The Potential Impact of the New York State Smokers’ Quitline on Population-Level Smoking Rates in New York 1
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Nathan Mann*, Harlan Juster, James Nonnemaker • ¹RTI International, Research Triangle Park, NC; ²New York State Department of Health
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All U.S. states maintain and operate state telephone tobacco cessation quitlines that offer free tobacco use cessation counseling 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 (Lichtenstein et al., 2010; CDC, 2014; USDHHS, 2014; Zhang et al., 2015; Fiore, 2008). For tobacco quitlines to have a meaningful impact on tobacco use at the population level, they must be able to provide effective interventions to a sufficient proportion of tobacco users (Schauer et al., 2014). On average, state quitlines in the United States reach only between 1% and 2% of smokers annually. Based on data from Centers for Disease Control and Prevention’s (CDC’s) National Quitline Data Warehouse, New York State Smokers’ Quitline (NYSSQL) reach was ranked between the second and fourth highest among 45 states that reported data for all quarters from 2011 through 2015 (www.cdc.gov/statesystem/). Purpose: The purpose of this study was to determine ●● the current impact of quitlines on population-level smoking prevalence; ●● how much annual quitline reach would need to increase to achieve a measurable reduction in population-level smoking prevalence; and ●● how much it would cost to increase annual quitline reach to the level needed to achieve measurable reductions in population-level smoking prevalence.
Results: Research Question 1
Results: Research Question 1 (continued)
What is the current impact of quitlines on population-level smoking prevalence?
What is the current impact of quitlines on population-level smoking prevalence?
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An average of 65,000 tobacco users received counseling and/or free NRT from the NYSSQL each year in 2014 and 2015 (Table 1)
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The percentage of those individuals expected to be smoke-free for 6 months or more 7 months after receipt of services from the quitline ranges from 5.76% to 10.62% depending on whether the intent-to-treat quit rate or the follow-up survey responder quit rate is used.
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To estimate the number of successful quitters among tobacco users who received services from the NYSSQL from 2011 through 2015, we multiplied the total unique number of quitline clients who received counseling and/or free NRT from the NYSSQL each year by the various quit rate measures from the 7-month follow-up evaluation survey data. To estimate the current impact of the NYSSQL on population-level smoking rates in New York, we calculated what the prevalence of current adult cigarette smokers in New York would be if the average annual number of quitline clients in 2014 and 2015 who were smokefree at 7-month follow-up remained permanently quit and were removed from the adult smoking population in New York.
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Research Question 2: How much would annual quitline reach have to increase to achieve a specific reduction in population-level smoking prevalence?
The change in statewide current adult cigarette smoking prevalence was calculated by subtracting actual prevalence in 2015 (15.20%) from the hypothetical target prevalence (14.95%). The formula to calculate the change in statewide smoking prevalence is given by Equation 1:
The number of quitline callers required to achieve the desired hypothetical change in prevalence was calculated by Equation 2:
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Data on annual operational costs of the NYSSQL and the amount and costs of paid television ads that were purchased by the New York State Department of Health to promote smoking cessation and the quitline telephone number were obtained from the New York State Department of Health for 2011 through 2015. Data on the adult population size in New York were obtained from the U.S. Census Bureau. Annual estimates of the prevalence of current adult cigarette smoking in New York for 2011 through 2015 were obtained from CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Data on quitline effectiveness from 7-month follow-up evaluation surveys collected from June 2010 through December 2014 were provided by Roswell Park Cancer Institute’s Survey Research and Data
Methods: Research Question 3 How much would it cost to increase annual quitline reach to the level needed to achieve a specific reduction in population-level smoking prevalence? ■■
2.48 M
350
To determine the cost to increase annual quitline reach, the total additional paid media costs and quitline operational costs that would be necessary to achieve the estimated increase in annual NYSSQL reach derived from Research Question 2 was calculated. To do this, we ●● scaled the actual average annual costs of paid television media and quitline operations by the ratio of hypothetical vs. actual total annual NYSSQL clients receiving services in 2014 and 2015; ●● calculated annual marginal paid television media and quitline operational costs by subtracting average annual costs for 2014–2015 from our forecasted scaled total annual costs; and ●● calculated all cost estimates separately for our simulation results based on the 7-month follow-up survey responder rate and intentto-treat variations of the 6-month quit rates.
2.56 M 2.24 M
2.37 M
300 250 200 150 100
2.0
214k 176k
163k 79k (2.88%)
1.5
159k 77k (3.09%)
76k (3.39%)
69k (2.71%)
50 0
2011
2012
2.5
2013
2014
114k
54k (2.29%)
2015
1.0 0.5
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0.0
Using the intent-to-treat approach, an estimated 16.99% of the NYSSQL clients sampled for 7-month follow-up evaluation surveys were smokefree for 7 days or longer, 13.51% were smoke-free for 30 days or longer, and 5.76% were smoke-free for 6 months or longer 7 months after receiving quitline services.
