Proactive peer support by telephone to help women quit smoking

HEALTH EDUCATION RESEARCH Theory & Practice Vol.11 no.3 1996 Pages 377-381 SHORT COMMUNICATION Proactive peer support by telephone to help women quit smoking Laura J.Solomon 1-2, Roger H.Secker-Walker 2-3, Brian S.Flynn 2^, Sally Christ 3, Greg S.Dana 3 and Anne L.Dorwaldt 3 Abstract This report describes a proactive, peer support intervention delivered by telephone for women interested in quitting smoking. Trained female volunteers were matched with women interested in receiving support while they attempted to quit smoking. Telephone contacts were initiated by the peer support counselor just before a designated quit day (if one were specified), on the quit day and weekly thereafter for 2-3 months. Of the 72 women who participated in the intervention, 49 (68%) were reached 1-2 years after enrollment to evaluate their smoking status. Results revealed that 25% of the women were ex-smokers when those not reached were classified conservatively as smokers. Furthermore, 14% were considered to be continuous ex-smokers, based on self-report data. The results of this pilot program suggest that a telephone support system for women staffed by trained ex-smoking peers can achieve long-term smoking cessation outcomes comparable to most behavioral interventions for smoking. Introduction Social support is considered an important ingredient in the mix of strategies to help women quit smoking. Numerous studies reveal the beneficial effects of naturally-occurring social support, particularly provided by partners, in the early 'Department of Psychology, 'Vermont Cancer Center, 3 Offlce of Health Promotion Research and 4 Department of Family Practice, University of Vermont, Burlington, VT 05405, USA stages of quitting and maintenance (Ockenc et al., 1982; Mermelstein et al., 1983; Copottelli and Orleans, 1985; Mermelstein et al. 1986; Morgan etal., 1988; Cohen and Lichtenstein, 1990). Unfortunately, most efforts to enhance indigenous support have failed to increase cessation rates, largely due to the difficulty associated with changing existing social dynamics (Lichtenstein etal., 1986; Mclntyre-Kingsolver et al., 1986; Lichtenstein and Glasgow, 1992). One exception is provided by Gruder et al. (1993) in a study that found a greater rate of short-term abstinence among subjects who received social support training for themselves and their self-designated non-smoking buddies; however, the social support intervention did not enhance long-term maintenance. Group cessation programs often attempt to enhance social support for quitting through the exchange of experiences and empathy of group members. Yet, efforts to increase the cohesiveness of cessation groups in order to increase quit rates have had mixed results (Etringer et al., 1984; Lando and McGovem, 1991). Additionally, participation in group cessation programs is poor, with only about 3% of the US smoking population choosing to attend such programs in any given year (Pierce, 1990). Barriers to group attendance include inconsistent availability, accessibility, acceptance and cost Efforts to enhance support through telephone hotlines have proven successful, but programs requiring subjects to initiate contacts are grossly under-utilized (Ossip-Klein et al., 1991; Glasgow et al., 1993). However, the concept of providing proactive support by telephone has led to some promising results (Orleans et al., 1991; Lando O Oxford University Press 377

