Evaluation of Colorado QuitLine outcomes among FY enrollees. January 2012

Evaluation of Colorado QuitLine outcomes among FY2010-2011 enrollees January 2012 Prepared for the Epidemiology, Planning and Evaluation Branch, Colorado Department of Public Health and Environment

Contents Summary and key findings... 1 Background... 2 Enrollee characteristics... 3 QuitLine use, perception, and outcomes among non pregnant enrollees... 6 Coaching call completion... 6 Perception of coaching importance... 7 Smoking cessation medication use... 8 Quit attempts and abstinence rates... 9 Results among pregnancy protocol enrollees... 11 Perception of coaches... 11 Coaching call completion... 12 Receipt of incentives... 12 Use of NRT... 12 Abstinence rates... 12 References... 13 Methodology... 14 Follow up survey questionnaire (general version)... 15 Follow up survey questionnaire (pregnancy version)... 20

Summary and key findings The Amendment 35 Program Evaluation Group (APEG), University of Colorado Cancer Center, evaluated Colorado QuitLine use and outcomes among a large sample of smokers who enrolled in QuitLine coaching services during July 2010 March 2011. The work was conducted under contract to the Colorado Department of Public Health Environment using federal funds awarded under the American Recovery and Reinvestment Act (ARRA). The study examined outcomes among all enrollees in the sample, those who were Medicaid beneficiaries, and those who were pregnant and received a specialized protocol with increased cessation coaching sessions to increase postpartum abstinence. Key findings: Seven months after QuitLine enrollment, 28.8% of the total study population was abstinent for at least 30 days, with Medicaid enrollees slightly less likely than privately insured and uninsured enrollees to report this status. Despite reporting similar utilization and perceptions of QuitLine services, Medicaid enrollees did not attain the abstinence rates seen among other enrollees: Six month continuous abstinence was less than half as common among Medicaid enrollees (8.2%) compared to privately insured (17.1%) and uninsured (18.6%) enrollees. Medicaid and non Medicaid enrollees were similarly likely to use a pharmaceutical aid for smoking cessation (nicotine replacement therapy, Chantix or bupropion). Compared with other enrollees, Medicaid enrollees were more likely to use either prescription medicine and less likely to use nicotine replacement therapy. Among pregnant QuitLine enrollees: Seven months after due date, 46.1% had been abstinent for at least 30 days. Pregnant enrollees were more likely than other enrollees to complete the series of coaching calls, to be satisfied with the service, to perceive that coaching was important, and to feel connected with their coach. Compared to non pregnant female enrollees, pregnant enrollees were less educated, more often on Medicaid, younger, and more often single. 1

Background The Colorado QuitLine first initiated smoking cessation coaching services in December 2002 under a grant from the Colorado Department of Public Health and Environment. Since inception, smokers who enroll in the telephone service have been offered up to five proactive coaching calls. In December 2005, the QuitLine added free nicotine replacement therapy (NRT as patches or gum). Initially, up to 8 weeks of free NRT (distributed as two, 4 week supplies) was available to enrollees who continued coaching through the distribution of the second 4 week supply. Starting July 1, 2007, all enrollees could receive a 4 week supply, but only those who reported smoking more than 20 cigarettes per day at intake were eligible for a second 4 week supply. In July 2010, the QuitLine received a grant funded through the American Recovery and Reinvestment Act (ARRA) to develop and implement a coaching protocol for pregnant women that encourages postpartum maintenance of abstinence. The grant also supported initiatives to increase awareness and use of smoking cessation benefits among Medicaid beneficiaries. As part of the ARRA award, the Amendment 35 Program Evaluation Group (APEG), University of Colorado Cancer Center, evaluated service use and smoking cessation outcomes among a large sample of smokers who enrolled in the QuitLine during July 2010 March 2011. The study examined outcomes among all enrollees in the sample, those who were Medicaid beneficiaries, and those who were pregnant and received a specialized protocol with increased cessation coaching sessions to increase postpartum abstinence. 2

Enrollee characteristics Table 1: Characteristics (weighted %) of study sample men women (not pregnant) pregnant women n= 571 n=970 n=99 race/ethnicity white 79.8 78.5 74.7 Latino 13.7 15.0 15.8 black 5.0 5.0 8.8 other 1.6 1.5 0.8 age group 18-24 6.4 6.2 29.8 25-34 20.7 18.5 54.4 35-44 18.1 19.2 12.6 45-54 18.0 19.9 3.2 55-64 19.9 23.0 0.0 65-74 14.0 10.2 0.0 75+ 2.9 3.0 0.0 marital status single 46.4 40.4 67.9 married 35.8 37.0 26.5 divorced 14.0 18.4 5.6 other 3.8 4.2 0.0 sexual orientation heterosexual 96.1 95.8 91.3 GLB 3.9 4.3 8.7 educational level <grade 9 2.6 2.2 0.9 grade 9-11 11.1 13.0 19.3 GED 8.2 6.7 10.2 HS grad 32.3 24.5 37.8 some college 29.2 34.3 22.0 college degree and more 16.7 19.3 9.9 insurance status* no insurance 38.2 31.6 15.1 Medicaid 10.9 22.7 59.7 private insurance 50.9 45.7 25.3 Among survey respondents only: n=272 n=460 n=28 mental health disorder yes 21.3 29.2 15.2 no 78.7 70.8 84.8 * significantl difference (p<0.05) betw een men and non-pregnant w omen A majority of the general study sample was female (58.9% * ), white, and aged 25 64 (table 1). Half had attended education beyond high school, and half were privately insured. Single adults were slightly more common than married adults. Women were twice as likely as men to be Medicaid beneficiaries. Among the study sample who responded to a follow up survey, one fourth reported a mental health disorder. Women who enrolled in the pregnancy protocol tended to be younger, more often single, less educated, and more often Medicaid beneficiaries than other female QuitLine enrollees; no difference was statistically significant. * See methodology section for details on sample selection and weighting Responded yes to: Has a doctor or healthcare provider ever told you that you have a mental health problem or mental illness? Missing data omitted, n=98. 3

