Systems Change: Treating Tobacco Use and Dependence

Based on the Public Health Service (PHS) Clinical Practice Guideline—2008 Update

Systems change describes specific strategies that health care administrators, managed care organizations, and purchasers of health plans can implement to treat tobacco dependence. These strategies include implementing a tobacco-user identification system; providing training, resources, and feedback; dedicating staff to provide tobacco dependence treatments and assessing delivery of treatment in staff performance evaluations; and promoting hospital policies that support and provide tobacco dependence services.

These strategies for systems change were extracted from information in Chapters 5 and 6 of the 2008 Guideline Update. 

Contents

Introduction | Background | Strategies | Recommendations | Evidence | Cost Effectiveness 

Introduction

Sponsored by the Public Health Service, the 2008 Update to the Clinical Practice Guideline presents evidenced-based guidelines for clinicians to use when treating their patients who use tobacco. The expert panel that developed this Guideline recognized that health professionals need the support of the health care systems in which they work in order for these treatment recommendations to be fully utilized.

The Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update, on which this Systems Change narrative is based, was developed by a multidisciplinary, non-Federal panel of experts, in collaboration with a consortium of tobacco cessation representatives, consultants, and staff. The Guideline Panel also reviewed and analyzed literature about health care-system support to clinicians. The following information is based on the conclusions and recommendations reached by the Guideline Panel.

Note: Citation numbers in the text refer to References in the Guideline Update on which this information is based. Table numbers refer to Tables of the Guideline Update.

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Systems Change: Background

For the guideline's recommendations to be fully realized, changes are needed in health care systems to support clinician interventions. Efforts to integrate tobacco intervention into the delivery of health care require the active involvement of clinicians, health care systems, insurers and purchasers of health insurance. Such integration represents an opportunity to increase rates of delivering tobacco dependence treatments, quit attempts, and successful smoking cessation.201

In contrast to strategies that target only the clinician or the tobacco user, systems strategies are intended to ensure that tobacco use is systematically assessed and treated at every clinical encounter. Importantly, these strategies are designed to work synergistically with clinician- and patient-focused interventions, ultimately resulting in informed clinicians and patients interacting in a seamless way that facilitates the treatment of tobacco dependence.202-204

Several considerations argue for the adoption of systems-level tobacco intervention efforts. First, such strategies have the potential to substantially improve population abstinence rates. Levy et al. estimated that, over time, widespread implementation of such strategies could produce a 2-to-3.5-percent reduction in smoking prevalence rates.205 Second, despite recent progress in this area, many clinicians have yet to use evidence-based interventions consistently with their patients who use tobacco.23,48,51 Some evidence indicates that institutional or systems support (e.g., adequate clinician training or automated smoker identification systems) improves the rates of clinical interventions.206-208 Finally, agents such as administrators, insurers, employers, purchasers, and health care delivery organizations have the potential to craft and implement supportive systems, policies and environmental prompts that can facilitate the delivery of tobacco dependence treatment for millions of Americans. For example, managed care organizations and other insurers influence medical care through formularies, performance feedback to clinicians, specific coverage criteria and marketing approaches that prompt patient demand for particular services.139-209 Purchasers have also begun to use tobacco measures in pay-for-performance initiatives in which managed care organizations, clinics, and individual physicians receive additional reimbursement by achieving specific tobacco treatment-related goals. Indeed, research clearly shows that systems-level changes can reduce smoking prevalence among enrollees of managed health care plans.210-212

Unfortunately, potential benefits of a collaborative partnership amongst health care organizations, insurers, employers and purchasers have not been fully realized. For example, treatments for tobacco use (both medication and counseling) are not provided consistently as paid services for subscribers of health insurance packages.213-215 Although substantial progress has been made since the publication of the first Guideline in 1996,1,216-218 neither private insurers nor state Medicaid programs consistently provide comprehensive coverage of evidence-based tobacco interventions.206,214,219

Findings such as these resulted in the Healthy People 2010 objective:

Increase insurance coverage of evidence-based treatment for nicotine dependency to 100 percent220

In sum, without supportive systems, policies, insurance coverage and environmental prompts, the individual clinician will likely not assess and treat tobacco use consistently. Therefore, just as clinicians must assume responsibility to treat their patients for tobacco use, so must health care administrators, insurers, and purchasers assume responsibility to craft policies, provide resources, and display leadership that results in a health care system that delivers consistent and effective tobacco use treatment.

