Wisconsin Tobacco Quit Line - Evaluation of the Provision of Free Nicotine Replacement Therapy
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Wisconsin Tobacco Quit Line
Evaluation of the Provision of Free Nicotine Replacement Therapy
Prepared for:
Wisconsin Department of Health Services, Division of Public Health, Bureau of
Community Health Promotion, Tobacco Prevention and Control ProgramACKNOWLEDGEMENTS
This evaluation was conducted by the University of Wisconsin Carbone Cancer Center, Tobacco
Surveillance and Evaluation Program, at the request of the Wisconsin Department of Health
Services, Division of Public Health, Bureau of Community Health Promotion, Wisconsin
Tobacco Prevention and Control Program.
The evaluation was supported by the Wisconsin Department of Health Services, Division of
Public Health, Bureau of Community Health Promotion, Wisconsin Tobacco Prevention and
Control Program.
Review of the survey instrument and helpful feedback was provided by the Wisconsin Center for
Tobacco Research and Intervention
Quit Line registration and call data were provided by Free & Clear, Inc.
For additional copies of this report, visit our website http://www.medsch.wisc.edu/mep/ or
contact:
Karen Palmersheim, Ph.D.
University of Wisconsin Carbone Cancer Center
370 WARF
610 N. Walnut St.
Madison, WI 53726
608-262-2825
kapalmersheim@uwcarbone.wisc.edu
TABLE OF CONTENTS
Executive Summary ……………………………………………………………………………... 1
Introduction ……………………………………………………………………………………… 3
Methods ………………………………………………………………………………………….. 4
Results …………………………………………………………………………………………… 6
Discussion ……………………………………………………………………………………… 14
Limitations ……………………………………………………………………………………... 16
Conclusions …………………………………………………………………………………….. 17
References ……………………………………………………………………………………… 18
Appendix ……………………………………………………………………………………….. 20
iEXECUTIVE SUMMARY
A program evaluation study was conducted in effort to assess the utility of adding free nicotine
replacement therapy (NRT) as an adjunctive therapy to telephone counseling offered by
theWisconsin Tobacco Quit Line. Assessment of the impact of the added free NRT component
was accomplished by comparing a sample of 2008 Quit Line callers, most of whom were offered
the free NRT in conjunction with Quit Line coaching, to a sample of 2007 callers, who were
generally offered the standard Quit Line coaching services. Key findings of the evaluation are as
follows.
Thirty-day quit rates at 7 months post-registration were 28.6% for the 2007 callers and
28.2% for the 2008 callers.
Among callers who were not 30-day abstinent at 7 months, the average longest quit
attempt was 23 days among the 2007 callers, and 25 days among the 2008 callers.
About half of the 2007 callers (49.0%) and nearly three-fourths of the 2008 callers
(72.7%) reported using NRT during the 7-month post-registration period.
Callers who reported using any NRT were slightly more likely to be 30-day abstinent
than those who did not use NRT (29.8% vs. 27.6% for the 2007 group, and 29.3% vs.
25.5% for the 2008 group, respectively).
Approximately three-fourths of the callers in each group rated their health as being a very
important reason for calling the Quit Line. The second most common reason identified
as very important was to save money.
Approximately three-fourths of the 2008 callers placed some importance on the free NRT
in their decision to call the Quit Line, ranging from 39% reporting it was “extremely
important” to 10% reporting it was “slightly important”; 24% stated that it was “not
important at all”.
Almost 80% of the 2008 callers reported that the January 1, 2008 cigarette price increase
played a part in their decision to call the Quit Line, ranging from 45% stating it was
“extremely important” to 9% stating it was “slightly important”; 21% reported stated it
was “not important at all”.
Approximately two-thirds of the 2007 callers reported that the January 1, 2008 cigarette
price increase played a part in motivating them to quit using tobacco, and/or not start
smoking again, ranging from 29% stating it was “extremely important” to 11% stating it
was “slightly important”; 35% stated it was “not important at all”.
1 Callers enrolled in the multi-call program were more likely to be 30-day abstinent at 7
months compared to those enrolled in the one-call program. The observed difference for
the 2007 callers was statistically significant (31.3% vs. 22.3%). The difference for the
2008 callers was not statistically significant (28.8% vs. 24.2%).
Among callers enrolled in the multi-call program, those who completed 4 or more calls
were significantly more likely to be 30-day abstinent at 7 months compared to those who
did not complete at least 4 calls (37.6% vs. 27.7%, for the 2007 callers; 36.6% vs. 25.6%,
for the 2008 callers).
A higher percentage of 2008 callers reported they were “very satisfied” with the Quit
Line compared to 2007 callers (47.1% vs. 38.8%).
90% of the 2008 callers and 86% of the 2007 callers said they would recommend the Quit
Line to a friend.
2INTRODUCTION
The state of Wisconsin has sponsored the Wisconsin Tobacco Quit Line service since 2001,
which offers both reactive counseling to callers and proactive counseling after referral from a
healthcare provider. The Quit Line is overseen by the University of Wisconsin Center for
Tobacco Research and Intervention (UW-CTRI) and supported by the Tobacco Prevention and
Control Program of the Wisconsin Division of Public Health. Its daily operations are managed
by Free & Clear, Inc.
Individuals who register with the Quit Line for cessation services are encouraged to commit to:
receiving four counseling calls, creating an individual plan for quitting, and setting a quit date.
Callers who are not able to commit to multiple calls receive condensed services in one call.
Registered callers can also call the Quit Line between 7 a.m. and 11 p.m. daily to speak to a
counselor.
Previous studies have revealed that telephone counseling can aid smokers interested in quitting.1-
7
There is also evidence that nicotine replacement therapy (NRT) used alone,8-9 and in
combination with telephone counseling,10-15 can help improve quit rates. These findings have
been shown for 30-day abstinence,4,12-14 as well as 7-day abstinence,5,11,15 at 6-month follow-up.
