Support Person Intervention to Promote Smoker
Utilization of the QUITPLAN®Helpline
Christi A. Patten, PhD, Christina M. Smith, Tabetha A. Brockman, MA, Paul A. Decker, MS,
Kari J. Anderson, BS, Christine A. Hughes, BA, Pamela Sinicrope, DrPH, Kenneth P. Offord, MS,
Edward Lichtenstein, PhD
Effective cessation services are greatly underutilized by smokers. Only about 1.5% of
smokers in Minnesota utilize the state-funded QUITPLAN®Helpline. Substantial evidence
exists on the role of social support in smoking cessation. In preparation for a large
randomized trial, this study developed and piloted an intervention for an adult nonsmok-
ing support person to motivate and encourage a smoker to call the QUITPLAN Helpline.
The support person intervention was developed based on Cohen’s theory of social support.
It consisted of written materials and three consecutive, weekly, 20–30 minute telephone
sessions. Smoker calls to the QUITPLAN Helpline were documented by intake staff.
Participants were 30 support people (93% women, 97% Caucasian, mean age 49). High
rates of treatment compliance were observed, with 28 (93%) completing all three
telephone sessions. The intervention was ranked as somewhat or very helpful by 77% of the
support people, and 97% would definitely or probably recommend the program. Five
smokers linked to a support person called the QUITPLAN Helpline.
An intervention using natural support networks to promote smoker utilization of the
QUITPLAN Helpline is both acceptable to a support person and feasible. A controlled
randomized trial is under way to examine the efficacy of the intervention.
(Am J Prev Med 2008;35(6S):S479–S485) © 2008 American Journal of Preventive Medicine
smokers who tried to quit used one or more types of
evidence-based cessation aids.1–3About 40% of smokers
report having made a quit attempt each year,2,4but
only about 3%–5% maintain abstinence up to 1 year
after quitting.5,6In addition, population-based studies
indicate most smokers (?80%) are not interested in
quitting within the next 30 days.7Thus, an important
public health challenge is how best to encourage quit
attempts using evidence-based treatments, and to reach
smokers with lower levels of readiness to quit.
The Updated Clinical Practice Guidelines on treatment
of tobacco use recommends quitlines as an evidence-
based intervention.8,9In 2001, ClearWay MinnesotaSM
ffective smoking-cessation treatments are greatly
studies indicate that only about 20%–30% of
funded the QUITPLAN®Helpline, a telephone-based
tobacco cessation counseling service for all Minneso-
tans. It is utilized by only about 1.5% of the estimated
666,000 smokers in Minnesota,10consistent with the
reach of other state funded quitlines.11,12With promo-
tional efforts (e.g., publicizing the availability of free
nicotine replacement therapy) the reach of quitlines
can be increased to 2%–6% of smokers.13–17
A novel approach is to promote smoker utilization of
quitline services through nonsmoking family members
and friends (i.e., a support person). Despite the evi-
dence on the role of social support in successful
smoking cessation,8literature reviews indicate that in-
terventions utilizing a support person had inconsistent
smoking abstinence outcomes.18,19It is thought that
support people add complexity to already intensive
clinic-based interventions, and not all smokers are
successful at engaging a support person. The literature
on social relationships and health suggests the effective-
ness of boosting natural support networks versus social
support groups, especially for maintenance of behav-
ioral change (see Cohen20for review). Indeed, while
clinic-based interventions have been generally ineffec-
tive, efforts to promote natural support in the context
of community-based or self-help smoking-cessation in-
terventions have been more successful.21–23A recent
From the Mayo Clinic College of Medicine, Department of Psychiatry
and Psychology, (Patten), Behavioral Health Research Program,
(Patten, Smith, Brockman, Hughes, Sinicrope), Division of Biostatis-
tics (Decker, Anderson, Offord), Rochester, Minnesota; and the
Oregon Research Institute (Lichtenstein), Eugene, Oregon
Address correspondence and reprint requests to: Christi A. Patten,
PhD, Mayo Clinic Cancer Center, Charlton 6-273, 200 First Street SW,
Rochester MN 55905. E-mail: email@example.com.
