Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
Telephone mediated advice and counselling to assist smoking cessation efforts has become increasingly a subject of interest to tobacco control programmes, in the search to provide accessible and affordable methods of quitting smoking.1 2 Telephone contact has been used mostly among patient populations to provide proactive relapse prevention for those who have completed some kind of smoking cessation intervention or to augment health professional advice to quit smoking.1 However, the telephone can also be used as a way of providing advice and help for smokers wanting to quit smoking on their own or with minimal assistance. These so-called “helplines”, “quitlines”, or “crisis lines” tend to be reactive, in that the call is initiated by the smoker, rather than the service provider. Increasingly, helpline services are being used to provide quit smoking assistance within the context of mass media anti-smoking campaigns. In some cases, these helplines additionally offer call back services aimed at preventing relapse, after the initial contact is made by the smoker.3
The article by Owen in this issue describes the outcomes associated with calling a helpline service that deals with around 500 000 calls each year in England.4 Similar, albeit less voluminous, services have been used in Australia,5-7Scotland,8 9 the Netherlands, and various parts of the USA.10-12 Follow up studies of callers to these types of services suggest that they are perceived as valuable by callers and associated with pleasing quit rates.3 4 7 8 Often, helpline services use a combination of live counsellors, answering bureaus, and message bank facilities, depending upon funding and the perceived importance of answering every call with a live person. In addition, calls are usually free or at minimal charge to smokers, so that the cost of the call is borne by the service provider.
Advertising stimulates call volume
Reactive telephone helplines rely upon widely advertising their availability to generate calls from smokers,13 14 so they are natural adjuncts to mass media anti-smoking campaigns. There are consistent findings that the amount of investment in anti-smoking television advertising tagged with the number of the helpline can dramatically increase call volume.15-19 Mapping weekly or daily call rates to periods of television advertising typically results in many times more calls than the baseline rate received during non-advertising periods—for example, the English helpline generated between 3.6 and 7.7 times as many calls over the pre-campaign baseline rate, during campaign periods from 1995 to 1998.18Principles derived from direct marketing suggest that call volume can be increased if the number appears on the screen for at least two seconds and a specific call to action is included (“Ring now . . .”), as well as an offer of what is available (“Ring now and we'll provide counselling . . .”).19
Australian research suggests that some smokers are hesitant to call helplines, having never previously sought help to change their smoking behaviour, nor made much use of helpline services in general.20 While Australian smokers had some notion that there was a telephone line they could call for assistance, they had little idea of what form the assistance might take and were consequently reluctant to call. The production of an advertisement as part of Australia's national anti-smoking campaign, which depicted a male smoker calling the helpline and the type of advice and help that was available, demystified the helpline and removed one potential barrier to calling. Weekly call volume increased even further when television advertisements graphically demonstrating the effects of smoking were followed by an advertisement specifically promoting a telephone helpline.19 21
Disparate needs, but most callers seek minimal advice
Helplines have an important symbolic role—they tell smokers that quitting is so important that there are dedicated services being provided to help those who need it. This means that helpline services must be organised in a way that permits the bulk of prospective callers to access the service when they wish to, even during periods of intensive media advertising, when call volume may be very high. Where helplines have a key role in supporting mass media campaigns, there must be priority given to answering every call and for providing at least a basic service, as not to do this can lead to adverse community reaction. For most practical purposes, this means that they should provide access to a standard or minimally tailored package of information about quitting smoking, which is then mailed to the caller's address.
When calling an advertised helpline, most smokers are seeking very minimal assistance—for example, around half of the calls answered by counsellors in the English Quitline involve simple requests for information, as judged by the call lasting less than 90 seconds.18 Similarly, in Australia, a majority of callers ring to request a “quit kit”, as opposed to seeking counselling assistance.7 In Australia, England, and Arizona, USA, around one fifth of callers are specifically seeking counselling assistance,7 18 22 but this ratio can be increased by offering the caller access to a counsellor.7 However, even when asked directly whether they would like to speak to a counsellor now about their smoking, half of callers decline.7 Further increases in preparedness to speak with a counsellor can be achieved when the service is described and/or a callback is made after the person has received printed materials describing the range of services available.
One of the challenges facing helplines is how to apportion services between reactive single call services (which may include provision of brief advice or a quit kit, or a longer call involving a counsellor) and the provision of add-on services, such as call back counselling. Where multiple service options are offered, callers need to be triaged, so that their disparate needs can be accommodated. Call triaging can be achieved by asking callers (through an automated call answering service or by using live people at an answering bureau) to self select into leaving their name and address to receive a quit package or to gain access to a live counsellor.