Moreover, the provision of free NRT through a state quit line has recently been associated with
increased quit line utilization.15
In effort to enhance utilization of the Wisconsin Tobacco Quit Line and facilitate caller
cessation, Wisconsin decided to add NRT to the State’s quit line service as an adjunct to
telephone cessation counseling. On December 17, 2007, the UW-CTRI and Free & Clear, Inc.,
via support from the Wisconsin Division of Public Health, began offering a free, 2-week supply
of NRT (nicotine patches, gum, or lozenges) to eligible callers. The free NRT incentive
continued through December of 2008. During that time, most adult tobacco users were eligible
to receive the free 2-week pack of NRT if they were willing to register for the Quit Line’s multi-
call program. Callers who had a recent heart attack, recent stroke, irregular heartbeat, angina,
skin patch reaction, dental/jaw problems, were pregnant or breastfeeding, were less than 18 years
of age and those with high blood pressure who were not on medication were not eligible to
receive the free NRT. [In 2007, a limited number of eligible callers were offered free
introductory NRT as supported by their employers. In addition, military personnel that served in
Iraq and Afghanistan were offered free NRT as a part of a program called Operation Quit
Tobacco.]
In order to assess the utility of adding free NRT to the State’s quit line service, the Wisconsin
Division of Public Health requested the Tobacco Surveillance and Evaluation Program (of the
UW Paul P. Carbone Comprehensive Cancer Center) conduct a program evaluation study. The
aims of the evaluation were to assess the impact of the additional program component on factors
associated with program effectiveness (i.e., caller reach, quitting behavior, caller satisfaction).
3Assessment of the impact of the added free NRT component was accomplished by comparing a
sample of 2008 Quit Line callers, most of whom were offered the free NRT in conjunction with
Quit Line coaching, to a sample of 2007 callers, who were generally offered the standard Quit
Line coaching services. Data for the evaluation were accessed, in part, from the Minimal Data
Set (MDS) provided by Free & Clear, Inc. Additional data were collected via a survey
developed by the Tobacco Surveillance and Evaluation Program, with helpful feedback provided
by the UW-CTRI and the Division of Public Health. This report summarizes the findings of the
evaluation.
METHODS
Sampling Procedures
The sampling frames for the evaluation study included tobacco users that registered with the
Wisconsin Tobacco Quit Line between January 1 and April 30, of each 2007 and 2008. In effort
to control for seasonal affects, the sampling frames were stratified by month, with the goal of
surveying 250 callers from each month. The University of Wisconsin Survey Center (UWSC)
was contracted to administer the survey via a telephone interview. Sample was drawn in random
replicates of 50 from each month of callers (Note: Due to large caller volume during January of
2008, random replicates of 100 were drawn). The drawn cases were sent advance letters
explaining the study and inviting the Quit Line callers to participate. Interviewers then made up
to 20 attempts to contact each selected Quit Line caller via telephone, confirm his/her name and
Quit Line registration date, and complete an interview. Cases that resulted in bad addresses,
wrong numbers, disconnected numbers, or faxes were referred to tracing, where efforts were
made to find new contact information. The UWSC completed interviews with 927 of the 2007
callers. After removing attempted cases that were unable to participate due to death, physical
incapacity, or other issues, those considered ineligible, and those for whom valid contact
information could not be verified, the resulting response rate for participation was 56.5%. 1,025
interviews were completed with 2008 callers, reflecting a response rate of 52.0%.
Data
Registration and Call Data
Data collected at the time callers registered with the Quit Line were provided by Free & Clear,
Inc. The data included information on demographic background, smoking history, current
tobacco use, level of addiction, readiness to quit, health conditions that may contraindicate NRT
use, and for women, whether they were pregnant of breastfeeding. Information on type of
program registration (one-call or multi-call), calls completed (type of call and date completed),
and provision of NRT (NRT type, dosage, and amount sent) were also made available by Free &
Clear, Inc.
4Survey Instruments
Separate, but similar survey instruments were constructed for the 2007 and 2008 callers. Data on
a few additional demographic variables were collected (household income and employment
status). Callers were asked about their tobacco use at the time of interview, their tobacco use
during the 7th month after they registered with the Quit Line, quit attempts, methods used to try
to quit using tobacco, reasons for wanting to quit and for contacting the Quit Line, and general
satisfaction with the Quit Line service. Additional questions focused on callers’ receipt of NRT
from the Quit Line and other sources, and their utilization of the NRT. Information on how NRT
users paid for NRT, type of health insurance coverage, and provision of NRT by their health
insurance provider was also obtained.
Analytical Samples
We limited our analytical samples to adult, cigarette smokers who requested an intervention from
the Wisconsin Quit Line service. In addition, we limited the female participants to those who
were not pregnant or breastfeeding at the time of registration with the Quit Line. Of the 924
surveys completed with the 2007 callers, 16 cases were eliminated due to the caller being
pregnant or breastfeeding at the time of their registration (1.7%). 24 cases were eliminated
because there was no evidence that the caller was a cigarette smoker (2.6%). Of the 1,025
surveys completed with the 2008 callers, 15 were eliminated because the callers were listed as
pregnant or breastfeeding at the time of their initial registration (1.4%). One caller that was
solely a pipe smoker was also eliminated (0.1%). Thus, analyses for this study included 884
2007 callers and 1,009 2008 callers.
Outcomes
The primary behavioral outcome of interest in the current study was 30-day abstinence during
the 7th month after the caller registered with the Quit Line service. The 30-day point prevalence
measure has been suggested as a more stable measure than 7-day point prevalence.2 In addition,
the study design required retrospectively assessing the 7-month quit status of the 2007 Quit Line
callers. The research team determined that retrospectively asking participants about their
abstinence during a specific month would result in more reliable information than asking about a
specific week. Further, the 30-day point prevalence measure has been suggested as a preferable
measure to continuous abstinence because many successful long-term quitters: 1) take some
period of time before they set an initial quit date; and/or 2) report slips during the first few
months after quitting.2
A secondary behavioral outcome of interest was the average longest quit attempt achieved by
those who were not 30-day abstinent at 7 months post-registration. In addition, caller volume
and characteristics are briefly presented for each month of the study period.
