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Blackwell Science, LtdOxford, UKADDAddiction0965-2140© 2004 Society for the Study of Addiction

908        C. L. Paul et al.

• pharmacotherapies such as bupropion or nicotine             the privacy of the home envir...
Telemarketing for smoking cessation       909

Acceptability                                                   • ‘Voucher...
910         C. L. Paul et al.

adult smokers who declined; this gave an overall response                       booklet (6...
Telemarketing for smoking cessation              911

Table 2 Participants who indicated that they would not use a proact...
912        C. L. Paul et al.

in relation to the data suggesting that only 5% of smokers        result of lower than expe...
Telemarketing for smoking cessation              913

 3. Lichenstein, E., Glasgow, R. E., Lando, H. A., Ossip-Klein, D. ...
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  1. 1. Blackwell Science, LtdOxford, UKADDAddiction0965-2140© 2004 Society for the Study of Addiction 98•••••• Original Article Telemarketing for smoking cessation C. L. Paul et al. RESEARCH REPORT Direct telemarketing of smoking cessation interventions: will smokers take the call? C. L. Paul1,2, J. Wiggers2,3, J. B. Daly2,3, S. Green3, R. A. Walsh1,2, J. Knight2,3 & A. Girgis1,2 Centre for Health Research and Psycho-oncology, Cancer Council of New South Wales1, University of Newcastle, Callaghan, NSW2 and Hunter Population Health, Wallsend, NSW, Australia3 Correspondence to: ABSTRACT Christine Paul Centre for Health Research and Aims Few smokers currently make use of available and effective cessation Psycho-oncology (CHeRP) Locked Mail Bag 10 strategies, despite their expressed desire to quit and reported interest in cessa- Wallsend, NSW 2287 tion support. This study aimed to explore the feasibility of a telephone-based Australia direct-marketing approach to delivering cessation strategies. Tel: +61 24 924 6368 Design, setting, measurements and participants A community survey was Fax: +61 24 924 6208 E-mail: conducted to explore the views of current adult smokers regarding the accept- ability, likely uptake and barriers to uptake of smoking cessation services offered Submitted 11 November 2003; by direct telephone marketing. initial review completed 23 December 2003; Findings Three quarters (73.8%) of smokers contacted agreed to be surveyed. final version accepted 16 February 2004 Of the 194 study participants, 75.3% reported that they would utilize vouchers for discount nicotine replacement therapy (NRT), 66.5% would use a mailed RESEARCH REPORT self-help booklet, 57.2% would take up the offer of regular mailings of person- alized letters and self-help materials and 46.4% would utilize a ‘we-call-you’ telephone counselling service. The characteristics of those indicating likely uptake of these services were also explored. The two major barriers to uptake of services were preferring to quit without help and a belief that a particular ser- vice would not help the participant. Conclusions The data suggest strong support for the direct marketing of smoking cessation strategies; they also highlight the need for further study of the cost-effectiveness of telephone-based direct marketing of smoking cessation strategies as a population-based strategy for reducing the prevalence of smok- ing in the community. KEYWORDS Smoking cessation interventions, telephone counselling, telephone marketing. INTRODUCTION only a minority of quitters achieving long-term cessa- tion. Therefore, it is imperative that effective strategies Despite evidence suggesting that 60–80% of current achieve a wide reach into the community in order to smokers express a desire to quit [1,2] and that many accomplish population-wide reductions in smoking report an interest in cessation assistance [2,3], only a prevalence. small minority of smokers obtain support during a quit While the various cessation strategies differ in their attempt [4,5]. Given the strength of nicotine addiction levels of effectiveness, there are a number that have been [6], it is not surprising that unsupported cessation shown to have some level of consistently positive effect. attempts have low long-term success rates [4,7]. These include: Decades of cessation research [8–16] have shown that • telephone counselling when used either as an adjunct while various cessation strategies can increase success to care provision by health-care providers [8] or as rates, even the most effective strategies will result in reactive or proactive help lines [9–11]; © 2004 Society for the Study of Addiction doi:10.1111/j.1360-0443.2004.00773.x Addiction, 99, 907–913
