Proactive Phone Counseling Improves Smoking Cessation Rates

Laurie Barclay, MD

June 10, 2011

June 10, 2011 — Proactive telephone counseling improves rates of smoking cessation, according to the results of a meta-analysis of randomized controlled trials reported online June 10 in the Journal of the National Cancer Institute.

"Systematic reviews demonstrated that proactive telephone counseling increases smoking cessation rates," write Flora Tzelepis, PhD, from the Health Behaviour Research Group, Faculty of Health, University of Newcastle in New South Wales, Australia, and colleagues. "However, these reviews did not differentiate studies by recruitment channel, did not adequately assess methodological quality, and combined different measures of abstinence."

Of 24 randomized controlled trials identified by the reviewers and published before December 31, 2008, 7 used active recruitment of smokers, 16 used passive recruitment, and 1 used mixed recruitment. Active recruitment methods included physician referral or direct mail or phone calls, and passive methods included posters or television advertisements.

Using the Quality Assessment Tool for Quantitative Studies, the reviewers assessed methodologic quality of the included trials in selection bias, study design, potential confounding variables, blinding, techniques used to collect data, and study withdrawals and dropouts.

The trials were analyzed together and separately based on method of recruitment and methodologic quality, with use of random-effects meta-analysis to pool the findings according to abstinence type and follow-up time. Statistical tests were two sided, and I2 was used to quantify the degree of statistical heterogeneity.

Of the 24 included trials, 2 were methodologically strong, 10 were moderate, and 12 were weak. Point prevalence abstinence was defined as nonsmoking at follow-up or abstinent for at least 24 hours, 7 days before follow-up. Prolonged/continuous abstinence was defined as absence of smoking for at least 3 months before follow-up.

When data were pooled from all 24 trials, point prevalence abstinence at 6 to 9 months, but not at 12 to 15 months after recruitment, was statistically significantly greater in participants who received proactive telephone counseling vs those who received self-help materials or no intervention (relative risk [RR], 1.26; 95% confidence interval [CI], 1.11 - 1.43; P < .001). Findings were similar for separate analysis of trials using active or passive recruitment channel, or trials with strong or moderate vs weak methodologic quality.

Proactive telephone counseling was also associated with statistically significantly greater rates of prolonged/continuous abstinence at 6 to 9 months (RR, 1.58; 95% CI, 1.26 - 1.98; P < .001; I2 = 49.1%) and at 12 to 18 months after recruitment (RR, 1.40; 95% CI, 1.23 - 1.60; P < .001; I2 = 18.5%).

"With the exception of point prevalence abstinence in the long term, these data support previous results showing that proactive telephone counselling has a positive impact on smoking cessation," the study authors write. "Proactive telephone counselling increased prolonged/continuous abstinence long term for both actively and passively recruited smokers."

Limitations of this study include possible bias related to exclusion of articles not published in a peer-reviewed journal or not written in English, possible nonreporting of information about study quality affecting the methodologic quality ratings, and lack of data from the active recruitment trials regarding cost-per-smoker recruited.

Recruitment May Not Reach All Smokers

In an accompanying editorial, Damon Vidrine, DrPH, and Jennifer Irvin Vidrine, PhD, from the University of Texas M.D. Anderson Cancer Center in Houston, agree that cost-effectiveness analyses are needed.

"An important caveat is that neither passive nor active recruitment approaches will be successful in reaching all smokers," Drs. Vidrine write. "...Active recruitment could also have a potential downstream effect, whereby smokers not ready to accept referrals at the time they are offered draw upon referral information at a later date to contact quitlines on their own when they are ready to quit. An important direction for future research will be to develop and evaluate innovative active recruitment approaches designed to maximize the reach of quitlines."

The Centre for Health Research & Psycho-Oncology, which is funded by the Cancer Council New South Wales and the University of Newcastle and receives infrastructure support from the Hunter Medical Research Institute and the University of Newcastle Priority Research Centre for Health Behaviour, supported this study. The study authors have disclosed no relevant financial relationships.

J Natl Cancer Inst. Published online June 10, 2011. Abstract Full text editorial

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