Reflections on the Quitline's 20th Anniversary
November 19, 2020
Tim McAfee, MD, MPH (Former Director of CDC Office on Smoking & Health and Washington state resident)
In November 2000, Washington state launched a new public health service: A telephone line that anyone in the state could call and receive free, confidential help quitting smoking or other tobacco use. The services offered were based on emerging evidence from California, Oregon, and right here in Washington state. Now, 20 years later, quitline services are a vital part of the public health landscape supporting state, national, and international efforts to reduce and ultimately eliminate the harms caused by commercial tobacco use.
The origins of the Washington State Quitline
Washington state played an important role in the history of quitline development. Our story starts in the 1980s, when researchers adapted proven techniques for in-person tobacco cessation counseling for complete delivery over the phone. Initially, many thought this was a far-fetched idea, but then Group Health Cooperative (GHC, now Kaiser Permanente Washington) conducted a study in which two thousand individuals interested in quitting were randomized to receive different forms of treatment – ranging from a simple brochure to multiple proactive phone counseling sessions. This study found that the phone sessions markedly improved people's chances of quitting.
Peer-reviewed literature is often destined to sit on a dusty library shelf, while the researchers who conducted the studies move on to explore other areas of inquiry. This was not the case with the GHC study; a group of researchers, clinicians, and developers worked over several years to build the capacity to deliver phone-based tobacco cessation counseling to thousands of people interested in quitting. They called the program Free & Clear. GHC began offering it to employers, and researchers continued to improve it. They then conducted a study to determine whether covering these services – along with quit-smoking medicines such as the nicotine patch and gum – improved utilization of services and successful quitting. The results of this trial, which were published in the New England Journal of Medicine, were definitive: People who were offered free phone counseling and free medication were more likely to use them, and more likely to quit successfully.
Building momentum
As GHC was rapidly developing and implementing one of the first health plan benefit designs in the world that provided smoking cessation treatment as a fully covered service, other groups in Washington state were considering ways to help people who smoke quit and keep kids from starting. In 1998, Chris Gregoire, then Attorney General, led 45 other state attorneys general in recovering excess Medicaid costs caused by smoking from the four largest cigarette manufacturers, now known as the landmark Master Settlement Agreement (MSA), payments for which the state continues to receive in 2020.
The Tobacco Free Washington coalition, along with Washington chapters of the American Cancer Society, American Heart Association, and American Lung Association, began working with the offices of the Attorney General and Governor, as well as the Department of Health, to develop plans for what could be done with this large influx of money to help people who smoke quit and prevent kids from starting. In 2000, the state legislature allocated $100 million of the first MSA payment to create a statewide, comprehensive tobacco control program and established the Washington Tobacco Prevention and Control Council.
One of the Council's primary recommendations was to create what we now know as the Washington State Quitline. The services were to be modeled on the evidence accumulated by GHC and the California Smokers' Helpline, which had been operating since 1992 with similar well-documented benefits to callers. The Council viewed the state's provision of free quitline services as an ethical imperative; the other recommended prevention and policy initiatives, including media campaigns, cigarette tax increases, and clean indoor air laws, would put strong pressure on Washingtonians to stop using nicotine, an inherently addictive substance – a truth that tobacco industry executives obscured from the public prior to the MSA. In other words, free tobacco dependence treatment would be a just use of MSA (and cigarette tax) revenue because those addicted to nicotine were the original source of this revenue. In November 2000, the Washington State Quitline answered its first calls.
Improving, validating, and sharing outcomes
Following the launch of the Washington State Quitline, the spirit of GHC's ongoing quality improvement continued, and Free & Clear services expanded. Employers and health plans soon began to leverage the quitline infrastructure to provide tobacco cessation benefits for their employees and members. This freed up state funding to provide additional resources to callers without insurance or cessation benefits. The Quitline also created the capacity to accept direct referrals from physician's offices. In addition, protocols were developed to enable direct shipment of nicotine replacement therapy to callers' homes.
Through the first decade of operation, the Quitline worked with researchers in Washington and Oregon to validate the positive outcomes on this broader scale. These studies provided powerful reinforcement for the population-level benefits of quitline services, finding increased effectiveness and cost-effectiveness when people received additional calls and a longer supply of medication. This research contributed to US Preventive Services Task Force recommendations, which later informed coverage of tobacco cessation services in the Affordable Care Act.
As Washington state shared its success, many other states followed suit. The number of state quitlines grew quickly, the North American Quitline Consortium was formed, and the National Cancer Institute created a national telephone portal (1-800-QUIT-NOW) through which callers are routed to their state's quitline service provider. The CDC began providing technical assistance and financial support to all states to help establish, enhance, or maintain quitline services. Since 2004, tens of millions of calls have been received by this service nationwide (including over 310,000 in Washington state), and millions of people who smoke have successfully quit. This national network of quitlines also provided the foundation for a nationwide mass media campaign, Tips From Former Smokers®, which has motivated millions of quit attempts since 2010.
The impact of Washington's quitline leadership has reached global proportions. From 2011-2017, Washington state researchers partnered with the Quitline service provider and the World Health Organization (WHO) to develop tools for low- and middle-income countries to establish toll-free quitlines and train staff to operate them. Today, tobacco quitlines are included as a key cessation component in Article 14 of the WHO Framework Convention on Tobacco Control.
Challenges and opportunities
As we celebrate Washington's important role in the first decade of the 21st Century in the creation, development, and spread of quitlines throughout the US and the world, it is important to acknowledge that Washington's tobacco control efforts faced significant headwinds in the second decade. Following the 2008 recession, MSA and tobacco tax revenues were diverted from the Quitline and other tobacco prevention programming. The state has since relied on CDC grants for the Quitline, and now funds other components of comprehensive tobacco control at an order of magnitude below the CDC-recommended level.
Department of Health staff have worked energetically to sustain minimum Quitline service levels in Washington, prioritizing underserved populations and investing in even less costly interventions, notably a smartphone app. Meanwhile, our sister states – with whom we paved the way for state-funded quitlines – are forging ahead. In 2016, California voters passed a $2 per-pack tax increase on cigarettes, enabling the state to augment California Smokers' Helpline services and reduce smoking among low-income Californians. Earlier this month, Oregon surpassed Washington's cigarette tax rate and committed to investing 10% of the revenue into helping people quit.
Our experience with the Quitline and other innovations has not only taught us how to effectively support population-level behavior change, but has also helped set a precedent for providing medical care through remote communication technology. This has proven critical in 2020 with the COVID-19 pandemic and the new challenges confronting the delivery of in-person health care services. The Washington State Quitline and the individuals and institutions that helped create, implement, maintain, and study its effectiveness helped lay the groundwork that has helped us transition to the remote delivery of health care services that has been so essential to help control transmission of COVID-19, while maintaining high quality service delivery.
In summary, the public and private sectors in Washington state collaborated to create innovative, highly effective new ways to help tobacco users receive help quitting over the past several decades. Ripples from this effort continue to improve the lives of millions of people in our state, our country, and in the world. More needs to be done in the 2020s to fully realize the potential of quitlines in Washington, but we are building on a strong and deep legacy.