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 Table of Contents  
Year : 2019  |  Volume : 4  |  Issue : 3  |  Page : 65-72

Systematic review on telephonic Quitline and its effects on smokeless tobacco

1 Research Fellow (Non Medical), Tata Memorial Centre (TMC), Mumbai, Maharashtra, India
2 Centre for Cancer Epidemiology, Tata Memorial Centre (TMC), Mumbai, Maharashtra, India

Date of Web Publication27-Sep-2019

Correspondence Address:
Dr. Atul Madhukar Budukh
Tata Memorial Centre, Centre for Cancer Epidemiology, ACTREC, Sector 22, Ustav Chowk, CISF Road, Kharghar, Navi Mumbai - 410 210, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jncd.jncd_26_19

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Tobacco consumption accounts for approximately 80% of total death in low and middle income countries. According to the Global Adult Tobacco Survey (2015) the prevalence of smokeless tobacco (SLT) consumption is being highest in India for about 33% in men and 18% in female. Countries like Bangladesh, Indonesia have highest prevalence of women SLT consumers than males. Quitting of tobacco products is although a difficult process. Evidence suggests two methods that enable a person to quit smokeless tobacco are pharmacotherapy and counselling or advice. The telephonic quit line services is very popular in the US and Europe, however they have predominantly handled smoking cessation. In this study we have done the systematic review on effect of telephone quit line services over smokeless tobacco cessation. We have taken articles from well-known library Pub-Med and Google Scholar with proper inclusion and exclusion criteria. In the systematic review it was noted that use of telephone quit line has reported the quit rate of SLT in the range of 25 to 30% over the population of 1000 despite of many limitations. The smokeless tobacco cessation through telephone quit line is useful and convenient way for tobacco control. The government of India has looked forward into this issue and has recently launched the national telephone quit line services for the tobacco control. This review recommends a policy which has to be made by the Low and Middle income countries to establish the quit line services for the SLT cessation by telephone counselling, which will play important role in tobacco control.

Keywords: Smokeless tobacco cessation, smokeless tobacco control, telephonic counseling

How to cite this article:
Singh A, Budukh AM, Chaturvedi P, Dikshit R. Systematic review on telephonic Quitline and its effects on smokeless tobacco. Int J Non-Commun Dis 2019;4:65-72

How to cite this URL:
Singh A, Budukh AM, Chaturvedi P, Dikshit R. Systematic review on telephonic Quitline and its effects on smokeless tobacco. Int J Non-Commun Dis [serial online] 2019 [cited 2023 Mar 31];4:65-72. Available from: https://www.ijncd.org/text.asp?2019/4/3/65/268137

  Introduction Top

Globally, around 7 million deaths are due to consumption of tobacco products. Tobacco consumption accounts for approximately 80% of the total deaths in low- and middle-income countries. Globally 65.5% of deaths are due to tracheal, bronchus, and lung cancers, whereas oral cavity cancers including lip cancer cause about 49% of the total deaths.[1] The present condition in India is much more challenging as India is the third-largest producer of tobacco products and the second largest in the consumption of tobacco products.[2] The mortality rates due to the use of tobacco products are estimated upward to 1.3 million.[3],[4] Around 37% of the total population of men are daily tobacco users and around 12.4% of women are daily tobacco users.[2] According to the Global Adult Tobacco Survey (2015), the prevalence of smokeless tobacco (SLT) consumption is being highest in India for about 33% in men and 18% in women.[5] Countries such as Bangladesh and Indonesia have the highest prevalence of female SLT consumers than males. In Bangladesh, male SLT consumers account for 26% and female SLT consumers account for 28%, which is also more than that in India.[5]

The severity of increased tobacco use has been recognized at an international level. Tobacco control has already become a part of the United Nations Agenda on Sustainable Development Goals, which is included in the third goal of good health and well-being. MPOWER measures- provided by WHO in 2008 for effective and productive implementation of tobacco control strategies are widely accepted by several governments. Where M stands for Monitor tobacco use and prevention policies;Pstands for Protect people from tobacco use; O stands for Offer help to quit tobacco use; W stands for Warn people about the dangers of tobacco use; E stands for Enforcing bans on tobacco advertising, promotion, and sponsorship; and R stands for Raise taxes on tobacco.[5] Quitting of tobacco products is a difficult process. Evidence suggest two methods that enable a person to quit tobacco, which include pharmacotherapy and counseling or advice. Pharmacotherapy including nicotine replacement therapy, bupropion, varenicline, and many other deals with the medicines, drugs, or any kind of medical therapy that can help a person to reduce the usage of tobacco products.[5] Apart from the pharmacotherapy, counseling and advice also play a crucial role in reducing the consumptions of tobacco products. Countries such as Ukraine, Egypt, China, India, Argentina, and Nigeria have about 2%–4% of attempts to quit the usage of tobacco products through pharmacotherapy. In India, 4% of the attempts to quit the usage of tobacco products are from pharmacotherapy and 9% of attempts to quit are from counseling or advice. Similarly, countries such as Nigeria, the Philippines, Panama, and Brazil have a higher percentage of attempts to quit the usage of tobacco products with the help of counseling or advice.[5] The Government of India has started tobacco Quitline services, and it will be interesting to know about quit rates from different states of India.[6] The cessation of smoking tobacco has always been easy with multiple health advice and counseling such as counter advertisement and warning signals in packaging. However, in spite of the warning signal in packages, the reduction of SLT consumption seemed to be very far behind the smoking tobacco consumption.