Am J Prev Med 2008;35(6S)
© 2008 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/08/$–see front matter
study24highlighted the role of social networks on
smoking among adults, indicating that health promo-
tion efforts targeted to people who are connected
socially with the smoker might be effective. Therefore,
prior research efforts have not optimally tapped the
potential role of supporters in tobacco cessation.
A different approach is to target nonsmokers directly
to support a smoker in quitting. Many nonsmokers are
willing to assist a smoker to quit25and to seek help on
behalf of a smoker.26A clinic-based intervention di-
rectly targeting support people was feasible in a previ-
ous study,27but the goal of that research was to train
the support person as a lay counselor to assist a smoker
in quitting. A broader, public health goal for support
people is to encourage a smoker to utilize an effective
cessation treatment (e.g., call the QUITPLAN Helpline).
The potential utility of this approach is suggested by
effective investigations in the alcoholism treatment
field. Working only with the concerned other, between
64% and 86% of substance users sought treatment,
regardless of the type of relationship with the substance
user (e.g., spouse, friend), or substance used.28,29The
potential public health significance of the approach is
also supported by research indicating that adding a
system within healthcare settings for identifying and
advising smokers to quit (e.g., the 5A’s) is associated
with increased quit attempts and use of effective cessa-
In preparation for a large RCT, this pilot study
examined treatment acceptability, compliance, and
study retention of a telephone-based intervention for a
support person. Procedures for documenting smoker
calls to the QUITPLAN Helpline were also piloted, and
the proportion of smokers who called during the study
period was estimated. Based on studies indicating in-
creases in the reach of quitlines to 2%–6% using
promotional efforts,13–17it was expected that 6% (2/
30) would call the QUITPLAN Helpline.
A sample of 30 support people was targeted to develop and
refine the intervention and to pilot study procedures. Recruit-
ment occurred over a 5-month period in 2007. Participants
were recruited statewide using flyers sent to various public
health organizations, health fairs, community events, and
advertisements in three small regional Minnesota newspa-
pers. Total recruitment costs were $3312 or $110 per partic-
ipant. The study was approved by the Mayo IRB.
Recruitment advertisements targeted individuals who were
concerned about and wanted to learn how to help their smoker.
Recruitment advertisements included a toll-free number and
electronic mail address. Individuals responding to the advertise-
ments underwent a brief telephone screen by a study assis-
tant. Eligible individuals were mailed a consent form and
baseline questionnaires, and once these were completed and
returned by mail, the support person was enrolled.
Volunteers were eligible if they: (1) were aged at least 18
years; (2) resided in Minnesota; (3) were a never or former
smoker (no smoking during the past 6 months); (4) were
interested in supporting a current cigarette smoker (?1
cigarettes smoked per day during the past 7 days) who was
aged ?18 and resided in Minnesota; (5) had current and
anticipated contact (face-to-face, telephone, and/or elec-
tronic mail) with the smoker at least 3 days per week for the
4-week study duration; (6) had access to a working telephone;
and (7) were willing and able to participate in all aspects of
the study. Individuals were excluded if another support
person from the same household had enrolled.
Of the 44 screened, 30 (68%) were eligible to participate.
Ineligibility was due primarily to lack of interest in the study,
being under age 18, or not residing in Minnesota.
The pilot evaluation applied a single-group design with
mailed assessments at Weeks 0 (baseline) and 4 (end-of-
treatment). All support people were mailed written materials
and scheduled to receive three consecutive, weekly, 10–30
minute, proactive, telephone-based sessions. One week after
completion of counseling, participants were mailed follow-up
forms. Participants received a check for $15.00 for the com-
pletion and return of these forms.
