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Predictors of Smokeless Tobacco Cessation Among Telephone Quitline Participants

      Background

      The prevalence of smokeless tobacco use in the U.S. is increasing and its use is a risk factor for a number of adverse health outcomes. Currently, there is limited evidence on the effectiveness of quitlines for tobacco cessation among smokeless tobacco users.

      Purpose

      To examine factors related to tobacco abstinence among exclusive smokeless tobacco users registering for services with the Oklahoma Tobacco Helpline.

      Methods

      Participants included 959 male exclusive smokeless tobacco users registering with the Helpline between 2004 and 2012; a total of 374 completed a follow-up survey 7 months post-registration. Data were collected between 2004 and 2013 and included baseline data at Helpline registration, services received, and 7-month follow-up for 30-day point-prevalence for tobacco abstinence. Univariate and multiple logistic regression examined associations between abstinence and participant characteristics, intensity of Helpline intervention, and behavioral factors. ORs and 95% CIs were reported. Analyses were completed in 2013.

      Results

      At the 7-month follow-up, 43% of the participants reported 30-day abstinence from tobacco. Each additional completed Helpline call increased the likelihood of tobacco cessation by 20% (OR=1.20, 95% CI=1.05, 1.38). Smokeless tobacco users with higher levels of motivation to quit at baseline were twice as likely to be abstinent than those with low or moderate levels of motivation (OR=2.05, 95% CI=1.25, 3.35). Use of nicotine replacement therapy was not associated with abstinence when adjusted for Helpline calls, income, and level of motivation.

      Conclusions

      Tobacco quitlines offer an effective intervention to increase smokeless tobacco abstinence.

      Introduction

      Despite decreases in smoking prevalence, an estimated 8.7 million U.S. adults use smokeless tobacco (ST).

      Office of Applied Studies, Substance Abuse and Mental Health Services Administration, USDHHS. Results from the 2008 National Survey on Drug Use and Health: national findings. Rockville MD: Office of Applied Studies; 2009. NSDUH Series H-36, HHS Publication No. SMA 09-4434.

