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Journal of the New Zealand Medical Association, 15-June-2007, Vol 120 No 1256

Changes in characteristics of New Zealand Quitline callers between 2001 and 2005

Judy Li, Michele Grigg

Abstract

Aims To identify trends in the demographic and smoking characteristics of new callers to the New Zealand Quitline, a national free-phone smoking cessation service, between 2001 and 2005.

Methods Demographic and smoking behaviour of Quitline callers were routinely collected by Quit Advisors over the phone. Characteristics of new callers were extracted from the client database, and compared across 5 years to determine changes over time.

Results Statistically significant differences were found in all variables (except for gender) across the 5-year period. The results show an increased proportion of callers are under 25 years old (67% increase), started smoking at 15 years old or older (10% increase), and/or have smoked for less than 10 years (86% increase). There is also an increased proportion of callers smoking roll-your-own cigarettes (13% increase). In terms of ethnicity, the proportion of Pacific people using the Quitline increased by 54%, while the proportion of Māori callers fluctuated at just above 20% of all new callers. The proportion of pregnant callers also increased over time (127% increase) although the overall percent remains small.

Conclusions The results indicate notable changes in the characteristics of new Quitline callers between 2001 and 2005. Such information will be of benefit to the future design of Quitline marketing and adapting service provision to best meet the needs of callers.

New Zealand’s national free-phone Quitline was established in 1999. Since then, no analysis has been conducted to identify trends in characteristics of callers over time. Similar research appears to be lacking in other countries, where researchers have built profiles using accumulated statistics without addressing changes over time.1–2

This study therefore aimed to explore this aspect by analysing the demographic and smoking characteristics of new callers registering with the New Zealand Quitline during the 5 years from 2001 to 2005.

In November 2000, the New Zealand Quitline became a world-first by providing heavily subsidised nicotine replacement therapy (NRT) in the form of patches and gum as an adjunct to its telephone smoking cessation service. Prior to the introduction of NRT, Quitline callers received information and practical strategies for quitting, along with proactive follow-up calls from a Quit Advisor for quit support and advice.

With the new service, callers are eligible to receive NRT when certain conditions are met (such as a satisfactory medical history and a commitment to quit). The availability of heavily subsidised NRT (a 92% reduction in the over-the-counter price) was well received by the smoking population, evidenced in the sharp increase of callers that was sustained for several years.3 This was similar to a more recent experience in Minnesota, USA where the Quitline offering free patches and gum to callers.4

An evaluation of the New Zealand Quitline by an external contractor suggests the provision of NRT as an adjunct to telephone support increases long-term quit rates and is cost-effective.5

The Quitline also airs mass-media campaigns on national television to motivate people to think about and take action on quitting smoking and to generate awareness of the Quitline. The campaigns target the 25 to 44 age group, with some television advertisements specifically targeting Māori, the indigenous population of New Zealand. Previous studies suggest television advertising campaigns are effective in attracting callers to the Quitline, including Māori and Pacific callers.6,7 (Pacific people in New Zealand are mostly of Samoan, Tongan, Niuean, or Cook Islands origin.)

Policy on tobacco control also motivates smokers to use the Quitline. An important policy change in New Zealand between 2001 and 2005 is the Smokefree Environments Act legislation that came into effect on 19 December 2004. This resulted in a significant increase in calls to the Quitline.8

Methods

New callers are defined as callers who have never previously called the Quitline. They comprise an average of 75% of all registered callers. Relapsed callers comprise an additional 25% but are not included in this analysis to avoid double counting of callers. The characteristics of new callers were obtained over the phone by the Quit Advisors, and stored into an electronic database.

Although the database contains data from 1999, the small number of callers who registered with the Quitline before the provision of NRT made comparisons infeasible. As mentioned, heavily subsidised NRT was first introduced in late 2000 and was in high demand. Moreover, the availability of heavily subsidised NRT from the Quitline might have attracted different types of callers from 2001. Thus a decision was made to exclude callers registered before 2001 from the analysis.

There was some missing data in the database, due partly to the information not being recorded or asked by Quit Advisors, or because callers refused to answer. From May 2005, a new system was used to distinguish new callers who ask for quitting information only from those who are ready to set a quit date. The former group is asked only to provide basic demographic data and is mailed some quit smoking resources, while the latter go through an in-depth initial conversation and provide information on their demographic and smoking characteristics on a voluntary basis.