To capture smoker calls to the QUITPLAN Helpline, a
study-specific toll-free number was established, which con-
nected smokers directly to an intake assistant at the
QUITPLAN Helpline. The written materials contained the
toll-free number and a study reference code. The code
contained a color (green) and a “P” for pilot and was linked
to the support person’s study identification number (e.g.,
GREEN P001). The materials emphasized that the support
people should inform their smoker to use the study toll-free
number and reference code when calling the QUITPLAN
Helpline. To ensure consistency in services provided, smokers
who called using the study number were eligible to receive all
QUITPLAN Helpline cessation services, and were not triaged
based on insurance status or current health plan, which is the
usual intake protocol. The intake assistant documented
smoker calls to the QUITPLAN Helpline and obtained the
reference code, but no other data were collected from the
smokers. Smokers were eligible to use the study toll-free
number for up to 6 months following the support person’s
enrollment in the study.
Intervention for Support People
Written materials. To enhance the generalizability of the
findings, the same written materials were chosen that the
QUITPLAN Helpline provides to individuals calling on be-
half of a smoker. These materials are consistent with those
provided to support people by other quitlines, websites, and
national organizations (e.g., American Lung Association).
The materials, primarily at a 6th-grade reading level, were:
(1) a 1-page leaflet entitled The Process of Stopping Tobacco
Use: Information for Support Persons, covering nicotine
dependence and withdrawal; (2) a 1-page leaflet entitled
When a Family Member or Friend Ends Tobacco Use: What
You Can Do To Show Support, describing positive and
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negative support behaviors; (3) an 11-page National Cancer
Institute (NCI) brochure entitled Why Do You Smoke? that
included tips for quitting; and (4) a 37-page NCI brochure
entitled Clearing the Air, describing quitting strategies and
resources. Two additional, study-specific materials were pro-
vided: (1) the contemplation ladder,26,32which provided a
visual aid to facilitate understanding of readiness to quit, and
(2) a 1-page leaflet on local Minnesota resources and referrals
including websites, cessation programs, and the QUITPLAN
Helpline. A laminated card was attached to this handout
containing the study toll-free number for the QUITPLAN
Helpline and reference code.
Telephone counseling. The intervention was developed us-
ing published guidelines on behavioral treatment develop-
ment.33The conceptual basis for the intervention was Co-
hen’s theory of social support and health,20which postulates
that supportive actions promote positive health practices of
others by encouraging more effective coping. The types of
support behaviors provided can be instrumental (e.g., provid-
ing material aid); informational (e.g., providing relevant
information or advice to make behavioral changes); or emo-
tional (e.g., expression of empathy, caring, reassurance).
Supportive behaviors are more likely to predict health out-
comes when matched to the demands of the situation, for
example, how ready the smoker is to quit.34Another impor-
tant theoretical dimension is the positive–negative nature of
behaviors engaged by the support person.35Increasing posi-
tive behaviors (e.g., encouragement) while avoiding negative
behaviors (e.g., nagging) is consistently associated with a
change in smoking behavior. Further, based on the substance
abuse treatment literature,28and previous work measuring
support provision36another theoretical dimension is the
support person’s self-behaviors or behaviors that maintain
well-being and morale.
Table 1 provides the major topics covered by the counselor
at each session and illustrative examples. The focus of the
intervention was to provide each support person with the skills
and information to encourage their smoker to call the
QUITPLAN Helpline, but also to recognize that any small
step toward quitting is progress (e.g., expressing interest in
quitting, or asking about the QUITPLAN Helpline). More-
over, the intervention focused on assisting the support person
to recognize or accept that it was ultimately up to the smoker
to call. Figure 1 illustrates how the intervention was
expected to influence study outcomes based on the theo-
Data on treatment acceptability and compliance were re-
viewed after each successive series of ten support people
completed the study, with the goal of refining the counselor
manual if necessary. Due to the generally high levels of
treatment acceptability and compliance with the intervention,
the only modification to the manual was to add examples
relevant to the support person’s helping a co-worker or
someone else with whom a close relationship was not
Counselors. The intervention was conducted by four trained
research counselors with a master’s or bachelor’s degree in a
social sciences–related field. A counselor manual was devel-
oped with a script for each session. A checklist was used to
compare the number of intervention components delivered
to the number intended. Overall counselor adherence to the
manual was 98%, thus the intervention was delivered accord-
ing to protocol. In addition, a sample of ten audiotapes was
randomly selected from early, middle, and late treatment
sessions and reviewed on a weekly basis to provide ongoing
feedback to the counselors.
