Transcript Challenges facing Australian Quitlines Ian Ferretter Quitline Manager Victoria, Australia European Network of Quitlines Amsterdam September 2008

Challenges facing Australian
Quitlines
Ian Ferretter
Quitline Manager Victoria, Australia
European Network of Quitlines
Amsterdam
September 2008
Acknowledgements
• Australian Quitline Managers Network:
Craig Black, Dan Nelson, Shannon Maxwell, Phil Hull, Lyndy Abram, Jason Wells,
Bonnie Travers, Gail Hamilton, Justin Heath, Melissa Seibold.
• Prof Ron Borland
VCTC
• Dr Cathy Segan
VCTC
• James Balmford
VCTC
• Suzie Stillman
Quit Victoria
• Ainslie Hannan
CCV
Australian Quitlines: Setting the Scene
Quitline 13 QUIT (13 7848)
•
National number
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Cost of a local call on a landline
40c for a local call with unlimited time
0.4 Australian Dollar = 0.23 Euro
Each state and territory funds the Quitline in their own jurisdiction
Each pays a share of the number rental
All callbacks are free of charge
Number and Quitline logo owned by the Cancer Council Victoria
Australian Quitlines
Number of Calls
Calls to the Quitline July 2007 to June 2008
20000
15000
10000
5000
0
NSW ACT VIC TAS QLD NT
SA WA
Australian Quitlines: Setting the Scene
• Each State and Territory has the responsibility of
providing Quitline services for its own jurisdiction
• Variety of models
• Various agencies
Australian Quitlines: Setting the Scene
Jurisdiction
Model
Australian Capital Territory
Outsourced to NSW
New South Wales and
Western Australia
Located in state based Alcohol and
Drug Information Services
Tasmania
Quit Tasmania
South Australia and Victoria State Cancer Councils
Northern Territory
Outsourced to Alcohol and Drug
Service in Queensland
Queensland
State Government Health Contact
Centre
Australian Quitlines: Setting the Scene
• Some Quitline established in high technology call
centre type environments
- EG Queensland in the Health Contact Centre
• Others located within smaller organisations, with
limited capacity to leverage off of technology
• Victorian Quitline well established, effective, in large
organisation, but not up to date technology
Australian Quitlines: Minimum Standard
1.1 The Quitline is answered 24 hours a day, 7 days a
week
1.2 A person answers the Quitline number at all times.
This could be a call centre agent, a Quitline Counsellor
or Quitline reception staff
1.3 Call answered within a maximum of 5 rings
1.4 The Quit Book is readily available and offered to all
callers to the Quitline
Australian Quitlines: Minimum Standard
4.1 Counselling available during minimum hours ie.
Business hours (0900-1700) plus out of hours as
dictated by call demand and determined by each
jurisdiction
5.1 A pro-active call-back service is available, which
takes the caller through the process of quitting and has
a well-structured schedule according to best evidence
Minimum standards cover…
• Opening hours, response times, hold times, answering
rate
• Availability and despatch times of Quit Pack
• Access to counsellors, recontact times if counsellors
are not immediately available, hours of counselling
• Referral program from health professionals to Quitline
• Tailored assistance for callers with special needs
• Evidence-based counselling content and advice
Minimum standards cover…
• Recruitment (including requirement that counsellors be
current non-smokers)
• Counsellor training: initial, ongoing professional
development
• Referral to other agencies: cessation services and
cessation products
• Collection of data: minimum data set
• Evaluation
Minimum standards development
As part of the development of Minimum Standards
the Network of Quitline Managers led the
development of protocols for each of the special
needs groups:
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Indigenous
Mental Health Conditions
Youth
Pregnancy
Cultural and Linguistic Diversity
Australian Quitlines: Issues
• New technologies
- Quit Coach
- SMS
• Relapse prevention
•Callers with mental health conditions
• Distribution of NRT from Quitlines
- Only one very limited trial in Australia to date
Australian Quitlines: Issues
• NRT (or is it therapeutic nicotine ?)
• - The tension between research and the regulations
•
- Different regulations for very similar products
*Pre-Quit patch
Australian Quitlines: Issues
NRT & Pregnancy
• Intermittent dosing products (such as the chewing gum, the
microtab or the inhaler) may be preferable as these usually
provide a lower daily dose of nicotine than patches.
• However, patches may be preferred if the woman is suffering from
nausea during pregnancy. If patches are used they should be
removed before going to bed.
• The use of the above products are also encouraged for
breastfeeding women.
Australian General Practice
Guidelines
Two strategies for providing patients with effective
cessation assistance:

