Proactive Telephonic Follow-up Calls by a Tobacco Cessation Clinic (TCC): Optimization for the Number of Calls General Dentistry ORIGINAL RESEARCH Brief Background

Abstract

Despite specific national effort for over a decade, in published reports on tobacco cessation from India, the quit rate has ranged from 2.6% to 28.6%. One of their challenges has been an inability to follow-up all those treated comprehensively. Objective It was to determine an optimum number of follow-up telephonic calls to be made proactively post the cessation treatment. Materials and Methods This study was conducted for a period of one year w.e.f. 5 th September 2017 at a Tobacco Cessation Clinic (TCC) of a private health sector tertiary care hospital to 296 patients currently using tobacco treated by counselling with/ without pharmacotherapy; and integration of the quitline methodology with follow ups at 3 rd and 7 th days, and thereafter at the end of 1 st , 3 rd , 6 th and 12 th months respectively, i.e., until 4 th September 2019. Results As per study protocol, the TTC could follow up 91.2% patients telephonically to achieve a quit rate of 42.9% while those who failed to quit and relapsed were 37.7% and 19.9% respectively. Staying on with the quit date set at the outset and adequacy of three follow-up calls have emerged as the statistically significant outcomes for p values of 0.000 and 0.001 respectively. Summary and Conclusions Achieving a quit rate of 42.9% through the proactive follow-up calls reinforces its perceived utility in tobacco cessation. Making at least 3 follow-up calls after primary intervention (on 3 rd , 7 th and at 1 month) is recommended to achieve a satisfying outcome. For an optimal outcome, the study recommends follow-ups until 6 months.

Full text

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JIDA - Journal of Indian Dental Association - Vol 14 - Issue 8 - August 2020
1. MS, FAIS, Honorary Consultant, Tobacco Treatment
Dept. of Deaddiction, Santokba Durlabhji Memorial
Hospital and Medical Research Institute
Jaipur, Rajasthan
2. M.Sc., Statistician
Healis Sekhsaria Institute of Public Health
Navi Mumbai, Maharashtra
3. MD, DM, Honorary Consultant
Gastroenterology and Alcohol Deaddiction
Depts. of Gastroenterology and Deaddiction
Santokba Durlabhji Memorial Hospital and Medical
Research Institute, Jaipur, Rajasthan
4. PhD, D Lit, Director
Healis Sekhsaria Institute of Public Health
Navi Mumbai, Maharashtra
5. MD, Medical Director and Head
Dept. of Pathology and Transfusion Medicine
Santokba Durlabhji Memorial Hospital and Medical
Research Institute, Jaipur, Rajasthan
Abstract
J
I
D
A
Proactive Telephonic Follow-up Calls by a Tobacco Cessation Clinic (TCC):
Optimization for the Number of Calls
Rakesh Gupta1, Sameer Narake2, Harsh Udawat3, P. C. Gupta4, G. N. Gupta5
XXXXXXXXXXXXXXX
ORIGINAL RESEARCH
Brief Background
Despite specific national effort for over a decade, in
published reports on tobacco cessation from India, the
quit rate has ranged from 2.6% to 28.6%. One of their
challenges has been an inability to follow-up all those
treated comprehensively.
Objective
It was to determine an optimum number of follow-up
telephonic calls to be made proactively post the cessation
treatment.
Materials and Methods
This study was conducted for a period of one year w.e.f.
5th September 2017 at a Tobacco Cessation Clinic (TCC)
of a private health sector tertiary care hospital to 296
patients currently using tobacco treated by counselling
with/ without pharmacotherapy; and integration of the
quitline methodology with follow ups at 3rd and 7th days,
and thereafter at the end of 1st, 3rd, 6th and 12th months
respectively, i.e., until 4th September 2019.