To ensure the aggregated data are comparable across the years, both types of callers in 2005 are combined together. This means that the amount of missing data on smoking characteristics is higher in 2005 due to the new system of recording just key demographic details for callers seeking information only (14.4% of new callers in 2005).

There is an organisational focus on attracting Māori and Pacific callers due to high rates of smoking prevalence in these two ethnic groups.9 In order to observe trends in this study, callers are categorised into three ethnic groups: Māori, Pacific people, and Other.

Callers were asked by Quit Advisors to indicate their ethnicity and multiple responses are allowed. Māori are those self-identified as Māori while Pacific callers include those who identified themselves as Samoan, Cook Island, Tongan, or Niuean, regardless of other ethnic groups they have identified with.

Callers of other ethnicities (such as New Zealand European, Asian, and Middle Eastern) are categorised as Other. As multiple responses are allowed, callers could be counted in more than one ethnicity category.

The mean and valid percentage of all variables were calculated using SPSS v14.0 software. Epi Info software was used to calculate χ2 (Chi-squared) for trends in proportion. Significance is reported at the 95% level.

Results

Overall trends—Between the years of 2001 and 2005 (inclusive), the New Zealand Quitline assisted an average of 30,000 new callers each year. Of these, around 18% received only a Quit pack containing information on quitting, while the remainder received support and advice from a Quit Advisor. Among the latter group of callers, around 82% received NRT as an adjunct to telephone support. Results are summarised in Table 1. Statistically significant trends are found for all variables except gender.

Table 1. Demographic and smoking characteristics of new callers to the New Zealand Quitline (callers registered between 2001 and 2005)

Year		2001	2002	2003	2004	2005	Chi-square trend	P value
Number of registered callers		n=36,568	n=44,446	n=27,234	n=23,126	n=19,978
Gender (%)	Male	n=36,568 44.9	n=44,310 46.0	n=27,059 46.4	n=22,956 45.9	n=19,445 46.0	2.33	0.13
Gender (%)	Female	55.1	54.0	53.6	54.1	54.0	1.86	0.17
Ethnicity	Māori	n=33,951 22.9	n=40,823 23.9	n=26,132 21.8	n=22,150 21.6	n=18,226 22.4	14.71	<0.001*
	Pacific	2.8	4.1	3.9	3.7	4.3	52.53	<0.001*
	Other	79.7	78.0	78.0	80.9	80.1	1.78	0.18
Pregnant (%)	Yes	n=16,082 1.1	n=15,550 1.3	n=9,468 2.1	n=8,392 1.7	n=8,320 2.5	78.37	<0.001*
Age at registration (%)	<15	n=27,834 0.5	n=28,902 0.9	n=21,452 1.4	n=22,696 1.3	n=18,536 1.4	121.82	<0.001*
	15–19	5.3	8.4	10.7	9.9	11.1	439.4	<0.001*
	20–24	9.5	12.0	13.5	12.8	13.1	124.81	<0.001*
	25–29	13.3	13.7	13.2	12.5	12.5	12.42	<0.001*
	30–34	15.2	15.0	13.7	13.5	13.1	46.71	<0.001*
	35–39	13.8	13.4	12.1	12.2	12.0	38.05	<0.001*
	40–44	12.8	11.4	11.1	11.0	10.4	48.81	<0.001*
	45–49	9.6	8.6	8.0	8.6	8.3	16.65	<0.001*
	50–54	7.8	6.4	5.9	6.3	6.3	38.56	<0.001*
	55+	12.2	10.1	10.3	11.9	11.7	.18	0.67
Age started smoking	<15	n=2,955 39.4	n=8,082 43.9	n=4,581 41.4	n=3,601 36.4	n=10,477 33.5	7.16	0.01*
	15–24	51.6	46.9	48.5	51.1	55.5	16.49	<0.001*
	25+	8.9	9.2	10.1	12.2	11.0	34.95	<0.001*
Years been smoking	<5	n=14,331 4.7	n = 8,161 7.7	n = 4,585 9.6	n = 3,604 9.7	n=10,482 12.2	391.18	<0.001*
	5-9	10.4	13.2	13.1	14.7	15.9	123.29	<0.001*
	10+	84.9	79.1	77.3	75.7	71.9	74.18	<0.001*
Type of tobacco	Tailor-made	n=22,674 49.6	n=28,400 51.5	n=17,379 51.3	n=15,383 49.0	n=15,516 49.2	2.38	0.12
	RYO	37.6	37.1	39.0	41.4	42.4	64.00	<0.001*
	Both	12.8	11.4	9.7	9.9	8.4	176.7	<0.001*

Note: The total percentage of ethnicity exceeds 100 as callers were coded into more than one category if they identified themselves under multiple ethnicity groups; RYO=Roll-your-own cigarettes; *Denotes statistically significant change.