Since 2005, the Mayo Clinic Tobacco Quitline has been the
vendor for the QUITPLAN Helpline counseling services. The
QUITPLAN Helpline is a free service provided to Minnesota
residents. Smokers who enroll in the program receive tele-
Table 1. Telephone-based intervention for a support
person: session topics
1. Provide rationale for the treatment
● Raise awareness of possible personal benefits of
treatment (e.g., dealing with anger or distress
regarding smoker’s behavior)
● You can’t control your smoker, only yourself. It is important
to focus on what you can do as a support person.
2. Describe the role of the support person in this program
● Your role is not to be a counselor or to make (smoker) quit.
There are two goals of this program (1) to help you better
understand or accept (smoker’s) smoking behavior, and (2)
to help you encourage (smoker) to move toward quitting and
to get help to quit. So, your role might be to motivate
(smoker) to start thinking about getting help.
3. Provide education on readiness to quit
● Review handout on the Contemplation Ladder and
ask support person to assess or decide where their
smoker fits on this ladder prior to the next session.
4. Provide education on nicotine dependence
● Remind yourself that the process of quitting smoking is
difficult for you and your smoker.
5. Describe the QUITPLAN®Helpline, what happens
when the smoker calls and benefits of using this service
● There are resources available to help smokers quit and there
are places for your smoker to get help including the
● Emphasize that the QUITPLAN Helpline could be
helpful to smokers regardless of their readiness to
quit and level of nicotine dependence.
1. Review readiness to quit
● Remember that smokers differ in their level of readiness to
2. Discuss supportive and nonsupportive behaviors and
statements to encourage the smoker to move forward in
the quitting process.
● It will take time so remember to be patient and accepting of
where he/she is in the process now.
1. Review nicotine dependence.
2. Discuss how to reinforce any progress the smoker makes
in the process of quitting (i.e., shaping). Examples of
behaviors to reinforce: smoker wrote down the number
for the QUITPLAN Helpline, or talked about his/her
reasons to quit. Examples of reinforcers: take the
smoker out to dinner, help the smoker with chores,
send a special card to the smoker.
3. Emphasize persistence beyond the program
● Supporting your smoker is a process, not a one shot deal.
Never give up on your smoker, and it is important to keep
December 2008 Am J Prev Med 2008;35(6S)
phone counseling, written self-help materials, and can receive
nicotine replacement (patches, lozenges or gum) by mail.
Depending on the smoker’s needs, the QUITPLAN Helpline
counselors provide information on other cessation medica-
tions that are prescribed by the smoker’s physician, including
Zyban and Chantix. For smokers not ready to quit, counselors
encourage them to consider the pros and cons of continued
smoking. Smokers enrolled in the program can receive up to
five telephone counseling sessions over a 6-month period.
The first assessment call is 45 minutes long and subsequent
calls are 15–20 minutes. After the five sessions, additional
support and encouragement calls are made by the counselor
at the smoker’s request.
When smokers called the QUITPLAN Helpline, the intake
assistant asked for their reference code. The intake assistant
then described the QUITPLAN Helpline services and asked if
the smoker was interested in speaking with a counselor.
Smokers expressing interest were transferred to a QUITPLAN
Helpline counselor who enrolled them in the program.
The intake assistants received four 1-hour training sessions
including role-play demonstrations of mock smoker calls.
Monthly 1-hour refresher trainings and test calls were contin-
ued with the intake staff for quality assurance.
Support person baseline characteristics. Characteristics as-
sessed were age, gender, education, marital status, tobacco-
use history (all forms of tobacco), type of relationship and
whether or not the support person lived with their smoker,
and prior attempts to help their smoker quit. Support people
also indicated the gender and race of their smoker.
Support Provided Measure (SPM). Participants completed
the 22-item SPM36at baseline and at Week 4, which taps
support delivered to a smoker over the previous 2-week
period. Participants indicated whether or not the behavior
occurred (i.e., yes or no). SPM items pertain to support
provided to a smoker irrespective of their level of readiness to
quit smoking and were derived based on the theoretical
model of social support.20The SPM was shown to have high
internal consistency (alpha?0.83) in a sample of 771 adults.36
The total score is calculated by summing the number of items
endorsed in the direction of supportive behaviors and can
range from 0 to 22.
