Implementation, Maintenance, and Outcomes of an Electronic Referral to a Tobacco Quitline Across Five Health Systems.

INTRODUCTION: Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients. AIMS AND METHODS: Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021-2022. RESULTS: Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p = .23), quit for 30 days (28.3% vs. 26.9%; p = .52), and quit for 6 months (13.6% vs. 13.9%; p = .88). CONCLUSIONS: With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers. IMPLICATIONS: This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention.

A Proactive Outreach Strategy Using a Local Area Code to Refer Unassisted Smokers in a Safety Net Health System to a Quitline: A Pragmatic Randomized Trial.

INTRODUCTION: Proactive outreach offering tobacco treatment is a promising strategy outside of clinical settings, but little is known about factors for engagement. The study objective is to examine the impact of caller area code in a proactive, phone-based outreach strategy on consenting low-income smokers to a quitline e-referral. AIMS AND METHODS: This pragmatic randomized trial included unassisted adult smokers (n = 685), whose preferred language was English or Spanish, in a Los Angeles safety-net health system. Patients were randomized to receive a call from a local or generic toll-free area code. Log-binomial regression was used to examine the association between area code and consent to a quitline e-referral, adjusted for age, gender, language, and year. RESULTS: Overall, 52.1% of the patients were contacted and, among those contacted, 30% consented to a referral. The contact rate was higher for the local versus generic area code, although not statistically significant (55.6% vs. 48.7%, p = .07). The consent rate was higher in the local versus generic area code group (adjusted prevalence ratio 1.29, 95% CI 1.01-1.65) and also higher for patients under 61 years old than over (adjusted prevalence ratio 1.47, 95% CI 1.07-2.01), and Spanish-speaking than English-speaking patients (adjusted prevalence ratio 1.40, 95% CI 1.05-1.86). CONCLUSIONS: Proactive phone-based outreach to unassisted smokers in a safety net health system increased consent to a quitline referral when local (vs. generic) area codes were used to contact patients. While contact rate did not differ by area code, proactive phone-based outreach was effective for engaging younger and Spanish-speaking smokers. IMPLICATIONS: Population-based proactive phone-based outreach from a caller with a local area code to unassisted smokers in a safety net health system increases consent to an e-referral for quitline services. Findings suggest that a proactive phone-based outreach, a population-based strategy, is an effective strategy to build on the visit-based model and offer services to tobacco users, regardless of the motivational levels to quit.

Re-engagement of Low-Income Smokers in Quitline Services: Effects of Incentives and Method of Contact.

INTRODUCTION: Financial incentives have been shown to improve recruitment of low-income smokers into tobacco quitline services and to improve cessation outcomes. The present study evaluated their use to re-engage low-income smokers who had already used a quitline. AIMS AND METHODS: Randomly selected Medicaid smokers (N = 5200) who had previously enrolled in a quitline were stratified by time since enrollment (3, 6, 9, or 12 months) and randomly assigned in a 2 × 4 factorial design to receive, by mail or telephone, an invitation to reengage, with an offer of no financial incentive or $10, $20, or $40. The primary outcome measure was re-engagement, defined as use of an additional evidence-based quitline service within 90 days. Data were collected from May 2014 to October 2015 and analyzed in 2022. RESULTS: Of 5200 participants invited to reengage in quitline services, 9.3% did so within 90 days, compared to 6.3% of a randomly selected comparison group (n = 22 614, p < .0001). Letters resulted in greater re-engagement than calls (10.9% vs. 7.8%, respectively, p = .0001). Among letters, there was a dose-response relationship between incentive level and re-engagement rates (p = .003). Re-engagement decreased as time since enrollment increased, from 13.7% at 3 months to 5.7% at 12 months (all p's < 0.0001). CONCLUSIONS: Low-income smokers who previously used quitline services can be motivated to reengage in treatment. Mailed letters and automated calls are effective re-engagement strategies. Financial incentives can increase the effectiveness of re-engagement letters. Inviting Medicaid smokers to re-engage with quitline treatment may help to address socioeconomic health disparities and should be standard practice. IMPLICATIONS: Nicotine addiction is a chronic relapsing disorder, yet most cessation services are designed to help smokers through only one quit attempt. Smoking is increasingly concentrated in populations with physical and psychological co-morbidities, which can make quitting more difficult and impact whether smokers reach out for additional help following relapse. This study examined whether the timing, method, and content of an offer for further assistance influenced re-engagement rates for a vulnerable population of smokers-Medicaid beneficiaries. Relapsing smokers are responsive to re-engagement offers as early as three months, but there is a closing window of opportunity to reach them.