Compared to enrollees with private or no insurance, Medicaid beneficiaries were less educated, more often Latino (22.1% vs. 16.0%) or black (8.3% vs. 3.9%), and twice as likely to report a mental health disorder (45.3% vs. 22.3; table 2). Table 2: Characteristics (weighted %) of general study sample, by insurance status Medicaid no insurance private n= 671 n= 359 n=515 race/ethnicity* white 63.7 72.0 77.0 Latino 22.1 16.7 15.4 black 8.3 5.1 3.1 other 6.0 6.2 4.4 age group* 18-24 7.3 7.8 4.8 25-34 20.9 20.5 18.4 35-44 23.8 20.9 15.3 45-54 17.7 16.8 21.2 55-64 18.4 25.9 19.9 65-74 9.6 7.1 15.9 75+ 2.3 1.0 4.6 marital status single 45.7 50.9 36.3 married 31.6 27.5 44.5 divorced 18.5 18.2 14.5 other 4.2 3.4 4.7 sexual orientation heterosexual 95.1 96.0 96.1 gay/lesbian/bisexual 4.9 4.0 3.9 educational level* <grade 9 5.1 1.5 1.9 grade 9-11 17.6 15.6 7.8 GED 11.2 6.6 6.4 HS grad 24.1 30.1 27.3 some college 30.9 27.2 36.1 college degree and more 11.1 19.0 20.5 Among survey respondents only: n=295 n=158 n=280 mental health disorder* yes 45.3 23.3 22.2 *characteristic is significantly different by insurance status (p<0.05) 4

Most enrollees smoked daily (table 3), and about half smoked within five minutes of waking, an established component of tobacco dependence. 1 Almost one in three men and one in five women smoked heavily (more than 20 cigarettes per day (CPD), the QuitLine eligibility threshold for receiving additional NRT), while one in ten men and one in six women were light smokers (fewer than 10 CPD). Most enrollees had smoked longer than 10 years and had made multiple quit attempts; one fourth had made five or more quit attempts at enrollment. Pregnant enrollees, whose ages ranged from 18 to 54, were significantly less likely than same aged non pregnant female enrollees to have smoked longer than 10 years. Pregnant enrollees also tended to smoke fewer CPD and to report fewer previous quit attempts; these differences were not significant. Medicaid enrollees * were more likely than privately insured and uninsured enrollees to smoke within five minutes of waking (59.0% vs. 45.1%; data not shown in table). Use of other tobacco products was scarce. Only 1.7% reported smoking cigarettes and using other tobacco products; an additional 2.1% reported using only non cigarette tobacco products. Among pregnant enrollees, 3.0% reported using cigarettes and other tobacco products (data not shown in table). Table 3: Smoking and quitting history (weighted %) of study participants women pregnant men (not pregnant) women n= 571 n=970 n=99 smoking status at intake everyday 95.2 96.6 82.3 occasionally 1.0 0.4 2.3 not at all 3.8 3.1 15.3 cigarettes per day 0 0.0 0.3 2.4 1-9 9.3 15.0 30.4 10-15 30.7 36.7 30.5 16-20 30.6 26.7 29.8 >20 29.4 21.3 7.0 lifetime quit attempts none 9.8 11.7 24.3 1-2 33.9 34.0 26.5 3-4 27.8 26.3 25.5 5 or more 28.6 28.0 23.7 time to smoke within 5 minutes 47.1 48.0 46.2 6-30 30.3 26.7 24.0 more than 30 22.6 25.3 29.8 length of time smoking^ 10 or fewer years 15.2 13.4 47.1 more than 10 years 84.8 86.7 52.9 ^ significant difference among women by pregnancy status, p<0.05 * Pregnant enrollees are omitted from this analysis. 5

QuitLine use, perception, and outcomes among non pregnant enrollees Coaching call completion Almost half of enrollees completed only the first coaching call, while one in nine completed all five available calls (table 4). Call completion rates Table 4: Coaching call completion rate, by insurance status (weighted %; n=1,545) number of calls did not differ significantly by insurance status. 0 1 2 3 4 5+ total 4.0 45.1 23.2 11.1 5.7 11.0 no insurance 3.7 50.1 24.1 10.5 3.5 8.2 Medicaid 3.1 44.7 22.1 11.2 6.4 12.7 private 4.6 41.7 23.0 11.5 7.0 12.3 Among heavy smokers (>20 CPD), call completion was associated with the number of NRT shipments (table 5). Because a second Table 5: Coaching call completion rate, NRT shipment is available only to heavy by cigarettes per day and number of NRT shipments smokers who continue coaching, it is (weighted %; n=1,381) number of calls* unclear whether this group completed # cigs # NRT 1 2 3 4 5 more sessions in order to obtain more per day shipments n=645 n=322 n=166 n=84 n=164 NRT, more coaching, or both. However, 20 n=1,054 total 0 1 2 48.6 54.9 48.8 6.1 24.1 24.1 23.6 41.7 12.3 7.1 12.8 24.8 5.7 8 5.2 9.4 9.4 5.9 9.7 18.0 more than half of heavy smokers receiving two NRT shipments completed all five calls, while NRT refills typically ship after call two or three; this result total 43.9 21.8 10.6 5.9 17.9 suggests that these enrollees valued 0 78.4 9.3 3.5 6.6 2.3 coaching as well as NRT. >20 n=327 1 52.1 23.9 9.5 5.5 9.1 2 0.5 23.9 17.9 6.4 51.3 rows in bold are significantly different, p<0.05, by NRT shipment *61 enrollees did not have any coaching calls recorded; 31.5% received one shipment of NRT while the rest received none Being sent no NRT at all was associated with completing fewer calls, especially among heavy smokers. Perhaps these enrollees needed medical approval to receive NRT and perceived the requirement as a barrier, or perhaps they were investigating QuitLine services but not ready to participate. Regardless of cigarette consumption level, about half of enrollees with one NRT shipment did not complete more than one call. While some of these enrollees may have called just to obtain free NRT, other reasons for stopping were often cited and are discussed in the next section of this report. 6