Support person treatment acceptability. Post-treatment, par-
ticipants were asked to judge the perceived helpfulness of the
overall program, the written materials, and the telephone
counseling, in assisting them to encourage their smoker to
call the QUITPLAN Helpline, and if they would recommend
the program to another support person.
Support person treatment compliance. Counselors recorded
whether or not each telephone session was completed with
the support person, and the duration of each call.
Smoker calls to the QUITPLAN®Helpline. The proportion
of the support person’s smokers who called the Minnesota
Helpline was assessed at least once during the interval from
enrollment through 180 days (6 months) documented by the
Minnesota Helpline intake staff. Any type of call, regardless
of the disposition of the call, was counted. Intake staff
recorded the reference code and the date, time, and dispo-
sition of the call (not interested, information only, or en-
rolled in the program). If the smoker could not recall or did
not have the reference code, the intake assistant asked the
smoker for the support person’s name.
Smoker readiness to quit as measured by a support per-
son. At baseline and at Week 4, support people indicated
the smoker’s readiness to quit as measured by the contem-
plation ladder.26,32The ladder operates as an 11-point
Likert scale with anchors ranging from 0?having no
thoughts of quitting to 10?being engaged in action to change
one’s smoking behavior.
Differences on mean SPM and contemplation ladder scores
were evaluated using a paired signed rank test. Two-tailed p
values of ?0.050 were considered significant.
Support people were primarily women, married, and
highly educated. As reported by the support people,
their smokers were primarily Caucasian men (Table 2).
Figure 1. Logic model illustrating the hypothesized links between the support person–intervention activities and smoker outcomes
S482 American Journal of Preventive Medicine, Volume 35, Number 6Swww.ajpm-online.net
Support Person Outcomes
Treatment acceptability, compliance, and study reten-
tion were high (Table 3). The mean and SD duration in
minutes for each of the three sessions was: (1) 27.1
[SD?4.6, range 17–37]; (2) 19.6 [SD?4.4, range 13–
30]; and (3) 21.0 [SD?6.0, range 10–35]. Most support
people (83%) recommended no change in the num-
ber, and 93% recommended no change in the duration
of sessions. A significant increase in the SPM score was
observed among support people from baseline to
There was a significant increase in the smoker’s contem-
plation ladder scores from baseline to post-treatment
(Table 3). Five smokers (17%, 95% CI?6% to 35%)
called the QUITPLAN Helpline. All five called only
once and all enrolled in the QUITPLAN Helpline
program. There was no significant association found
between smoker calls to the quitline and baseline
contemplation ladder or SPM scores (Table 4).
Table 3. Support person and smoker outcomes
% (n) or
SUPPORT PERSON (n?30)
Number telephone sessions completed
All 3 sessions completed
Amount of written materials read
All of it
Some of it
Study retention: completed post-treatment
Perceived helpfulness of the overall
Not at all helpful
A little helpful
Perceived helpfulness of written materials
Not at all helpful
A little helpful
Perceived helpfulness of telephone
Not at all helpful
A little helpful
Recommend program to another support
Definitely would not
Probably would not
Support provided measure score
Contemplation ladder scorea
Score 7–10 (high motivation)
Score 7–10 (high motivation)
Called the QUITPLAN®Helplineb
Number days since support person
enrolled to call the QUITPLAN
aAs reported by support people
bSmoker calls since support person’s enrollment in study as docu-
mented by QUITPLAN Helpline intake staff
*p?0.001 from paired signed rank test comparing baseline and
**p?0.014 from paired signed rank test comparing baseline and
Table 2. Support person baseline characteristics (n?30)
Support person characteristics
Highest level of education
Some college/trade school
Prior attempts to help their smoker quit
Two or more times
Gender of smoker, female
Race of smoker
Relationship to smoker
Lives with smoker
aBecause of rounding, not all percentages total 100.