Process outcomes of interest included receipt of free NRT from the Quit Line service, utilization
of NRT during the 7-month post-registration period, reasons for registering with the Quit Line,
level of contact with the Quit Line, and satisfaction with the Quit Line service. Additional
information on how callers paid for health care and NRT, caller knowledge of health care
5coverage for NRT, and how they heard about the Wisconsin Tobacco Quit Line are provided for
the interested reader in the appendix section of this report. Further, a comparison of the study
participants’ demographic and baseline tobacco use characteristics, relative to the sample pool
from which they were drawn, is included in the appendix.
Statistical Analysis
Independent samples two tailed t-tests were used to test differences between the 2007 and 2008
callers. Chi-square tests were employed for within year comparison of quit rates between callers
who used or received NRT and those who did not.
RESULTS
Sample characteristics for the 2007 and 2008 callers are displayed in Table 1.
Descriptive analyses revealed that the obtained samples of 2007 and 2008 callers were very
similar in terms of demographic backgrounds. While a slightly greater proportion of the 2007
callers were unable to work, and a slightly greater proportion of the 2008 callers were employed
for wages, these differences were not statistically significant (using a cutoff of pTable 1. Demographics, Tobacco Use and Stage of Readiness to Quit, by Group
2007 Callers 2008 Callers
(n=884) (n=1,009)
Registration Month
January 27.9% 25.1%
February 26.8% 25.5%
March 25.7% 24.8%
April 19.6% 24.7%
Age (years)
Minimum 18 18
Maximum 81 87
Mean 46.6 47.2
Median 48 48
Gender
Female 57.6% 57.7%
Race/Ethnicity
White 83.9% 86.9%
Other 14.3% 12.5%
Hispanic, any race 1.9% 1.6%
Education
Less than high school 11.1% 11.1%
High school diploma/ GED 37.6% 39.1%
Some college/Associates degree 31.9% 31.2%
College or University degree 17.5% 17.9%
Household IncomeTable 1. Demographics, Tobacco Use and Stage of Readiness to Quit, by Group
2007 Callers 2008 Callers
(n=884) (n=1,009)
Employment Status
Employed for wages 46.0% 50.2%
Self-employed 8.0% 6.3%
Out of work < 1 year 4.1% 4.7%
Out of work > 1 year 3.3% 4.3%
Homemaker 4.3% 5.3%
Student 2.0% 1.9%
Retired 15.3% 13.4%
Unable to work 16.5% 13.4%
# Cigarettes Smoked Per Day
Minimum 0 0
Maximum 80 60
Mean 19.1 18.6
Median 20 20
Time to 1st Cigarette after Waking
Smoke 60 minutes 14.5% 12.0%
Use of Other Tobacco 2.7% 2.0%
Stage of Readiness to Quit
Precontemplation 0.2% 0.0%
Contemplation** 2.8% 1.0%
Preparation*** 85.0% 94.5%
Action*** 11.5% 4.4%
Maintenance 0.1% 0.1%
Note: Comparison of 2007 Callers to 2008 Callers; Independent samples t-test, 2-tailed
*pThirty-day quit rates at 7 months post-registration were 28.6% for the 2007 callers and 28.2% for
the 2008 callers (Table 2). This difference was not statistically significant. Additional analysis
of data on the callers who were not 30-day abstinent at 7 months revealed a slightly greater
average “longest quit attempt” among the 2008 callers (25 days) than the 2007 callers (23 days);
though, the difference was not statistically significant.
Table 2. Abstinence from Cigarette Use - 7 Months Post-Registration, by Group
2007 Callers 2008 Callers
(n=884) (n=1,009) p-valuec
30-day abstinencea 28.6% 28.2% .850
Average longest quit attemptb 23 days 25 days .405
a
No cigarette smoking during the previous 30 days; Callers with missing or inconsistent data were excluded
b
Longest quit attempt of callers that were not 30-day abstinent at 7 months
c
Comparison of 2007 Callers to 2008 Callers; Independent samples t-test, 2-tailed
Examination of Quit Line data revealed that Free & Clear, Inc. sent nicotine replacement therapy
to a small proportion of the 2007 callers (7.6%) and to a large proportion of the 2008 callers
(80.7%) (Table 3). The follow-up survey data revealed that approximately half of the 2007
callers (49.0%) and nearly three-fourths of the 2008 callers (72.7%) reported having used NRT
during the 7-month period.
Table 3. Use of Nicotine Replacement Therapy, by Group
2007 Callers 2008 Callers
(n=884) (n=1,009)
Free & Clear sent caller NRTa 7.6% 80.7%
Caller indicated that they used some form of NRT in
49.0% 72.7%c
attempting to quit during the first 7 months
Caller has condition where NRT would not be
0.2% 1.0%
recommendedb
a
Free & Clear 2007 and 2008 data
b
Free & Clear 2007 and 2008 data, defined as: recent heart attack, recent stroke, irregular heartbeat,
angina, skin patch reaction, dental mouth/jaw problems and high blood pressure w/no medication
c
Not all 2008 callers that received NRT from Free & Clear used it. Some 2008 callers that did not receive
NRT from Free & Clear reported that they obtained NRT from other sources.
9Further investigation of quit rates, relative to NRT use during the 7-month period, found that
callers who reported using NRT were slightly more likely to be 30-day abstinent than those who
did not use NRT (29.8% vs. 27.6% for the 2007 group, and 29.3% vs. 25.5% for the 2008 group,
respectively) (Table 4). However, the differences were not statistically significant.
Additionally, the within-year quit rates between callers who received free NRT from the Quit
Line and those who did not were not significantly different. Though, the number receiving free
NRT in 2007 was relatively small.
