The key ingredient to optimal performance in tobacco cessation is to provide every tobacco user an evidence-based intervention at every visit.
For primary care practices, the economic return from consistent application of tobacco cessation counselling is substantial. A recent article in Medical Economics presented a way to model your practice revenue1. Now that you are persuaded that the economic return to your practice from tobacco cessation is worth pursuing, it is important to examine workflow, business performance, as well as your effectiveness. If any portion of your practice is capitated, then the return on investment is also well established2. In fee for service settings, the added revenue from optimal billing and coding will more than pay for the extra time spent helping your patients.
The key ingredient to optimal performance in tobacco cessation is to provide every tobacco user an evidence-based intervention at every visit. This approach is fully supported by clinical practice guidelines3 and should be billed and documented according to CMS requirements4. Repetition is one of the hallmarks of persuasion. The more often a message is repeated, the more like it is to stick. Every one of those repetitions, if documented to CMS standards is a billable visit.
It is rare to find a tobacco user who has not tried to stop. Successful quitters can make up to twenty attempts before they are successful. The patient narrative regarding quitting and relapse matters greatly. Most patients know how to stop smoking but are not equipped to deal with relapse. Ask about the longest interval tobacco free. How did that end? If the duration is greater than a month, you will likely uncover a life stress event that triggered relapse. The relapse narrative creates a teachable moment: One approach is to help the patient see a previous attempt as successful. The goal of the current and subsequent visits should be to prepare your patient to make a better and more sustained quit attempt that carries through future life stress events.
Most clinicians have never smoked and thus do not understand how tobacco use fits into the day to day fabric of smokers and vapers. Most tobacco users maintain a constant level of nicotine in their system. That’s why tobacco use is greater in the morning. In fact, the single most significant question about nicotine dependence you can ask is “how soon after awakening do you light up”? Some clinicians use a Fagerstrom test to help identify highly dependent users5. Many smokers are not very nicotine -dependent and the test can help these smokers focus on the behavioral methods and counseling that they need. Most smokers are able to stop smoking without medications, but if cravings for tobacco overwhelmed your patient the last time they tried, or if they failed with a medication, more intensive counselling can help patients with their personal behavior modification strategy. A written plan with a follow visit to your office can help structure a better quit attempt.
No one likes nagging and many patients have had uncomfortable conversations about tobacco in the past that may make them shut down when you raise the topic. There are ways to reframe the topic by asking about brand preference, how much is spent on tobacco, and how many puffs of nicotine have been consumed. Discussing brand preference makes it more personal and can lead to insights (for example, if a patient mentions a brand that you had never heard of, this might suggest that cost was a consideration. Some clinicians use a calculator to show the annual expense associated with tobacco (Multiply the cost of a pack a day for the average smoker by 365) and ask: What would you do with the amount spent on tobacco in a year. Persuade the patient to name what they would buy with that (perhaps a trip to Disney World) one year from today? Jot down the reply. On the next visit ask if they have thought about the trip to Disney World, the one they could have every year, if they stopped smoking.
Positive empowering messages are more effective than nagging. Today, most of the people who ever smoked cigarettes have stopped. There is little difference between your patient and those successful quitters and that information can help your patient make a better quit attempt. Additional tactics to re-frame your conversation can be found in the Consumerist Approach to Smoking Cessation championed by Alan Blum.6,7
Many clinicians have been trained to ask about readiness to change and limit their investment of time to only those who state they are ready to quit in the next month. In practice this eliminates almost all smokers. An emerging literature challenges this long-established paradigm (ref). Tobacco cessation programs are shifting from an opt-in approach to an opt-out approach with significant success (ref). There is not strong support for a trial of quitting, using a medication and counselling to help a patient create a new narrative about tobacco cessation.8
The relapse rate for tobacco cessation is high, and some patients require up to 20 attempts before they are successful. With each effort, they get better at understanding what they can do better the next time. You can enhance that process by scheduling in-person or telephonic follow-up, usually a week after a quit attempt. The best time to initiate a better quit attempt involving more counselling and better use of medication is during a slip or relapse. A valuable support system is available through Tobacco Treatment Specialists (TTS) who can be accessed by calling 1-800-QUIT-NOW. This single number links to all state-fundedQuit-lines that provide culturally and linguistically appropriate counseling by TTS. Many states also provided free nicotine replacement treatment. Patients with health insurance can also access TTS services through their health plan.
