NQDW Quitline Services Survey

Form Approved

OMB No. 0920-0856

Exp. Date XX/XX/XXXX

National Quitline Data Warehouse (NQDW)

Quitline Services Survey

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0856)

_{Year: Select data year}

Quarters: Select data quarters (2)

State:

Instructions for Completing Survey: Throughout this survey, please fill in -1 to indicate that data are not available for a particular question. Responses of -1 will be interpreted and presented in future reporting as “NA”.

Please respond to the following questions about your quitline during the two quarters (six months) of this reporting period specified in Question 3.

1. Please provide your contact information

Name:
Job Title:
Employer / Organization:
State:
Email:
Phone:
Second Phone:

2. What is the name of your state quitline?

3. Please provide information about the quitline number(s) that your state used during ____________(year) ___________ (quarters).

Primary Quitline Telephone Number
Did your state use and promote 1-800-QUIT-NOW as its primary quitline number?			Y/N
If “No”, what is your state’s primary quitline number?
Additional Quitline Telephone Numbers
Please list ALL additional quitline telephone numbers used by your state		Description of quitline number
1:
2:
3:
4:
5:

SERVICE PROVISION

The questions below deal with the services offered by your Quitline during this reporting period. For your convenience, the answers to some of these questions have been pre-populated with the responses you reported on your most recent prior submission. Please review and make any necessary revisions so that the answers to these questions accurately reflect the services offered by your quitline during this reporting period.

4. Please provide the hours of service of your quitline for the following categories of service:

Day	Hours of Operation by Service Type
	Live Pick Up of Incoming † Calls †	Counseling Services	Voicemail / Answering Service Pick Up of Calls
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

† May or may not have counseling services available.

5. How many days was your quitline closed during this reporting period, for example during holidays?

   N=

6. In which of the following languages did your quitline offer counseling?

Language		Offered (Select a response)
English:		☐ Bilingual Coach ☐ Translation Service
Spanish:		☐ Bilingual Coach ☐ Translation Service
French:		☐ Bilingual Coach ☐ Translation Service
Cantonese:		☐ Bilingual Coach ☐ Translation Service
Mandarin:		☐ Bilingual Coach ☐ Translation Service
Korean:		☐ Bilingual Coach ☐ Translation Service
Vietnamese:		☐ Bilingual Coach ☐ Translation Service
Russian:		☐ Bilingual Coach ☐ Translation Service
Greek:		☐ Bilingual Coach ☐ Translation Service
Amharic (Ethiopian):		☐ Bilingual Coach ☐ Translation Service
Punjabi:		☐ Bilingual Coach ☐ Translation Service
Deaf and Hard of Hearing (TTY):		Select a response
Deaf and Hard of Hearing with video relay:		Select a response
Other Languages (please describe):
1:		☐ Bilingual Coach ☐ Translation Service
2:		☐ Bilingual Coach ☐ Translation Service
3:		☐ Bilingual Coach ☐ Translation Service
4:		☐ Bilingual Coach ☐ Translation Service
5:		☐ Bilingual Coach ☐ Translation Service

7. How many counseling sessions did your quitline offer? (Please reply fully so we can understand the number of counseling sessions provided by your quitline, along with your quitline’s eligibility criteria for receiving counseling services.)

Eligibility Criteria This section includes the minimum eligibility criteria that apply to ALL participants who received any counseling. Additional eligibility criteria for populations that receive different numbers of counseling sessions are specified in the subsequent section below.
Criteria		Yes / No	Comments
Resident of state:		Y/N
Age:		Y/N
Readiness to Quit:		Y/N
Uninsured:		Y/N
Underinsured:		Y/N
Medicaid:		Y/N
Medicare:		Y/N
Privately Insured:		Y/N
Other:		Y/N
Number of Counseling Sessions Offered
Eligibility Criteria				Number	Comments
All Eligible Participants (based on eligibility criteria listed above)
Additional Eligibility Criteria If your quitline provided different numbers of counseling sessions for different populations, please specify the additional eligibility criteria, above and beyond the eligibility criteria listed above, for each population, along with the number of counseling sessions offered to each population.
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5:

8. Did your quitline provide quitting medications to clients?

Medication	Available Medications
	Free	Discounted	Voucher/Coupon	Comments
Nicotine Patches:	Y/N	Y/N	Y/N
Nicotine Gum:	Y/N	Y/N	Y/N
Nicotine Lozenges:	Y/N	Y/N	Y/N
Other (please specify):	Y/N	Y/N	Y/N

9. How many weeks of free Nicotine Patches per quit attempt did your quitline provide to clients? (Please skip this question if your quitline did not provide free nicotine patches.)