Perception of coaching importance Respondents who completed at least one coaching call rated the importance of their smoking cessation Figure 1: Enrollee's perceived importance coaching at a of coaching in quit attempt (1 7 scale) mean 4.5 on a scale of 1 (not at (very important) 7 all important) to 6 7 (very 5 important; figure 4 1). There was no 3 2 difference in the (not at all important) 1 rating by enrollee 0 5 10 15 20 25 30 insurance status. Percentage More than onefourth of enrollees rated coaching as very important. This top rating was least common among those who completed just one call (mean 4.0) and most common among those who completed five calls (5.4). Asked why they discontinued coaching, about one in five enrollees who had completed at least one call said it was because they had resumed smoking, and another one in five said it was because they had quit smoking and didn t think they needed coaching any more (figure Figure 2: Percent of respondents citing specified reason for having discontinued coaching calls (multiple responses permitted) other/don't know went back to smoking stopped smoking and didn't need QL didn't call when they said didn't help completed all trouble getting through didn't like new coach each time didn't like coach not enough phone minutes 13.2 12.2 8.3 7.2 7.3 3.0 2.9 21.0 20.5 2). Insufficient cell phone minutes were rarely cited as a reason, even among Medicaid respondents (3.2%). 44.1 Two reasons for discontinuation QuitLine didn t call when they said and trouble getting through represent session connection barriers. Together the two reasons were as commonly cited (20.4%) as either having quit smoking or having relapsed to smoking. It is unknown whether the QuitLine didn t call at the scheduled time; alternative possibilities include the 7

enrollee remembering incorrectly, having been unavailable at the scheduled time, or masking a reason that the enrollee was uncomfortable disclosing to the survey interviewer. Table 6: Percent of respondents citing specified reason for having discontinued coaching calls, by insurance status (multiple responses permitted) no Medicaid insurance private other/don't know 44.9 39.2 46.4 went back to smoking 23.9 24.2 18.4 stopped smoking and didn't need 16.0 21.5 21.3 QL didn't call when they said* 17.2 9.4 14.0 didn't help 14.2 7.6 14.1 completed all 9.6 8.5 7.7 trouble getting through 8.1 4.4 8.5 didn't like new coach each time* 8.8 3.5 8.9 didn't like coach 2.2 1.8 3.9 not enough phone minutes 3.3 4.6 1.9 *reason differs significantly by insurance status The prevalence of some reasons for coaching discontinuation differed by insurance status (table 6). Medicaid enrollees were more likely than privately insured or uninsured enrollees to say the QuitLine did not call on schedule. Medicaid and privately insured enrollees were more likely than uninsured enrollees to dislike having different coaches across coaching sessions. However, dislike of a coach and dislike of having different coaches were infrequent reasons to discontinue. More than two fifths of enrollees gave a reason other than those listed in the questionnaire or said they didn t know why they discontinued coaching. Analysis of these responses was beyond the scope of this report but may in the future provide additional insight into discontinuation. Smoking cessation medication use Among enrollees who smoked 20 CPD, more than four fifths were sent a four week supply of NRT (table 7). Among smokers, who were eligible for a second four week supply, three fifths were sent only one shipment and less than one fourth were sent a second shipment. Compared to privately insured enrollees, Medicaid enrollees were less likely, and uninsured enrollees were more likely, to receive at least one NRT shipment. Lower receipt of NRT among Medicaid enrollees may be related to Table 7: Number of NRT shipments, by smoking level and insurance status # of NRT shipments cigs per day 0 1 2 20 16.6 81.0 2.5 >20 16.7 60.8 22.4 insurance status* none 12.1 79.6 8.3 Medicaid 25.2 67.7 7.2 private 17.1 76.2 6.7 *significant difference, p<0.05 medical ineligibility or may be due to QuitLine promotion of other pharmacotherapy covered by Medicaid (see below). Among enrollees sent any NRT, 94.4% reported using it. Those sent one shipment used NRT for a mean 27.0 days, while those sent two shipments used it for a mean 45.4 days. These results indicate that QuitLine enrollees use nearly all the NRT they are sent, leaving unused only one patch with a four week supply or roughly 11 patches with an eight week supply. These NRT utilization rates are much higher than the mean 9.8 days reported among Colorado general population smokers who use NRT for cessation. 2 Duration of NRT use did not differ between Medicaid and enrollees. 8

