Introduction
Although 72% of Internet users have searched for health information, online quitline registration is not universally available. In 2014, QUITPLAN Services (Minnesota's quitline) added options (Individual Services: 2-week nicotine-replacement therapy starter kit, text messaging, e-mail messaging, quit guide) to the existing Helpline (telephone counseling, nicotine-replacement therapy, integrated e-mails and texts, quit guide) and online registration for all programs. Demographic and quit outcome differences by registration mode (online versus telephone) and program type (Individual Services versus Helpline) were examined.
Methods
A total of 4 years (March 2014–February 2018) of participants’ registration and utilization data (N=55,817) were examined. Data were also studied from subsets of participants who completed the outcome evaluations conducted in 2014 (n=1,127) and 2017 (n=872). Select demographic and program use characteristics and quit outcomes were analyzed by registration method and stratified by program type. Associations between registration mode and quit outcomes were examined within program and adjusted for available covariates using 2017 outcome study data. Data were analyzed in 2019.
Results
Overall, 65.8% of participants enrolled online, and 34.2% enrolled by telephone. Helpline participants were more likely to enroll by telephone than Individual Services participants (85.8% vs 25.3%). Younger adults were more likely to enroll online for either program type than older adults (p<0.001). No differences were found in 30-day point prevalence abstinence by registration mode within program after adjusting for covariates.
Conclusions
Online quitline registration has multiple benefits, including engaging younger tobacco users. Moreover, abstinence rates do not differ. Online registration may be particularly appropriate for nontelephone quitline services. Quitlines may wish to add online registration to capitalize on Internet use.
INTRODUCTION
Although all quitlines provide telephone registration, online registration is neither universally available
1
nor is there a national online registration portal comparable to 1–800-QUIT-NOW. Online registration potentially allows quitlines to engage tobacco users through technology and attract various populations. Almost 90% of U.S. adults use the Internet,North American Quitline Consortium
NAQC FY18 annual survey: progress update on state quitline.
NAQC FY18 annual survey: progress update on state quitline.
North American Quitline Consortium,
Phoenix, AZPublished July 19, 2019
https://cdn.ymaws.com/www.naquitline.org/resource/resmgr/2018_survey/NAQC_FY2018_Annual_Survey_Da.pdf
Date accessed: September 12, 2019
2
with 72% searching for health information.Pew Research Center
Internet and Technology: Internet/broadband fact sheet.
Internet and Technology: Internet/broadband fact sheet.
Pew Research Center,
Washington DCPublished June 12, 2019
www.pewinternet.org/fact-sheet/internet-broadband/
Date accessed: July 2, 2019
3
Individuals seeking diagnostic information online are younger and have higher education levels and SES, and no gender differences are observed.3
,4
By comparison, quitline callers’ median age is 49 years; 45% have a high school diploma, GED, or less; 53% have Medicaid or are uninsured; and 60% are female.1
,North American Quitline Consortium
NAQC FY18 annual survey: progress update on state quitline.
NAQC FY18 annual survey: progress update on state quitline.
North American Quitline Consortium,
Phoenix, AZPublished July 19, 2019
https://cdn.ymaws.com/www.naquitline.org/resource/resmgr/2018_survey/NAQC_FY2018_Annual_Survey_Da.pdf
Date accessed: September 12, 2019
5
In 2014, ClearWay Minnesota, an independent nonprofit organization, added online registration and service options to QUITPLAN Services (Minnesota's quitline). QUITPLAN Services now offers the QUITPLAN Helpline (Helpline: telephone counseling, nicotine-replacement therapy [NRT], integrated e-mail/text,
6
quit guide) and Individual QUITPLAN Services (Individual Services: 2-week NRT starter kit, text program,6
e-mail program, and quit guide). The Helpline serves uninsured and underinsured adult Minnesotans; all adult Minnesotans are eligible for Individual Services.7
Demographic differences between quitline users registering online and those registering by telephone are under-reported. In 2015, Nash et al.