Quitline Promotion to Medicaid Members Who Smoke: Effects of COVID-19-Specific Messaging and a Free Patch Offer.

INTRODUCTION: People who smoke are at increased risk of serious COVID-19-related disease but have had reduced access to cessation treatment during the pandemic. This study tested 2 approaches to promoting quitline services to Medicaid members who smoke at high rates: using COVID-19-specific messaging and offering free nicotine patches. The hypotheses were that both would increase enrollment. METHODS: A California Medicaid mailing from October 2020 to January 2021 (N=7,489,093) included 4 versions of a flyer following a 2 × 2 design comparing generic with COVID-19-specific messaging and a no-patch with free-patch offer. The main outcome measure was quitline enrollments. Quit outcomes (attempted quitting, quit ≥7 days, quit ≥30 days) were assessed at 2 months. A subsequent free-patch offer was sent to all members (N=7,577,198) from April 2021 to June 2021. Data were collected in 2020-2021 and analyzed in 2022. RESULTS: The first mailing generated 1,753 enrollments. Response rates were 0.023% and 0.024% for generic and COVID-19-specific messaging, respectively (p=0.538), and 0.006% and 0.041% for no-patch and free-patch offers, respectively, the latter being 6.7 times more effective than the former (p<0.0001). Quit outcomes were comparable across conditions. The subsequent free-patch offer generated 3,546 enrollments at $40.28 per enrollee. CONCLUSIONS: In a Medicaid mailing during COVID-19, offering free patches generated more than 6 times as many quitline enrollments as offering generic help. COVID-19-specific messaging was no more effective than generic messaging. Offering free patches was highly cost-effective. Medicaid programs partnering with quitlines should consider using similar strategies, especially during a pandemic when regular health care is disrupted.

Understanding health disparities affecting utilization of tobacco treatment in low-income patients in an urban health center in Southern California.

Tobacco use disproportionately affects low-income communities. Prevalence among patients in Federally Qualified Health Centers (FQHCs) is higher (29.3%) than the general population (20%). Little is known about the rates of referrals to cessation services and cessation pharmacotherapy practices in FQHCs. This study will examine referral and prescribing patterns based on patient characteristics at a large FQHC in Southern California. We conducted a retrospective analysis of EHR data from 2019. Patients who were ≥ 18 years old and had "tobacco use" as an active problem were included in analyses. We characterized the proportion of 1) those who were referred to California Smokers' Helpline (CSH), 2) referred to smoking cessation counseling (SCC) at the FQHC clinic, or 3) received pharmacotherapy. Associations of demographic characteristics and comorbidities with referral types and uptake of services were evaluated using mixed-effects multinomial and logistic regressions. Of the 20,119 tobacco users identified, 87% had some cessation intervention: 66% were advised to quit and given information to contact CSH, while 21% were referred to SCC. Patients were least likely to get referred to cessation services if they had more medical, psychiatric, or substance use comorbidities, were in the lowest income group, were uninsured or were Hispanic. Although EHR systems have enhanced the ease of screening, most patients do not receive more than brief advice to quit during a PCP visit. Most (70%) low-income smokers see their PCPs at least once a year, making FQHCs excellent settings to promote smoking cessation initiatives in low-income populations.

The Medi-Cal Incentives to Quit Smoking Project: Impact of Statewide Outreach Through Health Channels.

