Article Text

Randomised controlled trial
Adding live, reactive telephone counselling to self-help literature does not increase smoking cessation
  1. Hazel Gilbert
  1. Correspondence to Hazel Gilbert
    Research Department of Primary Care and Population Health, University College London Medical School, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK; hazel.gilbert{at}

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Telephone helplines to encourage and offer support to smokers during their attempts to quit are a flexible and convenient method of providing advice to those seeking minimal assistance. Quitlines began as reactive lines, where the smoker initiates the call to a designated number to receive advice and information. Many now also offer proactive callback services, where a trained counsellor initiates the call to the smoker, in an attempt to provide more continuous care to those who are reluctant to seek face-to-face treatment.

Randomised trials of proactive services have found them to be effective in increasing quit rates. Descriptive evaluations of reactive telephone counselling have reported encouraging quit rates and suggested that a reactive service is more successful than self-help materials alone.1 However, reactive helplines are difficult to evaluate in randomised trials because of the lack of an appropriate comparison group. Hence, there are no adequate randomised trials to assess the effectiveness of reactive counselling. A reactive call is a self-initiated action, instigated by the smoker, and therefore cannot be induced naturally. Thus a true untreated control group would be smokers not accessing the helpline.

Sood and colleagues attempted to bridge this gap in research by comparing reactive counselling for callers to a quitline with a control group who were not offered counselling but were mailed self-help materials only. Thus they tested the hypothesis that reactive telephone counselling is better than self-help materials in a group of smokers who had already initiated contact. They found no significant difference in abstinence rates between the two groups and concluded that telephone counselling is not more successful than self-help materials.

The control group in this study is also of reactive callers, people who called for help; the results cannot be generalised to the whole population of smokers, only to those sufficiently motivated to have instigated the action by calling the line for help. The 7-day point-prevalent abstinence rates quoted are comparable with other quitline rates but higher than would be found with self-help materials alone.2 Most helplines offer counselling to callers, and although many callers want only information, one fifth call seeking counselling.3 No details are given of the usual practice of the quitline in the study and how it differed during this trial, but to deny the opportunity for longer counselling and withhold help from people who have called the line for help might be considered unethical. It is also not clear in this study how many calls were made to the quitline by participants in the intervention group subsequently, or indeed how many calls might have been made by participants in the control group even though they were denied access to a counsellor at the first call. All lines will invite the caller to call again, and although few will do so4 we cannot exclude the possibility of further calls from the control group, thus confounding the data.

No one would argue with the recommendation that all helplines should endeavour to provide a proactive callback service for those smokers requesting, or accepting, the service. Nevertheless, we must not overlook the importance of the reactive quitline service in providing access to support and information for a large number of people. Reactive lines provide counselling on demand, initiated by the client, and can be accessed immediately, providing advice often in a crisis. They are convenient and anonymous and can provide a service to subgroups and underserved populations (eg, ethnic groups, younger people and rural communities), providing advice for smokers who want to quit on their own or with minimal assistance.

Telephone helplines provide an important route of access to support for smokers; their existence has a symbolic role emphasising the importance of smoking cessation.3 Simply having helplines available can make a positive contribution and stimulate quitting efforts, bringing many smokers a step nearer to quitting.

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  • Competing interests None.

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