LJ.Solomon et al. et al, 1992). For example, Orleans et al. (1991) found that the provision of four brief counselorinitiated telephone calls in conjunction with selfquitting materials and a social support guide for the quitter's family and friends resulted in greater abstinence rates at 8- and 16-month follow-up than comparison conditions which did not include the telephone counseling. Similarly, Lando et al. (1992) observed a significantly higher abstinence rate at 6-month follow-up among subjects who received only two brief supportive telephone calls compared with non-intervention control subjects. The provision of proactive support delivered by telephone may bypass many of the barriers noted in earlier efforts to enhance social support First, the approach avoids the difficulty associated with trying to alter already-existing social dynamics, since the support person has no prior history with the smoker, and the relationship is solely intended to provide encouragement, empathy and assistance to the smoker as she/he tries to quit. Secondly, the intervention can be readily available (e.g. it is not dependent upon discrete start dates as most groups are), readily accessible (e.g. participants can receive the calls at home) and provided at low cost Finally, the approach does not depend upon participants initiating contact, but instead allows the participant and the support counselor to negotiate the times and frequencies of the calls in order to tailor the dosage to the needs of the smoker. These pragmatic advantages over other supportenhancing efforts make the proactive telephone support approach worthy of further investigation. This article describes a proactive peer support smoking cessation intervention delivered over the telephone by trained volunteers. It is an uncontrolled pilot test of a volunteer support network that was embedded within a larger community intervention trial designed to help women quit smoking. Methods The peer support intervention was part of a community-wide effort to help women quit smoking conducted in one county in southern Vermont Health care providers in the county received training in the delivery of brief smoking cessation advice and were given simple forms to use to refer women with high intentions of quitting in the near future to the peer support system operated by our local community office. Self-referral to the peer support program was publicized through a smoking cessation brochure distributed in health and human service agencies and in public places where women congregated (e.g. laundromats, grocery stores, child care facilities). Subjects Subjects were 72 women smokers who were either self-referred or referred by a health care provider to participate in the proactive peer support system for smoking cessation delivered by telephone in 1991 and 1992. According to program staff reports, 80% of the women were self-referred and 20% were referred by health care providers. All women referred into the peer support system had high intentions of quitting smoking in the near future and were encouraged to set a quit date as part of their participation. The mean age of the subjects was 40.8 years (SD = 12.8 years); 36% had a high school education or less; 64% were employed; over 95% were Caucasian. Number of cigarettes smoked per day was not recorded at the time of referral. Peer counselors Peer counselors were female ex-smokers who had quit smoking for at least 6 months and who responded to a request for smoking cessation peer support volunteers publicized by program staff through local volunteer networks and by word-ofmouth. The peer counselors received 5 h of training in smoking cessation supportive counseling and continued contact from program staff during the course of their volunteer experience. The training, divided into two sessions, covered the logistics of telephone support; background on how women quit smoking; special issues women face when they try to quit, including coping with negative feelings, urges, others' smoking, withdrawal symptoms and weight gain; telephone counseling skills 378

Telephone support for smoking cessation which were discussed, modeled and practiced; and local referral options for women who faced difficulties beyond the capabilities of the peer counselors. Peer counselors were asked to commit to a 6-month volunteer experience which they could renew; they could also receive refresher training at any time. For quality assurance, staff periodically called women receiving support from the volunteers to ensure that the contacts were acceptable. By December 1992, about 20 volunteers were actively providing support, usually to only one or two women at a time. Telephone support Referral information received by program staff was transferred to a peer support volunteer, with an effort to match more experienced volunteers with heavier smokers. The volunteer then initiated telephone contact, preferably 2-3 days prior to quit day, and negotiated with the woman to contact her proactively on her quit day and then weekly thereafter for the next 2-3 months. Periodic contacts continued beyond this point for some of the women, if they requested it. Telephone contacts lasted anywhere from a few minutes to up to 1 h. During the first month the contacts were longer and more frequent; they tended to decrease in length and frequency after that point Women were also given the volunteer's telephone number, however, few women initiated calls. The telephone support calls were designed to praise women for making positive changes in their smoking, empathize with women who were struggling, provide encouragement to women to quit smoking and/or stay quit, and assist women by guiding them through a problem-solving process around any smoking-related difficulty they might be experiencing. Thus, the smoking cessation intervention consisted of ongoing interpersonal support and guidance from the peer counselor, no other smoking cessation resources were provided unless specifically requested by the woman. Records of issues that were discussed at each contact were maintained and reviewed periodically with the program staff. Assessment Evaluation staff who were not involved in the program implementation called subjects on two occasions to assess smoking status. These calls were made within 1 year of enrollment into the peer support system, and between 1 and 2 years after enrollment. Consent for these calls was obtained at the time of the first follow-up contact Results All 72 women were reached for the first followup assessment contact Of these, 25% (18 women) reported being abstinent; 75% (54 women) reported currently smoking at least one cigarette per day. Smokers were slightly younger than ex-smokers (40.6 and 41.4 years, respectively), had less education (39% of smokers and 28% of ex-smokers had a high school education or less) and were less likely to be employed (59% of smokers and 78% of ex-smokers were working outside the home). However, none of these differences reached significance given the small sample sizes; for all comparisons, P > 0.15. At the second follow-up assessment within 1-2 years of enrollment in the peer support system, 32% (23 women) could not be reached, 25% (18 women) reported being abstinent and 43% (31 women) reported currently smoking. The demographic characteristics of these three groups of women are presented in Table I. Again, no significant differences were observed, for all comparisons, P > 0.20. If women who could not be reached were excluded from the denominator, then Table L Demographic characteristics of women at the second follow-up (1-2 years after enrollment) by smoking status 0 Mean age (years) High school or less(%) Employed (%) Ex-Smokers Smokers Unable to Reach (n = 18) (n = 31) (n = 23) 41.3 28 67 * No differences were significant. 44_5 42 61 35.7 35 65 379