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Systems Change: Strategies

Five specific strategies will help ensure that tobacco intervention is consistently integrated into health care delivery:

  1. Implement a Tobacco-User Identification System in Every Clinic.
  2. Provide Education, Resources, and Feedback to Promote Provider Intervention.
  3. Dedicate Staff to Provide Tobacco Dependence Treatment and Assess Its Delivery in Staff Performance Evaluations.
  4. Promote Hospital Policies That Support and Provide Inpatient Tobacco Dependence Services.
  5. Include Tobacco Dependence Treatments (Both Counseling and Medication) Identified As Effective in the Guideline, as Paid or Covered Services in All Subscribers or Members of Health Insurance Packages. 

Systems Strategy 1. Implement a Tobacco-User Identification System in Every Clinic

ActionStrategies for implementation
Implement an office-wide system that ensures that for every patient at every clinic visit, tobacco-use status is queried and documented.

Office system change:
Expand the Vital Signs to include tobacco use or implement an alternative universal identification system.

Responsible staff:
Nurse, medical assistant, receptionist, or other individual already responsible for recording the vital signs. These staff must be instructed regarding the importance of this activity and serve as nonsmoking role models.

Frequency of utilization:
Every visit for every patient regardless of the reason for the visit.a

System implementation steps:
Routine smoker identification can be achieved by modifying electronic medical record data collection fields or progress note in paper charts to include tobacco use status as one of the vital signs.

Vital Signs
Blood Pressure: ______________________
Pulse: _______ Weight: _________
Temperature: ________________________
Respiratory Rate: _____________________
Tobacco Use (circle one): Current Former Never

aRepeated assessment is not necessary in the case of the adult who has never used tobacco or not used tobacco for many years, and for whom this information is clearly documented in the medical record. 

Systems Strategy 2. Provide Education, Resources, and Feedback to Promote Provider Intervention

ActionStrategies for implementation
Health care systems should ensure that clinicians have sufficient training to treat tobacco dependence, clinicians and patients have resources, and clinicians are given feedback about their tobacco dependence treatment practices.

Educate all staff. On a regular basis, offer training (e.g., lectures, workshops, inservices) on tobacco dependence treatments and provide continuing education (CE) and/or other incentives for participation.

Provide resources such as ensuring ready access to tobacco quit lines (e.g., 1-800-QUIT-NOW) and other community resources, self-help materials, and information about effective tobacco use medications (e.g., establish a clinic fax-to-quit service, place medication information sheets in examination rooms).

Report the provision of tobacco dependence interventions on report cards or evaluative standards for health care organizations, insurers, accreditation organizations and physician group practices (e.g., HEDIS, The Joint Commission, and Physician Consortium for Performance Improvement).

Provide feedback to clinicians about their performance, drawing on data from chart audits, electronic medical records, and computerized patient databases. Evaluate the degree to which clinicians are identifying, documenting, and treating patients who use tobacco.

 

Systems Strategy 3. Dedicate Staff to Provide Tobacco Dependence Treatment and Assess Its Delivery in Staff Performance Evaluations

ActionStrategies for implementation
Clinical sites should communicate to all staff the importance of intervening with tobacco users and should designate a staff person (e.g., nurse, medical assistant, or other clinician) to coordinate tobacco dependence treatments. Nonphysician personnel may serve as effective providers of tobacco dependence interventions.

Designate a tobacco dependence treatment coordinator for every clinical site.

Delineate the responsibilities of the tobacco dependence treatment coordinator (e.g., ensuring the systematic identification of smokers, ready access to evidence-based cessation treatments [e.g., quitlines], and scheduling of follow-up visits).

Communicate to each staff member (e.g., nurse, physician, medical assistant, pharmacist, or other clinician) his or her responsibilities in the delivery of tobacco dependence services. Incorporate a discussion of these staff responsibilities into training of new staff.

 

Systems Strategy 4. Promote Hospital Policies That Support and Provide Inpatient Tobacco Dependence Services

ActionStrategies for implementation
Provide tobacco dependence treatment to all tobacco users admitted to a hospital.