Free Nicotine Patches - Eligibility Criteria This section includes the minimum eligibility criteria that apply to ALL participants who received any amount of free nicotine patches. Additional eligibility criteria for populations that received different amounts of nicotine patches are specified in the subsequent section below.
Criteria		Yes / No	Comments
Resident of state:		Y/N
Geographic area:		Y/N
Age:		Y/N
Readiness to quit:		Y/N
Enrollment in counseling:		Y/N
Medical conditions:		Y/N
Uninsured:		Y/N
Underinsured:		Y/N
Medicaid:		Y/N
Medicare:		Y/N
Privately Insured:		Y/N
Limited supply:		Y/N
Research study:		Y/N
Other:		Y/N
Free Nicotine Patches - Amount Offered
Eligibility Criteria			Weeks Per Quit Attempt	Limit Per Year	Comments
All Eligible Participants (based on eligibility criteria listed above)
Additional Eligibility Criteria If your quitline provided different amounts of free nicotine patches for different populations, please specify the additional eligibility criteria, above and beyond the eligibility criteria listed above, for each population, along with the number of weeks of free nicotine patches per quit attempt offered to each population.
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2:
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5:

10. How many weeks of free Nicotine Gum per quit attempt did your quitline provide to clients? (Please skip this question if your quitline did not provide free nicotine gum.)

Free Nicotine Gum - Eligibility Criteria This section includes the minimum eligibility criteria that apply to ALL participants who received any amount of free nicotine gum. Additional eligibility criteria for populations that received different amounts of nicotine gum are specified in the subsequent section below.
Criteria		Yes / No	Comments
Resident of state:		Y/N
Geographic area:		Y/N
Age:		Y/N
Readiness to quit:		Y/N
Enrollment in counseling:		Y/N
Medical conditions:		Y/N
Uninsured:		Y/N
Underinsured:		Y/N
Medicaid:		Y/N
Medicare:		Y/N
Privately Insured:		Y/N
Limited supply:		Y/N
Research study:		Y/N
Other:		Y/N
Free Nicotine Gum - Amount Offered
Eligibility Criteria			Weeks Per Quit Attempt	Limit Per Year	Comments
All Eligible Participants (based on eligibility criteria listed above)
Additional Eligibility Criteria If your quitline provided different amounts of free nicotine gum for different populations, please specify the additional eligibility criteria, above and beyond the eligibility criteria listed above, for each population, along with the number of weeks of free nicotine gum per quit attempt offered to each population.
1:
2:
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4:
5:

11. How many weeks of free Nicotine Lozenges per quit attempt did your quitline provide to clients? (Please skip this question if your quitline did not provide free nicotine lozenges.)

Free Nicotine Lozenges - Eligibility Criteria This section includes the minimum eligibility criteria that apply to ALL participants who received any amount of free nicotine lozenges. Additional eligibility criteria for populations that received different amounts of nicotine lozenges are specified in the subsequent section below.
Criteria		Yes / No	Comments
Resident of state:		Y/N
Geographic area:		Y/N
Age:		Y/N
Readiness to quit:		Y/N
Enrollment in counseling:		Y/N
Medical conditions:		Y/N
Uninsured:		Y/N
Underinsured:		Y/N
Medicaid:		Y/N
Medicare:		Y/N
Privately Insured:		Y/N
Limited supply:		Y/N
Research study:		Y/N
Other:		Y/N
Free Nicotine Lozenges - Amount Offered
Eligibility Criteria			Weeks Per Quit Attempt	Limit Per Year	Comments
All Eligible Participants (based on eligibility criteria listed above)
Additional Eligibility Criteria If your quitline provided different amounts of free nicotine lozenges for different populations, please specify the additional eligibility criteria, above and beyond the eligibility criteria listed above, for each population, along with the number of weeks of free nicotine lozenges per quit attempt offered to each population.
1:
2:
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4:
5:

12. Did your quitline ask the following question on the NQDW Intake Survey?

In the past three months, did you hear about 1-800-QUIT-NOW from any advertisements with people telling personal stories about living with health problems that were caused by smoking?

