Quitlines have become an important component of tobacco control efforts. Because of the demonstrated efficacy and the convenience of telephone-based counselling, there has been a rapid adoption of quitlines in Europe and worldwide since the 1990 s. However, facts about how quitlines operate is scarce.

There are a variety of ways in which counsellors respond to quitline clients [1]. First-time callers may receive a variety of services. These include self-help materials, pharmacological consultation, brief advice, and extensive counselling. Quitlines may also refer callers to health professionals for further information or for a medical prescription. Counsellors may refer smokers to smoking cessation clinics and proactive call-back services.

The manner in which counsellors respond to callers is important. Motivational interviewing is crucial to the success of telephone counselling. This patient-centred approach improves the efficacy of quitline counsellors [2] and is a common element in the training of counsellors in Europe. In a previous study we examined the effectiveness of nine quitlines [3]. We found that the type of behavioural support (counselling, brief advice, information) did not affect success rates. However, when a caller received additional telephone support, specifically through more telephone counselling, there was an increase in continuous abstinence. This finding was supported in a recent meta-analysis of the efficacy of different types of support provided by quitlines [4]. This review concluded that the number of calls may improve success rates, but failed to show that any particular method of counselling or adjunctive self-help materials leads to higher success rates. Regardless, according to clinical guidelines, pharmacotherapy should be advised to nicotine addicted smokers [5, 6].

In this paper we examine whether the types of support quitlines offer is related to smokers' characteristics. Four important distinctions of smokers' characteristics were considered: level of addiction, education, caller's stage of change, and type of referral.

During the initial contact between the counsellor and the caller, the caller's level of addiction must first be assessed, which will determine whether or not information about pharmacotherapy is provided. A second consideration is educational level, since smokers with a lower education have more difficulty quitting [7, 8]. The third smoker characteristic considered is the caller's stage of change. Quitlines cater to two groups of callers: smokers seeking help with quitting in the near future (those in the preparation stage of change - planning to quit within four weeks), and those callers who have already quit smoking but are having difficulty staying smoke-free (those in the action stage who may have quit for less than 6 months). The needs of callers in these two stages of smoking cessation are different from each other. In the preparation stage, smokers actively seek information on how to quit. In the action stage, smokers who are already trying to quit need continued support to reinforce their decision [9]. We hypothesised that compared to callers in the preparation stage, those in the action stage are more likely to get immediate attention. This group will tend to receive more direct counselling or advice from the quitline and fewer referrals to outside help or literature, regardless of whether they were self-referred or referred by a health professional.

We conducted this study by collecting data on all callers seeking help with quitting smoking. This included both those smokers without referrals and those referred to the quitline by health professionals - general practitioners, medical doctors, nurses, midwives, pharmacists. Thus, we were able to categorize the callers based on referrals and how referred callers differed from those without referrals. We anticipated that referred callers would more often receive counselling, since many health professionals consider smoking cessation counselling as too time consuming to do it themselves [10–12].

For this study, we used data from seven European quitlines to examine which callers get which types of service from quitlines. Although some findings were consistent across quitlines, most seemed to be mediated by quitline characteristics.

As hypothesised, one consistent finding was that heavy smokers were more likely to receive information on pharmacotherapy, especially nicotine replacement therapy. This finding mirrors clinical guidelines on smoking cessation that recommend providing pharmacotherapy to more dependent smokers [5]. We also found that counsellors were likely to refer heavy smokers to a health professional, most likely to obtain a prescription for pharmacotherapy.

An unexpected finding was that low educated smokers, who generally have more difficulty quitting, were not getting intense counselling support. The length of call for lower educated smokers was shorter than for more highly educated smokers. This finding is disappointing since quitlines, with their centralized experience in smoking cessation, are particularly well placed to deal with disadvantaged groups [15]. When asked to explain these findings, quitline representatives justified the lengthier calls because it was their impression that highly educated smokers requested more specific and detailed guidance compared to the lower educated. Furthermore, it was their experience that higher educated callers are more willing to expressing fears and ask more questions, making it easier for them to be counseled. Therefore, we advise European quitlines to improve their counsellor training and support systems so that counsellors are better equipped to communicate with smokers from lower educated strata.

Smokers who had already quit and called for relapse prevention (action stage) were more likely to receive advice (in two quitlines) or counselling (in two quitlines) than smokers preparing to quit. They were also more likely to be further referred (in three quitlines). This finding partly confirmed our hypothesis that more acute crisis calls get more immediate attention from quitline counsellors. Further research should focus on why this finding was not the case in all quitlines.