      The prevalence of ST use in some states is as high as 9.8% and approximately 13.4% of men in Oklahoma are ST users.
      CDC
      Tobacco control state highlights 2012.
      ST use is associated with a number of ill health effects ranging from oral lesions to diabetes, cardiovascular disease, and cancers of the oral cavity, esophagus, pancreas, and lung.
      • Colilla S.A.
      An epidemiologic review of smokeless tobacco health effects and harm reduction potential.
      According to the 1986 Surgeon General’s Report,
      • Cullen J.W.
      • Blot W.
      • Henningfield J.
      • et al.
      Health consequences of using smokeless tobacco: summary of the Advisory Committee׳s report to the Surgeon General.
      ST use can result in nicotine addiction. In response to smoking restrictions, concerns about secondhand smoke, and the overall decline in cigarette consumption, leading cigarette manufacturers have acquired some of the ST companies, enhanced their marketing of ST products,
      • Curry L.E.
      • Pederson L.L.
      • Stryker J.E.
      The changing marketing of smokeless tobacco in magazine advertisements.
      and introduced new ST products designed to offer a less harmful, more convenient, and socially acceptable alternative to smoking.
      FTC
      Federal Trade Commission smokeless tobacco report for 2007 and 2008.
      • Tomar S.L.
      • Alpert H.R.
      • Connolly G.N.
      Patterns of dual use of cigarettes and smokeless tobacco among US males: findings from national surveys.
      The increasing prevalence of ST use,
      CDC
      Tobacco control state highlights 2012.
      State-specific prevalence of cigarette smoking and smokeless tobacco use among adults—United States, 2009.
      its association with serious health consequences, and growing concern about emerging smokeless products call for the development and implementation of effective strategies to prevent the initiation of ST use and encourage ST cessation.
      The 2008 update to Treating Tobacco Dependence Use and Dependence,
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating tobacco use and dependence. 2008 Update. Clinical practice guideline.
      also known as the Clinical Practice Guideline, identified the need for additional research related to the effectiveness of behavioral counseling and pharmacotherapy for the treatment of nicotine dependence among ST users. There are a limited number of published studies focused on ST cessation. Most of these studies are RCTs, assessing the effect of pharmacologic and behavioral interventions on ST cessation.
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating tobacco use and dependence. 2008 Update. Clinical practice guideline.
      • Ebbert J.
      • Montori V.M.
      • Erwin P.J.
      • Stead L.F.
      Interventions for smokeless tobacco use cessation.
      • Boyle R.G.
      • Enstad C.
      • Asche S.E.
      • et al.
      A randomized controlled trial of Telephone Counseling with smokeless tobacco users: the ChewFree Minnesota study.
      • Boyle R.G.
      • Pronk N.P.
      • Enstad C.J.
      A randomized trial of telephone counseling with adult moist snuff users.
      • Ebbert J.O.
      • Glover E.D.
      • Shinozaki E.
      • et al.
      Predictors of smokeless tobacco abstinence.
      • Severson H.H.
      • Gordon J.S.
      • Danaher B.G.
      • Akers L.
      ChewFree.com: evaluation of a Web-based cessation program for smokeless tobacco users.
      • Severson H.H.
      • Peterson A.L.
      • Andrews J.A.
      • et al.
      Smokeless tobacco cessation in military personnel: a randomized controlled trial.
      • Walsh M.M.
      • Langer T.J.
      • Kavanagh N.
      • et al.
      Smokeless tobacco cessation cluster randomized trial with rural high school males: intervention interaction with baseline smoking.
      These studies report limited effectiveness of pharmacologic interventions.
      • Ebbert J.
      • Montori V.M.
      • Erwin P.J.
      • Stead L.F.
      Interventions for smokeless tobacco use cessation.
      However, there has been inconsistent evidence of a positive impact of various behavioral interventions, including telephone-based counseling, on ST cessation.
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating tobacco use and dependence. 2008 Update. Clinical practice guideline.
      A recent meta-analysis of published studies reported quit rates among ST users at 12 months between 10.2% and 34.5% for behavioral interventions.
      • Ebbert J.
      • Montori V.M.
      • Erwin P.J.
      • Stead L.F.
      Interventions for smokeless tobacco use cessation.
      Telephone quitlines have become an integral part of state tobacco control programs over the past 20 years, and their effectiveness in assisting smokers to quit cigarette smoking is well established.
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating tobacco use and dependence. 2008 Update. Clinical practice guideline.
      • Cummins S.E.
      • Bailey L.
      • Campbell S.
      • et al.
      Tobacco cessation quitlines in North America: a descriptive study.
      These professionally run quitlines reportedly enhance 12-month abstinence by up to 30% among smokers.
      • Stead L.F.
      • Perera R.
      • Lancaster T.
      Telephone counselling for smoking cessation.
      There are a number of factors related to smoking abstinence among quitline participants. Previously conducted research focused on smokers utilizing state quitlines identified the following factors associated with abstinence: previous quit attempts, tobacco consumption, stage of change, number of quitline sessions, and nicotine replacement therapy (NRT).
      • Borland R.
      • Segan C.J.
      • Livingston P.M.
      • Owen N.
      The effectiveness of callback counselling for smoking cessation: a randomized trial.
      • Curry S.J.
      • McBride C.
      • Grothaus L.C.
      • et al.
      A randomized trial of self-help materials, personalized feedback, and telephone counseling with nonvolunteer smokers.
      Compared to cigarette smokers, quitline services are not aggressively marketed to ST users. Currently, there is insufficient evidence on the effectiveness of quitline intervention for ST users. This study examines the relationships among sociodemographics, tobacco use history, intrinsic and extrinsic behavioral factors, and the probability of tobacco abstinence among exclusive ST users registering for services with the Oklahoma Tobacco Helpline.

