The characteristics of the 55 individuals that agreed to be interviewed versus those that were invited but did not participate in the interviews are displayed in Table 1. Our iterative sampling required us to contact 170 individuals to achieve the sample of 55 (31% participation rate). Participants were an average age of 50.6 years; 76% were female, 58% were African American, and 57% received Medicaid. Overall, those that participated were similar across characteristics to those that did not participate.
Table 1. Characteristics of interview participants and non-participants
Characteristic
|
Total
N=170
|
Participants
n=55
|
Non-participants
n=115
|
Age, mean (std dev)
|
51.3 (13.2)
|
50.6 (12.0)
|
51.6 (13.8)
|
Female
|
108 (64%)
|
42 (76%)
|
66 (57%)
|
African American
|
95 (56%)
|
32 (58%)
|
63 (55%)
|
Insurance type
|
|
|
|
Commercial
|
4 (2%)
|
1 (2%)
|
3 (3%)
|
Medicaid
|
106 (62%)
|
31 (57%)
|
75 (65%)
|
Medicare
|
58 (34%)
|
21 (39%)
|
37 (32%)
|
Self-pay
|
1 (1%)
|
1 (2%)
|
0 (0%)
|
Our analysis generated six themes, or clusters of meaning, that shed light on the common experiences, motivations and understandings of those who did not complete the available five counseling sessions offered by the QL. We found that these themes crosscut the QL categories of ‘declined’ and ‘unable to be reached’. These themes are not mutually exclusive, and many patients reported more than one theme. We discuss each of the themes below. Additional example quotations for each theme are provided in Table 2.
Table 2. Thematic quotations from interviews with smokers e-referred to the Ohio Quitline
Differing expectations regarding the quitline referral
“You know, and I just wasn’t sure (what to expect). To be honest with you, I thought it was a program like a friend of mine went through some years ago where he actually went like to one of the clinics in the evenings.” [ID #08]
[Describing a visit during which the patient was in too much pain to ask questions clarifying the QL referral] “The only thing I got was ‘You call them, and they’ll call you back.’ That’s the only thing I got… I wanted to ask, but I was in pain… I wanted to know about like if you go to the hospital and you sit down with somebody. I wanted to ask those questions, but I honestly was not feeling good and I didn’t wanna hear anything.” [ID #14]
“I wanted patches. So that’s what I thought I was gon’ get, some patches. Like I was saying, that’s not what I wanted to do - them checking on me and this and that and all that… So you know, I told them, ‘That’s all right.’ If I couldn’t get the patches, that’s all right. That was the end of that conversation. [ID #25].”
Changing life circumstances and stressors
“My mother had a stroke, and but she wasn’t doing too good and wasn’t nobody here to take care of her, but me. You know how hard that was on me. She was bedridden, and she died like in August of last year. Yeah, and trying to take care of myself and trying to take care of her. It was a lot.”