INTRODUCTION: Little is known about how incentives may encourage low income smokers to call for quitline services. This study evaluates the impact of outreach through health channels on California Medicaid (Medi-Cal) quitline caller characteristics, trends, and reach. STUDY DESIGN: Longitudinal study. SETTING/PARTICIPANTS: Medi-Cal quitline callers. INTERVENTION: Statewide outreach was conducted with health providers, Medi-Cal plans (all-household mailings with tracking codes), and public health organizations (March 2012-July 2015). For incentives, Medi-Cal callers could ask for a $20 gift card; in September 2013, callers were offered free nicotine patches. MAIN OUTCOME MEASURES: Caller characteristics were compared with chi-square analyses, joinpoint analysis of call trends was performed accounting for Medi-Cal population growth, referral source among Medi-Cal and non-Medi-Cal callers was documented, and the annual percentage of the population reached who called the Helpline was calculated. Analyses were conducted 2016-2018. RESULTS: Total Medi-Cal callers were 92,900, a 70% increase from prior annual averages: 12.4% asked for the financial incentive, 17.3% reported the mailing code, and 73.3% received nicotine patches while offered. Among the two thirds of callers who completed counseling, 15.5% asked for the financial incentive, and 13.6% reported the mailing code. A joinpoint analysis showed call trends increased 23% above expected for the Medi-Cal population growth after mailings to providers and members began, and decreased after outreach ended. Annual reach increased from 2.3% (95% CI=2.1, 2.6) in 2011 to peak at 4.5% (95% CI=3.6, 5.3) in 2014. Among subgroups with higher reach rates, some also had higher rates of asking for the financial incentive (African Americans, American Indian), reporting the tracking code (whites), or both (aged 45-64 years). Medi-Cal callers were more likely than non-Medi-Cal callers to report providers (32.3% vs 23.8%) and plans (19.7% vs 1.4%) as their referral source, and less likely to cite media (20.2% vs 44.4%, p<0.001). CONCLUSIONS: Statewide outreach through health channels incentivizing Medi-Cal members increased the utilization and reach of quitline services. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Effects of Offering Nicotine Patches, Incentives, or Both on Quitline Demand.

INTRODUCTION: Previous studies found that offering free nicotine patches significantly increases calls to quitlines, although most used pre-post designs and did not directly compare the effects of patches and other incentives. The current study with California Medicaid members used a 2 × 2 design to directly assess the effects of offering free patches and incentives on calls to a quitline. The hypotheses were that offering either would make members more likely to call, and that offering both would increase demand even further. METHODS: Flyers were inserted into a mailing sent to 4,268,696 Medicaid households, with one of four offers: (1) free counseling; (2) counseling plus patches; (3) counseling plus a $20 gift card; and (4) counseling plus patches and gift card. Ninety percent received the first offer and 10% received one of the other three offers, in equal proportions. The mailers shipped late 2013 to early 2014. Data were collected 2013-2015 and analyzed 2018. RESULTS: Response rates were 0.029% for counseling, 0.115% for counseling plus patches, 0.122% for counseling plus gift card, and 0.200% for counseling, patches, and gift card. Both patches and gift cards had statistically significant effects (both p<0.001). Promotional costs were 59%-75% lower with an incentive. Non-whites responded more strongly than whites to a gift card offer. CONCLUSIONS: Offering either free patches or a $20 gift card quadrupled the likelihood of Medicaid smokers calling a quitline; offering both had a nearly additive effect. Incentive offers dramatically increased the cost-effectiveness of promotions. Piggybacking on existing Medicaid communications to promote cessation proved very successful. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Direct-to-Member Household or Targeted Mailings: Incentivizing Medicaid Calls for Quitline Services.