1. In-practice counselling
(unless good clinical reason to refer)

2. referral to specialist
support services
(Quitlines)
(where appropriate)
Fax referral to Quitline
RCT: Referral vs in-practice management
Cluster RCT randomisation by GP Practice
45 GPs

30 referral GPs
Quitline triage

15 in-practice
management
Recruited 1040 smokers
Baseline survey and 3 and 12 month surveys
Randomisation successful, no differences in samples
Borland et al, Family Practice, 2008
Help received
• Within practice
• Outside practice: Referral > In-practice
– 35% Referral got intensive help
- 30.5% Callback
- 4.4% QuitCoach
Main outcomes
Outcome 12 months:
In-practice Referral OR
10 months sustained abstinence
Available data: Intention to treat
(95% CI)
2.6%
6.5%
2.86
0.9-8.7
Imputing missing as smoking
1.7%
4.3%
3.08
1.0-9.3
NB: Intention-to-treat = all cases in allocated group regardless of help received
Referral
• Results in smokers getting more help
– Thus more quit
• Acceptable to smokers
– They appreciate it
• Acceptable to health professionals
– Fits better into busy schedules
– Easy way to do something they know they should
– But often don’t
• Just do it!
Can we help quitters embrace a nonsmoking lifestyle?
Intervening to prevent longer-term relapse
2 Tasks of Staying Quit ‘The 2Ts’
1. Learning to effectively deal with cravings and other
withdrawal symptoms without relapsing
2. Learning to enjoy and value smokefree lifestyle
– Starts when cravings drop to less than daily
– Finding alternative behaviours to replace functions previously
served by smoking
– Facing old smoking situations to extinguish habit
– Adopting new self-image by rejecting or growing out of smoker
self-image
Study Aim
• Can an extended callback service reduce
relapse rates compared to Quit’s standard
callback service?
Design:
Randomised controlled trial
2 Tasks of quitting framing
CONTROL
INTERVENTION
Standard service
Extended service
Yes
Yes
Pre-quitting callbacks
2
2
Post-quitting callbacks
up to 4
over 1 month
up to 10
over 3 months
The intervention: extra ‘integration’
callbacks to facilitate becoming a
non-smoker
•Structured intervention designed to minimise
perceived losses associated with quitting
•Starts when standard service ends (around 1
month after quitting) and offered 4-6 callbacks
over 2 month period
•Weekly or fortnightly calls with more frequent
calls provided around any slip up or relapse crises
•Same counsellors delivered both standard and
‘integration’ callbacks
12 month follow up
Measure/ Sig. Test
CONTROL
% quit (point prevalence) (n=409) 50.0
p=.88
% never relapsed
(still quit from baseline attempt)
p=.98
INTERVENTION
50.7
27.8
27.7
Mean length baseline
p=.29
quit attempt (days)
63.4
56.7
% lost to follow up
p=.85
41.0
41.8
Conclusions
• Extra ‘integration’ callbacks were ineffective in
reducing rates of longer-term relapse
• Cannot recommend the program in its current form –
no value in a couple of extra sessions beyond 1 month
to assist with 2nd task
Considerations – Why no effect?
• Poor quality intervention unlikely
• Lack of differentiation between control and
intervention condition
• Methodological challenges in implementing RCTs of
differing counselling protocols
Historical Comparison
1996
2002-04
22%
34%
% quit 12mths (point prevalence)
All smokers at recruitment
All offered callback counselling
www.QuitCoach.org.au
• Computer-tailored cessation program
• Assessment leads to tailored advice
• Designed to be used multiple times
– Flexible scheduling
• Strong focus on relapse prevention
• Tailors to increase relevance as well as on issues
• Advice on use of aids
Development and evaluation of a
Quitline service for smokers with a
history of depression
• Ainslie Hannan; Dr Catherine Segan; Dr Ron Borland;
A/Prof Kay Wilhelm; Ian Ferretter; Suzie Stillman;
Dr Sunil Bhar and A/Prof David Dunt
Overview
Why depression?
• How we’re evaluating the service
• Features of the service
• Issues and insights arising out of the development and