Two prescription medicines for smoking cessation bupropion and varenicline are unavailable through the QuitLine but covered by Medicaid. Medicaid QuitLine enrollees were more likely than uninsured QuitLine enrollees to use bupropion (11.5% vs. 3.0%), and more likely to use varenicline (19.4%) compared to privately insured (10.9%) or uninsured (7.1%) enrollees. The differences may indicate that private insurance is less likely than Medicaid to cover these medicines, or that providers are more aware of Medicaid coverage than private coverage. However, use of one or the other cessation pharmacotherapy (NRT or a prescription medicine) was similarly common among Medicaid vs. private and uninsured. Quit attempts and abstinence rates Among enrollees who had not yet quit smoking when they entered QuitLine services, 83.2% made a quit attempt * after starting coaching. Medicaid enrollees were less than half as likely as others to report 6 month continuous abstinence at follow up (table 8); insurance was the only factor associated with 6 month continuous abstinence. No demographic or smoking history factor was associated with 7 day or 30 day point abstinence. Table 8: Percent of respondents abstinent at 7-month follow-up duration of abstinence 7 days 30 days 6 mos. total 32.7 28.8 16.1 insurance status none 33.8 32.2 18.6 Medicaid 25.1 21.8 8.2 private 34.4 29.1 17.1 figure in bold differs significantly, p=0.01 This finding of lower cessation success among Medicaid enrollees is congruent with recent national population level data showing that those with private insurance are more likely than Medicaid enrollees to report having been quit for at least six months at the time of the survey (7.8% vs. 4.6%). 3 Reporting a mental health disorder at follow up was associated with significantly less 7 day (22.7% vs. 35.4%), 30 day (21.6% vs. 33.3%) and 6 month abstinence (9.2% vs. 19.0%) compared to enrollees not reporting a mental health disorder. Enrollees with a mental health disorder exhibited lower quit rates across all insurance groups Table 9: Percent of respondents abstinent (table 9). Among non Medicaid enrollees, those for 30 days at 7-month follow-up reporting a mental health disorder appeared less likely mental health disorder to be abstinent at follow up, although the difference was not significant. In contrast, abstinence rates yes no among Medicaid enrollees showed little or no no insurance 13.9 41.6 Insurance difference by mental health disorder, possibly Medicaid 20.3 23.7 status indicating that improved mental health support private 24.6 30.6 through the QuitLine might not improve quit rates no significant difference by insurance status among Medicaid enrollees. * Responded yes to: Since you first called the quitline (about seven months ago) did you stop using tobacco for 24 hours or longer because you were trying to quit? Respondents who didn t answer the mental health item are grouped with those reporting a mental health disorder because their quit rates were similar. 9

Seven day point abstinence was significantly associated with the number of completed coaching calls (table 10), while 30 day and 6 month abstinence rates showed the same trend but were not significant (p=0.08 and p=0.09, respectively). A significant increase in abstinence was seen among enrollees who Table 10: Percent of respondents abstinent at 7-month follow-up, by number of completed coaching calls duration of number of completed calls abstinence 1 2 3 4 5+ 7 days* 25.7 28.7 26.6 53.7 49.9 30 days 22.6 26.6 20.4 46.3 46.1 completed 4+ vs. 1 3 calls across all abstinence indicators (7 day: 51.9% vs. 26.9%; 30 day: 46.1% vs. 23.5%; 6 month: 26.6% vs. 12.5%). 6 months Among enrollees who were not 10.6 16.0 11.3 23.1 28.4 * significant difference, p<0.05, by number of completed calls abstinent at follow up (reported any tobacco use in past 30 days), 96.2% reported smoking cigarettes, 4.8% smoking cigars, 2.0% using chewing tobacco, 1.4% smoking pipes, and 3.2% using other types of tobacco. 10

Results among pregnancy protocol enrollees During the study period, 99 pregnant women enrolled in the QuitLine, of whom 32 completed a follow up survey seven months after the end of pregnancy. Such small numbers render the pregnancy protocol substudy a pilot test, where process measures and small scale outcomes can provide important formative information but require further testing. Key components of the pregnancy protocol that was studied * included: a consistent coach across sessions for each participant; up to four more calls (postpartum) than the standard five call protocol; an incentive gift card with funds added for each completed call; postpartum availability of NRT, even if NRT was used prenatally. Perception of coaches Most pregnant enrollees (90.6%) reported having the same coach in all sessions. Overall, pregnant enrollees rated coaching significantly more important than standard protocol enrollees did, with mean ratings of 5.4 vs. 4.4 on a scale of 1 (not at all important) to 7 (very important). Pregnant enrollees also rated coaches more favorably than standard protocol enrollees did on all but one Table 11: Attitudes toward coaches, pregnancy protocol enrollees vs. standard protocol enrollees 1-7 scale (1=strongly disagree, 7=strongly agree) pregnancy standard Trust in coach* 6.6 4.9 Confidence in coach's ability to help* 6.4 4.6 Worked well together* 6.6 4.5 Coach provided choices and options 5.6 4.6 Coach understood how I saw my smoking* 6.4 4.9 Coach conveyed confidence in quitting* 6.6 4.9 Coach listened* 6.7 5.0 Coach encouraged questions* 6.6 5.0 Coach understood before suggesting changes* 6.4 4.9 *significantly different, p<0.05 measure of alliance or relationship with their coaches (table 11). Such findings have not previously been reported and warrant further study. More positive feelings about coaches among pregnant enrollees could be due to this population having a consistent coach across sessions, having more contact with a coach (up to nine sessions vs. up to five in the standard protocol), other unidentified protocol differences, or factors unrelated to the protocol such as pregnancy related factors or population characteristics. * Cessation-related text messages were added to the protocol in December 2010 but are excluded from the current report because only 7.8% of pregnant participants in the current study received text messages. 11