INTRODUCTION: Innovative methods are needed to promote tobacco cessation services. The Medi-Cal Incentives to Quit Smoking project (2012-2015) promoted modest financial and medication incentives to encourage Medi-Cal smokers to utilize the California Smokers' Helpline (Helpline). This article describes the implementation and impact of two different direct-to-member mailing approaches. METHODS: Medi-Cal Incentives to Quit Smoking promotional materials were mailed directly to members using two approaches: (1) household mailings: households identified through centralized membership divisions and (2) individually targeted mailings: smokers identified by medical codes from Medi-Cal managed care plans. Mailings included messaging on incentives, such as gift cards or nicotine patches. Number of calls per month, calls per unit mailed, and associated printing costs per call were compared during and 1 month after mailings. Activated caller response was based on reporting a household mailing promotional code or based on requesting financial incentives for individually targeted mailings. Analyses were conducted in 2018. RESULTS: Direct-to-member mailings, particularly with incentive messaging, demonstrated an increase in call volumes during and 1 month after mailing, and increased Medi-Cal calls to the Helpline per unit mailed. Mailings with only counseling messages had the lowest percentage of activated calls per unit mailed, whereas the incentive messaging mailings were consistently higher. Although household mailings demonstrated lower printing costs per call, individually targeted mailings had a higher percentage of activated calls per unit mailed. CONCLUSIONS: Household and individually targeted mailings are feasible approaches to increase Medi-Cal calls to the Helpline, particularly with incentive messaging. Choosing an approach and messaging depends on available resources, timing, and purpose. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Helping Hospitalized Smokers: A Factorial RCT of Nicotine Patches and Counseling.

INTRODUCTION: Most smokers abstain from smoking during hospitalization but relapse upon discharge. This study tests the effectiveness of two proven treatments (i.e., nicotine patches and telephone counseling) in helping these patients stay quit after discharge from the hospital, and assesses a model of hospital-quitline partnership. STUDY DESIGN: This study had a 2×2 factorial design in which participants were stratified by recruitment site and smoking rate and randomly assigned to usual care, nicotine patches only, counseling only, or patches plus counseling. They were evaluated at 2 and 6 months post-randomization. SETTING/PARTICIPANTS: A total of 1,270 hospitalized adult smokers were recruited from August 2011 to November 2013 from five hospitals within three healthcare systems. INTERVENTION: Participants in the patch condition were provided 8 weeks of nicotine patches at discharge (or were mailed them post-discharge). Quitline staff started proactively calling participants in the counseling condition 3 days post-discharge to provide standard quitline counseling. MAIN OUTCOME MEASURES: The primary outcome measure was self-reported 30-day abstinence at 6 months using an intention-to-treat analysis. Data were analyzed from September 2015 to May 2016. RESULTS: The 30-day abstinence rate at 6 months was 22.8% for the nicotine patch condition and 18.3% for the no-patch condition (p=0.051). Nearly all participants (99%) in the patch condition were provided nicotine patches, although 36% were sent post-discharge. The abstinence rates were 20.0% and 21.1% for counseling and no counseling conditions, respectively (p=0.651). Fewer than half of the participants in the counseling condition (47%) received counseling (mean follow-up sessions, 3.6). CONCLUSIONS: Provision of nicotine patches proved feasible, although their effectiveness in helping discharged patients stay quit was not significant. Telephone counseling was not effective, in large part because of low rates of engagement. Future interventions will need to be more immediate to be effective. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01289275.

Fidelity monitoring across the seven studies in the Consortium of Hospitals Advancing Research on Tobacco (CHART).