delivery of the tailored service and in the data
collection
Why depression?
• Around 1 in 5 people experience depression during
their lifetime
• Smokers report more depressive symptoms, more
frequent and severe episodes of depression and
higher rates of suicidal ideation and suicide
Wilhelm et al 2006
Depression and smoking cessation
• Smokers with symptoms of depression tend to smoke
more and experience more severe withdrawal,
including greater negative mood
Breslau et al 1994; Wilhelm et al 2004
• Lifetime of symptoms of depression doesn’t predict a
failure to quit
Hitsman et al 2003
• Those with increased depressive symptoms while
quitting are more likely to relapse
Burgess et al 2002
Depression and smoking cessation
• Around 30% of quitters with symptoms of depression
will develop a new episode of depression
Glassman et al 2001; Killen et al 2003
• Chemicals in cigarettes can affect metabolism of some
antidepressants e.g. fluvoxamine
Zevin et al 1999
• Two antidepressants also function as ‘anti craving
agents’: bupropion and nortriptyline
Hughes et al 2003
The Victorian Quitline context
• Almost 1 in 3 Victorian Quitline callers disclose a
mental health condition, most commonly depression
• Doctor – Quitline co-management of smoking
cessation for people with current mental health
conditions
• For callers with a diagnosed history of depression an
additional tailored service is offered
Research questions
1. Can a tailored callback service for smokers with
symptoms of depression produce comparable quit
rates?
2. What factors predict depression recurrence?
3. Does depression predict failure to quit?
4. What do callers think of Doctor-Quitline coordinated
care?
Study design
• Prospective study - follow up 3 groups of callers over a
6 month period
• 3 caller groups
– Smokers without MHC n=400
– Smokers with past depression n=190
– Smokers with current depression n=140
• Research interviews
– Baseline
– 2 months (around end of Quitline service)
– 6 months
Service development within a research
context
Program enhancement
•
Counsellor training in the relationship between smoking cessation and
depression.
•
The development of counselling guidelines for callers with symptoms of
depression that complement Quit Victoria’s mental health policy.
•
The development of a joint Quit and beyondblue fact sheet on smoking
cessation and depression.
•
Continued development of the partnership between Quit and health
professionals.
Evaluation of the tailored service
•
Recruitment May 07 – May 08
•
Follow-up surveys until Dec 08
Key features of the additional service
• Introduction to
Quitline of the
Health Screen
Assessment
Tool which
documents the
caller’s
physical and
mental health
• Tailored callback service focusing on the relationship
between smoking, mood and the impact of quitting
on mood
• Smoking cessation and mood monitoring and
management techniques
• Doctor involvement and resourcing
• Development of quit plan in with the caller’s Doctor
• Letters to doctor reporting on progress
• Specialised resources and activity sheets
Caller responses to the service
• Thankful for greater awareness, normalisation of
experience and preparation for mood management
• Initial concern that their history of depression is being
assessed before being given smoking cessation
advice
Issues and insights
• The need to develop an understanding of the
relationship between smoking cessation and
depression
• Choose to smoke rather than take medication
• Use of mood management skills for other callers
without a history of diagnosed depression
• Considerations when delivering a tailored service
within a population service
• The role and acceptance of partnerships
• Resourcing a client centred service
Finally
• Improving cessation rates is not an easy task
– But one we need to continue to work on
• Getting more people to use effective services, and, or,
aids is somewhat easier
– And provides improved outcomes, even in a population not
selected initially by desire to quit