Coaching call completion Pregnant enrollees were far less likely than standard protocol enrollees to discontinue coaching after a single session, and twice as many pregnant enrollees completed the coaching protocol, which is longer for pregnant enrollees than the standard protocol for non pregnant enrollees (table 12). * The completion rate among pregnant enrollees compares favorably with the best results reported in the scientific literature. Receipt of incentives Respondents reported that they received post session incentive gift cards always (24.2%), sometimes (26.7%), occasionally (38.8%), or never (10.4%). One in five (19%) reported waiting a long time before receiving the card. Two thirds reported that the card worked great. One person reported being unable to use the card or to receive added rewards. Subsequent to the current study period, the QuitLine changed to single use cards to reduce problems with card use. Use of NRT During pregnancy, 33.8% of enrollees reported using some type of NRT, although not always from the QuitLine. Most enrollees who used NRT at all used it postpartum (29.2% of enrollees), and almost all who used it postpartum had begun using it during pregnancy, with only 7% of nonusers during pregnancy starting NRT use postpartum. These results suggest that NRT should be available through the QuitLine both during pregnancy and postpartum. Abstinence rates Table 12: Percent completing indicated number of coaching calls, by type of protocol enrollee received number of calls completed protocol 0 1 2 3 4 5 6 7 8 9 10 standard 4.0 45.1 23.2 11.1 5.7 4.2 2.3 1.0 1.5 0.6 1.4 pregnancy 1.9 17.7 13.0 14.1 9.2 5.7 8.9 4.7 5.4 3.0 16.5 Among enrollees who completed a survey seven months after pregnancy ended, 52.3% reported 7 day abstinence, 46.1% reported 30 day abstinence, and 42.9% reported 6 month continuous abstinence. More than half (55.2%) reported being abstinent at the end of pregnancy, of whom 24.9% subsequently relapsed (30 day) to smoking at follow up. Previous studies have reported that approximately 50% to 70% of smokers who quit during pregnancy relapse by six months postpartum. 4, 5, 6 The current results are thus promising. * The standard protocol includes five sessions. 12

References 1 Heatherton, T.F., Lozlowski, L.T., Frecker, R.C., Fagerstrom, K-O. (1991). The Fagerstrom test for nicotine dependence: a revision of the Fagerstrom tolerance questionnaire. British Journal of Addiction, 86, 1119-1127. 2 Burns, E.K., Levinson, A.H. (2008). Discontinuation of nicotine replacement therapy among smoking-cessation attempters. American Journal of Preventive Medicine, 34(3), 212-215. 3 Centers for Disease Control and Prevention. (2011). Quitting smoking among adults United States, 2001-2010. MMWR 60 (44), 1513-1519. 4 Solomon, L.J., Quinn, V.P. (2004). Spontaneous quitting: self-initiated smoking cessation in early pregnancy. Nicotine & Tobacco Research, 6(suppl. 2), S203-S216. 5 Edwards, N and Sims-Jones (1998). Smoking and smoking relapse during pregnancy and postpartum: Results of a qualitative study. Birth, 25(2), 94-100. 6 Solomon, L.J., Higgins, S. T., Heil, S. H., Badger, G. J., Thomas, C. S., & Bernstein, I. M. (2007). Predictors of postpartum relapse to smoking. Drug and Alcohol Dependence, 90, 224-227. 13

Methodology This study received expedited approval from the Colorado Multiple Institutional Review Board. Study participants were randomly sampled from all Colorado QuitLine enrollees during July 1, 2010 through March 31, 2011 at a rate that would yield 800 completed surveys assuming a 50% response rate. A total of 1,644 enrollees were randomly selected to be part of the study, including 99 women enrolled in the pregnancy protocol and 1,545 men and women enrolled in the standard protocol. Medicaid beneficiaries and pregnant women were oversampled in order obtain additional information about these two groups. Response rates were 53.5% for general enrollees (n=827) and 32.3% for pregnant enrollees (n=32). Standard enrollees completed the follow up survey at mean=7.6 months after enrollment date, while pregnant enrollees completed the survey at mean=7.7 months after due date. Pregnant smokers in the study enrolled on average during their sixth month of pregnancy, ranging from 6 days to 8.2 months before due date. Follow up was conducted by mixed mode (mail and telephone) survey. Enrollee information was received monthly from the Colorado QuitLine via secured files. Participants were prenotified by postal letter at one week and two weeks before the survey. A survey with a twodollar incentive was sent by postal mail, and a follow up survey was sent to non-respondents two weeks later. Non-respondents to the mailed surveys were called by a trained and experienced interviewer, with up to eight call attempts. The sampling methods used for the study support the construction and use of weights to produce approximately unbiased estimates that represent the whole population from which the sample was selected. The weights account for selection probability (a function of enrollment month, Medicaid status, and pregnancy status) and nonresponse. 14

1. What is today s date? / / (write the date) month / day / year Colorado QuitLine Follow-up Questionnaire 2. Have you smoked any cigarettes or used any other tobacco, even a puff or pinch, a. in the last 7 days? Ο yes Ο no b. in the last 30 days? Ο yes Ο no 3. When was the last time you smoked a cigarette, even a puff? / / (write the date) month / day / year 4. What types of tobacco have you used in the past 30 days? (mark all that apply) I did not use tobacco in the past 30 days cigarettes cigars, cigarillos, or little cigars a pipe (this is a traditional pipe, not a water pipe or hookah ) chewing tobacco, snuff, or dip any other type of tobacco 5. Do you currently smoke cigarettes every day, some days, or not at all? t at all if this is your answer, skip to question 11 everyday some days (less than 7 days per week, or less than 1 cigarette per day) If you currently smoke cigarettes every day or some days, answer questions 6-10 6. On how many days did you smoke in the last 30 days? days smoked in the last 30 days (write the number) 7. How many cigarettes do you smoke per day on the days that you smoke? cigarettes per day (write the number) 8. Do you intend to quit using cigarettes within the next 6 months? 9. Do you intend to quit using cigarettes within the next 30 days? 10. How soon after you wake up do you smoke your first cigarette? I do not currently smoke cigarettes at all within 5 minutes 6 to 30 minutes 31 to 60 minutes more than 60 minutes The survey continues on the next page. 15