The balance of services provided should ideally be based on the marginal cost of successfully helping the smoker to quit. Reactive helpline services can be quite economical—for example, excluding promotional costs, a service that provides written information in response to a single call can cost as little as US$3.35 per call, and where counselling is required, an additional $6–$10 per call.23 At this low cost, a small marginal increase in quitting can make the service very cost effective. However, even when compared with the known benefit of more intensive counselling and advice,1 3 it is probable that brief helpline assistance helps more people per hour of advice time, than more intensive services. This is an important concept since, as adjuncts to mass media campaigns, helplines should aim to help as many people as possible, in order to have any hope of contributing to reducing population smoking prevalence.8 This suggests that the balance of services need to be towards brief advice, and that call back services should only be provided where resources are available and an infrastructure to accommodate counselling can be developed. It may be possible to offer more intensive counselling on a fee-for-service basis, which could be partly used to subsidise the basic service, although we are not aware of any trials as to the acceptability of fee-for-service call back helplines of this kind.
Helplines promote easy access for all
One of the attractive qualities of telephone helplines is not only that they can be used to assist greater numbers of smokers, but that they can be more accessible to those who traditionally have not had access to smoking cessation help. For example, smokers who live in rural areas, where community based smoking cessation options are few, will benefit.24 Similarly, low income earners may not be able to afford some quit smoking methods such as nicotine replacement therapies, but helpline services which have a freecall number are accessible to all. Importantly, during anti-smoking campaign advertising, telephone helplines are also used by those who do not traditionally seek help to quit smoking. For example, during periods where anti-smoking public service announcements were broadcast on network television, there was a levelling of the usual demographic disparities in characteristics of callers seeking smoking cessation help to the US based Cancer Information Service, in relation to sex, race, age group, and highest level of educational attainment.17 This suggested that the advertising prompted those who would not usually seek advice to quit, to call the helpline.
Telephone helplines can also offer assistance in different languages and promotion can occur on ethnic specific television. Helplines are also appropriate for promoting calls from specific population subgroups, such as mothers of young children16 and pregnant women.25
Helpline promotion is only one function of anti-smoking campaigns
Of course, not every smoker will want to call a helpline to obtain help to quit, and indeed not every smoker will need to. The primary purpose of mass media anti-smoking campaigns is not, and should not be, to encourage callers to a helpline—rather, the helpline should be viewed as just one source of accessible information and advice, and principally for those most ready to take action to quit. There are likely to be direct effects of anti-smoking advertising on behaviour, and indirect effects, as mediated through informal interpersonal discussions and through changing the preparedness of policymakers and the public to pass and enforce legislation which itself is likely to reduce smoking behaviour.26-28 If the principal purpose of such advertising is to impart new knowledge, or to motivate smokers of the need for change, advertisements that specifically promote a helpline might conceivably interfere with some campaign messages. Telephone helplines ought to be thought of as one way of taking a step nearer to quitting, but they are not the only way and not everyone needs them.
There are nonetheless good conceptual reasons why telephone helplines might have an adjunctive effect on anti-smoking advertising to influence population smoking. One of the pathways through which mass media campaigns are thought to influence behaviour change is by making information and help seeking behaviour more likely and more persistent.27 28 Because they can be accessed so immediately, helplines can capitalise on the motivation generated by anti-smoking advertising, thus providing an opportunistic channel for smokers who are motivated to take some kind of action.
There have been several studies that have attempted to use the volume and type of calls to telephone helplines as one measure of anti-smoking advertising effectiveness. Research using the US Cancer Information Service in the mid-1980s showed that call volume appeared to be related to the nature of anti-smoking advertisements broadcast as public service announcements.17 In this study, an advertisement featuring the then US surgeon general, C Everett Koop, urging viewers not to smoke was associated with a ninefold increase above baseline in call volume. This increase was substantially greater than observed for other advertisements, which were broadcast much more frequently than the surgeon general advertisement. In Arizona, advertisements which followed a smoker through the stages of precontemplation, contemplation, preparation, and action (the “Chuck” series), showed a linear upward trend in the proportion of callers to the helpline who made a request for counselling, as opposed to brief information.22 Other research has been unable to find differential effects with different anti-smoking advertisements,18 21 concluding that the prime factor driving call volume is amount of advertising. This type of research is intriguing, and it is possible that it will teach us more about how smokers respond to different types of messages, especially those who are most ready to quit, and therefore likely to pick up the telephone.
There is no doubt that telephone helplines are an important part of the armoury of tobacco control strategies. However, they are not a panacea. In the context of anti-smoking mass media campaigns, helplines represent the merging of public health approaches, which aim to produce change in the population, with clinical approaches, which aim to produce change in individuals. Within a stepped care framework, mass media anti-smoking campaigns are a first line source of encouragement to quit smoking, and the ability to access minimal assistance through a helpline represents a second step along the pathway of assistance for quitting. A third step might be the provision of more intensive services provided by telephone, such as the opportunity to talk with a counsellor and the provision of call back counselling. Finally, those who are unable to quit using these services can be encouraged to use additional strategies, such as nicotine replacement products or other pharmaceutical aids, or to seek face-to-face counselling. However, when used in conjunction with mass media campaigns, a major challenge for helpline service providers is to maintain a high call answering rate, while providing at least minimal assistance to callers.
For all the reasons discussed above, telephone helplines for smoking cessation are here to stay; much is already known about preferred ways of delivering services, but more will be learnt in the coming years as research from the field and from controlled intervention trials continues to help improve practice.