“I just had a lot going on. A lot of issues with family, things going on lately. Our home was just burglarized a couple weeks ago. I’ve just had a lot going on… I mean it’s definitely something I’d like to do eventually. It’s just gotta be the right time, and a lot of times when you try to quit something and then you go back to it, becomes, you know it just becomes worse, I guess.” [ID #33]
“Well they sent me the brochures and everything. But my mindset wasn’t in the right frame of mind at that point, ‘cause my dad was in a nursing home. And he just recently passed away, so I wasn’t really in the right state of mind back then. It was kind of stressful, and that was like the stress-relief to get out the nursing home and have me a cigarette and go home.” [ID #44]
Unable to find time for counseling
“I’ve been at work so much that I never get a chance to conversate with them, ‘cause I’m at work like from morning ‘til late evening.” [ID #13]
“I actually received a couple calls that I missed because I was at appointments, or I was either at my kids’ school or something and didn’t answer the phone.” [ID #12]
“Usually when they call, sometimes I don’t answer because I’m either picking up my kid, or taking him to school… and then with Christmas, holidays. Everything is just, you know, and then trying to figure out with the doctor ‘cause well I just had another episode, so I was in the hospital.” [ID #22]
Cell phone barriers
“They probably tried to call me, but my phone’s been stupid… I cracked it, so sometimes it answers and sometimes it doesn’t.” [ID #54]
“Yeah, and then the phone I had, I lost it, and I ain’t been able to afford me another phone, but I got a birthday soon coming. I guess they’ll pitch in and buy me a phone, and I’m using a temporary phone now until I get me another real good phone. I had phones and kept having problems with them.” [ID #52]
“The MA asked if I had any interest in stopping and I told her yes, and then she gave me or told me about the quitline was supposed to call me, which I believe they may have, but the number comes up and if it’s an 800 number, I usually don’t answer it because you know it doesn’t come up under the quitline, you know, ID. It just comes up as an 800 number.” [ID #04]
Discomfort with/disbelief in the efficacy of quitline counseling
“I did (agree to be connected to the quitline), and we did speak. Someone did call me with the department of the quitline, and I was not comfortable. I’m not gonna lie to you… I think it was just the person that spoke to me over the phone. In reality, I know that it’s just your job to try to give information out, or try to help someone, but you need to feel comfortable with somebody when you speak to them over the phone, and I just didn’t feel comfortable with the first call I got. So I didn’t agree to the over-the-phone line quitting situation because, I don’t know. I just didn’t feel comfortable.” [ID #15]
“You know the first time, the lady was professional and generous. It’s just I don’t think it was very helpful to me.”[ID #41]
“Cause talking with somebody about quitting doesn’t do any good. I feel like talking wouldn’t do any good. ‘Cause I would go ahead on and say ‘Yeah. Um hmm. Yeah. You’re right. You’re right.’ and it’ll be going in one ear, coming out the other. [ID #23]
Quitting on their own
“I got a call and they asked me, you know they said ‘Are you interested in quitting?’ and I said ‘Yeah.’ I told them I was in the process of trying to quit then, you know, and they told me if I needed help, to get in touch with them.” [ID #28]
“They called me, but I didn’t really speak with them because I actually stopped, and I didn’t need the help. And I’ve been doing good ever since then. “[ID #03]
|
Reasons for QL disengagement
- Differing expectations regarding the QL referral
The degree to which participants understood what the QL counseling process involved varied a great deal. In some cases, participants expected the cessation counseling to be in-person, at a local hospital or clinic. When these participants became aware that the counseling was via telephone, some were uncomfortable with the prospect of speaking with a “stranger” or “random people”. In other cases, individuals did not understand they were accepting a referral. At the time, they were experiencing symptoms related to the reason for their visit to the doctor, such as trouble breathing, or intense pain: “I’m in too much pain sometimes when I go to the doctor. So I’m just like ‘Okay. Yeah, I know. I know.’” [ID# 14] Another area of misunderstanding was the role of the QL in supporting smoking cessation. Some participants believed the QL simply provides NRT free of cost, and had no interest in counseling: “Basically they was telling me that you gotta do counseling and stuff, and that’s not what I was looking to do. I was basically looking just to get the patches and try to do it on my own.” [ID# 39]
- Changing life circumstances and stressors
Another pervasive theme was that stress from traumatic events or changing life circumstances made it difficult for many participants to begin or stick with the program, and in some cases resulted in the participant no longer feeling ready to quit. The circumstances mentioned by these participants included stressors such as housing instability, serious illness or hospitalization, recent death of a loved one, and being the victim of a crime. One individual, who was living in a transitional housing unit, reports: “They call me every two weeks to coach me to stop smoking. But like I told them this past week - I was being honest with them ‘cause I was avoiding their calls when they came through - I never did stop smoking, or slow down, due to the fact that I am stressed big time, living in a box… And it’s a whole lot of other stressful stuff going on in my family, of me burying people. And I’m just out of it. So I’m not really on the right track of stop smoking.” [ID #24]
