tailored to their distinctive needs. Some of the QLs (27.3%) referred hookah and electronic cigarette users to third party resources (e.g. websites, downloadable or printed materials), although most treated hookah and e-cigarette users as if they were cigarette smokers. Future research needs to evaluate the efficacy of using a common protocol to treat noncigarette TNCPS. The use of TNCPs, regardless of the type of product, is an addictive behavior and common behavioral strategies might be effective for treatment of tobacco dependence. However, interventions that have been shown to work for increasing long-term abstinence among cigarette smokers have not been shown to have the same efficacy for ST users (Ebbert, Montori, Erwin, & Stead, 2011; Ebbert & Fagerstrom, 2012). Boyle and colleagues (2008) expressed the need for research on the components contributing to the effectiveness of a QL designed specifically for ST users, noting that although telephone intervention worked for their
ACCEPTED MANUSCRIPT sample of ST users, the proportion(s) of the intervention that most contributed to that success was unknown. Future research on non cigarette TNCP interventions should be directed toward
PT
discovering common and unique intervention components.
RI
Cigarette smoking is the leading cause of preventable death and disability and tobacco QLs have been a major contributor to smoking cessation across the nation (Fiore et al, 2009).
SC
More recently, the efficacy of QLs for ST users has been established (Boyle et al., 2008; Ebbert,
NU
Montori, Erwin, & Stead, 2011; Severson et al., 2014), but studies of QL interventions for other non cigarette TNCPs have not been reported (Maziak, Ward, & Essenberg, 2007). QL providers
MA
have the opportunity to implement novel protocols in the near future that may be efficacious for electronic cigarette users (Gromov, 2014), but 91.9% of quit lines are treating these users now
TE
D
without any evidence to justify their methods. It is reasonable to conclude that if an intervention is efficacious for one form of nicotine addiction (cigarettes), that it should work for another form
AC CE P
of nicotine addiction (e.g., hookah). On the other hand, research on ST suggests unique treatment protocols might be necessary. Most importantly, it appears that QLs (and presumably other providers as well) are using common protocols for the treatment of TNCPs. Ideally protocols would be designed to most effectively address TNCP users. A recent report by the North American Quitline Consortium highlights the importance of consistent treatment methods for dual and poly users of TNCPs, especially in regards to NRT distribution protocols for those who use e-cigarettes as a tobacco cessation method (NAQC, 2014b). Without research to validate the effectiveness of QL protocols for non cigarette TNCP users, interventionists may be less effective in the treatment of these new products (e.g. Vickerman et al, 2013). Tobacco treatment QLs are an effective cessation aid for cigarette smokers and in some cases for ST users, but whether or not they are effective for other TNCP users is unknown.
ACCEPTED MANUSCRIPT Research on the efficacy of smoking QLs for ST cessation requires us to reevaluate the ways service providers treat non cigarette TNCP callers; they may or may not be a homogenous group.
PT
It is possible that, with the use of tailored cessation intervention protocols depending on the
RI
product used, cessation rates will increase when providers implement tailored interventions for different TNCP users. On the other hand, it is possible that common components of tobacco
SC
dependence may work regardless of the TNCP. Further research is necessary to determine the
AC CE P
TE
D
MA
NU
effects of more personalized cessation interventions for non cigarette TNCP users.
ACCEPTED MANUSCRIPT Appendix 1: Tobacco QL Questionnaire
PT
1. Do you have an intervention protocol for your smoking cessation program? (Explain if need be.) ___Yes (go to Q2) ___No (Do not proceed; thank them and end call)
RI
2. How many standard protocol treatments do you currently have? ___
NU
SC
3. What tobacco products is (are) the protocol(s) intended to treat? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
MA
4. Which of those protocols, if any, do you use to treat: a. Hookah? b. E-cigarettes?
AC CE P
e. Dual/poly users?
TE
d. Cigars?
D
c. Smokeless tobacco?
5. If the QL does not have a standard protocol for the above items ask: What do you do with this individual? a. Refer them to a service (e.g., internet, pamphlets) that specializes in (hookah, e-cigs, ST, cigars) tobacco cessation (If they respond with this answer, ask): i. Are these materials on your web site/provided by your quit line or ii. Are these materials on a third party web site? b. Treat them with your telephone protocol that is used with smoking cigarettes and adapt it to the fact they are using (hookah, e-cigs, ST, cigars) c. Use a specialized telephone intervention protocol that is specific to (hookah, e-cigs, ST, cigars). Describe. d. This would be an off protocol call so interventionists use their discretion regarding recommendations based on the needs of the caller.