BACKGROUND: This paper describes fidelity monitoring (treatment differentiation, training, delivery, receipt and enactment) across the seven National Institutes of Health-supported Consortium of Hospitals Advancing Research on Tobacco (CHART) studies. The objectives of the study were to describe approaches to monitoring fidelity including treatment differentiation (lack of crossover), provider training, provider delivery of treatment, patient receipt of treatment, and patient enactment (behavior) and provide examples of application of these principles. METHODS: Conducted between 2010 and 2014 and collectively enrolling over 9500 inpatient cigarette smokers, the CHART studies tested different smoking cessation interventions (counseling, medications, and follow-up calls) shown to be efficacious in Cochrane Collaborative Reviews. The CHART studies compared their unique treatment arm(s) to usual care, used common core measures at baseline and 6-month follow-up, but varied in their approaches to monitoring the fidelity with which the interventions were implemented. RESULTS: Treatment differentiation strategies included the use of a quasi-experimental design and monitoring of both the intervention and control group. Almost all of the studies had extensive training for personnel and used a checklist to monitor the intervention components, but the items on these checklists varied widely and were based on unique aspects of the interventions, US Public Health Service and Joint Commission smoking cessation standards, or counselor rapport. Delivery of medications ranged from 31 to 100 % across the studies, with higher levels from studies that gave away free medications and lower levels from studies that sought to obtain prescriptions for the patient in real world systems. Treatment delivery was highest among those studies that used automated (interactive voice response and website) systems, but this did not automatically translate into treatment receipt and enactment. Some studies measured treatment enactment in two ways (e.g., counselor or automated system report versus patient report) showing concurrence or discordance between the two measures. CONCLUSION: While fidelity monitoring can be challenging especially in dissemination trials, the seven CHART studies used a variety of methods to enhance fidelity with consideration for feasibility and sustainability. TRIAL REGISTRATION: Dissemination of Tobacco Tactics for hospitalized smokers. Clinical Trials Registration No. NCT01309217.Smoking cessation in hospitalized smokers. Clinical Trials Registration No. NCT01289275.Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial. Clinical Trials Registration No. NCT01305928.Web-based smoking cessation intervention that transitions from inpatient to outpatient. Clinical Trials Registration No. NCT01277250.Effectiveness of smoking-cessation interventions for urban hospital patients. Clinical Trials Registration No. NCT01363245.Comparative effectiveness of post-discharge interventions for hospitalized smokers. Clinical Trials Registration No. NCT01177176.Health and economic effects from linking bedside and outpatient tobacco cessation services for hospitalized smokers in two large hospitals. Clinical Trials Registration No. NCT01236079.

A Multistate Asian-Language Tobacco Quitline: Addressing a Disparity in Access to Care.

OBJECTIVES: We conducted a dissemination and implementation study to translate an intervention protocol for Asian-language smokers from an efficacy trial into an effective and sustainable multistate service. METHODS: Three state tobacco programs (in California, Colorado, and Hawaii) promoted a multistate cessation quitline to 3 Asian-language-speaking communities: Chinese, Korean, and Vietnamese. The California quitline provided counseling centrally to facilitate implementation. Three more states joined the program during the study period (January 2010-July 2012). We assessed the provision of counseling, quitting outcomes, and dissemination of the program. RESULTS: A total of 2004 smokers called for the service, with 88.3% opting for counseling. Among those opting for counseling, the 6-month abstinence rate (18.8%) was similar to results of the earlier efficacy trial (16.4%). CONCLUSIONS: The intervention protocol, based on an efficacy trial, was successfully translated into a multistate service and further disseminated. This project paved the way for the establishment of a national quitline for Asian-language speakers, which serves as an important strategy to address disparities in access to care.

Nicotine patches and quitline counseling to help hospitalized smokers stay quit: study protocol for a randomized controlled trial.

BACKGROUND: Hospitalized smokers often quit smoking, voluntarily or involuntarily; most relapse soon after discharge. Extended follow-up counseling can help prevent relapse. However, it is difficult for hospitals to provide follow-up and smokers rarely leave the hospital with quitting aids (for example, nicotine patches). This study aims to test a practical model in which hospitals work with a state cessation quitline. Hospital staff briefly intervene with smokers at bedside and refer them to the quitline. Depending on assigned condition, smokers may receive nicotine patches at discharge or extended quitline telephone counseling post-discharge. This project establishes a practical model that lends itself to broader dissemination, while testing the effectiveness of the interventions in a rigorous randomized trial. METHODS/DESIGN: This randomized clinical trial (N = 1,640) tests the effect of two interventions on long-term quit rates of hospitalized smokers in a 2 x 2 factorial design. The interventions are (1) nicotine patches (eight-week, step down program) dispensed at discharge and (2) proactive telephone counseling provided by the state quitline after discharge. Subjects are randomly assigned into: usual care, nicotine patches, telephone counseling, or both patches and counseling. It is hypothesized that patches and counseling have independent effects and their combined effect is greater than either alone. The primary outcome measure is thirty-day abstinence at six months; a secondary outcome is biochemically validated smoking status. Cost-effectiveness analysis is conducted to compare each intervention condition (patch alone, counseling alone, and combined interventions) against the usual care condition. Further, this study examines whether smokers' medical diagnosis is a moderator of treatment effect. Generalized linear (binomial) mixed models will be used to study the effect of treatment on abstinence rates. Clustering is accounted for with hospital-specific random effects. DISCUSSION: If this model is effective, quitlines across the U.S. could work with interested hospitals to set up similar systems. Hospital accreditation standards related to tobacco cessation performance measures require follow-up after discharge and provide additional incentive for hospitals to work with quitlines. The ubiquity of quitlines, combined with the consistency of quitline counseling delivery as centralized state operations, make this partnership attractive. TRIAL REGISTRATION: Smoking cessation in hospitalized smokers NCT01289275. Date of registration February 1, 2011; date of first patient August 3, 2011.