  2. 2. 908 C. L. Paul et al. • pharmacotherapies such as bupropion or nicotine the privacy of the home environment. Similarly, the replacement therapies (NRT) [12]; potential effectiveness of such a strategy relies on a large • tailored self-help cessation materials such as leaflets number of smokers being willing to respond to such a ser- and manuals [13,14]; vice and to receive the recommended ‘dose’ of an inter- • intensive personalized assistance through group coun- vention [26]. Therefore, it is important to identify a selling or individual cessation counselling [15,16]; strategy that optimizes efficacy and feasibility. While effi- • opportunistic provision of brief advice by health-care cacy has been tested for most available strategies, feasi- providers [13,17], and bility in a mass-reach setting has not. Potentially • mass media campaigns. important aspects of feasibility include acceptability to With the exception of mass media and health-care the target group, suitability to mass-reach dissemination, provider provision of opportunistic cessation advice, utilization and health system costs. these smoking cessation strategies are provided in a pas- This study aimed to explore the feasibility of a sive manner, reactive to smoker expression of need for telephone-based direct-marketing approach to delivering help. However, a wide range of factors act as barriers to cessation strategies, addressing: smokers expressing such a need. These include a lack of 1 the acceptability of such an approach; readiness to quit [18], lack of congruence between avail- 2 the likely utilization of cessation strategies offered in able services and smokers’ readiness to quit [18,19], lim- this way; ited availability and accessibility of services [20] and 3 the perceived barriers to the utilization of proactive perceived inappropriateness of available services [18]. strategies offered in this way, and The capacity of opportunistic advice by health-care pro- 4 the demographic and other predictors of acceptability viders to produce population-wide reductions in smoking and utilization. rates is also problematic in that few patients actually receive this advice in practice [20,22]. As a result, not only is there an under-utilization of cessation services, METHOD but services reach only selected groups of smokers such as the more highly educated [18]. Ideally, smoking cessa- Sample and procedure tion strategies should be available to all smokers. A random sample of 1882 households was selected from One method of overcoming these barriers is not to rely the electronic White Pages in the Hunter Region of New on smoker identification of need as a trigger to the provi- South Wales (NSW), Australia. Each household was sion of care, but to actively contact and offer cessation mailed an information letter. This was followed by tele- care services in an unsolicited manner (i.e. direct market- phone contact from trained interviewers within 14 days. ing). Such a service could provide treatment access to Up to six attempts were made to contact each telephone individuals who might not otherwise seek cessation number. Eligible households were those containing an care—such as those not yet motivated to quit—as well as adult who was currently a smoker and was able to speak reaching less educated smokers [19,22] and smokers in sufficient English to complete the interview. The smoker rural areas. One such approach is proactive recruitment with the next birthday was invited to participate in a of smokers by mail or telephone [20,24]. Such an 10 minute telephone interview. approach has been trialed by Etter & Perneger [24]; in their study, randomly selected smokers in the community Measures were contacted by mail and, based on their responses to a questionnaire, were mailed tailored smoking cessation The telephone survey items included the following: advice. The intervention resulted in a modest enhance- ment of smoking cessation rates in the experimental Smoking status group relative to controls at 7 months (5.8% versus 2.2%, P < 0.001). Standard items [27,28] were used to measure frequency However, the likely impact of making unsolicited of smoking (daily, at least once a week, less than once a approaches to smokers to offer other smoking cessation week, not at all), whether the smoker had smoked a total services has not been tested. As mail-based cessation sup- of at least 100 cigarettes, number of cigarettes smoked port services have generally produced modest effects on per day, time taken to first cigarette after waking (within cessation [12,25], other, potentially more effective strat- 5 minutes, 6–30 minutes, 31–60 minutes, more than egies such as telephone counselling may yield greater 1 hour), intentions regarding quitting (not in the next cessation rates than those found by Etter & Perneger [24]. 6 months, in the next 6 months, in the next 30 days, One of the major barriers to such an approach may be already trying to quit) and number of quit attempts in the community resistance to service providers ‘intruding’ on previous 12 months. © 2004 Society for the Study of Addiction Addiction, 99, 907–913