ACCEPTED MANUSCRIPT
Protocol(s) treat all TNCPs?
How hookah handled?
How e-cigs handled?
How ST handled?
How cigars handled?
How dual/poly handled?
Adapt
Adapt
Adapt
Adapt
Adapt
Adapt
Adapt
Adapt
Third party referral
Adapt
Adapt
Adapt
Adapt
Adapt
Adapt
Adapt
1
Yes
Adapt
B
1
Yes
Adapt
C
1
Not e-cigs
Adapt
D
1
Not hookah
Third party referral
E
1
Yes
Adapt
Adapt
Adapt
Adapt
Adapt
F
1
Not hookah
Third party referral
Adapt
Adapt
Adapt
Adapt
G
1
Yes
Adapt
Adapt
Adapt
Adapt
Adapt
H
2
Yes
Adapt
Adapt
Specialized
Adapt
Adapt
I
1
Yes
Adapt
Adapt
Adapt
Adapt
Adapt
J
1
Yes
Adapt
Adapt
Adapt
Adapt
Adapt
K
1
Yes
Adapt
Adapt
Adapt
Adapt
Adapt
RI SC
NU
PT ED
CE
AC
PT
A
MA
Table 1: Survey Results* Service Number of tobaccoProvider related protocols?
* Data was collected from 11 service providers. Findings are displayed in random order so as to be deidentified.
ACCEPTED MANUSCRIPT References Agaku, I. T., King, B. A., Husten, C. G., Bunnell, R., Ambrose, B. K., Hu, S. S., … Day, H. R.
PT
(2014). Tobacco Product Use Among Adults — United States, 2012–2013. Morbidity
RI
and Mortality Weekly Report (MMWR), 63(25), 542-547.
American Lung Association (2011). Trends in Tobacco Use. http://www.lung.org/finding-
SC
cures/our-research/trend-reports/Tobacco-Trend-Report.pdf.
smoking/health-effects/smoking.html.
NU
American Lung Association (2014). Smoking. http://www.lung.org/stop-smoking/about-
MA
Anderson, C., & Zhu, S. (2007). Tobacco quitlines: looking back and looking ahead. Tobacco Control, 16(Suppl 1), i81-i86. PMCID: PMC2598521.
TE
D
American Lung Association (2014). Hookah Smoking: A Growing Threat to Public Health. http://www.lung.org/stop-smoking/tobacco-control-advocacy/reports-resources/cessation-
AC CE P
economic-benefits/reports/hookah-policy-brief.pdf. Boyle, R. G., Enstad, C., Asche S. E., Thoele, M. J., Sherwood, N. E., Severson, H. H., … Solberg LI. (2008). A randomized controlled trial of telephone counseling with smokeless tobacco users: the ChewFree Minnesota study. Nicotine & Tobacco Research, 10(9), 1433-1440. doi: 10.1080/14622200802279872. Centers for Disease Control (2013). The dangers of hookah smoking. http://www.cdc.gov/features/hookahsmoking/. Centers for Disease Control (2014). Tobacco Use among US Adults -- United States, 2012-2013. http://www.cdc.gov/tobacco/data_statistics/mmwrs/byyear/2014/mm6325a3/intro.htm. Colorado Department of Public Health and Environment (2013). Colorado QuitLine Enrollment. https://www.coquitline.org/enrollment/enroll.aspx.
ACCEPTED MANUSCRIPT Ebbert, J. O., & Fagerstrom, K. (2012). Pharmacological interventions for the treatment of smokeless tobacco use. CNS Drugs, 26(1), 1-10. doi: 10.2165/11598450-000000000-
PT
00000.
RI
Ebbert, J., Montori, V. M., Erwin, P. J., & Stead, L, F. (2011). Interventions for smokeless tobacco use cessation. Cochrane Database Syst Rev, 2, Cd004306. doi:
SC
10.1002/14651858.CD004306.pub4.