Table 4. Abstinence from Cigarette Usea - 7 Months Post-Registration, by Group, Free NRT Receipt,
and NRT Use
2007 Callers 2008 Callers
(n=884) p-valueb (n=1,009) p-valueb
Overall 30-day abstinence 28.6% (d=865) 28.2% (d=1,008)
Received free NRT
Yes 31.8% (d=66) 29.2% (d=813)
No 28.4% (d=799) .556 24.6% (d=195) .207
Used NRT during the first 7 months
Yes 29.8% (d=423) 29.3% (d=733)
No 27.6% (d=442) .477 25.5% (d=275) .223
a
No cigarette smoking during the previous 30 days; Callers with missing or inconsistent data were excluded
b
Quit rate comparison within year; Compared those who received or used NRT to those who did not; Chi-
square test
Note: d = denominator
A series of questions assessed the level of importance callers placed upon common reasons for
calling the Quit Line. Data displayed in Table 5 show the percentage of callers that reported a
particular reason as being “very important” in their decision to call the Quit Line.
Approximately three-fourths of the callers in each group (75.9% of 2007 callers and 74.9% of
2008 callers) rated their health as being a very important reason for calling the Quit Line. The
second most common reason identified as very important was to save money. The reason least
often identified as being very important was harder to smoke in public places. The percentage of
callers identifying each reason as being very important was similar in the two groups.
10Table 5. Percent of Callers Who Rated Reason as "Extremely Important"* in Their
Initial Decision to Register with the Quit Line, by Group
2007 Callers 2008 Callers
(n=884) (n=1,009)
Free cessation counseling 32.5% 30.5%
Your health 75.9% 74.9%
Somebody else's health 35.4% 32.4%
To save money 51.1% 54.0%
Family or friends wanted them to quit 49.0% 43.3%
Harder to smoke in public places 21.4% 21.3%
* Callers were asked how important each reason was in their decision to call the Quit Line using a
4-point Likert scale, ranging from “extremely important” to “not important at all”.
The 2008 callers were asked about the importance of the free NRT offer in their decision to call
the Quit Line. Approximately three-fourths of them placed some importance on the free NRT,
ranging from 39.1% reporting it was “extremely important” to 10.1% reporting it was “slightly
important”. 24.0% of the 2008 callers stated that it was “not important at all” (Table 6).
Table 6. Importance of Free NRT in Initial Decision to Register with the Quit Line: 2008
Callers
2008 Callers (n=1,009)
Extremely Important 39.1%
Moderately Important 26.3%
Slightly Important 10.1%
Not at all important 24.0%
The 2008 callers were also asked about the level of importance the January 1, 2008 cigarette
price increase played in their decision to call the Quit Line. Almost 80% of them reported that it
did have some level of importance in their decision, ranging from 45.3% stating it was
“extremely important” to 9.2% stating it was “slightly important”. 20.6% of the 2008 callers
reported that the price increase was “not important at all” (Table 7).
11Table 7. Importance of January 1, 2008 Cigarette Price Increase in Initial Decision to Register with
the Quit Line: 2008 Callers
2008 Callers (n=1,009)
Extremely Important 45.3%
Moderately Important 24.7%
Slightly Important 9.2%
Not at all important 20.6%
The 2007 callers were asked a parallel question with regards to the January 1, 2008 cigarette
price increase. Given the timing of the price increase relative to their registration with the Quit
Line, they were asked how important the price increase was in motivating them to quit using
tobacco, and/or to not start smoking again. Approximately two-thirds of them reported that it
was a factor in their decision to quit using tobacco or to stay tobacco-free, ranging from 29.2%
stating it was “extremely important” to 10.6% stating it was “slightly important”. 34.8% of the
2007 callers reported that the price increase was “not important at all” (Table 8).
Table 8. Importance of January 1, 2008 Cigarette Price Increase in Motivating Callers to Quit or
Not Start Smoking Again: 2007 Callers
2007 Callers (n=884)
Extremely Important 29.2%
Moderately Important 22.3%
Slightly Important 10.6%
Not at all important 34.8%
I was not tobacco free 2.5%
Type and level of caller contact with the Quit Line during the 7-month period following their
registration date was also examined (Table 9). The average number of calls was slightly greater
among the 2008 callers (2.7) than the 2007 callers (2.5). This coincides with a greater
percentage of the 2008 callers being registered for the multi-call program (88.1%), compared to
the 2007 group (71.0%). However, among those callers enrolled in the multi-call program, a
greater percentage of the 2007 callers completed four or more scheduled counseling calls
compared to 2008 callers (36.0% vs. 29.5%, respectively).
Within year analysis of 30-day abstinence among callers in the multi-call program revealed that
callers who completed 4 or more calls were significantly more likely to be abstinent at 7 months
compared to those who did not complete at least 4 calls (37.6% vs. 27.7%, for the 2007 callers;
36.6% vs. 25.6%, for the 2008 callers). Within year analysis comparing type of program
12enrollment revealed that callers enrolled in the multi-call program were more likely to be 30-day
abstinent at 7 months compared to those enrolled in the one-call program. The observed
difference for the 2007 callers was significant (31.3% vs. 22.3%). The difference for the 2008
callers was not significant (28.8% vs. 24.2%).