The use of telephonic Quitline services is well established in Western countries for smoking cessation, but for SLT cessation, it is found to be less.[5] This study is an attempt that has been made to see SLT quit rate through telephonic Quitline services. This study does the critical reviews of the articles stating cessation of SLT with the use of telephonic counseling or advice.

  Methodology Top

For our systematic review, we have taken published studies and articles from well-known libraries such as PubMed and Google Scholar. The articles were searched using keywords such as smokeless tobacco cessation, quitline smokeless tobacco, and smokeless tobacco telephone. The literature relevant to this systematic review was reviewed by the inclusion and exclusion criteria. The inclusion criteria for this study were that the articles must be published on or after the year 2000 and the interventional strategy for the cessation of tobacco consumption should be telephonic counseling or call-based counseling. Articles having cessation technique which is not call based or telephone based and participants who are not SLT users were excluded from the study. [Figure 1] shows the selection criteria of the articles for this systematic review.
Figure 1: Selection criteria for the articles

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  Results Top

In this systematic review, we have reviewed 11 articles which were related to the effects of telephonic Quitline for SLT users. Summarized results of these papers are shown in [Table 1]. There are multiple studies stating the cessation for smoking, but there were only very few studies that showed any kind of cessation for SLT. In this systematic review, we have gone through studies which have a main focus on SLT cessation with the help of a telephonic counseling.
Table 1: Review of the articles

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A study was conducted by Mushtaq et al. in the USA via Oklahoma Tobacco Helpline on 959 male SLT users who were followed up for 7 months.[7] The study aimed at finding the association between abstinence and participation characteristics. The results showed 43% tobacco abstinence for 30-day point prevalence and also stated that people with high income and high level of motivation are more likely to quit tobacco. Moreover, people who received 8 weeks of nicotine replacement therapy are more likely to quit tobacco. The other factors which were found to be associated with tobacco abstinence were number of completed scheduled helpline calls and annual income. The major drawback for this study is that sample size for the 30-day point prevalence of abstinence is very small.

In a pilot survey conducted by Cigrang et al.,[8] sixty military male participants were randomized into two groups including minimal contact intervention (two supportive phone calls were made for each participant) and usual care. The study results showed that 20 out of 31 participants agreed to participate in minimal contact intervention and 10 out of 27 participants (7-day point prevalence) reported abstinence from tobacco consumption. The major drawbacks for the study included small sample size, less follow-up period, and only two calls were made for each participant.

Multiple studies used the methodology of randomization of the participants into the group of intervention and control. However, in one of the studies, nicotine replacement therapy was given along with telephonic counseling.[7] In another study by Severson et al.,[9] randomization was done into three groups with nicotine lozenges and coach calls in which the group with both the interventions was found to have higher quit rate for SLT. However, the study included only male candidates for SLT cessation. Another study by Severson et al.[10] was conducted on 785 US military personnel in which the participants were randomized into two treatment groups. One was behavior and another was usual treatment group. The behavioral treatment had three calls of 15 min at subsequent periods of time. The results showed that 8.2% of the participants claimed to have abstinence at the first call, 20% reported abstinence at the second call, and 40% reported abstinence at the third call. However, the study had selected sample, its outcome dealt with only dental care, and it performed dental examinations. In the year 2000, a study by Severson et al.[11] randomized 1069 individuals into two groups namely manual only and assisted self-help. The study results showed that 34.8% of the participants quit SLT in 6-month follow-up survey and 82.7% set up the quit date. This study compared only the two interventions provided. It does not contain any control group for comparison. Both the studies of Severson et al. used videotape cessation activities along with telephonic counseling to see the quit rate among participants.[10],[11]

Another randomized controlled trial conducted in a rural area of Minnesota State, USA, by Boyle et al.[12] compared telephonic counseling with self-help manual which showed higher proportion of abstinence from tobacco, but readiness to quit tobacco was assessed by one single question. In this study, abstinence rate was found at 3 months and 6 months both in manual and telephonic interventions. At 3 months, the abstinence rate was 6.8% in manual and 30.9% in telephonic interventions. At 6 months, it was 9.8% in manual and 30.9% in telephonic counseling. Similar results were shown by another study by Boyle et al.[13] on adult males who were consuming moist snuff but could not find any significant difference in telephonic and manual interventions. All Participants belonged in this study had above average education category and had high income level. In that study, 25% of the participants under the control group and 40% of the participants in the intervention group quit the consumption. However, the difference in the two groups was not found to be significant.

