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 . 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 . 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 . 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 .
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 . 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 . 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.