Implement a system to identify and document the tobacco use status of all hospitalized patients.

Identify a clinician(s) to deliver tobacco dependence inpatient consultation services for every hospital and reimburse them for delivering these services.

Offer tobacco dependence treatment to all hospitalized patients who use tobacco.

Expand hospital formularies to include FDA-approved tobacco dependence medications.

Ensure compliance with The Joint Commission regulations mandating that all sections of the hospital be entirely smoke-free and that patients receive cessation treatments.

Educate hospital staff that first-line medications may be used to reduce nicotine withdrawal symptoms, even if the patient is not intending to quit at this time.

 

Systems Strategy 5. Include Tobacco Dependence Treatments (Both Counseling and Medication) Identified as Effective in This Guideline as Paid or Covered Services for All Subscribers or Members of Health Insurance Packages

ActionStrategies for implementation
Provide all insurance subscribers, including those covered by managed care organizations (MCOs), workplace health plans, Medicaid, Medicare, and other government insurance programs, with comprehensive coverage for effective tobacco dependence treatments, including medication and counseling.

Cover effective tobacco dependence treatments (counseling and medication) as part of the basic benefits package for all health insurance packages.

Remove barriers to tobacco treatment benefits (e.g., co-pays, utilization restrictions).

Educate all subscribers and clinicians about the availability of covered tobacco dependence treatments (both counseling and medication) and encourage patients to use these services.

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Systems Change: Recommendations

Health care delivery administrators, insurers, and purchasers can promote the treatment of tobacco dependence through a systems approach. Purchasers (often business entities or other employers, State or Federal units of government, or other consortia that purchase health care benefits for a group of individuals) should make tobacco assessment and coverage of treatment a contractual obligation of the health care insurers and/or clinicians who provide services to them.

In addition to improving the health of their employees or subscribers, providing coverage for tobacco dependence treatment will result in lower rates of absenteeism229-230 and lower utilization of health care resources.229,231 Health care administrators and insurers should provide clinicians with assistance to ensure that institutional changes promoting tobacco dependence treatment are implemented universally and systematically. A number of institutional policies would facilitate these interventions such as:

  • Implementing a tobacco-user identification system in every clinic (Systems Strategy 1).
  • Providing adequate training, resources, and feedback to ensure that providers consistently deliver effective treatments (Systems Strategy 2).
  • Dedicating staff to provide tobacco dependence treatment and assessing the delivery of this treatment in staff performance evaluations (Systems Strategy 3).
  • Promoting hospital policies that support and provide tobacco dependence services (Systems Strategy 4).
  • Including tobacco dependence treatments (both counseling and medication) identified as effective in this Guideline, as paid or covered services for all subscribers or members of health insurance packages (Systems Strategy 5).

These strategies are based on the evidence described in Chapter 6 of the Guideline Update as well as on panel opinion.

 

Systems Change: Evidence

System Recommendations and Evidence presents the information considered by the Guideline Panel, the results of meta-analyses for research studies, and the Panel recommendations. These recommendations cover:

Clinician Training and Reminder Systems
Cost Effectiveness of Tobacco-Dependence Interventions
Tobacco-Dependence Treatment as Part of Assessing Health are Quality
Providing Treatment for Tobacco Use and Dependence as a Covered Benefit 

Clinician Training and Reminder Systems

Recommendation: All clinicians and clinicians-in-training should be trained in effective strategies to assist tobacco users willing to make a quit attempt and to motivate those unwilling to quit. Training appears to be more effective when coupled with systems changes. (Strength of Evidence = B)

Meta-analyses were conducted to analyze the effects of clinician training and other systems changes. It was necessary to include studies in these analyses in which higher level units (clinicians or clinical sites) served as units of randomization. This strategy was adopted because relatively few studies in this area of research randomized individual patients to treatment or intervention conditions. Studies randomized at higher level units were considered for the analyses only if the study's analytic plan accounted for the dependency of data nested under such units or if the outcome, such as providing advice to quit, was analyzed at the same level as the randomization (e.g. clinician or clinic level). In fact, however, the few studies that analyzed data at the level of the clinician or clinic shared no common outcomes so they could not be used in the meta-analysis.