Results
As per study protocol, the TTC could follow up 91.2%
patients telephonically to achieve a quit rate of 42.9%
while those who failed to quit and relapsed were 37.7%
and 19.9% respectively. Staying on with the quit date set
at the outset and adequacy of three follow-up calls have
emerged as the statistically signicant outcomes for p
values of 0.000 and 0.001 respectively.
Summary and Conclusions
Achieving a quit rate of 42.9% through the proactive
follow-up calls reinforces its perceived utility in tobacco
cessation. Making at least 3 follow-up calls after primary
intervention (on 3rd, 7th and at 1 month) is recommended
to achieve a satisfying outcome. For an optimal outcome,
the study recommends follow-ups until 6 months.
Key Words
Tobacco, Cessation, Follow up, Telephonic calls, Quitline,
Smoking, Smokeless tobacco.
How to cite this article: Rakesh Gupta, Sameer Narake, Harsh
Udawat, P. C. Gupta, G. N. Gupta. Proactive Telephonic Follow-up
Calls by a Tobacco Cessation Clinic (TCC): Optimization for the
Number of Calls. JIDA 2020; XIV;12-18.
https://doi.org/10.33882/jida.14.26XXX.
Website:
jida.ida.org.in
DOI: 10.33882/jida.14.26XXX
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13
JIDA - Journal of Indian Dental Association - Vol 14 - Issue 8 - August 2020
Introduction
The health services of India for tobacco cessation have
improved evidenced by the inclusion of India by the
WHO among 23 countries that provide a comprehensive
coverage for the ‘O’ component of MPOWER at the
national level. This is due to the fact that India has a
national toll-free quitline, cost-coverage for NRT (nicotine
replacement therapy) and digital and mobile solution for
those who want to quit, in addition to the availability
of brief advise at the primary healthcare(1,2) through
its national flagship programme on tobacco control-
National Programme on Tobacco Control (NTCP).(3) But,
it still suffers from the quit rates that have stayed largely
unchanged at the population level for 7 years for smoking
(1.8%) as well as smokeless tobacco use (SLT, 1.2%).(4,5)
This may be due to the deficient intent of the tobacco
users to quit and the challenges the health care service
providers (HCPs) face for treating tobacco dependence
optimally.(6,7)
In reports published from India on tobacco cessation in
the last decade (8-14) the quit rates at 6 months and above
exceeded 50% only in two reports.(10,14) Otherwise, the
quit rates in the follow-up periods varying between 6
weeks and 9 months have ranged between 2.6% and
28.6%., With already existing challenges of a deficient
follow-up in the management of NCDs(15) and patients’
out-of-pocket expenses exceeding 75%,(16), those treated
for tobacco cessation are less likely to revisit the TCC.
A major deficiency in earlier studies appears to be the
need of an in-person and on-site regular follow-up
visits for staying motivated and minimising relapses.(6-
7,17-21) In view of the increased penetration of the mobile
telephones in India(21-24), the present study was undertaken
for a meaningful standardization of the follow-up process
through scheduled periodic telephone calls.
Objective
This study was done to determine an optimum number of
follow-up telephonic calls to be made proactively post the
cessation treatment.
Materials and Methods
Study design
This is a longitudinal, non-randomized, prospective study
conducted in the Tobacco Cessation Clinic (TCC) being run
under the Deaddiction Department of a multispeciality,
tertiary care hospital in the private health sector at Jaipur,
India.
The study population and duration
The patients recruited to receive the treatment for their
tobacco dependence for “a fee for the service” were
either those referred by the in-house consultants or those
that directly walked-in with a desire to quit during the
period 5th September 2017 to 4th September 2018. A
total of 350 patients were thus recruited. The mutually
concurred proactive follow-up calls were carried out until
4th September 2019 to complete a follow-up of at least
1-year in all cases enrolled from 4th September 2018.
