INCREASING THE ACCESSIBILITY
OF SMOKING CESSATION SERVICES
As part of an effort to redress this problem, the Tobacco Control Section of the California Department of Health Services began funding the California Smokers' Helpline in August 1992. Smokers from across the state are referred to the Helpline through a variety of means, including media advertisements and physician referral. When they call, they are offered a range of services according to their preference and their readiness to quit. Smokers who are not yet ready to quit are sent materials designed to spur them along, while those who do feel ready but who prefer to quit on their own receive self-help quit kits. Smokers who would like more intensive help can enroll in the Helpline's free telephone counseling program.
The first way in which the Helpline increases the accessibility of smoking cessation services is by educating smokers on where they can get help to quit. The Helpline is aggressively promoted by the media component of the state's Tobacco Control Section, which includes the Helpline's toll-free numbers in ads urging smokers to quit. These ads, in the six languages in which Helpline services are provided, appear on television, radio, and billboards and in newspapers across the state. The Helpline also provides detailed information about its services to health care providers and volunteer organizations so that they have a dependable referral source. Moreover, the Helpline publicizes other cessation programs by sending each caller a descriptive list of all the available programs in his or her area. In these ways, public awareness of help for smoking cessation is enhanced.
The Helpline also reduces many of the costs associated with getting help to quit smoking. The first of these is the actual financial cost. Supported
As mentioned previously, there are other less tangible costs that smokers may incur from traditional programs, including having to wait for cessation classes to form, taking time away from home to attend them, and the effort and expense of arranging for transportation and child care. Even the potential benefit of social support from attending group sessions may be outweighed, for some, by the prospect of facing a roomful of strangers. Some smokers face geographic or language barriers as well. The Helpline reduces all of these costs by enabling smokers to get help without leaving home and by providing services in six of the state's most common languages—English, Spanish, Mandarin, Cantonese, Vietnamese, and Korean. (The Helpline also has a TDD line for the hearing impaired and has recently added a line for smokeless tobacco users.)
The Helpline is also able to increase its accessibility by stretching its resources. The program operates out of a single site, minimizing overhead costs. Also, it employs a stepped-care approach; 19 that is, instead of attempting to provide every caller with its most intensive form of assistance—telephone counseling—it presents a variety of options, including simply receiving materials in the mail or attending one of the cessation groups noted on the referral list. The Helpline lets each caller select the services that he or she feels would be most useful. By allowing callers to “serve themselves” from a menu of different approaches, the Helpline is able to spread its resources among a greater number of people. In just over four years of operation, the Helpline has served more than 41,000 smokers in this way, an average of more than 10,000 people a year. An additional 2,300 nonsmokers have also called the Helpline to get help for their friends and families.
In many cases, it is smokers' own ambivalence that limits their access to programs. A study conducted in southern California when the Helpline was funded to provide counseling only in San Diego County may illustrate this point. In response to calls from more than 700 Los Angeles smokers who said they were planning to quit within a month, the Helpline sent self-help materials and a directory of all the smoking cessation programs in the Los Angeles area. Five weeks later, the Helpline staff called them back and asked if they had attended any of the programs in the directory. Only 6.2% had done so. Given that the first time they called they had appeared motivated to get help to quit, the low rate at which they actually did so suggests that, as a group, they experienced
To counteract this ambivalence and reduce the resulting attrition, the Helpline tested a proactive approach with its counseling clients. As part of a larger study, more than 3,000 smokers who said they were ready to quit within a week and who opted for telephone counseling were told by intake personnel that they would receive a packet of quitting materials in a few days, at which time they should call back to begin the counseling. Subjects were then randomized into two groups. Members of one group were left to call back as instructed; about 34.2% eventually did so and received counseling. In contrast, members of the other group were contacted directly by a counselor. In this group, 74.7% received counseling, demonstrating that a proactive approach to providing service can have a strong counteractive effect on clients' ambivalence.20