8
found that quitline participants selecting a web-only program were younger, had higher education levels, were more likely to be uninsured or commercially insured, and were more likely to register online than those choosing an integrated phone/web program; no gender differences were observed, and quit outcomes were not evaluated. This observational study builds on this research by assessing the differences in participant characteristics by registration mode (telephone versus online) and program type (Helpline versus Individual Services). Consistent with reports on Internet use and Nash et al.,8
online registrants are expected to be younger and not differ by sex.2
,Pew Research Center
Internet and Technology: Internet/broadband fact sheet.
Internet and Technology: Internet/broadband fact sheet.
Pew Research Center,
Washington DCPublished June 12, 2019
www.pewinternet.org/fact-sheet/internet-broadband/
Date accessed: July 2, 2019
3
,7
This study also measured online registration's impact on quit outcomes versus telephone registration. Understanding such differences can help inform states considering online registration.METHODS
Data from tobacco users registering for QUITPLAN Services by telephone or online between March 2014 and February 2018 (N=55,817) are reported; fax-referred registrants were excluded. Participants self-selected either the Helpline or any Individual Services.
Subsets of registrants participated in outcome studies in 2014 (n=1,127) and 2017 (n=872). Tobacco users who were aged ≥18 years, provided a telephone number or e-mail address, and consented for follow-up at registration were eligible to participate (Appendix Figure 1, available online, outcome evaluation flowchart). Helpline participants were exhaustively sampled to ensure sufficient power for analysis; Individual Services participants were randomly sampled owing to the numbers enrolling in this program. Response rates were 58.3% (2014) and 55.7% (2017).
Minnesota's service provider Optum collected registration and utilization data: registration mode (telephone or online), program type (Helpline or Individual Services), sex, age, tobacco type (cigarettes, smokeless tobacco, cigars), and receipt of minimum treatment using the North American Quitline Consortium definition (completing 1 counseling call, receiving NRT, or both).
9
Population density was measured using 2013 Rural–Urban Continuum Codes.10
Rural-Urban Continuum Codes. U.S. Department of Agriculture.https://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx#:∼:text=The%202013%20Rural%2DUrban%20Continuum,adjacency%20to%20a%20metro%20area. Updated May 10, 2013.
Outcome study participants were contacted 7 months after enrollment as recommended by the National American Quitline Consortium.
9
Both studies included online and telephone surveys, with up to 5 e-mail contacts and 14 calls. Individuals completing the 2014 study received a $10 incentive,7
whereas each respondent sampled for the 2017 study received a $2 incentive. Self-reported 24-hour quit attempts (Since you registered for QUITPLAN Services on [DATE] about seven months ago, did you stop using tobacco for 24 hours or longer because you were trying to quit?) and 30-day point prevalence abstinence (PPA) (Have you smoked any cigarettes or used other tobacco, even a puff or pinch, in the last 30 days? This does NOT include electronic cigarettes.) were measured.9
Year-over-year analysis of age, sex, and program type found no seasonal differences (results not reported); consequently, all the 4 years of data were aggregated. Characteristics and outcomes were compared by registration mode in bivariate analyses. Select characteristics (age, sex, population density) and outcomes were stratified by program type and compared by registration mode. Differences between online and telephone registrants were compared using chi-square tests. Associations between registration mode and outcomes were stratified by program type and adjusted for covariates in logistic regression models using 2017 outcome study data. Data were analyzed in 2019 using SAS, version 9.4.
The Minnesota Department of Health's IRB determined that this study is not human subjects research and did not require further review (MDH IRB# 18-485).
RESULTS
Participant characteristics by registration mode are summarized in Table 1. The differences between registration mode by age and population density were significant (p<0.001). Cigar smokers and smokeless tobacco users were more likely to register online, and cigarette smokers were more likely to register by telephone (p<0.001 for all).