Trends by gender, pregnancy, and age group—The gender composition of callers was similar across the years, with the percent of female callers exceeding that for males at all points-in-time. Only a small percentage (between 1.1% and 2.5%) of female callers was pregnant at the time of registration, yet the increase in this proportion over time is statistically significant.

There were significant changes in the age profile of Quitline callers for all except the ‘55 or over’ age bracket. Callers have become younger on the whole over the 5-year period. Specifically, there was an increase in callers aged 15–19 and 20–24 years, almost a 10% increase from 14.8% in 2001 to 24.2% in 2005; coupled with a slight increase in younger callers aged under 15. Table 2 also shows a decrease in the median age of callers from 2001 to 2005.

Table 2. Median age of new Quitline callers by year

Year registered	2001	2002	2003	2004	2005
Median age (years)	37	34	33	35	34

Trends by ethnic group—The proportion of Māori callers decreased significantly from 2002 to 2003, then became steady at just over 20% of all callers. The proportion of Pacific callers increased significantly overall. In 2005, Māori comprised 22.4% of all callers and Pacific people 4.3% of all callers.

Trends by smoking characteristics—There have been changes in the smoking history of new Quitline callers between 2001 and 2005. A majority of callers started smoking when they were aged 15 or over. The trend fluctuated during the 5-year period, initially dropping but showing an overall significant increase by 2005. There continues to be a large majority of callers who have been smoking for 10 years or more, yet this has dropped continuously from a high of 84.9% in 2001 to 71.9% in 2005.

Conversely, there was an increased proportion of callers who have been smoking for either less than 5 years or for 5 to 9 years. This variable was computed by deducting the number of years that callers have been smoking from their age—as callers were not asked directly about the age they started smoking. As such, this measure makes the assumption that callers have been smoking continuously since they first started smoking, thereby not accounting for any periods as an ex-smoker.

Tailor-made cigarettes were the most common type of tobacco reported, being used by around half of callers and with no trend over time. The use of roll-your-owns (RYOs) or loose tobacco, increased during the period to reach 42.4% in 2005, mirroring the decline in the proportion of callers using both tailor-mades and RYOs.

Discussion

Main findings and interpretations—Characteristics of new callers to the New Zealand Quitline between 2001 and 2005 changed significantly. Characteristics could be influenced by various factors, such as the volume and placement of television advertising, the introduction of smokefree environments legislation in December 2004, and changes made to the Quitline service.

Results of a previous study suggest that a quitline providing NRT might attract smokers who are more nicotine dependent and that this would therefore be the case in the New Zealand situation. That study suggested that smokers/ex-smokers who had used NRT have different demographic and smoking characteristics than those who have never used NRT.10 However the study was conducted in the United States where heavily subsidised NRT is not available nationwide. Thus, the subsidy scheme in New Zealand might have made NRT more affordable and accessible for all smokers meaning the Quitline does not necessarily attract a particular type of smoker with its provision of NRT.

In terms of the changes found in this analysis, there was a 67% increase of under 25-year-old callers. As a reflection of this changing age profile of callers, there was also a 10% increase of callers who started smoking at 15 years old or over and an 86% increase in those who had been smoking for less than 10 years. The gradual change in the age profile of callers may be attributed to a number of factors.

First, Quitline information could have become more accessible to young people via websites, health promoters, and school counsellors. Although the Quitline’s mass media campaigns target the 25–44 age group, the campaigns may also be appealing to youth. It is noted that a campaign in Australia targeting 18–40 year-olds also had an impact on adolescents aged 14–17—by encouraging them to cut down smoking or to quit.11 This study is of relevance to New Zealand as the Australian campaign has been adapted by the New Zealand Quitline for airing in New Zealand.

Although Māori made up 14.7% of New Zealand’s population, a high smoking rate (47%)9 and inequalities in tobacco-related and other health outcomes12 point to the need for making smoking cessation services both accessible and appealing to this group. The results are encouraging in that no fewer than 20% of new callers to the New Zealand Quitline are Māori callers, and the proportion was sustained throughout the 5-year period.