13. For each option listed below, please indicate if your state’s quitline provided the service in this reporting period: ____________(year) ___________ (quarters).

Quitline Services	Was the service offered?
Web-based self-help tools (e.g., a downloadable self-help cessation guide, a cost calculator, e-lessons on cessation)	yes no
Web-based chat rooms – (unmoderated or moderated)	yes no
Interactive web-based counseling (i.e., instant messaging or emailing with a cessation counselor, where content is tailored to the needs of the individual quitline participant)	yes no
Automated e-mail messages (i.e., a service that sends automated emails with no ability to tailor the email content to the needs of individual quitline participants)	yes no
One-way text messages to cell phones (i.e., one-way – message(s) sent by the quitline to the quitline participant, with no ability for the quitline participant to send a text message back to the quitline)	yes no
Interactive text messages to cell phones (i.e., interactive/ two-way text messages sent and received between quitline and quitline participant, including messages sent by an automated program or quitline counselor)	yes no
Mobile cessation apps – (i.e., software applications that can be downloaded to a smartphone or tablet from a distribution platform such as the Apple App Store or Google Play.)	yes no
Referral to other cessation services offered by public or private health plans	yes no
Referral to other public and private health services for chronic conditions (e.g., diabetes, hypertension)	yes no

14. If your state’s quitline provided services during this reporting period that are not captured in Question 13, please list and describe these services here:

15. During this reporting period, did your state’s quitline offer cessation protocols specifically tailored for any of the following populations? (A protocol is a set of guidelines which describe a process to be followed for providing cessation counseling and medications.) Please check all that apply.

Behavioral health conditions (offering tailored tobacco cessation services to quitline participants with a mental health condition, such as anxiety disorder, bipolar disorder, depression, posttraumatic stress disorder (PTSD), or schizophrenia, and/ or a substance use disorder.)

Native Americans (offering tailored services to Native Americans for cessation of commercial tobacco use)

Youth (under 18 years) (offering tailored tobacco cessation services to youth)

Pregnant/postpartum women (offering tailored tobacco cessation services to pregnant and postpartum women)

E-cigarette users (including exclusive e-cigarette users and/or dual users of e-cigarettes and conventional cigarettes who are seeking to quit e-cigarette use)

Other (Please specify): ________________________________________________

SERVICE UTILIZATION

Definition of direct call: A direct call is an inbound call to the quitline telephone system, regardless of whether the call was answered. This includes proxy calls or wrong numbers.

Definition of web visits to web enrollment page/site: Web visits to web enrollment page/site refers to any page view of the state quitline’s web enrollment page/site, regardless of whether the view results in any clicks or registrations.

Definition of referral: A referral is a client referral to the quitline from a health care provider,a (e.g., a physician, dentist, or pharmacist), or from state or community-based service organizations (e.g. WIC, Head Start, workforce development), on behalf of a patient or client who expressed interest in assistance with quitting tobacco and gave the provider consent to send the quitline their number, which generates an outbound call from the quitline to the patient.

16. How many direct calls did your state’s quitline receive during this reporting period?

Directions:

• Please report on the total number of direct calls to the quitline.

• Please do not report the number of unique individuals/participants. This data will be captured later in the survey.

• Please do not report the number of referrals. This data will be captured later in the survey.

• Please enter whole numbers with no decimals or other symbols.

• If you are unable to report the number of direct calls, enter "­9" (minus nine) rather than leaving it blank.

N=

17. Of the total DIRECT calls into the quitline during this reporting period, how many UNIQUE tobacco users called the quitline during this reporting period?

N=

18. How many web visits to the web enrollment page/site did your state’s quitline receive during this reporting period?

Directions:

• Please report on the total number of web visits to the web enrollment page/site.

• Please do not report the number of registrations. This data will be captured later in the survey.

• Please enter whole numbers with no decimals or other symbols.

• If you are unable to report the number of web visits to the web enrollment page/site please enter "­9" (minus nine) rather than leaving it blank.

N=

19. Quitlines use many types of promotions and referral networks to increase their reach to people who use tobacco. Please select all of the sources that generated referrals to your quitline.