      Methods

      Eligible participants for this study were 959 male exclusive ST users
      • Mushtaq N.
      • Williams M.B.
      • Beebe L.A.
      Concurrent use of cigarettes and smokeless tobacco among US males and females.
      who registered with the Oklahoma Tobacco Helpline between March 2004 and June 2012. The focus of this analysis was the 39% of these individuals (374) who completed a follow-up evaluation survey 7 months postregistration. Other eligibility criteria included English-speaking, aged ≥18 years and older, at least one intervention call completed, consent for follow-up, and private residence. The Oklahoma Tobacco Helpline, established in 2003, is a free statewide tobacco-cessation quitline operated by Alere Wellbeing, Inc., and funded by the Oklahoma Tobacco Settlement Endowment Trust, Oklahoma State Department of Health, Oklahoma Health Care Authority, and Oklahoma Employees Group Insurance Board. Services include mailed self-help materials, telephone counseling, a variety of U.S. Food and Drug Administration–approved tobacco-cessation medications, online support, and referral to community resources. Readiness to quit, participant preferences, and insurance status determine the level of intervention received from the Helpline. During the study period, eligibility criteria for services changed. From 2003 through 2010, all tobacco users were eligible for the multiple-call intervention and up to 8 weeks of NRT. Beginning in 2011, tobacco users with private insurance were only eligible for the single-call program and 2 weeks of NRT. State employees with HealthChoice insurance continued to be eligible for more intensive services through an arrangement with the Oklahoma Employees Group Insurance Board. Thus, ST users in this study may have received a single call or multiple call intervention, and anywhere from 0 to 8 weeks of NRT from the Helpline. The nicotine lozenge, as well as patch and gum, were available to ST users enrolled in the Helpline.
      Longitudinal data from 374 exclusive ST users who completed the 7-month follow-up survey were used for this analysis. Data were collected from 2004 to 2013, and came from the participants’ Helpline registration records, which included sociodemographic factors, tobacco use behavioral factors, and presence of any chronic disease. Sociodemographic factors included age, sex, race, area of residence, education level, and annual income. Behavioral factors were divided into two main categories: intrinsic and extrinsic factors. Intrinsic factors were composed of tobacco use characteristics (nicotine dependence, time to first chew, years of tobacco use, number of cans/pouches per week, number of past quit attempts, and length of the longest past quit attempt) and readiness to quit, which was measured by level of motivation to quit (low to moderate or high) and level of confidence to quit (low to moderate or high). Levels of motivation and confidence to quit were measured as ordinal scales (ranging from 1 to 10) and these responses were categorized as low to moderate (1–7) or high (8–10). For measuring nicotine dependence, an approach similar to heaviness of smoking index was used where time to first chew/dip and number of cans/pouches of ST per week were used to classify dependence as light, moderate, or heavy.

      Mushtaq N, Beebe LA. Exploring the role of Smokeless Tobacco Use Indices as brief measures of dependence. Proceedings of the 20th Annual Meeting of Society for Research on Nicotine and Tobacco; Seattle WA; 2014.

      Extrinsic factors consisted of access to tobacco and social influence factors (family influence, home smoking policy, and around smokers at home or at work). Information regarding Helpline interventions, such as the number of completed Helpline calls (one to five calls) and NRT provided by the quitline (no NRT and 2, 4, and 8 weeks) was also obtained from the Helpline services delivery database.
      Study participants completed a follow-up evaluation phone survey at 7 months post-registration. The 7-month follow-up survey was administered by the external evaluator of the Helpline, using a standardized protocol