Table 9. Caller Contacta with the Quit Line and Abstinence at 7 Months Post-Registration
2007 Callers 2008 Callers
(n= 884) p-value (n= 1,009) p-value
Average number of callsb 2.5 2.7
Percent of callers who registered for the multi-
71.0% 88.1%
call program
Average number of scheduled counseling
calls completed by callers in multi-call 2.95 2.76
programc
Percent of callers in multi-call program who
completed four or more scheduled counseling 36.0% 29.5%
callsc
30-day abstinence among callers enrolled in
31.3% 28.8%
multi-call program
30-day abstinence among callers enrolled in
multi-call program who completed four or 37.6% .012d 36.6% .001d
more scheduled counseling calls
30-day abstinence of callers enrolled in multi-
call program who did not complete four or 27.7% 25.6%
more scheduled counseling calls
Percent of callers who registered for the one-
29.0% 11.9%
call program
30-day abstinence among callers enrolled in
22.3% .008e 24.2% .287e
one-call program
a
Includes contact callers had with the Quit Line from the date of their registration (used for selection into
the study by the UWSC) through 7 months post-registration. Data are from Free & Clear, Inc.
b
Includes assessment call, scheduled counseling calls, and ad hoc calls; One-call program was counted as one
call. For scheduled counseling calls, only one call per caller per day was counted. For adhoc calls, more than
one call per day was allowed. Registration calls, call attempts where the caller was not reached, and
materials only calls were excluded.
c
Some callers registered with the Quit Line more than once during the 7-month period examined in this
evaluation. We combined calls across registrations within the evaluation period.
d
Within year Chi-square tests for 30-day abstinence among callers in the multi-call program who completed
4 or more calls vs. those who did not.
e
Within year Chi-square tests for 30-day abstinence among callers in the multi-call program vs. those in the
one-call program.
13Table 10 presents data on caller satisfaction with the Quit Line service. A higher percentage of
2008 callers reported they were “very satisfied” with the Quit Line compared to 2007 callers
(47.1% vs. 38.8%). Concomitantly, a greater percentage of the 2007 callers said they were
“somewhat satisfied” with the Quit Line than 2008 callers (25.0% vs. 18.0%). When asked if
they would recommend the Quit Line to a friend, 90.3% of the 2008 callers said “yes”, while
86.0% of the 2007 callers responded affirmatively.
Table 10. Caller Satisfaction with the Quit Line, by Group
2007 Callers (n=884) 2008 Callers (n=1,009)
Level of Satisfaction with Quit line
Very Satisfied 38.8% 47.1%
Mostly Satisfied 25.3% 25.6%
Somewhat Satisfied 25.0% 18.0%
Not at all Satisfied 9.8% 8.2%
Recommend Quit Line to a Friend
Yes 86.0% 90.3%
No 13.2% 9.1%
DISCUSSION
The Wisconsin Tobacco Quit Line experienced an increase in caller volume during January
through April of 2008, relative to each respective month of 2007 (see Appendix D1 through D4).
In particular, caller volume was exponentially greater during January, 2008, than it was during
January of the previous year. Thus, the offer of free nicotine replacement therapy may have had
a positive impact on smokers’ decision to call the Quit Line. In fact, approximately three-fourths
of the 2008 callers placed some importance on the free NRT, with 39% reporting it was
“extremely important”. However, our ability to determine the extent to which observed
outcomes are attributable to the Quit Line’s free NRT component is complicated by the state’s
introduction of another major initiative which took place shortly after the implementation of the
free NRT program. A one dollar increase in Wisconsin’s excise tax on a pack of cigarettes took
place on January 1, 2008. This price increase may also have played a role in the observed caller
volume increase. Previous studies suggest an increase in cigarette price encourages cessation
among established smokers.20 Nearly 80% of the 2008 callers in the current study reported that
the January 1st price increase did hold some level of importance in their initial decision to contact
the Quit Line, with 45% stating it was “extremely important”. Further, more than half of the
2008 callers reported that saving money was as an extremely important reason for calling the
Quit Line. Thus, the concurrent timing of events may have synergistically influenced smokers’
decisions to make a serious quit attempt, and call the Quit Line for assistance. This may be
especially true for the month of January, during which time New Year’s resolutions to quit
smoking are commonplace.
14A key behavioral outcome of interest in the current study was 30-day point prevalence
abstinence at 7 months after registration with the Wisconsin Tobacco Quit Line. Analyses
revealed that approximately 28% of both the 2007 callers and the 2008 callers reported being
abstinent at 7 months. Thus, these findings suggest that the added program component of free
nicotine replacement therapy, available to 2008 callers, did not provide an advantage for
successful 30-day abstinence for users of the Wisconsin Quit Line service, as may have been
expected apriori.
Previous studies have suggested the addition of free nicotine replacement therapy, as an adjunct
to telephone counseling, can improve quit rates. For comparison with the current study, similar
quit line evaluation studies, examining comparable treatment options and reporting 30-day point
prevalence abstinence approximately 7 months after registration with a telephone quit line
intervention service, are briefly presented.
For example, Swartz et al.14 conducted a study examining 30-day abstinence of Maine Tobacco
Helpline callers, 5-7 months after callers requested services. They found 23.4% of the callers
that received counseling only (n = 107) were abstinent, compared to 35.7% of the callers that
received counseling plus NRT (n = 345). 63% of the callers receiving NRT received 14 to 30
days supply of NRT, and 35% acquired 31 to 60 days supply. In another observational study of
cohorts of callers to the Minnesota QUITPLAN, An et al.12 assessed 30-day abstinence 6 months
after program registration with the state helpline, before and after the addition of access to free
NRT. 17.6% of the pre-NRT sample (n=216), and 31.1% of the post NRT sample (n=219),
reported being abstinent at follow-up. Callers registering for a multiple call program were
eligible for an 8-week supply of NRT.
A more recently published study by Fellows et al.13 examined the cost effectiveness of Oregon’s
“free patch initiative”. Their findings revealed a significant difference in 30-day abstinence at 6-
month follow-up, with quit line callers receiving free NRT more likely to be abstinent (29.7%)
than callers that did not receive the free NRT (16.4%). Participants in the Oregon free patch
initiative received a two-week supply of NRT from the Quit Line. Callers with insurance
coverage were encouraged to obtain additional patches from their health care providers. Further,
some insurers added NRT as a covered benefit for quit line recipients during the initiative. The
Oregon service was different from Wisconsin’s service in that it was “limited to a single in-depth
call and a mailed quit kit” due to fiscal constraints.