Table 6.31 depicts meta-analytic results for studies that examined the effects of training on abstinence outcomes. Only two studies, somewhat heterogenous, were available for this analysis. Thus, although the meta-analysis showed a significant effect of training, the panel elected to assign this recommendation a "B" strength of evidence. 

Table 6.31. Meta-analysis (2008): Effectiveness and estimated abstinence rates for clinician training (n = 2 studies).

InterventionNumber of armsOdds Ratio (95% C.I.)Estimated abstinence rate
(95% C.I.)
No intervention21.06.4
Clinician training22.0 (1.2-3.4)12.0 (7.6-18.6)

Select for articles used in the Update's meta-analysis.

Clinician training and other systems changes are intended to increase rates of tobacco use assessment and intervention. Therefore, additional meta-analyses were conducted to ascertain the effects of systems changes on outcomes such as clinician assessment of smoking status ("Ask"), provision of treatment ("Assist"), and arranging for treatment followup ("Arrange"). Thus, these meta-analyses focused on systems change impact on specific clinician behaviors. In the analyzed studies, clinician behavior was assessed via patient report or chart review (not via clinician report). Analyses of such clinician behaviors are of public health significance because of evidence that the provision of treatment has been shown to lead to higher tobacco cessation rates.

As noted in Table 6.32, training clinicians increases the percentage of smokers who receive treatment, such as a discussion of benefits/obstacles to quitting or strategies to prevent relapse, medication and provision of support. Further, combining clinician training with a charting system, such as chart reminder stickers or treatment algorithms attached to the chart, increases rates of tobacco use assessment (Table 6.33), setting a quit date (Table 6.34), providing materials (Table 6.35), and arranging for followup (Table 6.36). Thus, clinician training, especially when coupled with other systems changes such as reminder systems, increases the rates at which clinicians engage in tobacco interventions that reliably boost tobacco cessation. The Guide to Community Preventive Services92 found insufficient evidence to recommend provider education systems as stand alone interventions, separate from other system changes, but does recommend provider education when part of other system changes such as reminder systems. 

Table 6.32. Meta-analysis (2008): Effectiveness of clinician training on rates of providing treatment ("Assist") (n = 2 studies)

InterventionNumber of
arms
Odds Ratio (95% C.I.)Estimated abstinence rate
(95% C.I.)
No intervention21.036.2
Clinician training23.2 (2.0-5.2)64.7 (53.1-74.8)

Select for articles used in the Update's meta-analysis. 

Table 6.33. Meta-analysis (2008): Effectiveness of clinician training combined with charting on asking about smoking status ("Ask") (n = 3 studies)

InterventionNumber of
arms
Odds Ratio
(95% C.I.)
Estimated rate
(95% C.I.)
No intervention31.058.8
Clinician training32.1 (1.9-2.4)75.2 (72.7-77.6)

Select for the articles used in the Update's meta-analysis. 

Table 6.34. Meta-analysis (2008): Effectiveness of training combined with charting on setting a quit date ("Assist") (n = 2 studies)

InterventionNumber of
arms
Odds Ratio
(95% C.I.)
Estimated rate
(95% C.I.)
No intervention21.011.4
Clinician training25.5 (4.1-7.4)41.4 (34.4-48.8)

Select for the articles used in the Update's meta-analysis. 

Table 6.35. Meta-analysis (2008): Effectiveness of training combined with charting on providing materials ("Assist") (n = 2 studies)

InterventionNumber of
arms
Odds Ratio
(95% C.I.)
Estimated rate
(95% C.I.)
No intervention21.08.7
Clinician training24.2 (3.4-5.3)28.6 (24.3-33.4)

Select for the articles used in the Update's meta-analysis. 

Table 6.36. Meta-analysis (2008): Effectiveness of training combined with charting on providing materials ("Assist") (n = 2 studies)

InterventionNumber of
arms
Odds Ratio (95% C.I.)Estimated rate
(95% C.I.)
No intervention21.06.7
Clinician training22.7 (1.9-3.9)16.3 (11.8-22.1)

Select for the articles used in the Update's meta-analysis.

These meta-analyses support the finding that clinician training increases the delivery of effective tobacco use treatments. Training elements provided in these interventions included didactic presentation of material, group discussions and role playing. These studies also examined a range of clinician training, from formal training during residency to on-site clinician training within the community.