Effective tobacco cessation counselling can be delivered by anyone in a medical office including office staff, medical assistants, nurses. The strongest message comes from the doctor and his/her authority should be included in every counselling effort. Your medical assistants, nurses, and office staff should be included in an office strategy to support tobacco cessation. Operating under your leadership, they further support the billable visit. Creating a quality improvement project for tobacco cessation is a well proven strategy for optimizing performance.9 This would require taking a close look at the workflow and defining roles for everyone on your team. Measuring your outcomes in terms of counselling sessions offered and quit attempts, and successful quit attempts, will lay the groundwork for continuous quality improvement. There and other changes to workflow are described in a readily accessible sets of tools such as Million Hearts10 and Office Champions.11
Clinical Practice guidelines recommend use of medications for all smokers making a quit attempt, as medications are likely to double the effectiveness of any intervention. Varenicline is significantly better than other medications and some patients may require two medications concurrently. For patients with health insurance, all medications are available without copay.12
Your approach to setting up your office for success can make a profound difference in the lives of your patients. There are over 33 million smokers in the United States13, who on average will live ten years less if they don’t quit12. With tobacco cessation there is a strong alignment between clinical and economic outcomes for you, for your patients, and society at large.
Edward Anselm, MD, is Assistant Clinical Professor of Medicine, Icahn School of Medicine at Mount Sinai. You can read more of his writing at his website.
1.Anselm E. The economics of tobacco cessation: an overlooked resource in practice success. Medical Economics. 2023. May 8, 2023. Accessed July 2,2023.
2.Reisinger SA. Cost-effectiveness of community-based tobacco dependence treatment interventions: initial findings of a systematic review. Preventing Chronic Disease. 2019;16
3.Fiore MC. Smoking cessation: Clinical practice guideline. DIANE Publishing; 1996.
4.Collins ML, Ashley Counseling to Prevent Tobacco Use: Medicare Part B Preventive Services. NGS Medicare University. Updated 2/2/2023. Accessed 7/2/2023, https://www.ngsmedicare.com/documents/20124/121705/2472_013123_0202_tobacco_cessation_508.pdf/709ab85a-862d-dafc-d6c7-1d126353d521?t=1674586907289
5.Fagerstrom Test for Nicotine Addiction. The Calculator. Updated May 8, 2016. Accessed July, 2 2023, https://www.thecalculator.co/health/Fagerstrom-Test-For-Nicotine-Addiction-1037.html
6.Blum A. Consumer advocacy: a crafty approach to counseling. Patient Care. 1993;27(4):80-84.
7.Blum A. Cancer prevention: preventing tobacco-related cancers. Lippincott-Raven, Philadelphia, PA; 1997.
8.Ali A, Kaplan CM, Derefinko KJ, Klesges RC. Smoking cessation for smokers not ready to quit: meta-analysis and cost-effectiveness analysis. American journal of preventive medicine. 2018;55(2):253-262.
9.Presant CA, Ashing K, Yeung S, et al. Increasing clinician participation in tobacco cessation by an implementation science-based tobacco cessation champion program. Cancer Causes Control. Jan 2023;34(1):81-88. doi:10.1007/s10552-022-01619-1
10.Control CfD, Prevention. Tobacco Cessation Change Package. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services. 2020;
11.Practice AAoF. Office Champions: A Systems Change Approach. AAFP. Updated 2023. Accessed 7/2/2023, https://www.aafp.org/family-physician/patient-care/care-resources/tobacco-and-nicotine/office-champions.html#:~:text=In%202009%2C%20the%20AAFP%20introduced%20the%20Office%20Champions,patient%20engagement%20in%20the%20area%20of%20tobacco%20cessation.
12.Adams JM. Smoking Cessation-Progress, Barriers, and New Opportunities: The Surgeon General's Report on Smoking Cessation. JAMA. Jun 23 2020;323(24):2470-2471. doi:10.1001/jama.2020.6647
13.Han B, Volkow ND, Blanco C, Tipperman D, Einstein EB, Compton WM. Trends in Prevalence of Cigarette Smoking Among US Adults With Major Depression or Substance Use Disorders, 2006-2019. JAMA. Apr 26 2022;327(16):1566-1576. doi:10.1001/jama.2022.4790