Though the 2008 callers’ 30-day abstinence rate in the current study was not significantly
different from that reported by the 2007 callers, it was not dissimilar to the quit rates reported for
comparable treatment groups in previous studies. Perhaps more remarkable is the relatively high
prevalence of 30-day abstinence found among the 2007 Quit Line callers in the current study
when compared to the comparable treatment groups in previous studies. These findings may
suggest the Wisconsin Tobacco Quit Line’s normal and customary service (telephone counseling
alone) is of high quality, when compared to similar intervention approaches of other quit line
services. In addition, according to an evaluation conducted approximately one year after the
establishment of the Wisconsin Quit Line, quit rates at 6 months for persons that utilized the
service were higher than rates reported by the U.S. Department of Health and Human Services
for individuals who quit with no form of assistance or with self-help materials only.16
15With regards to utilization of the normal and customary services of the Quit Line service, the
current study revealed that callers enrolled in the multi-call program were more likely to be 30-
day abstinent at 7 months compared to those enrolled in the one-call program. In addition,
among callers enrolled in the multi-call program, those who completed 4 or more calls were
significantly more likely to be 30-day abstinent at 7 months compared to those who did not
complete at least 4 calls. These findings, which suggest that increased contact with counselors at
the Quit Line provides an important mechanism of support for persons trying to quit smoking,
adds supporting evidence to previous findings.
LIMITATIONS
There are a number of limitations to be considered when reviewing the findings presented in the
current report. Quit status was assessed using self-report, and biochemical confirmation was not
performed. Though, this method is not uncommon in outcome studies of telephone counseling
smoking cessation treatment.
As with many studies, recall can be a problem for respondents. To enhance respondent recall,
survey questions were customized for each caller relative to the timing of their registration with
the Quit Line. For example, callers who registered on January 1st of 2007 were asked about
their quit status during August of 2007, as opposed to being asked about whether they were quit
seven months after they registered with the Quit Line. This issue, particularly for the 2007
sample, was another reason a 30-day point prevalence measure was chosen instead of a 7-day
point prevalence measure. The research team determined it would be easier for callers to recall
their behavior when asked to think about a monthly period as opposed to isolating a specific
week.
Additional survey questions examined callers’ smoking status during the 30 days immediately
prior to their interview. Analyses revealed that 29% of the 2007 callers reported being abstinent
(data not shown). Further, we assessed continuous abstinence during the first 7 months after
registration with the Quit Line. Continuous abstinence was reported by 11.7% of the 2007
callers and 12.3% of the 2008 callers (data not shown). Ex-smokers’ ability to recall complete
(continuous) abstinence for the entire time period would likely be easier, in comparison to
relapsers’ ability to pin-point a briefer, more specific time during which they were previously
abstinent. Collectively, the findings suggest that the 2007 callers were doing as well as the 2008
callers with regards to quitting.
Another factor complicating our analysis is the allowance for multiple Quit Line registrations per
caller per year. At the time of study design, the research team held the understanding that callers
were only allowed to register with the quit line once in a given 12-month period. However, upon
analysis of the data, it became apparent that some callers registered a number of times over the
period of a few months in their attempts to quit. In light of this fact, contact with the Quit Line
was assessed by including an assessment call, and all counseling calls and ad hoc calls callers
had with the Quit Line from the date of their registration (used for selection into the study by the
UWSC) through 7 months post-registration.
16Our findings may also be complicated by the relatively high independent utilization of NRT
among the 2007 callers. While almost three-quarters of the 2008 callers reporting using some
form of NRT during the 7-month post-registration period, half of the 2007 callers also reported
doing so. Thus, a great many individuals that are trying to quit smoking, with assistance from
the Wisconsin Tobacco Quit Line, are also utilizing adjunctive therapies such as NRT. Within-
year examination of 30-day abstinence, relative to any NRT use during the 7 months after
registration, did reveal that callers using NRT were slightly more likely to be abstinent than those
that did not use NRT. However, the differences were not statistically significant.
Additional analysis for the current study revealed that many individuals obtained NRT products
on their own — either by purchasing it themselves or through their insurance provider (see
Appendix A). Interestingly, when asked whether their insurance covered NRT products,
approximately one-half of the callers said “no”, one-fourth said “yes”, and another one-fourth of
the callers reported that they did not know. Thus, an opportunity to assist callers in learning that
their health insurance will pay for NRT products may exist.
CONCLUSIONS
In sum, the current study did not find significantly different 30-day abstinent rates relative to the
additional program component whereby eligible callers could receive a free 2-week supply of
NRT. However, our findings did reveal quit rates comparable to those published in a number of
previous studies—particularly with regards to estimated 30-day abstinent rates among persons
engaging in telephone counseling in conjunction with the use of nicotine replacement therapy.
Further, quit rates among callers that registered with the Wisconsin Tobacco Quit Line prior to
the free nicotine replacement therapy offer were generally higher than those reported in previous
comparable studies. In addition, findings from the current study revealed that callers who had
greater contact with the Quit Line service were more likely to be abstinent at follow-up,
reinforcing the importance of support during the process of quitting, which is know to be a
difficult one.
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19APPENDIX
20Appendix A. Method of Payment for NRT and Health Care, and Knowledge of
Provider Coverage of NRT, by Group
2007 Callers 2008 Callers
(n=884) (n=1,009)
How paid for NRT?a (Of those who used NRT)
(Can say yes to more than 1 option)b
Employer Paid Health Insurance 16.4% 12.3%
Private Pay Health Insurance 12.6% 10.6%
Medicare 10.2% 7.4%
Medicaid 11.9% 6.0%
BadgerCare 5.1% 3.7%
Own money 64.0% 77.4%
Free 31.8% 11.1%
Other 15.4% 11.1%
Does your Health Insurance pay for NRT?
Yes 27.3% 21.1%
No 49.7% 53.4%
Don't Know 22.7% 25.5%
Refused 0.2% 0.0%
When you go to the Doctor how is it paid for?