      North American Quitline Consortium. Measuring Quit Rates. Quality Improvement Initiative. An L, Betzner A, Luxenberg ML, Rainey J, Capesius T, Subialka E, eds. Phoenix AZ: NAQC, 2009

      and trained survey staff. Participants for the follow-up survey were randomly selected and mailed a pre-notification letter. Up to 15 attempts were made by telephone to complete the survey. Thirty-day tobacco point-prevalence quit rates were based on the respondent’s self-report of being tobacco free for the last 30 days or more at the time of the 7-month survey. This study was approved by the University of Oklahoma IRB (IRB No. 2616).
      Exploratory univariate analysis of all the variables in the study was performed to obtain descriptive statistics. In order to evaluate the association between 30-day abstinence and various explanatory variables, logistic regression analyses were performed to obtain crude and adjusted ORs. These analyses were performed in three steps. First, the univariate association of individual factors with the abstinence was analyzed. Variables associated with 30-day abstinence at a significance level of 0.05 from simple logistic regression were used in the multivariate analysis. Multiple logistic regression analysis was performed separately for the aforementioned variable groupings, sociodemographic factors, intrinsic and extrinsic behavioral factors, and quitline interventions. A stepwise selection procedure with a significance level of 0.10 was applied to find a parsimonious solution to the association between abstinence and predictor variables in each model. Finally, the variables obtained from the multiple logistic regression analysis of the aforementioned categories were evaluated together. Confounding and effect modification were checked for the variables that were significantly associated with 30-day abstinence. All analyses were conducted in 2013 using SAS, version 9.2 (SAS Institute Inc., Cary NC), and a level of 0.05 was used for statistical significance. ORs and 95% CIs are reported.