- Unable to find a time for counseling
Several participants expressed that, although they were interested in quitting smoking, they found it difficult to find time to engage in a QL counseling call. Participants spoke of having a job or multiple jobs that kept them too busy to contact the QL, or unpredictable work schedules that made it difficult to keep appointments with the QL. In addition, many participants had responsibilities such as taking care of children, parents and other family members. These priorities often meant that QL counseling was either intentionally or unintentionally put on the backburner. Engaging in counseling sessions with the QL “takes too much time out of my days, and I don’t have the time.“ [ID #39]
- Cell phone barriers
Access to a properly functioning phone with a consistent number and uninterrupted service was a common barrier for the QL reaching participants. For some, a disruption in cell service precluded the QL from making contact with a participant: “I know that [the MA] recommended me, and the people were supposed to call me from the 1-800-quitline. But the time they was calling, my phone was cut off.” [ID #19] Further, if participants reported that their cell phone was lost, stolen, or no longer functioning, replacing it was not always viable immediately. In some cases, they had to wait until funds were available. Additionally, the QL phone number is a 1-800 number that does not appear with a description in caller ID. Some individuals were suspicious of unidentified numbers and/or had a policy of not answering 1-800 numbers. Although the QL does leave messages, many participants reported not listening to their messages, especially if it was from an unknown number.
- Discomfort with/disbelief in the efficacy of QL counseling
Another reason for declining the QL program or being unreachable was discomfort with the phone counseling experience, or the belief that it would not help them quit. Some participants did not feel a personal connection to the counselor, and therefore felt hesitant about discussing their situations. Others, even while acknowledging that the QL information was helpful, did not feel the counseling process would actually help them quit smoking: “I never knew about the phone therapy. That was my first time experiencing it, knowing about it. So I tried it out and I didn’t like it.” [ID #24].
- Quitting on their own
A few unreachable or disenrolled participants, as identified by the QL, had already quit smoking or cut back significantly prior to the completion of the QL protocol. These individuals felt confident in their ability to stay tobacco-free or continue the quitting process, and felt they no longer needed assistance from the QL.
Quitline benefits and ongoing support
Another common theme that emerged among those who had received any QL counseling, including those who at some point disengaged and did not complete the protocol (‘declined’ or ‘unable to be reached’), was that they benefitted from the experience. While some participants reported quitting or cutting down on their smoking, others reported an increased desire to quit, more awareness of their smoking behavior, or some other form of incremental progress in smoking cessation:
“It was helpful. It definitely was. When I do wanna smoke a cigarette, that (counseling advice) always plays in my ear. So I’ll never forget that every time I pick up a cigarette. So that’s making it better for me.” [ID #49]
Another finding was that several participants who completed the QL program, or were no longer receiving calls because they had been categorized as declined or unreachable, desired continued cessation support. One patient had agreed to the eReferral, but was in the hospital for an emergency surgery when the QL called, so she declined to speak with them at that time:
“Yes, I would (like to talk to the QL), because it was just a misunderstanding and the wrong moment. That’s all it was.”[ID #19]
Another patient had completed her 5 counseling sessions with the QL, but had not completely quit smoking yet:
“Yeah. I’d still like to talk to them. That way we can still set goals and have the motivation to keep going.” [ID #54]
With regard to the larger, primary care context of smoking cessation, the overwhelming majority of patients reported wanting providers’ continued offers of assistance and support with smoking cessation. When asked what role they wanted their primary care providers to play in their smoking cessation, participants expressed the desire for ongoing assistance and encouragement:
“’If this don’t work, let’s go to the next level,’ you know. In other words, let’s not give up on me. You know, “Come on - you keep trying until we find the right thing for you.’ That’s what I want.” [ID #14]
“Just check up to see how I’m doing. Am I still smoking? Am I not smoking?” ‘How are you doing with your smoking?’ or ‘If you are still smoking, is there something else that we can do to help you stop smoking?’ Those type of questions.” [ID#42]