Perceived barriers to adopting an Asian-language quitline service: a survey of state funding agencies.

This study examined the perceived barriers to adopting an Asian-language quitline service among agencies that fund current state quitline services across the U.S. A self-administered survey on organizational readiness was sent to the funding agencies of 47 states plus Washington D.C. that currently fund state quitlines in English and Spanish, but not in Asian languages (response rate = 58%). The 2010 Census and the 2009 North American Quitline Consortium Survey were used to obtain the proportion of Asians among the state population and state quitline funding level, respectively. The most frequently cited reasons for not adopting an Asian quitline are: the Asian population in the state would be too small (71.4%), costs of service would be too high (57.1%), and the belief that using third-party translation for counseling is sufficient (39.3%). However, neither the actual proportion of Asians among the state population (range = 0.7% to 7.3%), nor the quitline funding level (range = $0.17 to $20.8 per capita) predicts the reported reasons. The results indicate that quitline funding agencies need more education on the necessity and the feasibility of an Asian-language quitline. Three states are currently participating in a multi-state Asian-language quitline in which each state promotes the service to its residents and one state (CA) provides the services for all the states. This centralized multi-state Asian-language quitline operation, which helps reduce practical barriers in adoption and disparity in access to service, could be extended.

Tobacco cessation quitlines in North America: a descriptive study.

BACKGROUND: Quitlines have become an integral part of tobacco control efforts in the United States and Canada. The demonstrated efficacy and the convenience of telephone based counselling have led to the fast adoption of quitlines, to the point of near universal access in North America. However, information on how these quitlines operate in actual practice is not often readily available. OBJECTIVES: This study describes quitline practice in North America and examines commonalities and differences across quitlines. It will serve as a source of reference for practitioners and researchers, with the aim of furthering service quality and promoting continued innovation. DESIGN: A self administered questionnaire survey of large, publicly funded quitlines in the United States and Canada. A total of 52 US quitlines and 10 Canadian quitlines participated. Descriptive statistics are provided regarding quitline operational structures, clinical services, quality assurance procedures, funding sources and utilisation rates. RESULTS: Clinical services for the 62 state/provincial quitlines are supplied by a total of 26 service providers. Nine providers operate multiple quitlines, creating greater consistency in operation than would otherwise be expected. Most quitlines offer services over extended hours (mean 96 hours/week) and have multiple language capabilities. Most (98%) use proactive multisession counselling-a key feature of protocols tested in previous experimental trials. Almost all quitlines have extensive training programmes (>60 hours) for counselling staff, and over 70% conduct regular evaluation of outcomes. About half of quitlines use the internet to provide cessation information. A little over a third of US quitlines distribute free cessation medications to eligible callers. The average utilisation rate of the US state quitlines in the 2004-5 fiscal year was about 1.0% across states, with a strong correlation between the funding level of the quitlines and the smokers' utilisation of them (r = 0.74, p<0.001). CONCLUSIONS: Quitlines in North America display core commonalities: they have adopted the principles of multisession proactive counselling and they conduct regular outcome evaluation. Yet variations, tested and untested, exist. Standardised reporting procedures would be of benefit to the field. Shared discussion of the rationale behind variations can inform future decision making for all North American quitlines.