[D]

Impact = Reach x Efficacy x (AIM)

• Reach = Percent of people who would use intervention
• Efficacy = % who use intervention who benefit from it (ie quit)
• Reach & efficacy are moderated by rate of:
• Adoption
• Implementation
• Maintenance

The Impact Opportunity:

Quit lines:

• work
• Are actually used
• are "easy" to implement
• Can catalyze other state & local activity

The Challenge

• Few or no state-level quit lines have sufficient funding to maximize their impact
• Most potential funders will jump at the chance to have someone else fund
• Reach & program service goals are fit to existing budgets rather than opposite
• Total-systems perspective needed
• Different levels and types of services operate semi-independently

REACH: direct & collateral

• % of tobacco users who call Quit Line (QL)
• reach for specific services
• % of tobacco users impacted by QL existence, even though they never called
• healthcare
• media
• community

  [D]

Actual sustained direct contact reach:

• States:
  0.1 to 2% of tobacco users
• BUT:
• ALL states triage service mix
• NONE saturate promotion potential
• Health systems
• 1% to 10%
• BUT:
• NONE going whole-hog

What is the potential reach?

• 3% to 20%for general population
• 10-county trial (Ossip-Klein)
• Studied 1,813 smokers in 10 counties
• 5 counties with helpline, five self-help
• 35.9% called hot line
• 8.7% talked with counselor

  [D]

Effect not limited to Callers!

• Collateral reach:
  "It is likely that the observed hotline effect resulted from both higher abstinence rates among users as well as a ripple effect on nonusers, who may have been influenced by the knowledge that help was available if needed".

Healthcare synergy

• QL enables effective healthplan & clinic activity
• It’s a MESS out there - QL makes easier
• OR, GH-WA: helps implement "5A"s
• Referral & QL use:
• MD referral to QL ~ decrease ad need
• WA/OR/MN/UT - healthplans take some responsibility for members ~ QL concentrates f/u services on uninsured
• BEWARE THE COP-OUT!!!!!

  [D]

  [D]

Media ↔ QL

• Existence of QL "tag" may help
• smokers stay engaged
• politically
• Media campaign for QL results in "many" quitting who never call QL
• QL reach depends on a high-profile well-funded media campaign

Community, schools, etc

• Local cessation programs
• QL provides referral
• Community coalitions
• evidence-based focus
• Schools & worksites
• Significant others
• Special populations
• easy access, tailoring

Efficacy

• % of tobacco users using services under ideal conditions who quit
• make attempt who otherwise wouldn’t
• are successful when otherwise would have relapsed
• More service ~ higher efficacy
• Rate = 0% to 20% depending on service intensity/mix

Adoption, Implementation, Maintenance

• Adoption
• % of states/health systems creating QLs
• Implementation
• quality sustained compared to trials?
• extent of services as rich as trials?
• Maintenance
• how many QLs around in 10 years?

RE-AIM: How increase impact?

• Increase funding/increase states
• But for fixed pot of $$:
  MAY be possible to increase impact by "messing" with service & funder mix:
• More "basic" service, less high-end?
• More effective service to fewer?
• Get health systems/employers/etc to pay or deliver?
• Increase collateral benefits

Impact: health system & state
Group Health:	WA state QL:
pop’n: 580,000 adult smoking 15% 4,500/year use GH QL (~7.5% of smokers) All receive proactive follow-up 70% with pharmacotherapy =540 quits (12% AIQR)	pop’n: 5,800,000 adult smoking 23% 9,500/year use WA QL (~0.9% of smokers) 3000 receive proactive follow-up 6,500 receive single intervention =685 quits (12% & 5%)

National reach #s:

• Assume:
• 47 million smokers in US
  ~2% of smokers call ~ 1 million
  ~8% of smokers call ~ 4 million
  How much are "we" willing to spend to help these people quit?
• $50 per person? = $50 million to $200 million
• PLUS need a media/promotion budget
• lung transplants =$250,000/person
• so 200 lung transplants pays for 1 million calls
• Tobacco spending $150/smoker/year

In conclusion…tremendous additional opportunities to increase impact

• To maximize impact:
• total systems approach: all geographical levels, government, health systems, foundations, community (RE-AIM)
• Lower direct contact reach still results in collateral reach
• NEED invention, research & evaluation on different approaches
• Workshop will explore:
• how to synergize & integrate
• ideas for expanding impact