  3. 3. Telemarketing for smoking cessation 909 Acceptability • ‘Vouchers for discount nicotine replacement therapy products, such as nicotine patches or gum, to assist Participants were asked to rate the acceptability of having you to quit smoking.’ a health service undertake a telephone-based direct • ‘Enrolment in a quit-smoking group to help you to quit marketing approach to delivering smoking cessation smoking.’ strategies. • ‘An appointment with a smoking counsellor to help you quit smoking (face to face).’ Where respondents indicated they would take up pro- Likely utilization active services (by telephone, mail or e-mail), they were A five point Likert scale (very unlikely, unlikely, unsure, asked to indicate how likely they would be to accept the likely, very likely) was used to quantify the likelihood recommended dose of those services, i.e. two or three that each of a list of potential services would be used by times in the early weeks of giving up smoking and two or the respondent. Respondents were asked: ‘I am going to three times spread over the following months. read out a list of possible services. Imagine that once you were ready to quit, the services were available to Perceived barriers you for free, at a time convenient to you. How likely is it that you would take up these services when you were Where respondents indicated that they were unlikely to ready to quit?’. The services offered were those that take up a particular proactive service, they were asked to could be offered via direct marketing, including both give the main reason why they would not take up that those particularly suited to a tailored, mass-reach pro- type of service. active approach (a proactive telephone service, mailed proactive support, proactive e-mails and an automated telephone service) and other strategies known to have Predictors an effect (self-help booklets, NRT, reactive telephone ser- In addition to smoking status as a predictor, respondents vice, face-to-face individual counselling, group counsel- were asked to describe their demographic characteristics ling or a web-based program): including age, gender, marital status, education, employ- • Reactive telephone support, i.e. ‘a telephone informa- ment, country of birth, rural or urban area of residence tion and support service where you call us if you want and whether they were of Aboriginal or Torres Strait information or help with quitting’. Islander origin. • Proactive telephone support, i.e. ‘a we-call-you tele- phone support and information service for people who want to quit smoking. This would involve Analysis arranging convenient times for the service to call you Current smokers were defined as those who smoked to support you while you are in the process of giving tobacco products daily and had smoked at least 100 cig- up smoking. How often you receive the calls would be arettes in total. Occasional smokers were defined as those up to you’. who smoked at least once a week or less than once a week • Interactive voice response (IVR) proactive telephone and had smoked at least 100 cigarettes in total. Response support, i.e. ‘an automated pre-recorded phone coun- categories of very likely and likely were aggregated to pro- selling call tailored to your needs to help you quit. This duce frequencies and 95% confidence intervals for the would be a “we-call-you” approach; however, the call number of persons likely to take up each cessation strat- would be made by a computer and a pre-recorded voice egy. Chi-square statistics were calculated to compare could help you with things like suggesting quitting potential predictors with each of the outcome variables. strategies’. • Mailed proactive support, i.e. ‘personalized mailed let- ters and self-help materials like brochures tailored to RESULTS your needs to check on your quitting progress and pro- vide information and support’. Sample • E-mailed proactive support, i.e. ‘personalized e-mails tailored to your needs to check on your progress and Of the 1882 telephone numbers extracted from the elec- provide information and support to help you with tronic White Pages, 1687 were connected residential tele- quitting’. phones. Of these, 1291 households did not contain an • ‘Internet-based programs to help you quit smoking.’ adult smoker. The remaining 396 telephone numbers • ‘Having a self-help booklet about ways to quit mailed to yielded 194 interviews completed by an adult smoker, you.’ 124 non-contacts, nine incomplete interviews and 69 © 2004 Society for the Study of Addiction Addiction, 99, 907–913