At the end of follow-up, 296 patients were included as
evaluable and 54 were excluded for the following reasons:
1) Cessation before treatment (24 Patients);
2) The dead during the period of study (17 patients);
3) Patients either did not have a contact number or were
unwilling to set the quit date (10 patient);
4) The father of a minor patient asked not to follow-up
(1 patient);
5) The patient ran away from his home after rst two
follow-up calls (1 patient); and,
6) The patient disagreed that he should have been
charged fee unduly for “just talking (the counselling
given at the initial intervention” (1 patient).
The study process
It comprised :
A. Baseline Service:
1. All patients were managed by the rst author by
undergoing a pre-structured intensive intervention
(II) mostly spanning over 30 minutes to an hour in
some(25,26);
2. Rapport building was done followed by record of
demographic and contact details obtained from the
patients and at least one of their attendants who
agreed to respond to the follow-up calls;
3. Following the recording of the details of tobacco use
behaviour, counselling (II) was done through a mix of
Cognitive Behavioural Therapy (CBT) and Motivational
Interviewing (MI)(27,28) that (a) elaborated on harms
of tobacco use and benets of quitting; (b) could
"set the quit date"; and (3) empowered on the

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JIDA - Journal of Indian Dental Association - Vol 14 - Issue 8 - August 2020
“preparations and skills required to stay quit lifelong"
in concurrence with the patient;
B. Follow-up:
A concurrence was arrived at a year-long follow-up plan
by the treating physician with the patients for: (1) either
a revisit to the TCC to reinforce initial counselling or to
review the treatment prescribed- coinciding it with a
revisit to the OPD of the referring physician; and/or (2)
telephonic follow-up “at no additional fee” on 3rd and
7th days and at the end of 1st, 3rd, 6th and 12th month to
last for 3 to 5 minutes. These were structured to (i) greet
the patient (or his carer if the patient did not respond),
(ii) inquiring of his welfare overall along with his current
status for tobacco use as an open-ended question, (iii)
an end with advise on (a) relapse prevention if staying
quit or (b) to quit now (revising the quit date) if he had
failed to quit or had relapsed by either revising the quit
date to be eligible for another call after a week or revisit
the TCC if he could not decide to make another attempt
to quit then; Among those who followed-up in the TCC,
those willing were advised Urinary Cotinine Test (UCT) for
biochemical verification;
C. During the baseline service, the patients were
prescribed Nicotine Replacement Therapy (NRT) and/or
cessation medication- Bupropion or Varenicline, by the
treating physician (the first author) whenever indicated in
the usual manner and doses with brief on recommended
cautions and contraindications; and, in concurrence with
the patient;
D. Patients and even their carers’ were told to call back
for any questions or clarifications anytime to the TCC on
any week-day between 12 noon 4 PM;
E. A measure of the self-efficacy for the baseline session
was done through the scale of Indian rupee- familiar to all.
It assessed for the benefit in terms of paisas (zero to 100)
for the confidence generated through this interaction to
stay quit hereafter for a total abstinence; and,
F. The session was concluded by thanking them; and,
by sharing the contact number of the TCC and the first
author.
Data collection and analysis
The clinical record of every patient was entered in a
Microsoft Excel Sheet. It was managed dynamically for
every contact made by either party (TTC or the patient/s)
during the subsequent follow-ups. Those who stayed
quit for less than 1 month were categorized as staying
quit (STQ) whereas those staying quit for total abstinence
for 1 month or more from the “set quit date” were
categorized as successful quit (SQ); those who failed to
quit altogether from the “set quit date", even after a
follow-up call after 1 week, were categorized as failed to
quit (FTQ); those who began use of any tobacco product
after a SQ were categorized as Relapsed (Relapsed); a
failure to respond anytime during the course of 1-year
follow-up, after three follow-up calls in the subsequent
one week on 1st, 2nd and 7th day respectively categorized
patients as non-responders (NR); and, lastly, those who
died were categorized as Dead (Dead).
Data was analysed using SPSS (version 16). The p-value
was calculated for Chi-square test of association and its
significance was determined if <0.05. The confidence
intervals (CI) were calculated to check the significance of
difference between proportions.