NU
Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J. … Wewers, M. E. (2008). Treating Tobacco Use and Dependence: 2008 Update. U.S. Department of
MA
Health and Human Services, 1-276. http://www.ahrq.gov/professionals/cliniciansproviders/guidelines-
TE
D
recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf. Grana, R., Benowitz, N., & Glantz, S. A. (2014). E-cigarettes: a scientific review. Circulation,
AC CE P
129(19), 1972-1986. doi: 10.1161/CIRCULATIONAHA.114.007667. Gromov, N. (2014). IMPORTANT! Upcoming NAQC Resources on e-Cigarettes! http://www.naquitline.org/news/177515/IMPORTANT-Upcoming-NAQC-Resources-one-Cigarettes-.htm
Maziak, W., Ward, K. D., & Eissenberg, T. (2007). Interventions for waterpipe smoking cessation. Cochrane Database Syst Rev, 4, Cd005549. PMID: 17943865. North American Quitline Consortium (2014). http://www.naquitline.org/. North American Quitline Consortium (2014b). Cessation Treatment and E-Cigarettes: A Report on Current Literature and Quitline Practices. (L. Bailey, S. Kalkhoran and P. Ling). Phoenix, AZ. http://c.ymcdn.com/sites/naquitline.siteym.com/resource/resmgr/ECigarettes/ECigarettesReportFinal.pdf
ACCEPTED MANUSCRIPT O'Connor, R. J. (2012). Non-cigarette tobacco products: what have we learnt and where are we headed? Tobacco Control, 21(2): 181-190. doi: 10.1136/tobaccocontrol-2011-050281.
PT
Severson, H. H., Danaher, B. G., Ebbert, J. O., van Meter Ba, N., Lichtenstein, E., Widdop, C.,
RI
… Seeley, J. R. (2014, Aug 28). Randomized trial of nicotine lozenges and phone counseling for smokeless tobacco cessation. Nicotine & Tobacco Research, pii: ntu145.
SC
PMID: 25168034.
NU
Vickerman, K.A., Carpenter, K.M., Altman, T., Nash, C.M., & Zbikowski, S.M. (2013, May 8).
AC CE P
TE
D
MA
Nicotine & Tobacco Research. doi: 10.1093/ntr/ntt061.
S0306-4603(15)00087-8 doi: 10.1016/j.addbeh.2015.02.015 AB 4506
To appear in:
Addictive Behaviors
Please cite this article as: Linde, B.D., Ebbert, J.O., Wayne Talcott, G. & Klesges, R.C., Quitline Treatment Protocols for Users of Non Cigarette Tobacco and Nicotine Containing Products, Addictive Behaviors (2015), doi: 10.1016/j.addbeh.2015.02.015
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
PT
ACCEPTED MANUSCRIPT
RI
Quitline Treatment Protocols for Users of Non Cigarette Tobacco and Nicotine Containing
SC
Products
NU
Brittany D. Linde, PhD1
Jon O. Ebbert, MD, MSc2
MA
G. Wayne Talcott, PhD1
TE
1
D
Robert C. Klesges, PhD1
Department of Preventive Medicine, Center for Population Sciences, University of Tennessee
2
AC CE P
Health Science Center, 66 N Pauline, Suite 467, Memphis, TN 38163 Mayo Clinic, 200 First Street SW, Rochester, MN 55905
Corresponding Author: Jon O. Ebbert, MD, MSc, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Telephone: (507) 266-1944; Facsimile: (507) 266-7900; E-mail: [email protected]
Pages: 10 Number of Tables: 1 Number of Appendices: 1
ACCEPTED MANUSCRIPT Abstract Introduction: Use of non cigarette tobacco and nicotine containing products (TNCP) is
PT
increasing in the US. Telephone tobacco quit lines (QLs) are one of the most widely
RI
disseminated tools for providing cessation services to cigarette smokers, but the range of QL treatment services offered to non cigarette TNCP users needs to be determined.
SC
Methods: We surveyed QLs across 50 US states, Washington D. C, and Guam for the number of
NU
treatment protocols offered, products they were intended to treat, and how telephone counselors triaged patients reporting use of non cigarette TNCPs.
MA
Results: Thirteen organizations provided US QL interventions of which eleven agreed to be interviewed regarding their treatment services (84.6%). Seven of the eleven QL providers
TE
D
(63.6%) used a single intervention protocol adapted to the type of non cigarette TNCP used. Two of the eleven QLs (18.2%) referred hookah users to another provider and one QL (9.1%)
AC CE P
referred electronic cigarette users to third party resources for cessation support; otherwise a single intervention protocol was used for all other TNCP users. Only one QL (9.1%) had a specialized protocol for smokeless tobacco users in addition to a standard protocol for all other callers.