(Can say yes to more than 1 option)b
Employer Paid Health Insurance 44.7% 47.8%
Private Pay Health Insurance 12.7% 14.1%
Medicare 19.5% 19.7%
Medicaid 13.2% 11.2%
BadgerCare 5.1% 6.1%
Other 15.2% 15.7%
Do Not Have Insurance 6.4% 8.1%
a
The 2008 survey asked if callers obtained additional NRT, and if so, how they paid for the additional NRT
b
Percent Totals can exceed 100% due to option of answering yes in multiple categories
21Appendix B1. How Callers Heard About the Quit Line*, by Group
2007 Callers 2008 Callers
(n=884) (n=1,009)
Cell Cell
Percent Percent
Count Count
How Heard About
Family/ Friend 6.2% 55 28.4% 287
Health Professional 26.7% 236 12.2% 123
TV/Commercial 37.4% 331 10.7% 108
TV/News 0.5% 4 8.8% 89
Past Caller 3.4% 30 7.1% 72
Newspaper/Magazine 1.8% 16 5.5% 55
Brochure/Newsletter/Flyer 6.7% 59 5.3% 53
Employer/Worksite 1.1% 10 3.8% 38
Quit Report 0.5% 4 3.6% 36
Other 4.1% 36 3.5% 35
Community Organization 1.8% 16 2.4% 24
Health Department 3.2% 28 2.0% 20
Website 1.5% 13 2.0% 20
Radio 1.1% 10 0.9% 9
Does Not Remember 0.7% 6 0.8% 8
Cigarette Pack 0.6% 5 0.6% 6
Health Insurance 0.8% 7 0.5% 5
Not Collected 0.5% 4 0.5% 5
School 0.3% 3 0.5% 5
Outdoor Ad 0.5% 4 0.3% 3
Postcard 0.0% 0 0.3% 3
Re-enrollment 0.0% 0 0.3% 3
First Breath 0.0% 0 0.1% 1
Research Study/Project 0.3% 3 0.1% 1
Legislator Newsletter 0.1% 1 0.0% 0
Refused 0.1% 1 0.0% 0
UW-CTRI Employee 0.2% 2 0.0% 0
* Sorted descending by 2008 percentages
22Appendix B2. Caller Entry Method into the Quit Line System*, by Group
2007 Callers 2008 Callers
(n=884) (n=1,009)
Cell
Percent Cell Count Percent
Count
Entry Method – From F&C data
Inbound English Phone Call 82.6% 730 95.3% 962
Registration Short Form 0.3% 3 2.9% 29
Program Lookup Tool 0.0% 0 0.9% 9
Re-enrollment Offer 0.0% 0 0.5% 5
Warm Transfer From Partner 0.0% 0 0.3% 3
Fax Referral 16.4% 145 0.1% 1
Client Services 0.3% 3 0.0% 0
Electronic Consult 0.1% 1 0.0% 0
Inbound Spanish Phone Call 0.2% 2 0.0% 0
* Sorted descending by 2008 percentages
23Appendix C1. Demographics, Tobacco Use and Stage of Readiness to Quit:
Comparison of 2007 Sample Pool to 2007 Sample
2007 Sample Pool 2007 Sample
(n=2,887)* (n=884)
Age (years)
Minimum 18 18
Maximum 84 81
Mean 42.1 46.5
Median 43 48
Gender
Female 57.5% 57.5%
Race/Ethnicity
White 75.4% 83.9%
Other 23.4% 14.2%
Hispanic, any race 3.2% 1.9%
Education
Less than high school 16.0% 11.0%
High school diploma/ GED 39.5% 37.5%
Some college/Associates Degree 30.1% 31.9%
College or University Degree 13.1% 17.5%
# Cigarettes Smoked Per Day (registration)
Minimum 0 0
Maximum 80 80
Mean 19.0 19.0
Median 20 20
Time to 1st Cigarette after Waking
Smoke 60 minutes 11.6% 14.4%
Use of Other Tobacco 2.7% 2.7%
…continued on next page
24Stage of Readiness to Quit
Precontemplation 0.1% 0.2%
Contemplation 2.3% 2.8%
Preparation 88.4% 84.9%
Action 8.7% 11.5%
Maintenance 0.2% 0.1%
* The sample pool consisted of callers that registered with the Quit Line during January-April of 2007
who were cigarette smokers, wanted an intervention, were not pregnant or breastfeeding at the time of
registration, and were 18 years of age or older. The pool (n=2,887) includes the 884 members of the
2007 sample.
25Appendix C2. Demographics, Tobacco Use and Stage of Readiness to Quit:
Comparison of 2008 Sample Pool to 2008 Sample
2008 Sample Pool 2008 Sample
(n=15,201)* (n=1,009)
Age (years)
Minimum 18 18
Maximum 92 87
Mean 44.9 47.1
Median 46 48
Gender
Female 59.2% 57.6%
Race/Ethnicity
White 86.9% 86.9%
Other 12.3% 12.4%
Hispanic, Any Race 2.2% 1.5%
Education
Less than high school 12.4% 11.1%
High school diploma/ GED 44.3% 39.1%
Some college/Associates Degree 29.1% 31.2%
College or University Degree 13.5% 17.9%
# Cigarettes Smoked Per Day (registration)
Minimum 0 0
Maximum 80 60
Mean 19.5 18.6
Median 20 20
Time to 1st Cigarette after Waking
Smoke 60 minutes 10.5% 11.9%
Use of Other Tobacco 2.5% 2.0%
…continued on next page
26Stage of Readiness to Quit
Precontemplation 0.2% 0%
Contemplation 1.2% 0.9%
Preparation 92.3% 94.5%
Action 5.9% 4.3%
Maintenance 0.3% 0.09%
* The sample pool consisted of callers that registered with the Quit Line during January-April of 2008
who were cigarette smokers, wanted an intervention, were not pregnant or breastfeeding at the time of
registration, and were 18 years of age or older. The sample pool (n= 15,201) includes the 1,009
members of the 2008 sample.