      Results

      Among the 374 ST users in this study who completed the 7-month follow-up, 162 (43%) reported 30-day abstinence. The mean age of the sample was 41.3 (SD=13.2) years, and the majority of the participants were white (83%). Nearly two thirds (61%) of participants used ST products for at least 20 years, 68% used three or more cans/pouches of ST products per week, and 89% attempted to quit tobacco use in the past. This group had a high level of motivation (73%) and high level of confidence to quit (53%) at registration. The mean number of completed scheduled Helpline calls was 2.4 (SD=1.5), and >85% received NRT for either 2–4 weeks (65%) or 8 weeks (20%). An intent-to-treat analysis was applied to the total sample of 959 ST users who registered for services between 2004 and 2012, resulting in a 15% quit rate.
      Results of the univariate analysis demonstrated that individuals with higher income were 1.74 times more likely to quit tobacco use compared to participants with lower income (Table 1). No other significant association was observed between sociodemographic factors and tobacco abstinence. Behavioral factors were analyzed in two groups, intrinsic and extrinsic factors, to find their association with tobacco abstinence (Table 2). For the extrinsic factors, there was no association with tobacco cessation. Univariate analysis of the intrinsic behavioral factors showed that the participants who had a higher level of motivation at baseline were twice as likely to be abstinent at the 7-month follow-up.
      Table 1Thirty-day abstinence rates at the 7-month follow-up and crude association with sociodemographic characteristics (N=374)
      30-day abstinence from tobacco
      VariableYes n (%)No n (%)OR (95% CI)
      Race
       White136 (43.6)176 (56.4)1.13 (0.64, 1.98)
       Other24 (40.7)35 (59.3)ref
      Area of residence
       Urban87 (42.2)119 (57.8)0.93 (0.62, 1.41)
       Rural73 (44.0)93 (56.0)ref
      Marital status
       Single/separated47 (39.2)73 (60.8)ref
       Married115 (45.6)137 (54.4)1.30 (0.84, 2.03)
      Education level
       High school or less61 (43.0)81 (57.0)ref
       Some college or more101 (43.9)129 (56.1)1.04 (0.68, 1.59)
      Annual income ($)
       <20,00028 (32.9)57 (67.1)ref
       ≥20,000124 (46.1)145 (53.9)1.74 (1.04, 2.90)
      Table 2Thirty-day abstinence rates at the 7-month follow-up and crude association with intrinsic and extrinsic behavioral factors
      30-day abstinence from tobacco
      VariableYes n (%)No n (%)OR (95% CI)
      Intrinsic factors
       Nicotine dependence
        Light43 (44.6)59 (57.8)ref
        Moderate85 (42.5)115 (57.5)1.02 (0.63, 1.66)
        Heavy33 (45.8)39 (54.2)1.16 (0.63, 2.13)
       Time to first chew (minutes)
        ≤551 (43.2)67 (57.8)ref
        6–3054 (43.2)71 (57.8)1.00 (0.60, 1.66)
        31–6026 (42.6)35 (57.4)0.98 (0.52, 1.82)
        >6030 (43.5)39 (56.5)1.01 (0.55, 1.84)
       Cans/pouches per week
        ≤1 or12 (54.5)10 (45.5)ref
        2–362 (41.3)88 (58.7)0.59 (0.24, 1.44)
        >388 (43.6)114 (56.4)0.64 (0.27, 1.56)
       Years of ST use
        <2062 (43.7)80 (56.4)ref
        ≥2095 (43.0)126 (57.0)1.03 (0.67, 1.57)
       Number of past quit attempts
        017 (42.5)23 (57.5)ref
        135 (42.2)48 (57.8)0.99 (0.46, 2.12)
        2–575 (42.6)101 (57.4)1.00 (0.50, 2.01)
        ≥626 (48.1)28 (51.8)1.26 (0.55, 2.86)
       Length of longest quit attempt (months)
        <146 (39.3)71 (60.7)ref
        ≥139 (43.3)51 (56.7)1.18 (0.68, 2.06)
       Level of motivation
        Low to moderate21 (29.2)51 (70.8)ref
        High129 (47.4)143 (52.6)2.19 (1.25, 3.84)
       Level of confidence
        Low to moderate48 (39.3)74 (60.7)ref
        High94 (47.0)106 (53.0)1.37 (0.86, 2.16)
       Presence of chronic disease
        Yes21 (45.6)25 (54.4)1.11 (0.60, 2.07)
        No141 (43.0)187 (57.0)ref
      Extrinsic factors
       Influence of family to quit