Conclusions: QL providers do not have access to tailored protocols for non cigarette TNCP users, and it remains uncertain whether a common tobacco protocol will be efficacious for these users. Future research should both validate potential common protocols for non-cigarette TNCP users and address the need for and the development of specialized QL interventions for TNCP users to help them quit. Keywords: tobacco, cessation, telephone intervention, quit line, tobacco and nicotine containing products (TNCP)
ACCEPTED MANUSCRIPT Introduction Tobacco and nicotine containing products (TNCP) [e.g. cigarettes, cigars, hookah, e-
PT
cigarettes, and smokeless tobacco (ST)] contribute to the prevalence of total tobacco
RI
consumption (i.e. 26.2% for men and 15.4% for women; Centers for Disease Control, 2014). Unlike the decline in cigarette smoking since the 1950s, the use of non cigarette TNCPs have
SC
remained constant or increased in the last decade (ALA, 2011). Many of these products have
NU
health effects that are believed to be either similar, or potentially worse (e.g., hookah), than cigarette smoking and are a growing public health concern (Centers for Disease Control, 2013;
MA
American Lung Association, 2014a; Grana, Benowitz, & Glantz, 2014; O’Connor, 2012). A wide array of behavioral interventions have been shown to be effective for increasing
TE
D
tobacco abstinence rates in civilian populations, including face-to-face, internet and telephone quit line (QL) interventions (Fiore et al., 2009). One of the most widely validated, adopted, and
AC CE P
disseminated tobacco treatment interventions is the telephone tobacco quit line (QL) (NACQ, 2014). Services offered by QLs include coaching and/or counseling, referrals, mailed materials, training to healthcare providers, web-based services and, in some instances, free medications in the form of nicotine replacement therapy (NRT) (NAQC, 2014). Due to their ability to reach and serve widespread tobacco users, QLs are accessible in all 50 states, Washington D. C., and the U.S. territories (NAQC, 2014). US tobacco QLs received over 1.3 million calls in 2012; this number has increased every year except one since 2005 (NAQC, 2014). Telephone tobacco QLs were initially created to treat cigarette smokers, the leading cause of preventable and premature death in the United States (Anderson & Zhu, 2007; American Lung Association, 2014b). And although telephone QLs are effective methods of delivering evidencebased smoking treatment to large numbers of cigarette users (Stead, Perera, & Lancaster, 2006;
ACCEPTED MANUSCRIPT Fiore et al., 2009) and in some cases ST users (Boyle, Enstad, Asche, Thoele, Sherwood, Severson, et al., 2008; Ebbert, Montori, Erwin, & Stead, 2011), little is known about the range of
PT
services provided to non cigarette TNCP users or if they are effective for cessation. For example,
RI
a recent survey of QL providers reported that 10-30% of QL callers were e-cigarette users, often in addition to other TNCPs (NAQC, 2014b; Vickerman, Carpenter, Altman, Nash, & Zbikowski,
SC
2013). Interestingly, e-cigarette users were less likely to be quit seven months after calling a QL
NU
compared with those who had never tried e-cigarettes (Vickerman et al., 2013). Even without evidence of their effectiveness for the treatment of users of non cigarette TNCPs, many QLs are
MA
encouraging all tobacco users to utilize their cessation treatment services (e.g. Colorado State QuitLine; CDPHE, 2013).
TE
D
In order to determine how QLs address non cigarette TNCP users, we conducted a survey of US tobacco QLs to determine the number and type of intervention protocols available, the
AC CE P
types of tobacco products they are intended to treat, and how each caller is handled (by product type) when they seek assistance from the QL. This study will inform future studies of QL intervention protocols and treatment plans for TNCP users. Methods
Contact information for each telephone quit line (QL) provider was collected from the NAQC website (see http://map.naquitline.org/reports/operators/ for a list of current providers). Initial contact with the service provider aided in the search for individuals associated with detailed implementation of tobacco intervention protocols. No demographic information was collected from the QL respondent. Verbal consent was granted by the qualified representative (typically a program manager, director, or supervisor) prior to the questionnaire being administered. All questionnaires were completed between June 2014 and July 2014. The
ACCEPTED MANUSCRIPT Wilford Hall Ambulatory Surgical Center Institutional Review Board (FWH20140079E) approved the execution of this exempt study.