Results
The table below (Table -1) represents the profile of 296
study participants. Males constituted 92.9% of the sample
and most were between 30-59 years of age (78.0%).
Majority smoked tobacco (48.0%) followed SLT users
(38.2%) and the dual users (13.9%). Over two-thirds
(68.2%) adhered to the “set quit date” whereas another
20.9% and 10.8% respectively revised it for 2nd, 3rd to a
maximum of 6th time. Pharmacotherapy was prescribed to
206 patients (69.6%). Over and above telephonic follow-
ups of all patients, 35 (11.8%) were followed-up in the
TCC at least once.
The study observed a quit rate of 42.9 % (Table-2; 127
patients- the - the SQs). The FTQs and NRs, clubbed
together accounted for failure rate of 37.2% (110 patients);
the rest 19.9% relapsed. Biochemical verification through
the UCT, done altogether in 13 patients, was negative in 7,
positive in 5 and false-positive in 1 patient. The outcomes
were significantly better among males and those with a
single quit attempts (p value <0.05). No association of
quitting was observed with age and type of tobacco used.
All responded promptly and fully along with attentive
listening and honestly even if they had failed to quit or
relapsed; and, in either case whether they were willing/
unwilling/unable to make another attempt to quit.

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JIDA - Journal of Indian Dental Association - Vol 14 - Issue 8 - August 2020
Table 1: Prole of the study respondents
Characteristics N (296) N % 95% Lower CL 95% Upper CL
Age 15-29 23 7.8% 5.1% 11.2%
30-39 89 30.1% 25.1% 35.5%
40-49 83 28.0% 23.2% 33.4%
50-59 59 19.9% 15.7% 24.8%
60+ 42 14.2% 10.6% 18.5%
Sex Male 275 92.9% 89.6% 95.4%
Female 21 7.1% 4.6% 10.4%
Tobacco type Smoker 142 48.0% 42.3% 53.7%
SLT user 113 38.2% 32.8% 43.8%
Dual user 41 13.9% 10.3% 18.1%
No. of quit attempts 1 202 68.2% 62.8% 73.3%
2 62 20.9% 16.6% 25.9%
3 or >3 32 10.8% 7.7% 14.7%
Mode of Follow-up Telephonic 261 88.2% 84.0% 91.4%
Revisit 35 11.8% 8.6% 16.0%
Table 2: The latest status (after 1-year follow-up) of respondents according to demographic variable.
SQ FTQ/NR Relapsed
P value n % (95% CI) n % (95% CI) n % (95% CI)
Overall 127 42.9 (37.4,48.6) 110 37.2 (31.8,42.8) 59 19.9 (15.7,24.8)
Age
15-29 10 43.5 (25,63.5) 9 39.1 (21.4,59.4) 4 17.4 (6.2,36.2)
0.939
30-39 36 40.4 (30.7,50.8) 33 37.1 (27.6,47.4) 20 22.5 (14.8,31.9)
40-49 41 49.4 (38.8,60.0) 28 33.7 (24.3,44.3) 14 16.9 (10.0, 26.0)
50-59 22 37.3 (25.8,50.0) 25 42.4 (30.4,55.1) 12 20.3 (11.6,31.9)
60+ 18 42.9 (28.8,57.9) 15 35.7 (22.6,50.8) 9 21.4 (11.2,35.5)
Sex
Male 121 44 (38.2,49.9) 104 37.8 (32.2,43.7) 50 18.2 (14.0,23.1) 0.024
Female 6 28.6 (12.9,49.7) 6 28.6 (12.9,49.7) 9 42.9 (23.7,63.8)
Tobacco type
Smoker 60 42.3 (34.4,50.5) 56 39.4 (31.7,47.6) 26 18.3 (12.6,25.3)
0.885SLT user 50 44.2 (35.3,53.5) 38 33.6 (25.4,42.7) 25 22.1 (15.2,30.4)
Dual user 17 41.5 (27.4,56.7) 16 39 (25.3,54.3) 8 19.5 (9.7,33.5)
No. of quit attempts
1 108 53.5 (46.6,60.3) 58 28.7 (22.8,35.2) 36 17.8 (13,23.5)
0.0002 11 17.7 (9.8,28.6) 32 51.6 (39.3,63.7) 19 30.6 (20.2,42.8)
3 8 25 (12.6,41.7) 20 62.5 (45.2,77.6) 4 12.5 (4.4,27)
Note:*=The Chi-square statistic is signicant at the .05 level; CI= Condence Interval.

