To the Editor: The editorial on web and telephone counselling in Australia1 has the capacity to seriously mislead readers. It asserts:

The assertion was based on a review commissioned by the Commonwealth Department of Health and Ageing and from a review in the United Kingdom, but is simply not true. It may be true for services designed to deal with mental health problems, narrowly defined, but it is patently false if it is taken to include services to facilitate smoking cessation. We note that nicotine dependence is a recognised mental disorder,2 and thus, strictly speaking, even if the review asserted that it was restricted to mental health, it would still be wrong.

We do not know about the accuracy of the statements in relation to other drug use problems, but for smoking cessation there are a number of randomised trials of telephone-based systems,3 and at least two web-based resources are translations to the Internet of tailored computer advice services shown to be effective in RCTs.4,5 Both include Australian examples of RCTs. Our group demonstrated that the Quitline callback service as operated by Quit Victoria (phone 131 848) enhances cessation outcomes.6 Another study showed that an interactive personalised computer advice program called the QuitCoach (www.theQuitCoach.org.au) is effective in facilitating cessation, particularly by reducing relapse.4 It is currently available through the Department of Health and Ageing’s website at www.quitnow.info.au.

We wonder why this omission has happened. What makes a health issue as important as smoking so invisible? Are other drug and alcohol issues similarly invisible? Tobacco kills about 19 000 Australians each year, and disables many more. There is increasing evidence suggesting it plays an important aetiological role in the development of some mental disorders. Smoking rates among people with schizophrenia and depression are extraordinarily high.7-9 The Victorian Quitline has pioneered the integration of support for psychiatric conditions with smoking-cessation counselling,10 and, although this service has not yet been subject to outcome evaluation, it is apparent that it meets the proximal needs of both smokers with concurrent mental disorders and their carers.

Telephone and web-based services hold tremendous potential both as stand-alone services and as integrable components of comprehensive, coordinated care. High quality evaluations are required, and they need to be seen as an integral part of service delivery. People in other healthcare areas could learn a lot from what has been achieved in smoking cessation.

In reply: Borland and Segan are correct in assuming that we did not include substance disorder randomised controlled trials (RCTs) in the assessment of the efficacy of web and telecounselling services in our editorial.1 Our definition of web and telecounselling was also strict in that we included only contact that involved a person (a counsellor) online or by telephone. We specifically excluded interactive personalised web programs such as www.theQuitCoach.org.au or others specifically in mental health (narrowly defined), which have been found effective when delivered by the Internet. (Such programs include Panic Online,2 MoodGYM and BluePages.3) The use of RCTs in evaluating the areas of substance use, anxiety, depression and other mental health problems is to be applauded. Borland and Segan’s letter is also instructive in reminding us of the importance of coexistent substance-use disorders and mental health problems. Organisations such as SANE are committed to reducing the health costs of smoking in people with mental health problems and have developed specific programs for this purpose. Importantly, we are in agreement with Borland and Segan that telephone and web-based services “hold tremendous potential both as stand-alone services and as integrable components of comprehensive, coordinated care”. However, our editorial reported that web and telecounselling (not integrated web-based management systems) have yet to be evaluated through RCTs.

One point we contest is the view that smoking is invisible. Our systematic review of funding allocations to mental health research has found that the category of substance-use disorders, of which smoking was the third-largest component (below alcohol and opioids), received the most Australian research funding in 2000.4 The level of funding for substance use exceeded that for childhood disorders and dementia. Compared with substance-use research, depression research received less than half, and psychosis and anxiety less than a third, of funding. Affective disorders contribute the highest disease burden, and dementia has the highest health system costs. Although all our projects in these important areas require proportionately more funding, it is not helpful to claim that the omission of smoking outcome research is due to failure to recognise its importance.