LJ.Solomon et al. the self-reported abstinence rate at 1-2 years postenrollment was 37%. A small subset of 10 women (14% of the total sample) reported abstinence at both assessment contacts and these women were considered continuously quit The mean age of these women was 44.7 years, 30% had a high school education or less and 70% were employed. Compared to the total sample these women were slightly older, slightly more educated and slightly more likely to be employed; however, because of small sample sizes, none of these differences was significant Discussion The results of this small pilot study of peer support delivered proactively by telephone reveal that the' self-reported smoking status of women 1-2 years after enrollment (25% abstinent) is comparable to the quit rates associated with most standard behavioral smoking cessation group programs (Hughes, 1994). This finding is encouraging in light of the fact that the intervention was delivered by volunteers, reached women in their own homes, and required only part-time staff support for training and volunteer management purposes. Additionally, an ongoing telephone support system enables health care providers to make referrals precisely when smokers are motivated to act, rather than having to wait for group programs that have discrete start dates. These advantages over traditional support programs warrant further exploration of proactive telephone peer support Small differences were observed in age, education and employment for women who successfully quit smoking through the peer support system compared to women who continued to smoke; however, none of these differences reached significance. There was a tendency toward a greater proportion of continuing smokers having less education than ex-smokers. From these data it is difficult to know whether the peer support system was equally effective with women of different education levels or was more effective with women of higher education. A larger scale study is needed to answer this question. Finally, there are obvious limitations to this pilot work. Outcome assessments were based entirely upon self-report, women enrolled in the peer support system were volunteers who already had high intentions of quitting smoking in the near future and no comparison group was available against which to measure outcomes. From a logistical standpoint the volunteer peer support system worked well, but required ongoing supervision from staff with repeated reminders to complete and turn in support logs documenting telephone calls. As with any volunteer system, record keeping must be kept to a minimum and quality control checks must occur repeatedly to insure fidelity to the intervention. With these caveats in mind, we recommend a full-scale investigation of a proactive peer support system delivered by telephone as a way to assess the efficacy of such a pragmatic approach to enhancing support for women trying to quit smoking. Acknowledgements The authors gratefully acknowledge the work of the volunteer peer counselors. This pilot project was supported by grant HL40685 from the National Heart, Lung and Blood Institute, Bethesda, MD. References Coppotelli, H. and Orleans, C. S. (1985) Partner support and other determinants of smoking cessation maintenance among women. Journal of Clinical Psychology, 53, 455 460. Glasgow, R. E., Lando, H., Hollis, J., McRae, S. G. and La Chance, P. (1993) A stop-smoking telephone help line that nobody called. American Journal of Public Health, 83, 252-253. Grader, E. L., Mermelstein, R. J., Kirkendol. S., Hedeker, D., Wong, S. C, Schreckengost, J., Wamecke, R. B., Burzette, R. and Miller, T. Q. (1993) Effects of social support and relapse prevention training as adjuncts to a televised smoking cessation intervention. Journal of Consulting and Clinical Psychology, 61, 113-120. Hughes, J. R. (1994) Behavioral support programs for smoking cessation. Modem Medicine, 62, 22-27. Lando, H. A., Hellerstedt, W. 1_, Pirie, P. L. and McGovem, P. G. (1992) Brief supportive telephone outreach as a recruitment and intervention strategy for smoking cessation. American Journal of Public Health, 82, 41-46. Lando, H. A. and McGovem, P. (1991) The influence of group cohesion on the behavioral treatment of smoking: a failure 380

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