Figure 2. Quit Status at 7 Months after Receipt of New York State Smokers’ Quitline (NYSSQL) Services, 7-Month Follow-Up Evaluation Survey Data, 2011–2014 50%
31.33%
16.99%
13.51%
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Intent-to-Treat
Total adult population in New York, 2015 (Census)
15,585,000
15,585,000
Prevalence of current adult cigarette smoking, 2015 (BRFSS)
15.20%
15.20%
Number of current adult cigarette smokers, 2015
2,369,000
2,369,000
Average annual quitline clients who received counseling and/or free NRT, 2014–2015
65,000
65,000
10.62%
5.76%
Smoke-free for 7 days or longer
Smoke-free for 30 days or longer
We simulated the total number of tobacco users who would need to receive counseling and/or free NRT from the NYSSQL to reduce current adult cigarette smoking in New York by 0.25% from 15.20% to 14.95% (Table 2). A simulated total of 368,000 to 673,000 tobacco users (an increase of 5.7 to 10.4 times the annual average of 65,000) would need to receive counseling and/or free NRT from the NYSSQL depending on whether the 7-month follow-up responder rate or the intent-to-treat rate of the 6-month quit rate is used.
Table 2. Simulation Results for a Hypothetical 0.25% Reduction in Adult Cigarette Smoking Prevalence in New York State Actual Annual Average, 2014–2015
Simulation Results (Based on Follow-Up Survey Responders 6-Month Quit Rate)
Simulation Results (Based on Intent-to-Treat 6-Month Quit Rate)
Annual total quitline clients
65,000
368,000
673,000
Annual television media costs
$5.01 million
$28.40 million
$51.97 million
Annual quitline operational costs
$3.68 million
$20.86 million
$38.18 million
Measure
Follow-Up Survey Respondents
Intent-to-Treat
Quitline quitters: number of quitline clients smoke-free for 6 months or longer 7 months after use of Quitline services
6,900
3,700
Current adult cigarette smokers minus Quitline quitters
2,362,100
2,365,300
State-level quit rate associated with Quitline quitters
0.29%
0.16%
Estimated prevalence of current adult cigarette smoking associated with Quitline quitters
15.16%
15.18%
Estimated change in annual state-level smoking prevalence associated with Quitline quitters
−0.04%
−0.02%
are among all individuals who were sampled for and contacted to complete 7-month follow-up evaluations, regardless of whether or not they completed the evaluation. This measure attempts to control for nonresponse bias by assuming that all individuals who were contacted for, but did not complete, a 7-month follow-up evaluation failed to remain smoke-free.
Notes: Follow-up survey responders’ rates are among individuals who completed a 7-month follow-up evaluation survey. Intent-to-treat rates are among all individuals who were sampled for and contacted to complete 7-month follow-up evaluations, regardless of whether or not they completed the evaluation. This measure attempts to control for nonresponse bias by assuming that all individuals who were contacted for, but did not complete, a 7-month follow-up evaluation
From 2011 through 2015, the NYSSQL had an average annual reach of around 3%, which was nearly 3 times higher than the national average and made New York one of the top five states in the United States in terms of state quitline reach.
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At current levels of quitline reach, state quitlines have a very low impact on population-level smoking prevalence.
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Increasing reach to the necessary levels to realize meaningful reductions in prevalence would be prohibitively expensive.
References These results suggest it might be necessary to rethink the role of
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quitlines in tobacco control efforts. In New York, quitlines are being integrated into a larger effort to promote cessation through health systems change efforts. For example, quitline callers are being informed about insurance coverage of cessation resources and encouraged to follow-up with their health care providers regarding cessation counseling and medications.
References Lichtenstein E, Zhu SH, Tedeschi GJ. Smoking cessation quitlines: An underrecognized intervention success story. Am Psychol. 2010 May-Jun;65:252-61. doi:10.1037/a0018598. Centers for Disease Control and Prevention (CDC). Best practices for comprehensive tobacco control programs—2014. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.
Zhang L, Vickerman K, Malarcher A, Carpenter K. Changes in quitline caller characteristics during a national tobacco education campaign. Nicotine Tob Res. 2015 Sep;17:1161-6. doi:10.1093/ntr/ntu271. Fiore MC. Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2008.
Notes: Follow-up survey responders’ rates are among individuals who completed a 7-month follow-up evaluation survey. Intent-to-treat rates are among all individuals who were sampled for and contacted to complete 7-month follow-up evaluations, regardless of whether or not they
Schauer GL, Malarcher AM, Zhang L, Engstrom MC, Zhu SH. Prevalence and correlates of quitline awareness and utilization in the United States: An update from the 2009–2010 National Adult Tobacco Survey. Nicotine Tob Res. 2014 May;16:544-53. doi:10.1093/ntr/ntt181.
completed the evaluation. This measure attempts to control for nonresponse bias by assuming that all individuals who were contacted for, but did not complete, a 7-month follow-up evaluation failed to remain smoke-free.
