Reduce Tobacco Use

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Fast Facts
  • Smoking is the leading cause of preventable disease and death in the United States, accounting for more than 480,000 premature deaths every year, or nearly 1 in 5 deaths.
  • Tobacco use leads to more than $300 billion in medical costs and lost productivity each year.
  • While the adult cigarette smoking prevalence has fallen to 14.0%, it remains higher among certain populations, including adults of lower socioeconomic status, adults with mental health conditions, and adults with substance use disorders.­
Evidence-Based Interventions
  1. Increase access to evidence-based tobacco cessation treatments, including individual, group, and telephone counseling and cessation medications approved by the Food and Drug Administration (FDA), in accordance with the 2008 Public Health Service Clinical Practice Guideline.
  2. Remove barriers that impede access to covered cessation treatments, such as cost sharing and prior authorization.
  3. Promote increased use of covered treatment benefits by tobacco users.

What You Could Do to Reduce Tobacco Use:

Healthcare Providers

Use the 5 A’s approach:

  1. Ask every patient about tobacco use at every visit
  2. Advise patients who use tobacco to quit
  3. Assess patients’ willingness to make a quit attempt
  4. Assist patients in their quit attempt, including offering cessation medications unless contraindicated and providing or referring for cessation counseling
  5. Arrange follow-up.

Physicians can delegate the “Ask” and “Arrange” steps to other members of the health care team, including nurses, physician assistants, and medical assistants. Team members can share the “Assist” step.

Payers

  • Use multiple avenues to identify plan members who use tobacco products. This can help you connect these members with cessation assistance, ensure you understand the scope of the problem, and track progress in reducing members’ tobacco use.
  • Change policies or programs to cover all evidence-based cessation treatments, including individual, group, and telephone counseling and the seven FDA-approved cessation medications, with no or minimal barriers.
  • Promote cessation coverage to members who use tobacco products and health care providers to increase awareness and use of covered treatments.

Selected Studies Behind the Interventions

Healthcare Providers

Access to tobacco cessation treatments

Harvard Vanguard Medical Associates, an affiliate of Atrius Health, carried out a health systems change initiative to institutionalize routine smoking cessation treatments at 17 Harvard Vanguard primary care clinics. The initiative included changes to workflow and electronic health record systems, as well as upgrades to medication decision support, information technology, team training, patient health education, and marketing. Harvard Vanguard, in collaboration with the Massachusetts Tobacco Control Program, analyzed more than 4 million electronic health record encounter records from January 1, 2005 to November 30, 2010, and found:

  • The study defined achieving “systems change” as the first month when more than half of all office visits at a clinic included identification of smoking status.
  • At clinics that achieved systems change, a clinical intervention occurred during 82.5% of visits where patients were identified as smokers, compared with 59.4% of visits at clinics that did not achieve systems change.
  • Quitline electronic referrals were implemented, and referrals doubled within 3 months.
  • The number of quits increased in clinics that made systems changes, compared with clinics that did not:
    • Smoking prevalence was reduced by 10% in participating clinics.
    • Decreases in self-reported smoking prevalence were 40% greater at clinics that achieved systems change than at clinics that did not initiate systems changes.
    • On average, the likelihood of quitting increased by 2.6% per brief intervention.
    • After 3 years, a patient with a history of smoking who had 3 visits per year would be as much as 26% more likely to have quit smoking.1,2

Payers

Access to tobacco cessation treatments

Massachusetts Medicaid
In 2006, Massachusetts Medicaid created and extensively promoted an evidence-based Medicaid tobacco cessationpdf icon benefit that covered:

  • Up to 16 individual or group cessation counseling sessions.
  • Two 90-day courses per year of FDA-approved cessation medications (including over-the-counter and prescription medications).

Within three years after the benefit began:

  • More than one in three (37%) of smokers enrolled in the state Medicaid program used the benefit. 3
  • The smoking rate among Medicaid enrollees decreased from 38% to 28%.4
  • Annual hospitalizations for heart attacks and other acute heart disease diagnoses fell by almost half.5
  • A study found that every $1 in program costs was associated with $3.12 in savings in hospital costs for averted acute cardiovascular events alone. This savings resulted in a return on investment of $2.12 for every dollar spent.6

These findings suggest that a tobacco cessation benefit that covers cessation counseling and medications, is easy to access, and is heavily promoted to smokers and their healthcare providers can increase use of cessation treatments, reduce smoking prevalence, lead to improved health outcomes, reduce healthcare costs, and generate a positive return on investment all within a relatively short amount of time.