PT
The questionnaire began with an overview of the purpose of the study followed with
RI
questions specific to the intervention protocols. We inquired about: 1) the existence and number of all treatment protocols; 2) the tobacco products the protocols were intended to treat; and 3) the
SC
procedures implemented when a non cigarette user calls in to the QL. Appendix 1 presents the
NU
survey questions in detail. Results
MA
We identified thirteen QL service providers who were contracted to deliver services. One QL was undergoing reorganization (QL personnel could not be reached to complete the survey)
TE
D
and another QL point-of-contact could not be reached after multiple attempts. Thus, 11 QL providers (84.6%) completing the survey. Four of the eleven providers (36.4%) delivered
AC CE P
services to multiple states/districts/territories. The remaining seven providers (63.6%) operated a single state QL. No state was represented by more than one service provider. Every QL service provider who participated in the survey (n = 11, 100.0%) had at least one established tobacco cessation intervention protocol (i.e. a plan for treatment with specific procedures/language used) that was followed when someone called the QL for cessation assistance (Table 1). Seven out of eleven providers (63.6%) treated every caller the same; they treated callers with the only protocol available and adapted it to the product being used (e.g. the word ―cigarette‖ was replaced with ―hookah‖ or ―cigar‖ as needed). Three out of eleven service providers (27.3%) referred participants to a variety of third party resources (i.e. not provided by the QL website or counselor; e.g. websites, downloadable materials, or mailed pamphlets; NAQC, 2014b) if they used hookah or e-cigarettes; any other non cigarette TNCP user was
ACCEPTED MANUSCRIPT treated with the standard protocol and adapted it to the product being used. Only one provider used a specialized telephone intervention protocol (9.1%) for one of the non cigarette TNCPs on
PT
our questionnaire; the specialized intervention was created and implemented for smokeless
RI
tobacco (ST) users. This specialized ST protocol used unique language and modified procedures during the behavioral component of the treatment intervention in conjunction with the provision
SC
of dedicated printed materials. This protocol was applied in addition to a standardized protocol
NU
used for all other TNCPs. Discussion
MA
The current study surveyed telephone tobacco QL providers in the United States. Most of the QLs (63.6%) adapted a single standardized intervention protocol for all non cigarette
TE
D
TNCP users who called in for assistance. Only one QL (9.1%) had a tailored treatment for any form of non cigarette TNCP user; in this case, ST users were treated with a unique intervention
AC CE P
tailored to their distinctive needs. Some of the QLs (27.3%) referred hookah and electronic cigarette users to third party resources (e.g. websites, downloadable or printed materials), although most treated hookah and e-cigarette users as if they were cigarette smokers. Future research needs to evaluate the efficacy of using a common protocol to treat noncigarette TNCPS. The use of TNCPs, regardless of the type of product, is an addictive behavior and common behavioral strategies might be effective for treatment of tobacco dependence. However, interventions that have been shown to work for increasing long-term abstinence among cigarette smokers have not been shown to have the same efficacy for ST users (Ebbert, Montori, Erwin, & Stead, 2011; Ebbert & Fagerstrom, 2012). Boyle and colleagues (2008) expressed the need for research on the components contributing to the effectiveness of a QL designed specifically for ST users, noting that although telephone intervention worked for their
ACCEPTED MANUSCRIPT sample of ST users, the proportion(s) of the intervention that most contributed to that success was unknown. Future research on non cigarette TNCP interventions should be directed toward
PT
discovering common and unique intervention components.
RI
Cigarette smoking is the leading cause of preventable death and disability and tobacco QLs have been a major contributor to smoking cessation across the nation (Fiore et al, 2009).
SC
More recently, the efficacy of QLs for ST users has been established (Boyle et al., 2008; Ebbert,
NU
Montori, Erwin, & Stead, 2011; Severson et al., 2014), but studies of QL interventions for other non cigarette TNCPs have not been reported (Maziak, Ward, & Essenberg, 2007). QL providers
MA
have the opportunity to implement novel protocols in the near future that may be efficacious for electronic cigarette users (Gromov, 2014), but 91.9% of quit lines are treating these users now
TE
D
without any evidence to justify their methods. It is reasonable to conclude that if an intervention is efficacious for one form of nicotine addiction (cigarettes), that it should work for another form
AC CE P
of nicotine addiction (e.g., hookah). On the other hand, research on ST suggests unique treatment protocols might be necessary. Most importantly, it appears that QLs (and presumably other providers as well) are using common protocols for the treatment of TNCPs. Ideally protocols would be designed to most effectively address TNCP users. A recent report by the North American Quitline Consortium highlights the importance of consistent treatment methods for dual and poly users of TNCPs, especially in regards to NRT distribution protocols for those who use e-cigarettes as a tobacco cessation method (NAQC, 2014b). Without research to validate the effectiveness of QL protocols for non cigarette TNCP users, interventionists may be less effective in the treatment of these new products (e.g. Vickerman et al, 2013). Tobacco treatment QLs are an effective cessation aid for cigarette smokers and in some cases for ST users, but whether or not they are effective for other TNCP users is unknown.