Table 1Participant Characteristics by Registration Mode
| Characteristic | Registration mode | |||
|---|---|---|---|---|
| Online, | Telephone, | |||
| n (%) | n (%) | χ 2 Pew Research Center Internet and Technology: Internet/broadband fact sheet. Pew Research Center,
Washington DCPublished June 12, 2019 www.pewinternet.org/fact-sheet/internet-broadband/ Date accessed: July 2, 2019 | p-value | |
| Sex | 0.0 | 0.989 | ||
| Female | 20,420 (65.9) | 10,591 (34.2) | ||
| Male | 16,318 (65.9) | 8,460 (34.1) | ||
| Age, years | 6,131.7 | <0.001 | ||
| 18–24 | 4,471 (82.6) | 942 (17.4) | ||
| 25–34 | 11,272 (81.1) | 2,632 (18.9) | ||
| 35–44 | 8,171 (73.6) | 2,929 (26.4) | ||
| 45–54 | 6,895 (60.1) | 4,581 (39.9) | ||
| 55–64 | 4,596 (46.8) | 5,232 (53.2) | ||
| ≥65 | 1,333 (32.9) | 2,724 (67.1) | ||
| Population density | 163.5 | <0.001 | ||
| Metropolitan ≥1,000,000 | 22,576 (67.3) | 10,966 (32.7) | ||
| Metropolitan <1,000,000 | 5,903 (65.3) | 3,136 (34.7) | ||
| Urban area ≥20,000 | 2,129 (64.6) | 1,165 (35.4) | ||
| Urban area 2,500–19,999 | 4,739 (60.8) | 3,056 (39.2) | ||
| Rural area <2,500 | 963 (58.3) | 688 (41.7) | ||
| Tobacco type: cigarette | 115.8 | <0.001 | ||
| No | 2,311 (74.8) | 780 (25.2) | ||
| Yes | 34,432 (65.3) | 18,293 (34.7) | ||
| Tobacco type: smokeless | 534.9 | <0.001 | ||
| No | 33,014 (64.4) | 18,231 (35.6) | ||
| Yes | 3,682 (81.5) | 838 (18.5) | ||
| Tobacco type: cigar | 65.6 | <0.001 | ||
| No | 35,291 (65.5) | 18,589 (34.5) | ||
| Yes | 1,407 (74.5) | 481 (25.5) | ||
Note: Boldface indicates statistical significance (p<0.001).
Overall, 65.8% of participants enrolled online, and 34.2% enrolled by telephone (Table 2). Individual Services participants were more likely to enroll online, and Helpline participants were more likely to enroll by telephone (p<0.001 for all). Participants receiving minimum treatment were more likely to enroll online (66.3% vs 60.8%, p<0.001).
Table 2Program Selection and Use by Registration Mode
| Variable | Registration mode | |||
|---|---|---|---|---|
| Online, | Telephone, | |||
| n (%) | n (%) | χ 2 Pew Research Center Internet and Technology: Internet/broadband fact sheet. Pew Research Center,
Washington DCPublished June 12, 2019 www.pewinternet.org/fact-sheet/internet-broadband/ Date accessed: July 2, 2019 | p-value | |
| Program | 11,418.1 | <0.001 | ||
| Helpline | 1,173 (14.3) | 7,059 (85.8) | ||
| Individual Services | 35,571 (74.8) | 12,014 (25.3) | ||
| All enrollments | 36,744 (65.8) | 19,073 (34.2) | ||
| Individual Services | ||||
| NRT starter kit | 180.3 | <0.001 | ||
| No | 4,749 (68.3) | 2,206 (31.7) | ||
| Yes | 30,822 (75.9) | 9,808 (24.1) | ||
| E-mail program | 147.9 | <0.001 | ||
| No | 23,726 (73.1) | 8,732 (26.9) | ||
| Yes | 11,845 (78.3) | 3,282 (21.7) | ||
| Text message program | 59.0 | <0.001 | ||
| No | 23,840 (73.7) | 8,507 (26.3) | ||
| Yes | 11,731 (77.0) | 3,507 (23.0) | ||
| Quit guide | 424.6 | <0.001 | ||
| No | 18,599 (78.9) | 4,975 (21.1) | ||
| Yes | 16,972 (70.7) | 7,039 (29.3) | ||
| Received minimum treatment | 58.2 | <0.001 | ||
| No | 2,919 (60.8) | 1,880 (39.2) | ||
| Yes | 33,825 (66.3) | 17,193 (33.7) | ||
Note: Boldface indicates statistical significance (p<0.001).
a Minimum treatment is defined as receiving telephone counseling, NRT, or both.NRT, nicotine-replacement therapy.