Training should be directed at both clinicians-in-training as well as practicing clinicians. Training should be reinforced throughout the clinicians' education and practice.363-368 Such training has been shown to be cost-effective.369 For clinicians-in-training, most clinical disciplines currently neither provide training nor require competency in tobacco use interventions,370 although this is improving slowly.371-372 One survey of U.S. medical schools found that most medical schools (69%) did not require clinical training in tobacco dependence treatment.373 The National Cancer Institute's Prevention and Cessation Education in Medical Schools (PACE) reported that, in 2004, about 36% of medical school courses offered about 10 hours of tobacco-related teaching over 4 years374 and PACE has developed competencies for graduating medical students375

Similarly, the American Dental Education Association has guidelines recommending tobacco use cessation clinical activities (TUCCA) education for dental and dental hygiene students and, in 1998, 51% of dental schools reported clinical training in this area.376 Tobacco-related curricula may be taught as part of a preventive medicine or substance abuse course or as a class by itself. Similar recommendations would be relevant to virtually all other clinical disciplines. Training in tobacco use interventions should not only transmit essential treatment skills (Chapter 3) but also inculcate the belief that tobacco dependence treatment is a standard of good clinical practice.130,208,250

Several factors would promote the training of clinicians in tobacco intervention activities:370

  • Inclusion of education and training in tobacco dependence treatments in the required curricula of all clinical disciplines.
  • Evaluation of effective tobacco dependence treatment knowledge and skills in licensing and certification exams for all clinical disciplines.
  • Adoption by medical specialty societies of a uniform standard of competence in tobacco dependence treatment for all members.

Finally, clinicians who currently use any tobacco product should participate in treatment programs to stop their own tobacco use permanently. Clinicians are important role models for their patients, and those who use tobacco are probably less likely to counsel their patients to quit.374 Therefore, it is heartening that many types of clinicians have dramatically decreased their own tobacco use over the past 40 years,378 although this has not been universal.

Future Research

The following topics regarding clinician training require additional research:

  • Effectiveness of training programs for other health disciplines such as nursing, psychology, dentistry (including hygienists), social work, and pharmacy.
  • Effective elements in successful training programs (e.g., continuing medical education, interactive components).
  • Combined effect of multiple systems changes, such as clinician training, reminder systems, clinician feedback, incentive payments, and recruitment of opinion leaders.

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Cost-Effectiveness of Tobacco Dependence Interventions

Recommendation: The tobacco dependence treatments shown to be effective in this guideline (both counseling and medication) are highly cost-effective relative to other reimbursed treatments and should be provided to all smokers. (Strength of Evidence = A)

Recommendation: Sufficient resources should be allocated for systems support to ensure the delivery of efficacious tobacco use treatments. (Strength of Evidence = C)

Smoking exacts a substantial financial burden on the United States. A recent report of the United States Centers for Disease Control and Prevention estimated that tobacco dependence costs the nation more than $96 billion per year in direct medical expenses and $97 billion in lost productivity.28 Given these substantial costs, research has focused on the economic impact and cost-effectiveness of tobacco cessation interventions.

Tobacco use treatments, ranging from brief clinician advice to specialist-delivered intensive programs, including medication, have been shown to be not only clinically effective, but also extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments. Cost-effectiveness analyses have shown that tobacco dependence treatment compares quite favorably with routinely reimbursed medical interventions such as the treatment of hypertension and hypercholesterolemia as well as preventive screening interventions such as periodic mammography or Papanicolaou smears.222,224,374-382 For example, the cost per life-year saved of tobacco dependence treatment has been estimated at $3,539,194 which compares favorably to hypertension screening for men, ages 45-54 ($5,200) and annual cervical screening for women, ages 34-39, ($4,100).383 Treating tobacco dependence also is important economically in that it can prevent the development of a variety of costly chronic diseases, including heart disease, cancer, and pulmonary disease. In fact, tobacco dependence treatment has been referred to as the "gold standard" of health care cost effectiveness.225

Cost-effectiveness can be measured in a variety of ways, including cost per quality-adjusted-life-year saved (QALY), cost per quit, health care costs and utilization pre- and post-quit, and return on investment (ROI) for coverage of tobacco dependence treatment.