December 2008 Am J Prev Med 2008;35(6S)
This preliminary study found that a telephone-based
intervention for a support person to encourage smoker
utilization of the QUITPLAN Helpline was acceptable
and feasible, as indicated by excellent measures of
treatment compliance and study retention. Similar to
a previous study,27the program was successful in
reaching smokers with low to moderate levels of
readiness to quit (in contrast, most cessation trials
recruit only highly motivated smokers). Moreover, a
significant improvement in theoretically supportive
behaviors was observed among support people’s pre–
Limited inferences can be made from this pilot study
given the small sample size and lack of inclusion of a
comparison or control group. One important aspect of
feasibility was not examined, that is, the potential reach
to the support person and how the intervention might
affect quitting on a population level. The participants
were mostly Caucasian, educated, and employed
women. It is not clear if this is only a segment of the
support person population that might be reached, or if
these characteristics are representative of potential
supporters. Zhu and colleagues26found that 6% of calls
to the California Helpline were from nonsmokers seek-
ing help on behalf of a smoker. These callers were
primarily women (79%) and living in the same house-
hold as the smoker. A study of young adults (aged
18–24 years) found that women were more willing to
help a smoker than men.37
The goal of the support person intervention was to
prompt a smoker to call the QUITPLAN Helpline. It
was encouraging that five smokers (17%) called and
enrolled in the program, a percentage that was higher
than the expected rate of 6%. However, an important
caveat is that because all of the smokers in this study
had a support person, the observed rate of quitline
utilization is not directly comparable to prior studies
examining the impact of promotional efforts to in-
crease quitline utilization.13–17The cost of recruiting
and training the support people also limits generaliz-
ability, but there are obviously costs with other adver-
tising campaigns. If the intervention is found to be
efficacious in the RCT, future studies could test this
approach on a broader population level, using mass
media targeted to nonsmoking family members and
friends, and examining the effect on smoker call rates
before and after the campaign. A support person
intervention, utilizing natural networks to enhance
behavioral change, may have an effect that would be at
least as similar as the advertising campaigns used in
prior studies. If this new system is found to be effective,
potential adopters could include HMOs, health insur-
ance plans, and employers.
Future studies are needed to examine the cost effec-
tiveness of the intervention, based on the amount of
resources spent to reach the support people, number of
calls generated, and quitting among smokers38Future
research could also examine the characteristics of the
support person or smokers associated with increased
utilization of quitlines. Although the sample size limits
statistical power to detect differences, Table 4 provides
some insights into these potential characteristics. Inter-
estingly, smokers who called were similar to those who
did not call on baseline readiness to quit; only one of
the five smokers who called was highly motivated to
quit. However, a higher proportion of smokers who
called lived with their support person (80% vs 56%;
p?0.62). Support people who live with their smoker
may have more opportunities to provide support. Thus,
in our future RCT, we are stratifying the randomization
on whether or not the support person lives with their
smoker. In conclusion, an intervention using natural
support networks to encourage smoker utilization of
the QUITPLAN Helpline is feasible and acceptable to
This research was funded by ClearWay MinnesotaSMresearch
program grant RC-2005-0022. The contents of this manu-
script are solely the responsibility of the authors and do not
necessarily reflect the official views of ClearWay MinnesotaSM.
We are grateful for the input and guidance on this project
from Dr. Shu-Hong Zhu, University of California San Diego.
Table 4. Association of support person/smoker
characteristics and smoker calls to the QUITPLAN®
Did smoker call the
% female gender
Baseline SPM score
Change in SPM score
% lives with smoker
Type of relationship
% female gender
mean baseline CL
% baseline CL score
aAll values are mean?SD except where noted.
bFrom two-sample rank sum test for continuous variables and Fisher’s
exact test for dichotomous variables
CL, contemplation ladder score (scores of 7–10 indicate high levels of
readiness to quit); SPM, support provided measure score
S484 American Journal of Preventive Medicine, Volume 35, Number 6Swww.ajpm-online.net
We also appreciate the assistance of the QUITPLAN®Hel-
pline intake staff in the conduct of this study.
No financial disclosures were reported by the authors of
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