        Yes65 (43.1)86 (56.9)1.07 (0.70, 1.63)
        No93 (44.7)115 (55.3)ref
       Home smoking policy
        Not allowed144 (45.3)174 (54.7)1.54 (0.79, 3.00)
        Allowed15 (34.9)28 (65.1)ref
       Around smokers at work or at home
        Yes67 (46.2)78 (53.8)ref
        No52 (46.4)60 (53.6)1.00 (0.62, 1.65)
      ST, smokeless tobacco.
      The stepwise selection procedure in multiple logistic regression analysis retained level of motivation as the significant predictor of tobacco abstinence among intrinsic and extrinsic behavioral factors. There was no interaction between income and the level of motivation (p=0.703). The results of the multivariate analysis showed that both level of motivation and income remained significantly associated with abstinence (OR=2.10, 95% CI=1.17, 3.75 and OR=1.79, 95% CI=1.04, 3.09, respectively).
      The univariate analysis of the Helpline interventions showed a moderately strong positive association between number of completed scheduled calls and tobacco abstinence (Table 3, Table 4). Each additional completed Helpline call resulted in a 20% increase in the likelihood of tobacco cessation (OR=1.20, 95% CI: 1.04, 1.38). When Helpline calls were categorized as a two-level factor, ST users who completed more than one call were 1.77 times more likely to quit tobacco use as compared to those who completed a single call. The majority of the participants (85%) received NRT from the Helpline (Table 3). Findings of the univariate analysis demonstrated that tobacco abstinence exhibited a positive NRT gradient: ST users who received 8 weeks of NRT were more likely to quit tobacco compared to non-NRT users. However, there was no statistically significant difference in abstinence rates between those who received 2–4 weeks of NRT and non-NRT users (crude OR=1.30, 95% CI=0.70, 2.43, Table 4).
      Table 3Association between helpline interventions and 30-day abstinence from tobacco (N=374)
      Helpline interventions30-day abstinence from tobacco
      Yes n (%)No n (%)χ2 (p-value)
      Number of completed scheduled helpline calls9.66 (0.046)
       157 (35.4)104 (64.6)
       230 (46.1)35 (53.9)
       325 (52.1)23 (47.9)
       419 (42.2)26 (57.8)
       531 (56.4)24 (43.6)
      NRT from the helpline8.22 (0.016)
       No NRT18 (34.6)34 (65.4)
       2–4 weeks100 (40.8)145 (59.2)
       8 weeks44 (57.1)33 (42.9)
      NRT, nicotine replacement therapy.
      Table 4Crude and adjusted association between helpline interventions and 30-day abstinence from tobacco (N=374)
      Helpline interventions30-day abstinence from tobacco
      Crude OR (95% CI)Adjusted OR (95% CI)
      Adjusted for number of completed scheduled helpline calls, annual income, and level of motivation at baseline.
      Number of completed scheduled helpline calls
       1ref
       ≥21.77 (1.16, 2.70)1.97 (1.32, 2.93)
      Nicotine replacement therapy
       Noref
       2–4 weeks1.30 (0.70, 2.43)1.04 (0.51, 2.15)
       8 weeks2.52 (1.22, 5.22)1.90 (0.78, 4.59)
      Level of motivation
       Low to moderateref
       High2.19 (1.25, 3.84)2.05 (1.25, 3.35)
      Annual income ($)
       <20,000ref
       ≥20,0001.74 (1.04, 2.90)2.19 (1.36, 3.53)
      a Adjusted for number of completed scheduled helpline calls, annual income, and level of motivation at baseline.
      Two-way interactions between Helpline interventions, income, and level of motivation were evaluated; no significant interaction was observed among these variables. However, there was confounding between NRT and other variables. Therefore, the observed positive overall association between NRT and tobacco abstinence did not remain significant when the model was corrected for level of motivation, income, and number of completed scheduled calls. Results of the multivariate analysis indicated that level of motivation, income, and Helpline calls were strong predictors of tobacco abstinence when adjusted for each other (Table 4).