The results also showed an increased proportion of Pacific callers, although the overall percent remains low. The Quitline has recently aired a new cessation media campaign targeting Pacific people to make the service more relevant for this group.13 An evaluation of its effectiveness in future will be valuable.

The gender ratio of callers has been static for a number of years. The higher proportion of female callers is similar to what has been experienced by Quitlines in California and Massachusetts.1–2 It could be that a helpline type of service is more suitable and convenient for females who may have childcare or other household responsibilities, in comparison to other smoking cessation services such as face-to-face intervention.2 Males may also perceive a counselling type of service as less appealing than females.

The increased proportion of pregnant callers registered with the Quitline is a positive sign that this group is becoming increasingly likely to use the Quitline service to quit smoking. A national report in New Zealand provides evidence for a slightly reduced smoking prevalence in women of childbearing age (15–34 years) between 2001 and 2003. There has also been an overall decrease in the smoking prevalence rate among females of all age groups.9

Therefore, the increased proportion of pregnant Quitline callers provides indirect evidence for the increased proportion of women attempting to quit smoking during pregnancy, rather than a greater proportion of females smoking. A study in the United States also indicates a reduced smoking rate during pregnancy between 1990 and 2000.14

The increased proportion of pregnant callers to the Quitline could be attributable to an increased awareness of the harmful effect of prenatal maternal smoking, such as its contribution to pregnancy complications, low birth weight, and premature birth. Related to this, a recent New Zealand study indicates that both smokers and non-smokers were significantly more likely to support smokefree homes in 2004, than in 1999.15 This change suggests that the general population is becoming more conscious of the harms associated with second-hand smoke to household members.

Relatively few studies have been conducted on RYO or loose tobacco. An overseas multi-country study indicates the prevalence of RYO-use varies differently across countries, and that RYOs are being disproportionally used by low incomes and/or low education smokers.16 Anecdotal information in New Zealand supports this finding. Nevertheless, the limited data available in this area means it is difficult to interpret the trends of the increased proportion of Quitline users smoking RYO.

Limitations—The analysis relies on self-reported data provided by Quitline callers over the telephone.

The way in which Pacific callers were categorised could also be problematic. In this study, only four Pacific ethnic groups (Samoan, Cook Island, Tongan, and Niuean) were clustered to form Pacific callers. This excludes other Pacific groups such as Tokelauan and Fijian. This categorisation system was used because ethnicity information recorded in the database is not in sufficient detail to identify all Pacific callers. Pacific callers represent a small proportion of all callers, and the consistency in ethnicity coding across the 5-year period means trends over time could be observed.

While some important demographic and smoking characteristics are available from the database, socioeconomic data is not. Thus studies are needed to address this limitation.

Implications for research—In future, it will be important to explore the reasons underlying these changes over time. They might reflect one or more of the following: general changes in the characteristics of the New Zealand smoker population as a whole;9 changes in the social acceptance of smoking (especially following recent introduction of more restrictions on smoking indoors);15,17 and perceptions of the Quitline; or social marketing strategies used by the Quitline.6,7,13

Implications for service delivery—The similarities and differences in the characteristics of new Quitline callers over a 5-year period revealed in this study are valuable in forecasting future trends. The provision of heavily subsidised NRT is an important feature of the New Zealand Quitline, as evidenced by the increased registration rate when NRT was introduced to the service. As NRT is only distributed to callers under 18 at the Quit Advisor’s discretion, the increased proportion of younger callers suggests a development of alternative cessation support for youth may be useful such as using text messaging to quit and stay abstinent.

Similarly, NRT is not usually prescribed to women during pregnancy. The Quitline could continue to attract more pregnant women to the service by ensuring a tailored intervention is made available to them.

Competing interests: Both authors are employees of The Quit Group, a not-for-profit organisation operating the Quitline on contract to the Ministry of Health.

Author information: Judy Li, Michele Grigg; Researchers; The Quit Group, Wellington

Correspondence: Judy Li, The Quit Group. PO Box 12605, Wellington.
Fax: (04) 470 7632; email: Judy.Li@quit.org.nz

Acknowledgements: This study was funded by The Quit Group that runs the New Zealand Quitline on contract to the Ministry of Health. We also thank Dr Nick Wilson and some other reviewers from The Quit Group for their helpful comments on this paper.

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