In another randomized controlled trial conducted by Danaher et al.,[14] 1683 SLT users were randomized under four groups namely web based, Quitline, web + Quitline, and control and analyzed by intent-to-treat (ITT) analysis. The 7-day point prevalence for tobacco abstinence was found to be 36.3% at Quitline intervention, whereas that of the web-based and web + Quitline interventions was at 34.7% and 33.6%, respectively. This study had used the web-based Quitline intervention along with telephonic counseling to see how these interventions are useful for the participants to quit the consumption of SLT. The main limitation was that it could not validate the self-reported abstinence for tobacco consumption.

Most of the randomized trials have used ITT analysis for checking the quitting prevalence of SLT users. The assessment of readiness to quit has been done through contemplation ladder, a ten-point scale stating the stage of readiness to quit tobacco. Multiple studies have used the contemplation ladder to judge the self-reporting readiness to quit rate.[9],[12],[13],[14]

There are some studies which have used some selected population for implementing telephone-based Quitline intervention to seek tobacco cessation rate. One cluster randomized trial study by Walsh et al.[15] selected 44 random schools in rural California and randomized into strata (prevalence of SLT use and number and size of baseball teams). In the intervention arm, there were multiple strategies for tobacco cessation such as face-to-face counseling session, usage of gums and seeds, telephonic follow-up, and support from others. The study focused on tobacco cessation through multiple intervention techniques, which led to fewer number of schoolchildren to fall under telephonic follow-up (n = 39). In the intervention arm, the study had 27% of tobacco cessation in comparison to the control arm which had only 14% of tobacco cessation, but the study was not able to give the picture for telephone-based intervention. Another study by Keller et al.[16] used data from quit plan services at Minnesota and Wisconsin. The study results showed that younger and middle-aged adults (18–54 years) are more likely to get enrolled for tobacco cessation in Minnesota State. The study also reported that telephonic Quitline could help in increasing the cessation among SLT users. The main limitation of the study was that it could not give quit rate from either of the Quitline services.

Marshall et al.[17] compared data of 45 states of USA and assessed variation in Quitline reach by race and ethnicity. The Quitline reach was assessed as the proportion of smokers and SLT users who utilized Quitline services during each year, which was calculated by dividing the number of state-specific Quitline registrants in each year by the number of adult tobacco users in the state. The study results showed that the Quitline approach (a behavioral intervention) of tobacco cessation was able to reach minority population. The study could provide the quit rate for SLT cessation, and Quitline reach was assessed both by smokers and SLT users.

No study has been found yet in which female participants were included. In one study,[11] only thirty females were recruited for evaluating the cessation of SLT, but no data was obtained. Only three studies have a sample of >1000.[9],[11],[14] Studies with 60, 200, and/or fewer number of participants do not have proper validation of choosing the sample size and the prevalence for tobacco cessation cannot be justified. Studies have shown that there is an improvement in participants when they have started quitting the consumption or have decided to quit SLT within someday.

One of the limitations of the studies reported in this systematic review was that the population defined in each study was purposive in nature[15],[16] which could lead to biased results. All the studies were based on the male population basically allocated to the US continent. None of the studies were found to be linked to tobacco cessation in low- and middle-income countries. The studies stated in this systematic review have smaller sample sizes. None of the studies have reported any other factors such as sociodemographic factors associated with SLT cessation. Some studies have no control arm to access the impact of intervention over any control group.[11],[13] Studies have shown that the cessation of SLT is basically on self-reporting basis without any proper scientific scales. Only one tool to judge readiness to quit which came to picture in this systematic review is contemplation ladder, a 10-point scale.

Overall, this systematic review shows a picture of some probability for SLT cessation through telephonic Quitline, but no proper evidence was found. The major gap found in this systematic review is that we could have used some better scale to check the readiness to quit or quit level in the population.