  4. 4. 910 C. L. Paul et al. adult smokers who declined; this gave an overall response booklet (66.5%), mailed proactive support (57.2%), face- rate of 49.0% and a consent rate of 73.7%. to-face individual counselling (55.7%), a proactive tele- Of the 194 current smokers, 190 (97.9%) were daily phone service (46.4%) and a reactive telephone service smokers, three smoked once a week and one smoked less (42.3%). than once a week. Of the current smokers, 20.5% smoked One hundred and seventy-five current smokers less than 10 cigarettes per day, 39% smoked 11–20 cig- (90.2%, 95% CI: 86.0, 94.4) responded that they were arettes per day and 31.1% smoked 21–30 cigarettes per likely or very likely to take up one or more of the four tai- day. Almost one third (30.2%) of the sample intended to lored proactive services (proactive telephone service, IVR quit in the next 6 months, 9.3% intended to quit in the proactive telephone service, mailed proactive support or next 30 days, 14.9% were already trying to quit and e-mailed proactive support). 37.7% did not intend to quit in the next 6 months. All Of the participants who indicated that they would use respondents spoke English. The age and gender profile of each proactive service, the following proportions indi- the participants is comparable to that found in a recent cated that they would use the recommended dose of calls sample of smokers drawn from a NSW-wide population or letters: 97% (n = 87, 95% CI: 91.5, 99.4) for a tele- omnibus survey [29]. phone service; 87% (n = 26, 95% CI: 75.9, 99.1) for an IVR proactive telephone service; 88.6% (n = 99, 95% CI: 83.0, 94.3) for mailed proactive support, and 94.5% Acceptability of telephone-based direct marketing of (n = 45, 95% CI: 84.9, 98.9) for proactive e-mail support. cessation services Of the 194 participants, 180 (92.8%) indicated that it Barriers to the use of proactive services was acceptable for the health service to contact people by telephone to offer smokers assistance to quit, nine (4.6%) Of those who indicated that they would not use a partic- participants were unsure regarding the acceptability of ular proactive service (telephone-based, mail-based or e- the approach and five (2.6%) considered that making mail-based), the reasons mentioned most often were pre- contact in this way was not acceptable. ferring to quit without help (12.843.7%) and a belief that the service would not help them (9.2–34.8%, see Table 2). The primary barrier mentioned in relation to Likely utilization of services not using an IVR proactive telephone service was a dislike Table 1 lists the proportion of current smokers who indi- of that technology (i.e. talking to computers rather than a cated that they were likely or very likely to take up each of real person). Additional barriers to the uptake of mail- the services described by the interviewer. As shown in based or e-mail-based proactive support were the likeli- Table 1, the services most likely to be taken up were hood of throwing the information away, or not opening vouchers for discounted NRT (75.3%), a mailed self-help the mail or e-mail. Table 1 Proportion of current smokers (n = 194) indicating that Predictors of potential users of each service they were likely or very likely to take up the offer of a quitting service. The demographic characteristics and smoking status (frequency, number smoked, time to first cigarette of the Likely to take up offer day and readiness to quit) of potential users and non- Service offered n % 95% CI users of each type of service were compared using Chi- square statistics. Older participants were more likely than Vouchers for discounted NRT 146 75.3 (69.2, 81.4) younger participants to report that they would use an Mailed self-help booklet 129 66.5 (59.8, 73.2) IVR proactive telephone service (c2 = 9.1382, d.f. = 2, Proactive mailed support 111 57.2 (50.2, 64.2) P < 0.05). Younger participants were more likely than Face-to-face individual counselling 108 55.7 (48.7, 62.7) older participants to report that they would take up the Proactive telephone service 90 46.4 (39.4, 53.4) offer of mailed proactive support (c2 = 7.3974, d.f. = 2, Reactive telephone service 82 42.3 (35.3, 49.3) Group counselling 70 36.1 (29.3, 42.9) P < 0.05) or a mailed self-help booklet (c2 = 14.4807, E-mailed proactive supporta 47 24.2a (18.5, 29.9) d.f. = 2, P < 0.001). Internet-based programb 49 25.3b (19.5, 31.1) Women were more likely than men to report that they IVR proactive telephone service 30 15.5 (10.4, 20.6) would accept mailed proactive support (Fisher’s exact test: P = 0.0090), a mailed booklet (Fisher’s exact test: a Asked of those with access to e-mail (n = 98); however, the proportion given P = 0.0477) or a proactive e-mail service (Fisher’s exact uses the whole sample (n = 194) as a denominator.bAsked of those with Inter- net access (n = 105); however, the proportion was calculated using the whole test: P = 0.0316). Those employed, unemployed or sample (n = 194) as a denominator. unable to work were less likely than those on home © 2004 Society for the Study of Addiction Addiction, 99, 907–913