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JIDA - Journal of Indian Dental Association - Vol 14 - Issue 8 - August 2020
Table 3: Correlations with Follow-up calls
Outcome 1st (%) 2nd (%) 3rd (%) 4th (%) 5th (%) 6th (%)
STQ 237 (80.1) 226 (76.4) 0 0 0 0
SQ 0 0 198 (86.8) 173 (87.4) 142 (82.1) 127 (89.4)
FTQ 54 (18.2) 59 (20.6) 26 (11.4) 0 0 0
NR 5 (1.7) 9 (3.0) 4 (1.8) 6 (3.0) 3 (1.7) 3 (2.1)
Relapsed 0 0 0 19 (9.6) 28 (16.2) 12 (8.5)
Total (% of the
total)
296 296 (100) 228 (77.02) 198 (66.89) 173 (58.44) 142 (47.97)
Table 4. Overall comparison of quit rate
Status 3rd follow-up 6th follow-up
SQ 198 (66.9) 127 (42.9)
FTQ/NR 98 (33.1) 110 (37.2)
Relapsed 0 59 (19.9)
Total 296 (100) 296 (100)
The Table-3 correlates outcomes of the study with all six
follow-ups with percentages calculated from the total
number followed-up in that particular follow-up round.
The quit rates at 3rd, 4th, 5th and 6th follow-ups were
86.8% (198/228 patients), 87.4% (173/198 patients),
82.1% (142/173 patients) and 89.4% (127/142 patients)
respectively with no significant difference between these
(p value- 0.256). Maximal patients failed to quit by the
end of 2nd follow-up- 59 out of 85 (69.41%). The relapse
rate, observed at 4th follow-up as 9.6%, was the highest
for the study at the 5th follow-up, i.e. at end of 6th month
(16.2%); another 8.5% relapsed at the 6th follow-up,
i.e., at the end of 1-year.
The Table-4 reveals that the quit rates at 3rd and 6th follow-
ups, i.e., at the end of 1 month and at the end of 1 year,
were 66.9% and 42.9% respectively.
Discussion
Follow-up calls, observed as a significant proactive
predictor of smoking relapse by Wu et al(18) were added
to the methodology in this study to remotely sustain
motivation of the tobacco-using patients(21-22): (1) to
help them stay quit amid the absence of any self-help
support and existence of the adverse situations socially;
(2) to remind them and/or reinforce the skills taught at
the initial intervention to avoid, negate or eliminate any
tempting situation to relapse; and, (3) to eliminate the
pitfalls of a shorter follow-up of less than 6 months(18).
The authors concur with others (18-19) that the systematic
follow-ups should be part of comprehensive tobacco
treatment as these not only help sustain the initial success
and promote long-term abstinence but also help reducing
relapses.