      Discussion

      Among male ST users who enrolled in the Oklahoma Tobacco Helpline and completed a 7-month follow-up survey, 43% reported tobacco abstinence for at least 30 days. This respondent quit rate of 43% is based on 39% of all ST quitline callers completing the 7-month follow-up survey. Using an intent-to-treat approach to the calculation of the quit rate, where non-respondents are included in the denominator, results are more conservative with an estimated quit rate of 15%. Even this conservative estimate is within the range of quit rates (9.6%–40.4%) reported by other ST cessation studies.
      • Ebbert J.
      • Montori V.M.
      • Erwin P.J.
      • Stead L.F.
      Interventions for smokeless tobacco use cessation.
      Rates of abstinence among ST users in this study were higher than reported in previous studies that employed other behavioral interventions such as self-help, dental clinic behavioral treatment, and group support.
      • Ebbert J.
      • Montori V.M.
      • Erwin P.J.
      • Stead L.F.
      Interventions for smokeless tobacco use cessation.
      • Carr A.B.
      • Ebbert J.
      Interventions for tobacco cessation in the dental setting.
      Although a number of studies have been conducted to assess the effectiveness of interventions for ST cessation, limited research has been conducted to identify the predictors of ST cessation.
      • Ebbert J.O.
      • Glover E.D.
      • Shinozaki E.
      • et al.
      Predictors of smokeless tobacco abstinence.
      • Kauffman R.M.
      • Ferketich A.K.
      • Wee A.G.
      • et al.
      Factors associated with smokeless tobacco cessation in an Appalachian population.
      This is the first study to identify the predictors of tobacco abstinence among ST users registering with a state quitline, and it examined a broader range of determinants of tobacco abstinence among ST users.
      Behavioral interventions have been shown to be effective in tobacco abstinence among ST users.
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating tobacco use and dependence. 2008 Update. Clinical practice guideline.
      • Ebbert J.
      • Montori V.M.
      • Erwin P.J.
      • Stead L.F.
      Interventions for smokeless tobacco use cessation.
      • Boyle R.G.
      • Enstad C.
      • Asche S.E.
      • et al.
      A randomized controlled trial of Telephone Counseling with smokeless tobacco users: the ChewFree Minnesota study.
      • Boyle R.G.
      • Pronk N.P.
      • Enstad C.J.
      A randomized trial of telephone counseling with adult moist snuff users.
      • Severson H.H.
      • Gordon J.S.
      • Danaher B.G.
      • Akers L.
      ChewFree.com: evaluation of a Web-based cessation program for smokeless tobacco users.
      • Severson H.H.
      • Peterson A.L.
      • Andrews J.A.
      • et al.
      Smokeless tobacco cessation in military personnel: a randomized controlled trial.
      • Walsh M.M.
      • Langer T.J.
      • Kavanagh N.
      • et al.
      Smokeless tobacco cessation cluster randomized trial with rural high school males: intervention interaction with baseline smoking.
      Telephone counseling is used as one of the behavioral interventions for tobacco cessation. There is experimental evidence of its efficacy in tobacco cessation, as the results of RCTs of ST users have reported higher rates of abstinence among ST users who were enrolled in telephone-based counseling.
      • Boyle R.G.
      • Enstad C.
      • Asche S.E.
      • et al.
      A randomized controlled trial of Telephone Counseling with smokeless tobacco users: the ChewFree Minnesota study.
      • Boyle R.G.
      • Pronk N.P.
      • Enstad C.J.
      A randomized trial of telephone counseling with adult moist snuff users.
      • Severson H.H.
      • Peterson A.L.
      • Andrews J.A.
      • et al.
      Smokeless tobacco cessation in military personnel: a randomized controlled trial.
      Telephone-based services for tobacco cessation are an integral part of comprehensive tobacco control programs in the U.S., but their effectiveness with ST users who are quitline participants has not been previously reported. The number of completed quitline calls has been found to be one of the determinants of successful tobacco cessation among smokers.
      • Zhu S.H.
      • Stretch V.
      • Balabanis M.
      • et al.
      Telephone counseling for smoking cessation: effects of single-session and multiple-session interventions.
      Similar to the findings for smokers, the results of the current study also indicated that a greater number of completed quitline calls by ST users resulted in higher rates of tobacco abstinence at the 7-month follow-up. These findings are worth noting, as ST users who enroll in telephone quitline benefit from the completion of quitline calls irrespective of their baseline level of motivation.
      The effectiveness of NRT for smoking cessation has been well established, but such effectiveness has not been demonstrated in ST users.
      • Fiore M.C.
      • Jaen C.R.
      • Baker T.B.
      • et al.
      Treating tobacco use and dependence. 2008 Update. Clinical practice guideline.
      • Ebbert J.
      • Montori V.M.
      • Erwin P.J.
      • Stead L.F.
      Interventions for smokeless tobacco use cessation.
      Similarly, this study did not find a significant contribution of NRT in tobacco abstinence among ST quitline participants, after controlling for level of motivation, income, and the number of completed Helpline calls. These findings are consistent with those of previously conducted ST cessation research.
      • Ebbert J.
      • Montori V.M.
      • Erwin P.J.
      • Stead L.F.
      Interventions for smokeless tobacco use cessation.
      The majority of the participants (85%) obtained some NRT from the Helpline, and findings of the univariate analysis demonstrated more favorable outcomes along the NRT gradient, but the results of the multivariate analysis could not validate this association. However, these findings should be cautiously interpreted, as there was a significant difference in the sample size across different levels of NRT and the study did not examine the role of different types of NRT in tobacco cessation. These findings call for careful evaluation of the role of NRT in tobacco cessation among ST users.
      Social influence factors contribute to tobacco cessation, but high levels of self-efficacy and a positive attitude toward quitting are associated with higher rates of cessation success.

      van den Putte B, Berg B, Yzer M, Willemsen M. An integrative model of smoking cessation determinants: the difference between successful and unsuccessful attempts. Proceedings of the Annual meeting of the International Communication Association. Dresden International Congress Centre, Dresden, Germany; 2006.