ACCEPTED MANUSCRIPT Research on the efficacy of smoking QLs for ST cessation requires us to reevaluate the ways service providers treat non cigarette TNCP callers; they may or may not be a homogenous group.
PT
It is possible that, with the use of tailored cessation intervention protocols depending on the
RI
product used, cessation rates will increase when providers implement tailored interventions for different TNCP users. On the other hand, it is possible that common components of tobacco
SC
dependence may work regardless of the TNCP. Further research is necessary to determine the
AC CE P
TE
D
MA
NU
effects of more personalized cessation interventions for non cigarette TNCP users.
ACCEPTED MANUSCRIPT Appendix 1: Tobacco QL Questionnaire
PT
1. Do you have an intervention protocol for your smoking cessation program? (Explain if need be.) ___Yes (go to Q2) ___No (Do not proceed; thank them and end call)
RI
2. How many standard protocol treatments do you currently have? ___
NU
SC
3. What tobacco products is (are) the protocol(s) intended to treat? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
MA
4. Which of those protocols, if any, do you use to treat: a. Hookah? b. E-cigarettes?
AC CE P
e. Dual/poly users?
TE
d. Cigars?
D
c. Smokeless tobacco?
5. If the QL does not have a standard protocol for the above items ask: What do you do with this individual? a. Refer them to a service (e.g., internet, pamphlets) that specializes in (hookah, e-cigs, ST, cigars) tobacco cessation (If they respond with this answer, ask): i. Are these materials on your web site/provided by your quit line or ii. Are these materials on a third party web site? b. Treat them with your telephone protocol that is used with smoking cigarettes and adapt it to the fact they are using (hookah, e-cigs, ST, cigars) c. Use a specialized telephone intervention protocol that is specific to (hookah, e-cigs, ST, cigars). Describe. d. This would be an off protocol call so interventionists use their discretion regarding recommendations based on the needs of the caller.
ACCEPTED MANUSCRIPT
Protocol(s) treat all TNCPs?
How hookah handled?
How e-cigs handled?
How ST handled?
How cigars handled?
How dual/poly handled?
Adapt
Adapt
Adapt
Adapt
Adapt
Adapt
Adapt
Adapt
Third party referral
Adapt
Adapt
Adapt
Adapt
Adapt
Adapt
Adapt
1
Yes
Adapt
B
1
Yes
Adapt
C
1
Not e-cigs
Adapt
D
1
Not hookah
Third party referral
E
1
Yes
Adapt
Adapt
Adapt
Adapt
Adapt
F
1
Not hookah
Third party referral
Adapt
Adapt
Adapt
Adapt
G
1
Yes
Adapt
Adapt
Adapt
Adapt
Adapt
H
2
Yes
Adapt
Adapt
Specialized
Adapt
Adapt
I
1
Yes
Adapt
Adapt
Adapt
Adapt
Adapt
J
1
Yes
Adapt
Adapt
Adapt
Adapt
Adapt
K
1
Yes
Adapt
Adapt
Adapt
Adapt
Adapt
RI SC
NU
PT ED
CE
AC
PT
A
MA
Table 1: Survey Results* Service Number of tobaccoProvider related protocols?
* Data was collected from 11 service providers. Findings are displayed in random order so as to be deidentified.
ACCEPTED MANUSCRIPT References Agaku, I. T., King, B. A., Husten, C. G., Bunnell, R., Ambrose, B. K., Hu, S. S., … Day, H. R.
PT
(2014). Tobacco Product Use Among Adults — United States, 2012–2013. Morbidity
RI
and Mortality Weekly Report (MMWR), 63(25), 542-547.