No difference was found in the association of sex and registration mode for the Helpline (Table 3); although this association was significant for Individual Services (p<0.04), the actual difference was small. Younger participants were more likely to enroll online, regardless of the program type (p<0.001). Differences were observed in population density by registration mode, stratified by program type. Participants living in very densely populated metropolitan areas or very sparsely populated rural areas had the highest Helpline online enrollment rates (p=0.03). Individual Services participants living in very densely populated metropolitan areas were more likely to enroll online (p<0.001).
Table 3Comparison of Select Participant Characteristics, by Registration Mode, Within Program
| Characteristic | Helpline | Individual Services | ||||||
|---|---|---|---|---|---|---|---|---|
| Online registration | Telephone registration | Online registration | Telephone registration | |||||
| n (%) | n (%) | χ 2 Pew Research Center Internet and Technology: Internet/broadband fact sheet. Pew Research Center,
Washington DCPublished June 12, 2019 www.pewinternet.org/fact-sheet/internet-broadband/ Date accessed: July 2, 2019 | p-value | n (%) | n (%) | χ 2 Pew Research Center Internet and Technology: Internet/broadband fact sheet. Pew Research Center,
Washington DCPublished June 12, 2019 www.pewinternet.org/fact-sheet/internet-broadband/ Date accessed: July 2, 2019 | p-value | |
| Sex | 1.6 | 0.21 | 4.3 | 0.04 | ||||
| Female | 650 (13.8) | 4,051 (86.2) | 19,770 (75.1) | 6,540 (24.9) | ||||
| Male | 522 (14.8) | 2,998 (85.2) | 15,796 (74.3) | 5,462 (25.7) | ||||
| Age, years | 435.3 | <0.001 | 4,531.6 | <0.001 | ||||
| 18–24 | 133 (29.9) | 312 (70.1) | 4,338 (87.3) | 630 (12.7) | ||||
| 25–34 | 324 (25.6) | 940 (74.4) | 10,948 (86.6) | 1,692 (13.4) | ||||
| 35–44 | 280 (20.2) | 1,105 (79.8) | 7,891 (81.2) | 1,824 (18.8) | ||||
| 45–54 | 224 (11.7) | 1,684 (88.3) | 6,671 (69.7) | 2,897 (30.3) | ||||
| 55–64 | 167 (7.6) | 2,041 (92.4) | 4,429 (58.1) | 3,191 (41.9) | ||||
| ≥65 | 43 (4.3) | 960 (95.7) | 1,290 (42.2) | 1,764 (57.8) | ||||
| Population density | 11.0 | 0.03 | 153.6 | <0.001 | ||||
| Metropolitan ≥1 million | 734 (15.1) | 4,126 (84.9) | 21,842 (76.2) | 6,840 (23.9) | ||||
| Metropolitan <1 million | 187 (13.9) | 1,159 (86.1) | 5,716 (74.3) | 1,977 (25.7) | ||||
| Urban area ≥20,000 | 53 (10.7) | 441 (89.3) | 2,076 (74.1) | 724 (25.9) | ||||
| Urban area 2,500–19,999 | 156 (12.5) | 1,088 (87.5) | 4,583 (70.0) | 1,968 (30.0) | ||||
| Rural area <2,500 | 39 (14.3) | 233 (85.7) | 924 (67.0) | 455 (33.0) | ||||
Note: Boldface indicates statistical significance (p<0.05).
According to the unadjusted analyses of 24-hour quit attempts and 30-day PPA by registration mode and program type found in 2014, online Helpline enrollees were less likely to make a 24-hour quit attempt than telephone Helpline enrollees (p=0.01) (Table 4). After adjusting for study covariates in the 2017 outcome study data, registration mode was not associated with quitting in any models (Appendix Table 1, available online).
