Telephone counselling for smoking cessation
Editorial Group: Cochrane Tobacco Addiction Group
Published Online: 12 AUG 2013
Assessed as up-to-date: 20 JUN 2013
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Stead LF, Hartmann-Boyce J, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD002850. DOI: 10.1002/14651858.CD002850.pub3.
- Publication Status: Edited (no change to conclusions)
- Published Online: 12 AUG 2013
Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.
To evaluate the effect of proactive and reactive telephone support via helplines and in other settings to help smokers quit.
We searched the Cochrane Tobacco Addiction Group Specialised Register for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2013.
randomized or quasi-randomised controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters.
Data collection and analysis
One author identified and data extracted trials, and a second author checked them. The main outcome measure was the risk ratio for abstinence from smoking after at least six months follow-up. We selected the strictest measure of abstinence, using biochemically validated rates where available. We considered participants lost to follow-up to be continuing smokers. Where trials had more than one arm with a less intensive intervention we used only the most similar intervention without the telephone component as the control group in the primary analysis. We assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. We considered trials recruiting callers to quitlines separately from studies recruiting in other settings. Where appropriate, we pooled studies using a fixed-effect model. We used a meta-regression to investigate the effect of differences in planned number of calls, selection for motivation, and the nature of the control condition (self help only, minimal intervention, pharmacotherapy) in the group of studies recruiting in non-quitline settings.
Seventy-seven trials met the inclusion criteria. Some trials were judged to be at risk of bias in some domains but overall we did not judge the results to be at high risk of bias. Among smokers who contacted helplines, quit rates were higher for groups randomized to receive multiple sessions of proactive counselling (nine studies, > 24,000 participants, risk ratio (RR) for cessation at longest follow-up 1.37, 95% confidence interval (CI) 1.26 to 1.50). There was mixed evidence about whether increasing the number of calls altered quit rates but most trials used more than two calls. Three studies comparing different counselling approaches during a single quitline contact did not detect significant differences. Of three studies that tested the provision of access to a hotline two detected a significant benefit and one did not.
Telephone counselling not initiated by calls to helplines also increased quitting (51 studies, > 30,000 participants, RR 1.27; 95% CI 1.20 to 1.36). In a meta-regression controlling for other factors the effect was estimated to be slightly larger if more calls were offered, and in trials that specifically recruited smokers motivated to try to quit. The relative extra benefit of counselling was smaller when it was provided in addition to pharmacotherapy (usually nicotine replacement therapy) than when the control group only received self-help material or a brief intervention.
A further eight studies were too diverse to contribute to meta-analyses and are discussed separately. Two compared different intensities of counselling, both of which detected a dose response; one of these detected a benefit of multiple counselling sessions over a single call for people prescribed bupropion. The others tested a variety of interventions largely involving offering telephone counselling as part of a referral or systems change and none detected evidence of effect.
Proactive telephone counselling aids smokers who seek help from quitlines. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness. There is limited evidence about the optimal number of calls. Proactive telephone counselling also helps people who receive it in other settings. There is some evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increase the chances of quitting compared to a minimal intervention such as providing standard self-help materials, or brief advice, or compared to pharmacotherapy alone.
Plain language summary
Is telephone counselling effective as part of a programme help people stop smoking?
Background: People trying to quit smoking can be helped with medication or by face-to-face behavioural support such as counselling and group therapy.
Objectives: We wanted to to find out whether support was also effective when it was provided by telephone.
Search methods: The most recent search for evidence was in May 2013. We identified 77 controlled trials with a total of almost 85,000 participants.
Results:This review identified trials evaluating the effect of any type of telephone counselling. We included trials where the participants had called helplines offering support for people trying to quit smoking (quitlines). We also included trials where people had received telephone calls from counsellors or other healthcare providers. Some of these compared telephone support with very minimal support such as self-help leaflets, and others looked at whether adding telephone calls was more helpful than just face-to-face support, or just providing a smoking cessation medication such as nicotine replacement therapy (NRT). Some trials only recruited people who were trying to stop smoking, whislt others offered support even if people were not actively planning to quit. Trials had to be randomized, and to follow up participants for at least six months.
A small number of trials were judged to be at risk of bias but we did not think that the overall results were likely to be biased. Trials in quitline populations were more likely to be unable to contact everyone for follow-up and generally relied on participants' self report of not smoking, rather than checking using biochemical tests. Trials used a wide range of numbers and lengths of calls, and there was some variation between the results of different trials which means that we cannot be certain that all types of counselling have the same effect.
Twelve trials involving over 30,000 people tested the effect of additional telephone calls from a counsellor for people who had called a quitline. When we pooled their results there was evidence that people receiving call-back counselling were more likely to have stopped smoking than those only sent self-help materials or given brief advice and support during the initial call. Calls increased the relative success by between 25% and 50%, but since the proportion quitting in the control groups was quite low this was equivalent to an absolute increase of only 2 to 4 percentage points.
Fifty-one trials involving over 30,000 people tested the effect of telephone counselling for people who had not called a quitline, some of whom might not have been actively planning to quit. Overall when pooled these showed a small benefit of the telephone calls, increasing the relative success by between 20% and 36%, equivalent to an absolute increase of 2 to 3 percentage points. In an analysis that took into account different characteristics of the trials (metaregression) there was evidence that offering a larger number of calls, and having participants who were interested in trying to quit, increased the effect. Trials which tested the additional benefit of telephone counselling for people who were using a smoking cessation medication had a slightly smaller relative benefit, but since people in these studies were benefitting from the medication the absolute benefit from adding telephone calls was about the same. Two trials that compared different numbers of calls detected a benefit of more calls compared to a single contact.
Six other trials tested other uses of telephone counselling including systems for referral of smokers to support. We did not pool these and none of them showed clear evidence of an effect.