  5. 5. Telemarketing for smoking cessation 911 Table 2 Participants who indicated that they would not use a proactive service: proportion nominating each of the major perceived barriers to cessation servicesa. Perceived barrier Prefer to or Prefer Unlikely to able to quit Service would Lack of Dislike of Not wanting face-to-face Dislike of open, read Service offered without help not help me time technology pressure help phone calls or act on it Mailed proactive support 24.1 21.7 16.9 – – 6.0 – 22.9 (n = 83) Proactive telephone counselling 32.7 25.0 12.5 – 8.7 7.7 5.8 – (n = 112) Reactive telephone counselling 32.1 34.8 6.3 – – 5.4 7.2 – (n = 104) E-mailed proactive support 17.1 9.8 – 4.9 – – – 58.6 (n = 41b) Proactive automated telephone 12.8 9.2 3.7 62.2 1.8 4.3 1.8 – counselling (n = 164) a Where respondents indicated that they were unlikely to take up a particular proactive service, they were asked to give the main reason why they would not take up that type of service.bThis was only asked of those who had access to e-mail and indicated that they would not utilize an e-mail service. duties, retired or a student to report being likely to accept NRT is available over the counter in Australia, but with- an IVR proactive telephone service (c2 = 7.3093, d.f. = 2, out any form of government subsidy such as that pro- P < 0.05). Employed people were more likely to report vided for Bupropion. This suggests that cost currently taking up an offer of NRT (c2 = 6.7030, d.f. = 2, P < 0.05) represents a barrier to the widespread use of NRT, despite or a mailed self-help booklet (c2 = 6.2526, d.f. = 2, a relatively low proportion of smokers in Australia nom- P < 0.05). inating costs as a reason for not using NRT [29]. Such a Those who smoked more than 20 cigarettes per day suggestion is supported by the preliminary findings of were less likely than those who smoked fewer cigarettes to studies reporting high demand for discounted NRT choose to accept a proactive e-mail service (c2 = 8.6047, [30,31]. d.f. = 2, P < 0.05). Those who smoked their first cigarette Mail-based strategies (booklets and proactive mailed within 5 minutes of waking were more likely than those support) were second to discounted NRT in terms of the who smoked their first cigarette after longer periods to proportion of smokers reporting that they were likely to report that they would use an IVR proactive telephone take up the offer of such services. Slightly less than half of service (c2 = 6.5564, d.f. = 2, P < 0.05). As there were the sample reported that they would utilize a proactive relatively few significant associations found, no multi- telephone service, 10–20% less than the number report- variate analyses were performed. ing that they would take up a mail-based service. A high proportion of those interested in proactive services indi- cated that they would receive up to six contacts at times DISCUSSION already identified as being likely to enhance success [26]. The relatively low levels of effectiveness of mail-based Almost all smokers (92.8%) reported that telephone- strategies compared with telephone-based strategies [32] based direct marketing was an acceptable method of and the finding that some groups were more likely than offering cessation support services. The study data sug- others to report being likely to use mail-based strategies gest that intended utilization of cessation services could suggests that there is a need to compare mailed informa- be quite high compared with the currently low levels of tion versus proactive telephone counselling in terms of utilization [4,5]. Therefore, appropriate organizations the cost per quitter achieved when used via a direct mar- can expect to make use of such an approach without risk- keting approach. The participants’ reports in this study ing a negative response from smokers in the community. that mailed prompts can be easily ignored also suggests Given the potential for such an approach to improve pop- that a telephone-based service may be better placed to ulation-level cessation rates, further research into its fully deliver the intervention at a population level, where cost-effectiveness is warranted. smokers with low levels of motivation may be recruited. The strategy received most favourably by the study The proportion of people reporting that they would sample was that of vouchers for discount NRT. Currently, utilize a reactive telephone service (42.3%) appears high © 2004 Society for the Study of Addiction Addiction, 99, 907–913
