Telephone support for smoking cessation : The Swedish example

Abstract: Background : Tobacco is a major public health problem that needs to be addressed. The Swedish quitline is a telephone-based free-of-charge tobacco cessation service. Objective : To study the effectiveness and the cost-effectiveness of the Swedish quitline. Methods : The study population comprised clients calling the quitline and returning a registration questionnaire mailed home to the caller directly after first call from April 1999 to November 2002. Each individual was followed up 12 months after first contact (follow-up questionnaire). All those returning the registration questionnaire were included in the study base. The questionnaires assessed point prevalence abstinence as well as several factors potentially related to abstinence. Study I comprised 496 and 629 smokers receiving a reactive and a proactive treatment respectively. Studies II, III and IV comprised all 1131 smokers who had signed up for smoking cessation treatment from February 2000 to November 2001. Of those, 741 individuals (66%) reporting to have been abstinent for at least 24 hours were examined in study II. In study III, a sample of 84 out of 475 non-responders were included in a drop-out analysis. Study IV, was based on 354 abstinent smokers. Outcome measures were cost per quitter and cost per life year saved ( LYS). Main findings : Factors significantly related to abstinence (I) included no nicotine use at baseline, the adjusted OR and 95% CI, being 6.4 (2.1-19.4), additional support from health care professionals 3.5 (1.0-12.3), additional social support 3.1 (1.6-6.1), absence of stress or depressive mood 2.7 (1.6-4.7), nicotine replacement therapy (NRT) for five weeks or more 2.1 (1.1-4.1), and no exposure to second-hand smoke 1.9 (1.1-3.3). High intensity of craving, irritability, apprehension/anxiety, difficulties concentrating, restlessness, depressed mood, and insomnia were related to unsuccessful quitting attempts (II). With the exception of insomnia all these symptoms comprised a factor labelled psychological which was related to unsuccessful quitting attempts. Using NRT for five weeks or longer was correlated with lower intensity of the psychological symptoms. Of the non-responders in study III, 39% claimed to have been smoke-free at the time they received the 12-month follow-up questionnaire compared with 31% of the responders in the original study population (III). The cost per quitter in the investigated cohort (IV) was 1062 USD and cost per life year saved was estimated to be 311 USD. Conclusions : The Swedish quitline proved to be a cost-effective intervention that significantly increased 12 month abstinence. Treatment efficacy may be further enhanced by focusing on factors identified in the different studies as being related to 12 month abstinence. Non-responders to the 12 month follow-up questionnaire were not more likely to be unsuccessful quitters.