Table 4Association Between Quitting and Registration Mode
| Variable | Online registration, % | Telephone registration, % | χ 2 Pew Research Center Internet and Technology: Internet/broadband fact sheet. Pew Research Center,
Washington DCPublished June 12, 2019 www.pewinternet.org/fact-sheet/internet-broadband/ Date accessed: July 2, 2019 | p-value |
|---|---|---|---|---|
| 24-hour quit attempt rate | ||||
| 2014 Helpline | 71.2 | 86.0 | 7.8 | 0.01 |
| 2014 Individual Services | 84.0 | 83.8 | 0.0 | 0.95 |
| 2017 Helpline | 84.3 | 86.1 | 0.1 | 0.90 |
| 2017 Individual Services | 83.6 | 80.0 | 0.6 | 0.45 |
| 30-day PPA rate | ||||
| 2014 Helpline | 27.3 | 30.7 | 0.3 | 0.59 |
| 2014 Individual Services | 24.6 | 26.9 | 0.4 | 0.54 |
| 2017 Helpline | 31.4 | 30.4 | 0.0 | 1.00 |
| 2017 Individual Services | 27.1 | 26.3 | 0.0 | 0.95 |
Note: Boldface indicates statistical significance (p≤0.01).
PPA, point prevalence abstinence.
DISCUSSION
Adding online registration to QUITPLAN Services engaged larger percentages of younger participants, smokeless tobacco users, and cigar smokers. Differences persisted in online registration rates on the basis of age and population density after stratifying by program type. Importantly, no significant differences in 30-day PPA by registration mode or by program type were found after adjusting for covariates.
Offering online registration for quitline services aligns with the demographic characteristics of those seeking health information online.
3
,4
In this study, online registrants tended to be younger, regardless of program type, which is consistent with the study by Nash et al.8
and data on Internet use by age.3
,4
,11
Because quitline participants tend to be older,- Ryan C.
Computer and Internet use in the United States: 2016. American Community Survey Reports.
U.S. Census Bureau, U.S. Department of Commerce, Economic and Statistical Administration,
Suitland-Silver Hill, MDPublished August 2018
www.census.gov/content/dam/Census/library/publications/2018/acs/ACS-39.pdf
Date accessed: July 2, 2019
1
,North American Quitline Consortium
NAQC FY18 annual survey: progress update on state quitline.
NAQC FY18 annual survey: progress update on state quitline.
North American Quitline Consortium,
Phoenix, AZPublished July 19, 2019
https://cdn.ymaws.com/www.naquitline.org/resource/resmgr/2018_survey/NAQC_FY2018_Annual_Survey_Da.pdf
Date accessed: September 12, 2019
5
adding online registration may increase use by younger adults. In addition, no sex differences by registration mode or by program type were observed. Although consistent with studies of Internet use by gender,3
,4
these findings differ from the surveys showing that more female individuals call quitlines.1
,North American Quitline Consortium
NAQC FY18 annual survey: progress update on state quitline.
NAQC FY18 annual survey: progress update on state quitline.
North American Quitline Consortium,
Phoenix, AZPublished July 19, 2019
https://cdn.ymaws.com/www.naquitline.org/resource/resmgr/2018_survey/NAQC_FY2018_Annual_Survey_Da.pdf
Date accessed: September 12, 2019
5
Analyzing data from other quitlines would help assess whether these findings are unique to Minnesota.Population density variations were observed by registration mode and by program type. The highest percentage of online enrollments in Individual Services occurred in very densely populated metropolitan areas; this percentage fell as population density decreased. By contrast, a “U”-shaped pattern in online registrations was seen for the Helpline, with the highest rates occurring among participants living in either the most or least densely populated areas. Studies indicate that rural residents are less likely than urban residents to have or use the Internet.
2
,Pew Research Center
Internet and Technology: Internet/broadband fact sheet.
Internet and Technology: Internet/broadband fact sheet.
Pew Research Center,
Washington DCPublished June 12, 2019
www.pewinternet.org/fact-sheet/internet-broadband/
Date accessed: July 2, 2019
11
However, because Internet use by age varies,- Ryan C.
Computer and Internet use in the United States: 2016. American Community Survey Reports.
U.S. Census Bureau, U.S. Department of Commerce, Economic and Statistical Administration,
Suitland-Silver Hill, MDPublished August 2018
www.census.gov/content/dam/Census/library/publications/2018/acs/ACS-39.pdf
Date accessed: July 2, 2019
3
,4
age and population density may have influenced these findings. Moreover, small group sizes may have affected online Helpline findings.No differences in 30-day PPA by registration mode or when stratified by program type were found. This finding persisted after adjusting the 2017 outcome study data for covariates. These findings suggest that online registration may not adversely impact this key effectiveness metric.