The next questions are about your satisfaction with the quitline 11. Overall, how satisfied were you with the service you received from the quitline? very satisfied mostly satisfied somewhat satisfied t at all satisfied 12. How many coaching calls were you able to complete with the quitline? 1 call 2 calls 3 calls 4 calls 5 calls more than 5 calls 13. On a scale of 1 to 7, where 1 is not at all important and 7 is very important, how important was quitline coaching for your quit attempt? 1 2 3 4 5 6 7 not at all very important important 14. Why did you stop using quitline coaching? (mark all that apply) I completed all five coaching calls. I did not like the coach(es). The calls were not helping me quit. I went back to smoking and did not want to talk to the coach about it. I stopped smoking and did not need coaching anymore. I didn t have enough cell phone minutes. I didn t like speaking to a new coach each time. I had trouble getting through on the phone to a coach. The quitline didn t call me when they said they would. Another reason (Please describe the reason) why I stopped using coaching. 15. Here are some statements about quitline coaching sessions. For each statement, circle a number from 1 to 7 that best represents how you feel about your sessions. For example, would mean you strongly disagree with the statement. would mean you strongly agree with the statement. strongly strongly disagree agree a. I trusted my quitline coach(es). 1 2 3 4 5 6 7 b. I was confident in my coach(es) ability to help me. 1 2 3 4 5 6 7 c. My quitline coach(es) and I worked well together. 1 2 3 4 5 6 7 d. e. f. I felt that my coach(es) provided me with choices and options about smoking (including not quitting). I felt like my coach(es) understood how I saw things with respect to my smoking. My coach(es) conveyed confidence in my ability to make changes regarding my smoking. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 g. My coach(es) listened to how I wanted to do things regarding my smoking. 1 2 3 4 5 6 7 h. My coach(es) encouraged me to ask questions about my smoking. 1 2 3 4 5 6 7 i. My coach(es) tried to understand how I saw my smoking before suggesting any changes. 1 2 3 4 5 6 7 The survey continues on the next page. 16

The next questions are about your recent smoking history. Since you first called the quitline (about seven months ago) 16. did you stop using tobacco for 24 hours or longer because you were trying to quit? 17. how many times did you stop smoking for 24 hours or longer because you were trying to quit? (write total number of times) 18. what is the longest time you have gone without smoking a cigarette? (write the number AND mark which one applies) days weeks months 19. have you used any of the following products or medications to help you quit? (mark all that apply) other products or medications nicotine patches nicotine gum nicotine lozenges nicotine spray nicotine inhaler Zyban (also called Wellbutrin or bupropion) Chantix (also called varenicline) other (please write the medication) 20. Other than the quitline or medications, did you use any other kinds of assistance to help you quit over the past seven months? (mark all that apply) other kinds of assistance advice from a health professional website telephone program counseling program self-help materials other (please write the method) The next questions are about using nicotine patches for your quit attempt. 21. How many nicotine patches did you receive from the quitline? four-week supply (one shipment) eight-week supply (two shipments) I didn t receive any nicotine patches. 22. How long did you use the nicotine patches from the quitline? I did not use nicotine patches at all. (write the number AND mark the time period below to show how long you used the patches) days weeks The next questions are about you and your household 23. What is your job status? (mark one) employed for wages stay-at-home parent self-employed student and not working for money student and working for money retired unemployed unable to work / disabled 24. How many children live in your household who are ages 0-17 years old? (number of children ages 0-17 years old) 25. Not counting yourself, how many other adults ages 18 or older usually live in your household? (number of adults, not counting yourself) 26. Not counting yourself, how many other adults in your household smoke cigarettes? (Include adults who smoke every day or some days.) (number of adult smokers, not counting yourself) 27. During the past 12 months, what was the total combined income of all members of your household? less than $10,000 $10,000 to $25,000 $25,000 to $50,000 $50,000 to $75,000 more than $75,000 28. Has a doctor or healthcare provider ever told you that you have a mental health problem or mental illness? Ο no Ο yes The survey continues on the next page. 17

29. Here are some statements about life in general. For each statement, circle a number from 1 to 7 that best represents you. For example, would mean the statement is not at all true of you. would mean the statement is extremely true of you. Not at all Extremely true true of me of me a. I can think of many ways to get out of a jam. 1 2 3 4 5 6 7 b. I energetically pursue my goals. 1 2 3 4 5 6 7 c. There are lots of ways around any problem. 1 2 3 4 5 6 7 d. I am easily downed in an argument. 1 2 3 4 5 6 7 e. I can think of many ways to get the things in life that are most important to me. 1 2 3 4 5 6 7 f. Even when others get discouraged, I know I can find a way to solve the problem. 1 2 3 4 5 6 7 g. My past experiences have prepared me well for my future. 1 2 3 4 5 6 7 h. I ve been pretty successful in life. 1 2 3 4 5 6 7 i. I meet the goals that I set for myself. 1 2 3 4 5 6 7 30. Do you currently smoke cigars, cigarillos, or little cigars every day, some days, or not at all? t at all if this is your answer, skip to question 34 every day some days (less than 7 days per week or less than 1 cigar per day) If you currently smoke cigars, cigarillos, or little cigars every day or some days, answer questions 31-33 34. Do you currently smoke pipes every day, some days, or not at all? t at all if this is your answer, skip to question 38 every day some days (if less than 7 days per week or less than 1 pipe per day) If you currently smoke pipes every day or some days, answer questions 35-37 31. How many days did you smoke a cigar, cigarillo or little cigar in the last 30 days? days (write the number) 32. How many cigars, cigarillos, or little cigars do you smoke per week during the weeks that you smoke? (write the number) 33. Do you intend to quit using cigars, cigarillos, or little cigars in the next 30 days? 35. How many days did you smoke a pipe in the last 30 days? days (write the number) 36. How many pipes do you smoke per week during the weeks that you smoke? (write the number) 37. Do you intend to quit using a pipe in the next 30 days? The survey continues on the next page. 18