American Lung Association (2011). Trends in Tobacco Use. http://www.lung.org/finding-
SC
cures/our-research/trend-reports/Tobacco-Trend-Report.pdf.
smoking/health-effects/smoking.html.
NU
American Lung Association (2014). Smoking. http://www.lung.org/stop-smoking/about-
MA
Anderson, C., & Zhu, S. (2007). Tobacco quitlines: looking back and looking ahead. Tobacco Control, 16(Suppl 1), i81-i86. PMCID: PMC2598521.
TE
D
American Lung Association (2014). Hookah Smoking: A Growing Threat to Public Health. http://www.lung.org/stop-smoking/tobacco-control-advocacy/reports-resources/cessation-
AC CE P
economic-benefits/reports/hookah-policy-brief.pdf. Boyle, R. G., Enstad, C., Asche S. E., Thoele, M. J., Sherwood, N. E., Severson, H. H., … Solberg LI. (2008). A randomized controlled trial of telephone counseling with smokeless tobacco users: the ChewFree Minnesota study. Nicotine & Tobacco Research, 10(9), 1433-1440. doi: 10.1080/14622200802279872. Centers for Disease Control (2013). The dangers of hookah smoking. http://www.cdc.gov/features/hookahsmoking/. Centers for Disease Control (2014). Tobacco Use among US Adults -- United States, 2012-2013. http://www.cdc.gov/tobacco/data_statistics/mmwrs/byyear/2014/mm6325a3/intro.htm. Colorado Department of Public Health and Environment (2013). Colorado QuitLine Enrollment. https://www.coquitline.org/enrollment/enroll.aspx.
ACCEPTED MANUSCRIPT Ebbert, J. O., & Fagerstrom, K. (2012). Pharmacological interventions for the treatment of smokeless tobacco use. CNS Drugs, 26(1), 1-10. doi: 10.2165/11598450-000000000-
PT
00000.
RI
Ebbert, J., Montori, V. M., Erwin, P. J., & Stead, L, F. (2011). Interventions for smokeless tobacco use cessation. Cochrane Database Syst Rev, 2, Cd004306. doi:
SC
10.1002/14651858.CD004306.pub4.
NU
Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J. … Wewers, M. E. (2008). Treating Tobacco Use and Dependence: 2008 Update. U.S. Department of
MA
Health and Human Services, 1-276. http://www.ahrq.gov/professionals/cliniciansproviders/guidelines-
TE
D
recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf. Grana, R., Benowitz, N., & Glantz, S. A. (2014). E-cigarettes: a scientific review. Circulation,
AC CE P
129(19), 1972-1986. doi: 10.1161/CIRCULATIONAHA.114.007667. Gromov, N. (2014). IMPORTANT! Upcoming NAQC Resources on e-Cigarettes! http://www.naquitline.org/news/177515/IMPORTANT-Upcoming-NAQC-Resources-one-Cigarettes-.htm
Maziak, W., Ward, K. D., & Eissenberg, T. (2007). Interventions for waterpipe smoking cessation. Cochrane Database Syst Rev, 4, Cd005549. PMID: 17943865. North American Quitline Consortium (2014). http://www.naquitline.org/. North American Quitline Consortium (2014b). Cessation Treatment and E-Cigarettes: A Report on Current Literature and Quitline Practices. (L. Bailey, S. Kalkhoran and P. Ling). Phoenix, AZ. http://c.ymcdn.com/sites/naquitline.siteym.com/resource/resmgr/ECigarettes/ECigarettesReportFinal.pdf
ACCEPTED MANUSCRIPT O'Connor, R. J. (2012). Non-cigarette tobacco products: what have we learnt and where are we headed? Tobacco Control, 21(2): 181-190. doi: 10.1136/tobaccocontrol-2011-050281.
PT
Severson, H. H., Danaher, B. G., Ebbert, J. O., van Meter Ba, N., Lichtenstein, E., Widdop, C.,
RI
… Seeley, J. R. (2014, Aug 28). Randomized trial of nicotine lozenges and phone counseling for smokeless tobacco cessation. Nicotine & Tobacco Research, pii: ntu145.
SC
PMID: 25168034.
NU
Vickerman, K.A., Carpenter, K.M., Altman, T., Nash, C.M., & Zbikowski, S.M. (2013, May 8).
AC CE P
TE
D
MA
Nicotine & Tobacco Research. doi: 10.1093/ntr/ntt061.
