A Multistate Asian-Language Tobacco Quitline: Addressing a Disparity in Access to Care

Objectives. We conducted a dissemination and implementation study to translate an intervention protocol for Asian-language smokers from an efficacy trial into an effective and sustainable multistate service.Methods. Three state tobacco programs (in California, Colorado, and Hawaii) promoted a multistate cessation quitline to 3 Asian-language-speaking communities: Chinese, Korean, and Vietnamese. The California quitline provided counseling centrally to facilitate implementation. Three more states joined the program during the study period (January 2010–July 2012). We assessed the provision of counseling, quitting outcomes, and dissemination of the program.Results. A total of 2004 smokers called for the service, with 88.3% opting for counseling. Among those opting for counseling, the 6-month abstinence rate (18.8%) was similar to results of the earlier efficacy trial (16.4%).Conclusions. The intervention protocol, based on an efficacy trial, was successfully translated into a multistate service and further disseminated. This project paved the way for the establishment of a national quitline for Asian-language speakers, which serves as an important strategy to address disparities in access to care.Smokers who speak Asian languages and have low English proficiency have had limited access to tobacco cessation resources in the United States. The idea of a multistate cessation program for this population grew out of a desire to address this disparity in access to care. The goal was to provide Asian-language smokers the same quality of tobacco cessation services currently afforded to English- and Spanish-speaking smokers.Smoking is the leading preventable cause of death and is a primary contributor to health disparities.1–3 Yet even among long-term smokers, quitting smoking has immediate health benefits and reduces long-term harms.4,5 Telephone quitlines are a proven strategy for helping smokers quit.6 The effectiveness of telephone counseling has been well documented, and tobacco quitlines are accessible to any resident of the United States.7,8 Quitlines offer an individualized intervention, but with a broader reach than clinic-based programs. Prior to the multistate project, California was the only state with a quitline offering direct service in Asian languages; most other states used third-party translation services to accommodate Asian-language speakers.9 Translation services have proven beneficial in fact-based information exchanges, such as physician and hospital visits, but behavioral counseling can be more nuanced if provided directly by someone who speaks the client’s language.10–12Asian immigrant men have higher rates of smoking than do their US-born counterparts, perhaps because of the cultural acceptability of smoking in their home countries.13,14 For example, smoking among men is estimated to be 56% in Vietnam, 52% in China, and 40% in Korea.15–17 Asians are the only ethnic group in the United States for whom cancer is the leading cause of death, with especially high mortality rates from lung cancer.18 And although Hispanics still represent the largest ethnic minority in the United States, since 2009, more Asians than Hispanics have immigrated to the United States.19 Most Asians living in the United States (74%) are foreign born, and of those, only about half are proficient in English.19 Limited English proficiency is a major barrier to health service access and results in underuse of services, less compliance with medications and programs, and greater likelihood of stopping treatment prematurely.20–25One public health dilemma is how to ensure that Asian-language speakers receive the same level of smoking cessation service as their English- and Spanish-speaking counterparts. The California quitline, which is operated by the University of California, San Diego, established its Chinese-, Vietnamese-, and Korean-language quitline services in 1993. A large randomized controlled trial was conducted from 2004 to 2008 to establish the efficacy of the Asian-language counseling protocol. The study showed that telephone counseling significantly increased quitting success (odds ratio [OR] = 2.26; 95% confidence interval [CI] = 1.73, 2.94), both overall and for each language group.26 However, until the multistate program, California was the only state to offer direct Asian-language quitline services.To facilitate the adoption of Asian-language services by other states, we obtained an dissemination and implementation (D&I) grant from the Centers for Disease Control and Prevention (CDC). D&I research is the study of the processes involved in translating evidence-based research into practice.27 D&I studies represent the final stage of research from efficacy to implementation. They examine issues related to making a program work and ensuring its sustainability. Our D&I grant proposed the creation of a multistate Asian-language quitline with several simultaneous aims. One aim was to replicate the results of the randomized efficacy trial with a broader clientele, thereby showing the real-world effectiveness of the counseling service. Another aim was to show that the multistate service could be adopted by several states and implemented from a centralized location while retaining the counseling impact. The final aim was to show that the service could be disseminated more broadly.The multistate project began with 3 participating states (California, Colorado, and Hawaii), with the goal of disseminating the services to additional states. To participate, states had to agree to promote the service and provide quitting aids (such as nicotine patches) consistent with those provided to their English and Spanish speakers. We report on the implementation and impact of the counseling service by comparing results from the multistate program with those of the previous efficacy trial. We also report on efforts to disseminate the services to additional states.