Sample Table Shells

RACEThe National Quitline Data Warehouse Sample State Report: STATE System (Updated Quarterly)

State Name

Quitline Services

Hours of Operation:

(when live pick-up/counseling is available)

Available Languages: English, Spanish, etc.

Counseling

Group 1 (i.e., All Adults)

Group 2 (i.e., Persons who receive Medicaid)

xxam - xxpm

No. of Sessions

x x

Medications

Nicotine Replacement Therapy

• Patch

• Gum

• Lozenge

• Inhaler

• Nasal Spray Prescription Medications

• Buproprion

• Chantix

No. of weeks

Eligibility Criteria

(such as age, location, insurance, or readiness to quit)

Total Call Volume and Services Received

Total Number of Calls (N)

Caller Type

Calling for help/information for themselves (N, Percent) Calling to assist someone else (N, Percent)

Other (N, Percent)

Services Tobacco Users Received

Any Service (counseling, medication, or both) (N) Counseling (N, Percent)

Medication (N, Percent)

Referral Source

Learned of Quitline Through:

Media (TV, Radio, etc.) (N, Percent) Other Advertising (N, Percent)

Health Professional Referral (N, Percent) Other (N, Percent)

Mode of Entry to Quitline

Called the quitline (N, Percent) Fax referral (N, Percent) Website (N, Percent)

Other (N, Percent)

Characteristics of Callers Who Received Counseling

Sex:

Men (N, Percent) Women (N, Percent)

Race/Ethnicity:

American Indian/Alaska Native, (N, Percent) Asian (N, Percent)

Black/African American (N, Percent)

White, (N, Percent)

Highest Level of Education:

• Less than high school (N, Percent)

• High school diploma (N, Percent)

• GED (N, Percent)

• Some college/technical school (N, Percent)

• College Degree (N, Percent)

Age:

18-24 Years (N, Percent) 25-44 Years (N, Percent) 45-64 Years (N, Percent) 65+ Years (N, Percent)

Type of Tobacco:

Cigarettes (N, Percent) Cigars (N, Percent) Pipes (N, Percent)

Chewing Tobacco or Snuff (N, Percent) Other Tobacco Products (N, Percent)

Number of Quitters (quit for 30-days at 7-months post enrollment)

Number of persons who received a service who quit (N, Percent)