9
Notably, only uninsured or underinsured adults are eligible for the Helpline, whereas all adults are eligible for Individual Services. A total of 6% of Minnesotans aged 19–64 years are uninsured
12
; the uninsured are more likely to be male (57% vs 43%),Health insurance coverage of adults 19-64. Kaiser Family Foundation.www.kff.org/other/state-indicator/adults-19-64/?currentTimeframe=0&selectedRows=%7B%22states%22:%7B%22minnesota%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Updated 2018. Accessed November 11, 2019.
13
and more than 23.8% of the uninsured smoke.Distribution of the nonelderly uninsured adults by gender. Kaiser Family Foundation.www.kff.org/uninsured/state-indicator/distribution-by-gender-2/?currentTimeframe=0&selectedRows=%7B%22states%22:%7B%22minnesota%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Updated 2018. Accessed November 11, 2019.
14
Limiting Helpline eligibility potentially influenced study findings. Conducting this analysis in states without quitline eligibility criteria and demographically different from Minnesota are needed to gauge whether these findings can be replicated.Online registration offers multiple benefits, including reaching smokers who will never call quitlines.
15
However, inadvertently reducing access for populations with higher smoking prevalence should be avoided. For example, lower educational level and income are associated with higher prevalence and lower Internet use.3
,16
,17
Ideally, quitlines would offer and adequately promote both online and telephone registration to guard against exacerbating disparities.Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality
Results from the 2016National Survey on Drug Use and Health: detailed tables.
Results from the 2016National Survey on Drug Use and Health: detailed tables.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality,
Rockville, MDPublished September 7, 2017
Limitations
In this observational study, participants were not randomized to registration mode or program type. In addition, because of changes in measure definitions over time as well as missing data for some variables, additional participant characteristics (e.g., race, ethnicity, quit readiness) or tobacco use patterns (e.g., cigarettes per day) were not evaluated. Both the lack of randomization and the limited set of variables analyzed may have affected these results. Finally, eligibility criteria for the Helpline and Individual Services differ,
7
which possibly influenced the findings.CONCLUSIONS
These findings suggest that online registration can engage various populations in quitlines while not adversely affecting abstinence rates. Adding online registration may be particularly appropriate for nontelephone quitline services. Quitlines may wish to add online registration to capitalize on Internet use.
ACKNOWLEDGMENTS
This project was funded by ClearWay Minnesota.
The authors who are either employed by ClearWay Minnesota or are ClearWay Minnesota contractors were involved in study design; collection, analysis, and interpretation of data; writing the report; and deciding to submit the report for publication.
No financial disclosures were reported by the authors of this paper.
Appendix. SUPPLEMENTAL MATERIAL
SUPPLEMENT NOTE
This article is part of a supplement entitled The Role of Quitlines in Tobacco Cessation, which is sponsored by the U.S. Centers for Disease Control and Prevention (CDC), an agency of the U.S. Department of Health and Human Services (HHS), with support from RTI International under contract # 200-2014-61263.
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Rural-Urban Continuum Codes. U.S. Department of Agriculture.https://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx#:∼:text=The%202013%20Rural%2DUrban%20Continuum,adjacency%20to%20a%20metro%20area. Updated May 10, 2013.
- Computer and Internet use in the United States: 2016. American Community Survey Reports.U.S. Census Bureau, U.S. Department of Commerce, Economic and Statistical Administration, Suitland-Silver Hill, MDPublished August 2018www.census.gov/content/dam/Census/library/publications/2018/acs/ACS-39.pdfDate accessed: July 2, 2019
Health insurance coverage of adults 19-64. Kaiser Family Foundation.www.kff.org/other/state-indicator/adults-19-64/?currentTimeframe=0&selectedRows=%7B%22states%22:%7B%22minnesota%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Updated 2018. Accessed November 11, 2019.
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Article info
Footnotes
This article is part of a supplement entitled The Role of Quitlines in Tobacco Cessation, which is sponsored by the U.S. Centers for Disease Control and Prevention (CDC), an agency of the U.S. Department of Health and Human Services (HHS), with support from RTI International.
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