SoonerCare
Oklahoma’s Medicaid program (SoonerCare) and the Oklahoma State Department of Health collaborated to ensure that all SoonerCare enrollees have easy access to a robust tobacco cessation benefit.7 The program sought to:

  • Remove common barriers to obtaining tobacco cessation medications and counseling.
  • Increase the number of Medicaid enrollees referred to the state quitline, the Oklahoma Tobacco Helpline.
  • Increase the rates of enrollment in quitline counseling among Medicaid enrollees referred to the state quitline.

As a result:

  • SoonerCare removed copayments and prior authorization for cessation medications.
  • The smoking prevalence of SoonerCare enrollees fell from 48% in 2008 to 43% in 2013.
  • The Oklahoma Tobacco Helpline saw an 82% increase in the number of SoonerCare callers from 2009 to 2012.
Removing Barriers to Cessation Treatments

Reducing tobacco users’ out-of-pocket costs can involve policy or program changes that make evidence-based cessation treatments, including counseling and medication, more affordable and accessible. The CDC Community Preventive Services Task Force found that reducing tobacco users’ out-of-pocket costs for evidence-based cessation treatments has strong evidence of effectiveness in increasing the number of tobacco users who quit.8

Resources
Providers, Health Systems, and Health Plans

2015 U.S. Preventive Services Task Forces Tobacco Cessation Recommendationexternal icon
Provides updated recommendation for effective tobacco cessation interventions that primary care clinicians can implement for adult patients who use tobacco products, together with an updated evidence review on this topic.

2008 Public Health Service Clinical Practice Guideline on Treating Tobacco Use and Dependenceexternal icon
Provides in-depth recommendations and accompanying evidence reviews on effective cessation interventions, including cessation counseling, medications, and clinical, health system, and health insurer interventions.

Tobacco Cessation Protocol and Implementation Guidanceexternal icon
The customizable Million Hearts® Tobacco Cessation Protocol template is accompanied by implementation guidance on how to adopt and use a treatment protocol as well as examples for use in practices and health care systems.

Identifying and Treating Patients Who Use Tobacco: Action Steps for Clinicianspdf iconexternal icon
Provides evidence-based, tested tobacco use identification and intervention strategies from the Million Hearts® program for busy clinicians.

The Community Guide – Reducing Tobacco Use and Secondhand Smoke Exposureexternal icon
The Community Preventive Services Task Force provides policy and program recommendations about reducing tobacco users’ out-of-pocket costs for evidence-based cessation treatments.

Louisiana State University Health System’s Tobacco Control Initiativepdf icon
This question and answer style case study provides an overview of Louisiana State University’s Health System’s Tobacco Control Initiative, focused on developing and implementing a systematic approach to treating tobacco use in one of the largest safety-net health delivery systems in the country.

Employers

NIOSH Current Intelligence Bulletin 67: Promoting Health and Preventing Disease and Injury through Workplace Tobacco Policies
Comprehensive review of the status of tobacco use and secondhand smoke exposure among workers, the health and safety consequences of tobacco use and secondhand smoke exposure for workers, and interventions to prevent or reduce tobacco use and secondhand smoke exposure in this population.

1Land TG, Rigotti NA, Levy DE, Schilling T, Warner D, Li W. The effect of systematic clinical interventions with cigarette smokers on quit status and the rates of smoking-related primary care office visits. PLoS ONE 2012;7(7):e41649.

2Q&A with Harvard Vanguard Medical Associates and Atrius Health about Health Systems Change to Address Smoking. Available at https://www.cdc.gov/tobacco/quit_smoking/cessation/pdfs/qa_harvard-vanguard.pdfpdf icon

3Land T, Warner D, Paskowsky M, et al. Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence. PLoS One 2010;5:e9770

4Land T, Warner D, Paskowsky M, et al. Medicaid coverage for tobacco dependence treatments.

5Land T, Rigotti NA, Levy DE, et al. A longitudinal study of Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease. PLoS Med 2010;7:e1000375.

6 Richard P, West K, Ku L. The return on investment of a Medicaid tobacco cessation program in Massachusetts. PloS One. 2012;7(1)e29665. doi: 10.1371/ journal.pone.0029665.

7 Medicaid Tobacco Cessation Coverage in Oklahoma: A Case Study in Leveraging Systems and Partnerships.pdf icon Accessed March 4, 2019.

8Rigotti NA, Bitton A, Kelly JK, Hoeppner BB, Levy DE, Mort E.  Offering population-based tobacco treatment in a healthcare setting: a randomized controlled trial. Am J Prev Med.  2011; 41(5): 498-503.