Note: Referrals are client referrals to the quitline from health professionals, other intermediaries or services (including Web sites) that trigger a proactive call to the client initiated by the quitline.

• Fax referral system

• Community organization networks

• Online advertising (paid)

• Web referrals( Links from web sites, not paid ads)

• Central call center (“triage”) separate from the quitilne

• Other (please describe):

20. Please report the total number of referrals received from each referral mode during this reporting period. Please report on all that apply.

Directions:

• Please report on the total number of referrals to the quitline for each referral mode listed.

• Please do not report the number of registrations. This data will be captured later in the survey.

• Please enter whole numbers with no decimals or other symbols.

• If you are unable to report the number of referrals, enter "­9" (minus nine) rather than leaving it blank.

Quitline Referral Mode of Receipt	Total number of referrals the quitline received from listed referral mode
20a. Fax Referral: a referral received by a quitline via fax.	N=
20b. Email or Online Referral: a referral received by a quitline via email or online file transmission (i.e., flat files).	N=
20c. EHR referral/ e-Referral: a referral received by a quitline electronically from an electronic health record.	N=
20d. Other Referral Modes reported in Question 13	N=
20e. Total referrals [sum of rows a – d]	N=

21. How many participants who called or were referred to the quitline received the services listed below?

Note: Report only on those who received service for the first time. For the purposes of this question, we define “received” service as anyone who received quitline self-help materials and/or began at least one counseling call with the quitline and/or received medications through the quitline.

Service	Number of Participants
Self-help materials only with no counseling
Counseling Provided (began at least one session)
Phone1
Face-to-Face, Individual/Group
Web
Other Mechanism
Medications provided through the quitline2
Provided with phone counseling OR medications OR both phone counseling and medications3

¹ Defined as a caller-centered, person-tailored, in-depth, motivational interaction that occurs between cessation specialist/counselor/coach and caller.

² NRT or other FDA-approved medications for tobacco cessation.

³ Total provided EITHER phone counseling OR medications OR both (Note: this will likely not total the sum of b and f because many of those who receive medications will also have received counseling. This is the number that will be used to calculate treatment reach using standard calculation.)

22. Please report in the following table the total number of completed registrations for phone counseling and/or cessation medications (including NRT starter kits), by mode of entry.

Definition of registration: Registration refers to questions asked by the state quitline of tobacco users seeking cessation assistance to enroll the tobacco user in cessation services.

Definition of direct call: A direct call is an inbound call to the quitline telephone system, regardless of whether the call was answered. This includes proxy calls or wrong numbers.

Definition of web visits to web enrollment page/site: Web visits to web enrollment page/site refers to any page view of the state quitline’s web enrollment page/site, regardless of whether the view results in any clicks or registration entry.

Definition of web enrollment: Web enrollment refers to an online intake form for enrollment in cessation services offered by the state quitline and completed via the state quitline’s web enrollment page/site.

Definition of referral: A referral is a client referral to the quitline from a health care provider,a(e.g., a physician, dentist, or pharmacist), or from state or community-based service organizations (e.g. WIC, Head Start, workforce development) on behalf of a patient or client who expressed interest in assistance with quitting tobacco, which generates an outbound call from the quitline to the patient.

Directions:

• Please report on the total number of completed registrations for each mode of entry listed.

• Please do not count partial or incomplete registrations.

• Please enter whole numbers with no decimals or other symbols.

• If you are unable to report the number of completed registrations, enter "­9" (minus nine) rather than leaving it blank.

22a. How many completed registrations for phone counseling and/or cessation medications (including NRT starter kits) were generated by direct calls during this reporting period?	N=
22b. How many completed registrations for phone counseling and/or cessation medications (including NRT starter kits) were generated by web enrollment during this reporting period?	N=
22c. How many completed registrations for phone counseling and/or cessation medications (including NRT starter kits) were generated by referrals during this reporting period?	N=
22d. How many completed registrations for phone counseling and/or cessation medications (including NRT starter kits) were generated by other efforts during this reporting period?	N=
22e. Total number of completed registrations received during this reporting period for phone counseling and/or cessation medications (including NRT starter kits). (sum of a-d)	N=

NQDW Quitline Services Survey - 16