This study also makes it clear that there are differences in how callers to EU quitlines are served. In particular, we found that callers referred to quitlines by health care providers were likely to receive counselling, although this association was significant in only four of seven quitlines. This finding suggests that quitlines can play a role in supporting physicians who seek additional counselling for their smoking patients. It also suggests that further research is needed to examine more closely the different practices of quitlines in different countries.

From a public health perspective, it appears that despite national differences in quitline services, not many patients seem to find their way to quitlines yet, since only 10.7% of calls were referrals from health care providers. In contrast, in California, between 14.5% and 51.3% of callers (variance depended on whether they used nicotine replacement therapy) heard about the quitline from a health care provider [16]. It seems worthwhile for European quitlines to put more effort into bridging the current gap between the health care system and quitlines. This could be done, for example, by experimenting with pro-active enrolment models where names and telephone numbers of patients are forwarded to the quitline. Such systems have been shown to increase the use of quitline services by referred patients [17].

Our study has both strengths and limitations. One strength is that some findings were consistent across quitlines. These findings will probably hold true for many quitlines in developed countries beyond those studied here. However, because there was so much variance among quitlines, it is difficult to make general conclusions without further examining how quitline or country variables may mediate results. The conceptual framework that we developed previously could be useful for guiding such future research [3]. In this framework, we identified the factors that are most likely to directly or indirectly affect the types of quitline services provided to callers. These factors were identified at the micro level (caller characteristics and counselor variables), the meso level (quitline organizational factors), and the macro level (mass media promotion, the health care system, and tobacco control environment, including differences in tobacco epidemic and restrictiveness and type of control measures).

In our research we found that how quitlines matched their services to caller characteristics varied. This raises an important question: Is more standardisation in quitline protocols needed to match services to caller characteristics? Further research might identify the most effective caller/service combinations. In particular, qualitative research is needed to determine which individual quitline protocols can be successfully adapted to local settings, so that other quitlines can learn from these best practices. An important task for the international quitline networks is to disseminate this information among network members.

One limitation of the study is that we did not ask callers their preferences for type of service. Therefore, we do not know to what extent the type of service rendered is the result of a specific request from the caller. Counsellors are expected to match the services offered to the needs of the caller. This requires following formalized protocol. For instance, counsellors are advised to follow ENQ quitline protocols, rather than giving callers what they ask for. However, it is unclear how smokers' preferences influence counsellors' decisions. There is consensus among smoking cessation experts that evidence, patient preference, and patient experience are important considerations when deciding the best treatment [18]. Future quitline research should take into account caller characteristics as well as callers' needs, variations in quitline protocol, counsellor characteristics such as level of experience and training, and the quitline's level of maturity.

This study was limited to one-session calls. We do not know whether calls resulted in further call-back appointments or whether the advice callers received from counsellors were followed. Future studies should monitor the callers' actions after their initial call.

Another potential limitation of this study is that we cannot be sure how accurately counsellors' recorded callers responses to our questionnaire and if it was done consistently across quitlines. We are confident, however, that this was not a problem because we used four strategies to increase classification reliability. First, representatives from all seven quitlines helped us to accurately define the services used in this study. Second, we conducted a full day's training workshop for representatives of all quitlines. This included how to implement the study protocol, as well as how to record callers' responses on the score sheet. Third, we provided detailed written instructions to all quitlines that could be used to train their own counsellors in the research tasks. Finally, the definitions of the services were printed on the questionnaire in close proximity to the pertinent questions, so the counsellors always had the definitions at hand when they had to record the type of service they had provided. However, despite these precautions, some differences in interpretation may have occurred.

The broadest conclusion we can make from this study's findings is that, in general, quitline services appropriately matched the smoker's level of addiction (as measured by the Heaviness of Smoking Index) and the smoker's stage of change. Our findings also provided evidence that quitlines might improve their services in two areas. First, we found that quitlines did not consider the educational level of callers in their responses. Therefore, we advise European quitlines to improve their services for this important target group. This is especially important in light of the increasing socio-economic gradient of the smoking problem in developed countries. Second, we found that there are a low number of referrals to quitline services by European health professionals. Based on this, we strongly advise quitlines and policy makers to explore ways of integrating quitlines into their country's health care system.