      The present study found high level of motivation at registration to be a strong predictor of tobacco abstinence. These results highlight the role of self-efficacy in tobacco cessation among ST users. There was no confounding between level of motivation and number of Helpline calls; therefore, the effects of these factors on tobacco abstinence are independent of each other. According to the Integrative Model of Behavioral Prediction, if number of quitline calls is considered an explicit behavioral social influence, even ST users with lower self-efficacy can benefit from the quitline calls.
      • Fishbein M.
      A reasoned action approach to health promotion.
      Study findings indicate a significant association between annual income and tobacco abstinence. When adjusted for level of motivation and quitline calls, ST users who had annual income >$20,000 were twice as likely to quit tobacco. However, we did not find any significant associations between other sociodemographic factors and tobacco use characteristics with tobacco abstinence in this group.
      This study has some limitations. Main study findings are based on the 39% of ST quitline callers who completed the 7-month follow-up survey. As a result, study findings may be prone to selection bias. All participants were male ST users, and the majority of them were white. The stages of behavior change as conceptualized by the stages of change model is a significant predictor of smoking cessation.
      • Ward K.D.
      • Klesges R.C.
      • Zbikowski S.M.
      • et al.
      Gender differences in the outcome of an unaided smoking cessation attempt.
      Most of the participants of the current study were in contemplation phase at the time of Helpline registration and are assumed to have a high likelihood of progressing to the action stage with delivery of the intervention. Demographic characteristics and the stage of behavior change of the participants of the current study distinguish them from the ST users in the general population; thus, the results may not be generalizable. Data regarding behavioral factors were missing for some participants, ranging from <1% for sociodemographic factors to >10% for some of the behavioral factors. Data for the motivation level were missing for 9% of the participants. These missing data might introduce bias; however, analysis of the missing data showed that there was no statistically significant difference in the pattern of missing data for other study variables, such as tobacco abstinence and number of completed Helpline calls. Thus, the authors assume the data were missing completely at random, having minimal effect on the findings. Another potential limitation in the study is not biochemically verified abstinence. Self-reporting of tobacco abstinence is typical in quitline studies and has been shown to be accurate.
      • Patrick D.L.
      • Cheadle A.
      • Thompson D.C.
      • et al.
      The validity of self-reported smoking: a review and meta-analysis.
      The effect of NRT on tobacco abstinence was evaluated by administrative data (i.e., NRT provided by the quitline). Other information such as NRT compliance and information regarding the use of NRT from other sources was not obtained. However, evaluation reports of state tobacco quitline services utilize similar proxy variables to assess the effect of NRT on tobacco cessation among quitline participants.
      • Kazura A.
      • Haskins A.
      • Cowan T.
      The Maine Tobacco HelpLine and Medication Voucher Program: an evaluation of service utilization in 2007, user satisfaction, and quit outcomes.
      In conclusion, this study suggests that telephone counseling delivered through a state quitline is an effective strategy for exclusive ST users wanting to quit tobacco. The study identifies important factors that are predictors of tobacco abstinence among ST users participating in a state quitline, such as motivation to quit, income, and the number of completed calls. However, based on the findings of the current study and evidence from past research, the significance of NRT for tobacco cessation among ST users remains inconclusive.

      Acknowledgments

      Publication of this article was supported by the Oklahoma Tobacco Research Center (OTRC), with funding from the Oklahoma Tobacco Settlement Endowment Trust (TSET).
      This study was funded by TSET.
      No financial disclosures were reported by the authors of this paper.

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