27Appendix D1. Caller Volume, Demographics, Tobacco Use and Stage of
Readiness to Quit: Comparison of January 2007 Quit Line
Registrations* to January 2008 Quit Line Registrations*
January 2007 January 2008
Registrations Registrations
(n=880) (n=12,089)
Age (years)
Minimum 18 13
Maximum 80 92
Mean 41.8 45.2
Median 43 46
Gender
Female 56.7% 59.5%
Race/Ethnicity
White 80.1% 88.6%
Other 18.6% 10.6%
Hispanic, Any Race 3.1% 2.0%
Education
Less than high school 17.8% 11.7%
High school diploma/ GED 37.8% 44.7%
Some college/Associates Degree 28.2% 29.1%
College or University Degree 14.5% 13.5%
# Cigarettes Smoked Per Day (registration)
Minimum 0 0
Maximum 80 80
Mean 19.3 19.5
Median 20 20
Time to 1st Cigarette after Waking
Smoke 60 minutes 10.0% 10.4%
Use of Other Tobacco 4.9% 3.8%
…continued on next page
28Stage of Readiness to Quit
Precontemplation 0.2% 0.1%
Contemplation 2.0% 1.1%
Preparation 87.2% 92.5%
Action 9.4% 5.6%
Maintenance 0.5% 0.3%
* The sample pool consisted of callers that registered with the Quit Line during January of each
respective year as a tobacco user who wanted an intervention. Only the first registration within the
year was used for the measure. All users, including those less than 18 years old, pregnant and
breastfeeding women, and non-cigarette users were included.
29Appendix D2. Caller Volume, Demographics, Tobacco Use and Stage of
Readiness to Quit: Comparison of February 2007 Quit Line
Registrations* to February 2008 Quit Line Registrations*
February 2007 February 2008
Registrations Registrations
(n=840) (n=1,597)
Age (years)
Minimum 18 15
Maximum 79 84
Mean 41.8 43.0
Median 41 44
Gender
Female 59.3% 56.8%
Race/Ethnicity
White 74.0% 84.2%
Other 24.3% 14.9%
Hispanic, Any Race 3.8% 2.6%
Education
Less than high school 17.4% 13.9%
High school diploma/ GED 38.5% 42.8%
Some college/Associates Degree 30.4% 26.5%
College or University Degree 12.3% 15.0%
# Cigarettes Smoked Per Day (registration)
Minimum 0 0
Maximum 80 80
Mean 18.8 18.3
Median 20 20
Time to 1st Cigarette after Waking
Smoke 60 minutes 13.5% 11.0%
Use of Other Tobacco 4.8% 5.7%
…continued on next page
30Stage of Readiness to Quit
Precontemplation 0.0% 0.3%
Contemplation 1.1% 1.4%
Preparation 91.0% 90.6%
Action 7.6% 7.1%
Maintenance 0.1% 0.3%
* The sample pool consisted of callers that registered with the Quit Line during February of each
respective year as a tobacco user who wanted an intervention. Only the first registration within the
year was used for the measure. All users, including those less than 18 years old, pregnant and
breastfeeding women, and non-cigarette users were included.
31Appendix D3. Caller Volume, Demographics, Tobacco Use and Stage of
Readiness to Quit: Comparison of March 2007 Quit Line
Registrations* to March 2008 Quit Line Registrations*
March 2007 March 2008
Registrations Registrations
(n=750) (n=1,207)
Age (years)
Minimum 18 14
Maximum 84 84
Mean 41.8 42.8
Median 42 44
Gender
Female 58.0% 55.7%
Race/Ethnicity
White 73.7% 79.7%
Other 24.8% 19.1%
Hispanic, Any Race 3.5% 2.6%
Education
Less than high school 13.1% 14.3%
High school diploma/ GED 39.7% 40.1%
Some college/Associates Degree 32.1% 30.2%
College or University Degree 13.6% 13.9%
# Cigarettes Smoked Per Day (registration)
Minimum 0 0
Maximum 60 80
Mean 17.8 18.1
Median 20 20
Time to 1st Cigarette after Waking
Smoke 60 minutes 12.4% 12.2%
Use of Other Tobacco 5.5% 4.8%
…continued on next page
32Stage of Readiness to Quit
Precontemplation 0.3% 0.3%
Contemplation 2.8% 1.7%
Preparation 88.1% 91.0%
Action 8.1% 6.4%
Maintenance 0.3% 0.4%
* The sample pool consisted of callers that registered with the Quit Line during March of each
respective year as a tobacco user who wanted an intervention. Only the first registration within the
year was used for the measure. All users, including those less than 18 years old, pregnant and
breastfeeding women, and non-cigarette users were included.
33Appendix D4. Caller Volume, Demographics, Tobacco Use and Stage of
Readiness to Quit: Comparison of April 2007 Quit Line
Registrations* to April 2008 Quit Line Registrations*
April 2007 April 2008
Registrations Registrations
(n=617) (n=862)
Age (years)
Minimum 18 13
Maximum 81 87
Mean 40.7 41.9
Median 41 42
Gender
Female 57.7% 57.9%
Race/Ethnicity
White 72.6% 78.4%
Other 26.3% 20.1%
Hispanic, Any Race 2.3% 4.3%
Education
Less than high school 16.0% 15.0%
High school diploma/ GED 40.2% 40.3%
Some college/Associates Degree 28.0% 29.8 %
College or University Degree 14.6% 12.9%
# Cigarettes Smoked Per Day (registration)
Minimum 0 0
Maximum 70 60
Mean 18.3 17.5
Median 20 20
Time to 1st Cigarette after Waking
Smoke 60 minutes 12.5% 12.6%
Use of Other Tobacco 5.0% 5.2%
…continued on next page
34Stage of Readiness to Quit
Precontemplation 0.0% 0.1%
Contemplation 3.9% 1.2%
Preparation 88.0% 91.3%
Action 7.8% 7.0%
Maintenance 0.0% 0.1 %
* The sample pool consisted of callers that registered with the Quit Line during April of each
respective year as a tobacco user who wanted an intervention. Only the first registration within the
year was used for the measure. All users, including those less than 18 years old, pregnant and
breastfeeding women, and non-cigarette users were included.
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