38. Do you currently use chewing tobacco, snuff or dip every day, some days, or not at all? t at all if this is your answer, skip to question 42 every day some days (if less than 7 days per week) If you currently use chewing tobacco, snuff or dip every day or some days, answer questions 39-41 39. How many days did you use chewing tobacco, snuff or dip in the last 30 days? days in the last 30 days (write the number) 40. How many pouches or tins do you use per week during the weeks that you use chewing tobacco or snuff? (write the number) 41. Do you intend to quit using chewing tobacco, snuff, or dip in the next 30 days? 42. Do you currently use other types of tobacco every day, some days, or not at all? t at all If this is your answer, the survey ends here. every day some days (if less than 7 per week) If you currently use another type of tobacco every day or some days, answer questions 43-46 43. What kind of tobacco do you use? hookah, shisha, tobacco in waterpipe Revel, Taboka, Snus, spitless tobacco other (please describe) 44. How many days did you use the other type(s) of tobacco in the last 30 days? I don t currently use other tobacco (write the number) 45. How much of the other type(s) of tobacco do you use per week during the weeks that you use the other type(s) of tobacco? I don t currently use other tobacco (write the number) 46. Do you intend to quit using the other type(s) of tobacco in the next 30 days? The survey ends here. Thank you for your time and assistance! 19

Colorado QuitLine Follow-up Questionnaire 1. What is today s date? / / (write the date) month / day / year 2. Have you smoked any cigarettes or used any other tobacco, even a puff or pinch, a. in the last 7 days? Ο yes Ο no b. in the last 30 days? Ο yes Ο no 3. When was the last time you smoked a cigarette, even a puff? / / (write the date) month / day / year 4. Think back to the very end of your pregnancy. How much were you smoking at the end of your pregnancy? t at all everyday some days (if less than 7 days per week or less than 1 cigarette per day) 5. What was the last date of your pregnancy (i.e. the date that your baby was born or you were no longer pregnant)? / / (write the date) month / day / year 6. In order to make your survey answers the most useful for improving the QuitLine, can you please tell us if your pregnancy ended in a live birth?, it did, it did not 7. If you started smoking again after the last day of your pregnancy, how much time passed before you started smoking? (write the number AND mark the time period below to show how much time passed before you started smoking) days weeks months OR I have stayed quit the whole time OR I was smoking at the end of my pregnancy 8. What types of tobacco have you used in the past 30 days? (mark all that apply) I did not use tobacco in the past 30 days cigarettes cigars, cigarillos, or little cigars a pipe (this is a traditional pipe, not a water pipe or hookah ) chewing tobacco, snuff, or dip any other type of tobacco 9. Do you currently smoke cigarettes every day, some days, or not at all? t at all every day some days (less than 7 If this is your answer, skip to question 15 days per week or less than 1 cigarette per day) If you currently smoke cigarettes every day or some days, answer questions10-14 The survey continues on the next page. 20

10. On how many days did you smoke in the last 30 days? days smoked in the last 30 days (write the number) 11. How many cigarettes do you smoke per day on the days that you smoke? cigarettes per day (write the number) 12. Do you intend to quit using cigarettes within the next 6 months? 13. Do you intend to quit using cigarettes within the next 30 days? The next questions are about your satisfaction with the QuitLine 15. Overall, how satisfied were you with the service you received from the QuitLine? very satisfied mostly satisfied somewhat satisfied not at all satisfied 16. How many coaching calls were you able to complete with the QuitLine? 1 call 2 calls 3 calls 4 calls 5 calls more than 5 calls 17. On a scale of 1 to 7, where 1 is not at all important and 7 is very important, how important was QuitLine coaching for your quit attempt? 14. How soon after you wake up do you smoke your first cigarette? I do not currently smoke cigarettes at all within 5 minutes 6 to 30 minutes 31 to 60 minutes more than 60 minutes 1 2 3 4 5 6 7 not at all very important important The survey continues on the next page.

18. Here are some statements about QuitLine coaching sessions. For each statement, circle a number from 1 to 7 that best represents how you feel about your sessions. For example, would mean you strongly disagree with the statement and would mean you strongly agree with the statement. strongly strongly disagree agree a. I trusted my QuitLine coach. 1 2 3 4 5 6 7 b. I was confident in my QuitLine coaches ability to help me. 1 2 3 4 5 6 7 c. My QuitLine coach and I worked well together. 1 2 3 4 5 6 7 d. e. f. g. I felt that my QuitLine coach provided me with choices and options about smoking (including not quitting). I felt like my QuitLine coach understood how I saw things with respect to my smoking. My coach conveyed confidence in my ability to make changes regarding my smoking. My QuitLine coach listened to how I wanted to do things regarding my smoking. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 h. My QuitLine coach encouraged me to ask questions about my smoking. 1 2 3 4 5 6 7 i. My QuitLine coach tried to understand how I saw my smoking before suggesting any changes. 1 2 3 4 5 6 7 j. My QuitLine coach was helpful with quitting when I was pregnant. 1 2 3 4 5 6 7 k. l. My QuitLine coach was helpful with quitting or staying quit after I was no longer pregnant. The money I got after completing coaching calls was important for keeping me involved in the QuitLine. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 m. I liked having the same QuitLine coach. 1 2 3 4 5 6 7 n. When I was no longer pregnant, I felt like I was starting over with quitting. 1 2 3 4 5 6 7 19. Why did you stop using QuitLine coaching? (mark all that apply) I completed all of my coaching calls. I did not like the coach. The calls were not helping me quit. I went back to smoking and did not want to talk to the coach about it. I stopped smoking and did not need coaching anymore. I didn t have enough cell phone minutes. I didn t like speaking to a new coach each time. I had trouble getting through on the phone to a coach. The QuitLine didn t call me when they said they would. Another reason (Please describe the reason) why I stopped using coaching. The survey continues on the next page.