  6. 6. 912 C. L. Paul et al. in relation to the data suggesting that only 5% of smokers result of lower than expected contact rates (69%). There- access telephone support in a given year [11]. This sug- fore, the generalizability of the results to the population of gests that a direct marketing approach may increase the smokers may be somewhat limited. However, the age and uptake of this service. gender profile of the participants is comparable with A sizeable proportion of the participants reported that those reported in other studies, suggesting that the data they would utilize face-to-face individual counselling. It are likely to be valid. Secondly, approximately one quarter should be noted that the question indicated that the time of those contacted did not complete the survey, which and place of the counselling would be convenient to suggests that the proportion of smokers who would utilize them. As it is unlikely that many health services would services offered by telephone-based direct marketing have the resources to offer a highly flexible and conve- would be lower than the proportions reported here. Even nient face-to-face service, this could not be advocated as a taking this into account, a large majority of smokers con- primary strategy for population-level cessation services. sidered direct marketing by telephone to be acceptable. This may be suitable in some institutions, such as hospi- Thirdly, the disparity between the proportion of the sam- tals with quit clinics or counsellors. It should also be ple reporting that they would utilize a reactive telephone noted that more participants indicated an interest in indi- service and the proportion of smokers who currently con- vidual counselling than indicated an interest in group tact the existing Quitline service in Australia suggests counselling, yet currently face-to-face counselling is most that participants’ responses may be influenced to some often provided in a group setting. The data indicates a degree by social desirability, resulting in their overesti- demand for such services when promoted, and suggests mating the likelihood that they would utilize a particular that some smokers have an interest in this more intensive service. For any of the services offered, there is likely to be approach. a gap between the number of respondents who report an Of the services likely to be most appropriate to a intention to use a particular service and the number who population-based approach, the vast majority of smokers actually make use of that service. Additional in-depth (90%) reported that they would take up at least one of face-to-face studies exploring intentions, behaviour and these options. This suggests that direct telemarketing is barriers to service utilization would be useful. worthy of further study. A study that involved the actual Despite its limitations, the study supports the possibil- provision of the services selected by smokers would per- ity that a direct marketing approach has potential as a mit the retention rates of each service to be examined and population-based strategy for reducing the prevalence of would clarify whether the initial selection of the service smoking. While there is continuing refinement of existing by smokers translated into a longer-term commitment. cessation strategies and a search for new ones, reducing Such a study might also explore the relative cost- smoking prevalence requires a parallel focus on achiev- effectiveness of telemarketing proactive cessation strate- ing a much higher uptake of strategies known to be effec- gies and mail-based strategies. While moderate to high tive. Research is required to answer the questions about rates of relapse and attrition are likely, the cost per quitter the effectiveness and costs of a direct marketing approach for such an approach is unknown. The likelihood that a in order to confirm whether it can play a significant role direct marketing approach may engage hard-to-reach in the tobacco control effort. groups and smokers who are otherwise unlikely to access cessation support also warrants exploration. The finding Acknowledgements that age, gender and employment status were related to the possibility of taking up some forms of support sug- The assistance of Craig Nicholas with the statistical anal- gests that a single strategy may not meet the needs of all yses is gratefully acknowledged. This research was groups requiring support. However, as the relationships funded by the Hunter Centre for Health Advancement found between socio-demographic characteristics and and the Centre for Health Research and Psycho-oncology. interest in support did not show a consistent pattern, and The views expressed in this article are not necessarily has potential for spurious associations (due to the large those of the Cancer Council NSW, the University of New- number of comparisons), this aspect of the study war- castle or the Hunter Area Health Service. rants further exploration. It would also be useful to make a more in-depth exploration of barriers to uptake of these References services. 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