  Discussion Top

This systematic review provides evidence from 11 studies enrolling participants who consume SLT and are ready to quit through call-based counseling. This systematic review has noted behavioral interventions which include telephonic counseling and Quitline to stop SLT use.[18],[19] We could find only fewer studies related to SLT consumption and its cessation through Quitline services as compared to studies for smoking cessation specifically for the Indian context. It can be noted that majority of the included studies highly deal with developed countries. However, the effort made to decrease tobacco use by the Indian government cannot be neglected. The Government of India has established Quitline services under the Act of Cigarettes and other Tobacco Products (Packaging and Labelling) Rules (2008) amended in 2018 which states a toll-free helpline number for tobacco cessation on every smoking and SLT product.[6] This law has created a new opportunity to reduce tobacco use in India by providing a helpline number that connects a trained counselor to the individuals who want to quit tobacco but lack motivation and support. In India, the Quitline services have produced positive response. One of the examples is an initiation of Telephonic Tobacco Cessation Program “PEHAL” by the Government of Rajasthan and Rajasthan Cancer Foundation. The analysis of the data gathered through this program reported that SLT consumers were three times higher in number compared to smoked tobacco users in quitting tobacco.[20] Apart from this, under the guidance of the Government of India, other institutes such as Vallabhbhai Patel Chest Institute and Tata Memorial Centre have initiated the Quitline services to reach out the larger population of the country.[21] A report on the National Framework on TB-Tobacco Collaborative Activities submitted by the Government of India (2017) noted that the prevalence of SLT and smoking tobacco is, respectively, 26% and 14% that indicates SLT consumption has almost double burden compared to smoking tobacco in India.[22] Considering Rajasthan state's initiatives and the overall form of tobacco use present in the Indian scenario, the Quitline services will be a great mode of intervention to reduce the overall SLT use.

In addition, majority of the Indian population resides in rural area. Consumption of tobacco in smokeless form is relatively common in rural population. A cross-sectional analysis supported that SLT use is statistically correlated to socioeconomic status and the study also mentioned that low-income population is twice likely to use SLT compared to wealthy population.[23],[24] Several studies indicate that Quitline is a more effective way than the pharmacotherapy, specifically to reach rural and low socioeconomic population.[16],[17]

In developing countries such as India, Bangladesh, and Indonesia where tobacco consumption is highly prevalent in low socioeconomic group, Quitline services could be more useful in reaching out the large population.

Social support is a highly underrated factor for reducing SLT use.[25],[26] The Quitline is a tool that encourages the individuals and provides needed support to them in quitting tobacco consumption. A technical report presented by the WHO (2018) emphasizes on CATCH approach (mTobacco Cessation and Quitline). This approach is an evidence-based and effective intervention to control the SLT products' use, especially in South East Asian region nations – Bangladesh, Bhutan, India, Myanmar, and Nepal.[27] This approach highly recommends the strategic implementation of Quitline services to stop SLT use.

Behavioral interventions can increase tobacco abstinence rates among SLT users, whether or not they are already motivated to stop and are seeking treatment. Telephone counseling, oral examination, and feedback about SLT-induced mucosal changes may be useful components for a behavioral intervention. Studies have shown that most of the participants were interested in quitting SLT consumption. Binnal et al. (2016)[24] found that sociodemographic variables and cessation of SLT are highly associated with each other. In this study, the authors also mentioned the possible barriers for not able to quit SLT in different age groups. Response of the participants with regard to possible barriers indicates lack of support and encouragement from others. Quitline services provide answer for such barriers where a trained person can guide and encourage the individuals who want to quit SLT. However, none of the studies in this systematic review have shown or identified the potential of Quitline services.

Many studies have indicated that women have the readiness to quit tobacco. However, factors such as lack of family support and household environment influence the low level of SLT cessation rate.[28] In countries such as Bangladesh and Indonesia where prevalence of SLT consumption among females is higher than that of males,[5] the need for counseling and Quitline services is far much required.

It is recommended that a tobacco Quitline should be initiated where trained counselors and health-care providers are available to provide support to people consuming SLT.[29],[30] With this strategic intervention, developing nations such as India would have the possibility of reducing the consumption of SLT products. Quitline services need to be encouraged by responsible institutions and governments. As per our review, A population of 1000 with SLT consumption has 30% Quit Rate (approx. 300 people quit SLT consumption). Another systematic review showed that behavioral interventions such as Quitline can help in SLT abstinence.[31] Hence, it could be proposed that use of Quitline services for tobacco cessation is more effective in countries where the proportion of SLT users is high than smokers. It is also evident from the Global Tobacco Adult Survey that counseling services are more useful in countries of South East Asian nations.[5]

This study has produced enough evidence to support country-specific national guideline development for SLT cessation by providing an evidence-based review. This process can be expensive and time-consuming. However, it provides a starting point for the consideration of telephone-based Quitline services for SLT cessation. This review recommends a policy which has to be made by the low and middle-income countries to establish the Quitline services for the SLT cessation by telephone counseling, which will play an important role in tobacco control.

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Conflicts of interest

There are no conflicts of interest.

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Danaher BG, Severson HH, Zhu SH, Andrews JA, Cummins SE, Lichtenstein E, et al. Randomized controlled trial of the combined effects of web and Quitline interventions for smokeless tobacco cessation. Internet Interv 2015;2:143-51.  Back to cited text no. 14
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