Since you first called the QuitLine. 20. Did you stop using tobacco for 24 hours or longer because you were trying to quit? 21. How many times did you stop smoking for 24 hours or longer because you were trying to quit while you were pregnant? (write total number of times) 22. How many times did you stop smoking for 24 hours or longer because you were trying to quit after you were no longer pregnant? (write total number of times) 23. What is the longest time you went without smoking a cigarette while you were pregnant? (write the number AND mark which one applies) days weeks months 24. What is the longest time you went without smoking a cigarette after you were no longer pregnant? (write the number AND mark which one applies) days weeks months 25. Have you used any of the following products or medications to help you quit? (mark all that apply, please mark both during and after pregnancy if applicable or leave blank if not at all). During After pregnancy pregnancy a. nicotine patches o o b. nicotine gum o o c. nicotine lozenges o o d. nicotine spray o o e. nicotine inhaler o o f. Zyban (also called Wellbutrin or o o bupropion) g. Chantix (also called varenicline) o o h. other (please write in the o o medication) 26. Other than the QuitLine or medications, did you use any other kinds of assistance to help you quit since you first called the QuitLine? (mark all that apply, please mark both during and after pregnancy if applicable or leave blank if not at all). During pregnancy After pregnancy a. advice from a health professional o o b. website o o c. telephone program o o d. counseling program o o e. self-help materials o o f. other o o (please write the method) The survey continues on the next page.

The next questions are about using nicotine patches for your quit attempt. 27. How many nicotine patches did you receive from the QuitLine? four-week supply (one shipment) eight-week supply (two shipments) other I didn t receive any nicotine patches. 28. How long did you use the nicotine patches from the QuitLine? During After pregnancy pregnancy I did not use nicotine patches at all. o o write the number AND mark the time period below to show how long you used the patches) o days o weeks o months The next questions are about you and your household o days o weeks o months 29. What is your job status? (mark one) employed for wages stay-at-home parent self-employed student and not working for money student and working for money retired unemployed unable to work / disabled 31. How many children live in your household who are ages 0-17 years old? (number of children ages 0-17 years old) 32. Not counting yourself, how many other adults ages 18 or older usually live in your household? (number of adults, not counting yourself) 33. Not counting yourself, how many other adults in your household smoke cigarettes? (Include adults who smoke every day or some days.) (number of adult smokers, not counting yourself) 34. During the past 12 months, what was the total combined income of all members of your household? less than $10,000 $10,000 to $25,000 $25,000 to $50,000 $50,000 to $75,000 more than $75,000 35. Has a doctor or healthcare provider ever told you that you have a mental health problem or mental illness? 30. Here are some statements about life in general. For each statement, circle a number from 1 to 7 that best represents you. For example, would mean the statement is not at all true of you. would mean the statement is extremely true of you. Not at all Extremely true true of me of me a. I can think of many ways to get out of a jam. 1 2 3 4 5 6 7 b. I energetically pursue my goals. 1 2 3 4 5 6 7 c. There are lots of ways around any problem. 1 2 3 4 5 6 7 d. I am easily downed in an argument. 1 2 3 4 5 6 7 e. I can think of many ways to get the things in life that are most important to me. 1 2 3 4 5 6 7 f. Even when others get discouraged, I know I can find a way to solve the problem. 1 2 3 4 5 6 7 g. My past experiences have prepared me well for my future. 1 2 3 4 5 6 7 h. I ve been pretty successful in life. 1 2 3 4 5 6 7 i. I meet the goals that I set for myself. 1 2 3 4 5 6 7 The survey continues on the next page.

36. Do you currently smoke cigars, cigarillos, or little cigars every day, some days, or not at all? t at all If this is your answer, skip to question 40 every day some days (less than 7 days per week or less than 1 cigar per day) 40. Do you currently smoke pipes every day, some days, or not at all? t at all If this is your answer, skip to question 44 every day some days (if less than 7 days per week or less than 1 pipe per day) If you currently smoke cigars, cigarillos, or little cigars every day or some days, answer questions 37-39 If you currently smoke pipes every day or some days, answer questions 41-43 37. How many days did you smoke a cigar, cigarillo or little cigar in the last 30 days? days (write the number) 41. How many days did you smoke a pipe in the last 30 days? days (write the number) 38. How many cigars, cigarillos, or little cigars do you smoke per week during the weeks that you smoke? (write the number) 39. Do you intend to quit using cigars, cigarillos, or little cigars in the next 30 days? 42. How many pipes do you smoke per week during the weeks that you smoke? (write the number) 43. Do you intend to quit using a pipe in the next 30 days? The survey continues on the next page.

44. Do you currently use chewing tobacco, snuff or dip every day, some days, or not at all? t at all if this is your answer, skip to question 48 every day some days (if less than 7 days per week) If you currently use chewing tobacco, snuff or dip every day or some days, answer questions 45-47 48. Do you currently use other types of tobacco every day, some days, or not at all? t at all if this is your answer, the survey ends here. every day some days (if less than 7 per week) If you currently use another type of tobacco every day or some days, answer questions 49-52 49. What kind of tobacco do you use? 45. How many days did you use chewing tobacco, snuff or dip in the last 30 days? days in the last 30 days (write the number) 46. How many pouches or tins do you use per week during the weeks that you use chewing tobacco or snuff? (write the number) 47. Do you intend to quit using chewing tobacco, snuff, or dip in the next 30 days? hookah, shisha, tobacco in waterpipe Revel, Taboka, Snus, spitless tobacco other (please describe) 50. How many days did you use the other type(s) of tobacco in the last 30 days? I don t currently use other tobacco (write the number) 51. How much of theother type(s) of tobacco do you use per week during the weeks that you use the other type(s) of tobacco? I don t currently use other tobacco (write the number) 52. Do you intend to quit using the other type(s) of tobacco in the next 30 days? The survey ends here. Thank you for your time and assistance!