Results: Research Question 3 How much would it cost to increase annual quitline reach to the level needed to achieve a specific reduction in population-level smoking prevalence? ■■
In 2014 and 2015, New York State spent approximately $5 million annually on television media (Table 2).
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The average total costs of operating the NYSSQL $3.68 million annually in 2014–2015.
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Smoke-free for 6 months or longer
Intent-to-Treat
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U.S. Department of Health and Human Services (USDHHS). The health consequences of smoking: 50 years of progress: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.
10.62% 5.76%
Follow-Up Survey Responders
failed to remain smoke-free.
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24.92%
10% 0%
Survey Respondents
Estimation Results
Among these survey respondents, 31.33% were smoke-free for 7 days or longer, 24.92% were smoke-free for 30 days or longer, and 10.62% were smoke-free for 6 months or longer 7 months after receiving quitline services (Figure 2).
20%
How much would annual quitline reach have to increase to achieve a specific reduction in population-level smoking prevalence?
Table 1. Estimated Impact of the New York State Smokers’ Quitline (NYSSQL) on Adult Cigarette Smoking Prevalence in New York Follow-Up
Discussion
Notes: Follow-up survey responders’ rates are among individuals who completed a 7-month follow-up evaluation survey. Intent-to-treat rates
From June 2010 through December 2014, 7-month follow-up evaluation surveys were completed by 7,842 individuals among a random sample of 14,461 NYSSQL clients, yielding a total survey response rate of 54.23%.
30%
Results: Research Question 2
These results suggest that, at its current level of reach, the NYSSQL could be responsible for annual reductions in current adult cigarette smoking of 0.02% to 0.04% each year.
Quitline quit rate: percentage of quitline clients smoke-free for 6-months or longer 7 months after use of Quitline services
The annual proportion of current adult cigarette smokers in New York who received counseling and/or free NRT from the NYSSQL averaged 2.87% from 2011 through 2015 and ranged from 2.29% in 2015 to 3.39% in 2014
40%
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Estimation Inputs/Parameters
3.0
Quitline Clients Who Received Counseling and/or Free NRT Quitline Clients who Received (Quitline Treatment Reach) Counseling and/or Free NRT (Quitline Treatment Reach) CurrentAdult AdultCigarette CigaretteSmokers SmokersininNew NewYork York Current
Percentage of Quitline Clients at 7-Months after Use of Service
Methods: Data Data on quitline utilization from 2011 through 2015 were obtained from the NYSSQL service provider, Roswell Park Cancer Institute. ●● Quitline utilization measures include the annual total number of calls to the NYSSQL and the annual number of quitline callers who received counseling and/or free nicotine replacement therapy (NRT) from the NYSSQL.
2.75 M
Callstotothe theNew NewYork YorkQuitline Quitline Calls
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400
The total number of adult smokers who the NYSSQL would need to reach in a single year to achieve a hypothetical reduction of 0.25% in the prevalence of current adult cigarette smoking in New York was calculated.
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Approximately 71,000 tobacco users received counseling and/or free NRT from the NYSSQL each year from 2011 through 2015 with a range from 54,000 in 2015 to 79,000 in 2011 (Figure 1).
Figure 1. Number of Current Adult Cigarette Smokers in New York, Number of Calls to the New York State Smokers’ Quitline (NYSSQL), and Number of NYSSQL Clients Who Received Counseling and/or Free NRT, 2011–2015
Methods: Research Question 2 ■■
The total number of current adult cigarette smokers in New York declined from 2.75 million in 2011 to 2.37 million in 2015. During this period, calls to the NYSSQL averaged around 165,000 per year and ranged from 114,000 in 2015 to 214,000 in 2013 (Figure 1).
Number of Adult Cigarette Smokers (millions)
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Methods: Research Question 1
Number of Calls to the Quitline and Quitline Clients (thousands)
Introduction
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By inflating these costs, we estimate that between $28 million to $52 million in annual paid television media expenditures would be required to increase the number of tobacco users receiving services from the NYSSQL by 5.7 to 10.4 times more annually.(Table 2). If New York State was successful at increasing the annual number of NYSSQL clients receiving services 5.7 to 10.4 times, the estimated total annual operational costs for the quitline would be somewhere between $21 million and $38 million.
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.
Funding This work was supported by the New York State Department of Health (contract number C028511).
More Information *Presenting author: Nathan Mann 919.485.5584
[email protected] RTI International 3040 E. Cornwallis Road Research Triangle Park, NC 27709
www.rti.org
RTI International is a trade name of Research Triangle Institute.
