Increasing a Quitline's Reach to Low-Income Tobacco Users Through 211 Agencies

Low-income individuals bear a disproportionate share of the burden of tobacco use. This study tested the feasibility of increasing a quitline's reach to low-income tobacco users by collaborating with 211 information and referral agencies, which primarily serve people experiencing economic hardship.

Study participants (N = 114 888) were adult tobacco users referred to the California quitline by 211 agencies, referred by healthcare clinics, or self-referred from April 17, 2021 to December 31, 2023. All were offered telephone counseling. Those referred by 211 received $20 for completing one counseling session. A subset (n = 2021) was followed up at 7 months. Referral outcomes, baseline characteristics, counseling and quitting aid utilization, and quitting outcomes were analyzed by referral source in 2024.

Over a 2.7-year period, 211 agencies referred 55 151 clients to the quitline. Participants referred by 211 were more than twice as likely as healthcare-referred participants to enroll in quitline services (34.0% vs. 15.9%, p < .0001). They were more likely than healthcare- and self-referred participants to be female, lesbian, gay, bisexual, transgender, or queer/questioning, Black or multiracial, younger, less educated, and Medicaid-insured; more likely to complete a first counseling session (64.2% vs. 59.7% and 55.7%; both ps < .0001); and completed a similar number of sessions, 2.4. They were less likely to use quitting aids. Quit rates (ie, 30-day point prevalence abstinence) at 7-month follow-up were similar for all three groups.

A collaboration between a quitline and 211 agencies connected large numbers of underserved, low-income tobacco users to evidence-based cessation treatment.

The study shows that quitlines and 211 agencies can collaborate effectively to help low-income tobacco users quit. It shows that when offered a modest incentive, 211-referred participants engage in counseling as much as healthcare- and self-referred participants and are as likely to quit. If 211 agencies across the US referred at the same rate as agencies in this study, an estimated 65 000 additional tobacco users annually would receive treatment. Total reach at full implementation would likely be much higher. Quitline and 211 funders and other supporters should find ways to sustain these gains and expand their reach.