This study could follow-up 91.6% patients telephonically
as a substitute for their scheduled follow-up for the entire
1-year; 11.8% patients among these also followed up
in the TTC once at least (Table 1). The study showed a
quit rate of 42.9% for total abstinence from the effective
quit date, i.e., the date after which the patient has stayed
abstained totally- be this the very first time s/he decides
to stay quit or after one or more failed attempts (Table
2). This quit rate seems to be the highest among the
contemporary Indian studies published in the preceding
decade at the end of 1-year(8-13). We are inclined to
attribute it the conduct of follow-up by the treating
doctor himself to whom the patients/his or her relatives
responded promptly and fully along with due attention
and honestly since the only other similar Indian study that
had the counselor do the follow-up similarly had a quit
rate of 10%(11). But, since it is a subjective and qualitative
observation in this study, it will be worth evaluating in
future whether the determinant for this difference was
the title/post/position of the interviewer- the treating
doctor vs. a counsellor/nurse/any other health worker.
The present study categorized those failing even once
anytime during the 1-year follow-up as a “Relapse”
although others have recommended allowing for some
lapses between 3 and 6 months.(21) The period of 1-year
follow-up planned and duly executed in this study was
longer than the usually accepted norm of 6 months,(17-18)
but in view of the observation of SQ of over 80% right
from the third follow-up (Tables 3 and 4), we endorse

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JIDA - Journal of Indian Dental Association - Vol 14 - Issue 8 - August 2020
the norm recommended of making at least first 3 of the
6 follow-up calls(18,21-23) on 3rd, 7th days and at the end of
1 month unless the resources allow for the maximal gain
which, in the present study, was ~3% from 3rd to 6th
follow-up.
In addition, setting-up the quit date has been considered
critical for the user to stay quit. In present study, out of
over two thirds (68.2%) who stayed quit right from the
date they had decided to quit, the quit rate was 53.5%
(p value- 0.000) vs. those who altered it twice or more
than 2 times; in latter cases, the quit rates were 17.7%
and 25.0% respectively. Hence, “staying with the set quit
date” can be a useful predictor of a SQ that contributes
to the value of follow-up calls as emphasized in the
preceding text.
Another additional factor could be the use of intensive
intervention delivered uniformly through a framework of
behavioural intervention utilizing a combination of both
CBT and MI as reliance solely on brief intervention, self-
help materials, mails or telephone calls have otherwise
been found ineffective.(21,25-28)
Limitations of the study
Following were the limitations of the study:
(1) It could not randomize the patients for number of
follow-up calls (from 3 to 6 calls) in view of the fewer
referrals to this newly established service in its rst
year and, therefore, lesser number of new patients
enrolling to the TTC;
(2) Also, it was not possible to blind the interviewer-
their doctor and the TTC in-charge, on follow-up
calls which could have brought the socially desirable
outcomes “staying quit and/have quitted successfully
for a total abstinence”,(18) thus, avoiding/eliminating a
disappointment to their treating doctor and spoiling
the relationship;
(3) Further, the study has relied solely on self-reporting
by the patients on their respective outcomes since
a biochemical verication could not be done in 283
(96%) patients,(17,18) not only because of the delay
in establishing the testing facility at the hospital for
almost rst six months of the study but also due
to patients inability/refusal to travel solely for the
biochemical conrmation.
Conclusions
Obtaining a quit rate of 42.9% for the total abstinence at 1
year follow-up- the highest observed in the contemporary
studies published from India in the preceding decade, is
largely attributed to an ability to accomplish a follow-up in
91.6% patients for pre-scheduled six proactive telephonic
calls through the entire 1 year of follow-up. Since the quit
rate at the end of 3rd vs. 6th follow-up (66.9% vs. 42.9%)
was significant statistically (p value- 0.001), while under
the constraint of the resources, making first three calls on
3rd and 7th day and at the end of 1 month should suffice
to get a satisfying quit rate. The additional contributory
factors towards this achievement were: (1) ability of the
patients to persist with the “quit date” set at the outset;
and (2) delivery of the initial intervention through a
combination of CBT and MI and follow-up calls solely by
the treating physician.
Acknowledgement
The authors are grateful to the hospital management
and administration of SDM Hospital, Jaipur, for the
infrastructure support and resources during the
conduction of study.
Conicts of Interest
There are no conflicts of interest.
Source of Support: Nil

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