Cost per Quality-Adjusted-Life-Year Saved and Cost per Quit

Numerous analyses have estimated the cost per Quality-Adjusted-Life-Year (QALY) saved resulting from use of effective tobacco dependence interventions.187,222,380,384-389 In general, evidence-based tobacco use interventions compare quite favorably with other prevention and chronic disease interventions such as treatment of hypertension and mammography screening when using this criterion. Specific analyses have estimated the costs of tobacco use treatment to range from a few hundred to a few thousand dollars per QALY saved.228,385 Separate analyses have computed the estimated costs of treatment in terms of the cost per quit. Compared to other interventions, the cost of tobacco use treatments has been modest, ranging from a few hundred to a few thousand dollars per quit.194,212,384,390-393

Managed Care Organizations (MCOs) often assess the per member per month (PMPM) cost of a benefit and the PMPM for tobacco use treatment has been assessed in a variety of settings. In general, the PMPM for tobacco use treatments have been low relative to other covered benefits, ranging from about $0.20 to about $0.80 PMPM.210,228,391,394

Health care Costs and Utilization Pre- and Post-Quit

A substantial body of research has investigated the effect of tobacco use treatment on health care costs.395-399 A synthesis of these findings suggests that: 1) among individuals who quit tobacco use, health care costs typically increase during the year in which smokers quit then decline progressively, falling below those of continuing smokers for one to 10 years after quitting; 2) in general, smokers' health care costs begin to rise in the time period immediately prior to quit attempts; and 3) higher health care utilization predicts smoking cessation among smokers with and without chronic diseases. These findings suggest that quitting smoking often occurs in response to serious and expensive health problems. Such research also suggests that increases in health care costs, including hospitalizations, during the year of quitting may be a cause rather than a consequence of successful smoking cessation.

Return on Investment for Coverage of Tobacco Dependence Treatment

Return on investment (ROI) is a frequently used tool to estimate the amount of time it takes for an expenditure to earn back some or all of its initial investment. The economic arguments supporting the decision to provide insurance coverage for tobacco use treatments would be enhanced if the costs of such coverage are modest compared to economic benefits resulting from successful cessation (reductions in health care expenditures, increased productivity, and/or other costs).

Studies have documented that tobacco dependence treatments provide a timely return on investment when considered by the employer. Such analyses have concluded that providing coverage for tobacco use treatment for employees often produce substantial net financial savings through increased health care savings, increased productivity, reduced absenteeism, and reduced life insurance payouts.229,400-402

Financial savings are more difficult to attain for a health plan given factors such as member turnover, the difficulty of attributing reduced health care expenditures to tobacco dependence, and the absence of economic benefits resulting from productivity gains. Although most analyses have not demonstrated cost savings, insurance coverage of evidence-based tobacco dependence treatments are highly cost-effective relative to other frequently paid-for health care services. One recent effort to simulate the financial implications of covering tobacco use treatments by managed care organizations found that at five years, coverage of tobacco use treatment cost an MCO a modest $0.61 PMPM, with quitters gaining an average of 7.1 years of life and a direct coverage cost of about $3,500 for each life-year saved.228 The authors concluded that coverage of such cost-effective tobacco use treatment programs by MCOs should be strongly encouraged. Another study examined the trend in health care costs for former smokers over 7 years post-quitting compared to continuing smokers.395 The authors found that, by the seventh year, former smokers' cumulative costs (including increased cost in the year they quit) were lower than those of continuing smokers. A more recent analysis concluded that at 10 years, the ROI of providing a comprehensive tobacco use treatment benefit, considering only health care costs, ranged from 75-to-92 percent, indicating that health care savings alone have repaid more than three-fourths of the investment.229 Other analyses have shown that multiple tobacco use treatment components, including telephone counseling and various medications, yield a favorable ROI.227,403-404 The American Health Insurance Plans (AHIP), has provided a web link for health plans to compute their ROI for the provision of tobacco use treatment: http://www.businesscaseroi.org/roi/default.aspx

Tobacco cessation treatment is particularly cost-effective in certain populations such as hospitalized patients and pregnant women. For hospitalized patients, successful tobacco abstinence not only reduces general medical costs in the short-term, but also reduces the number of future hospitalizations.9,355,405 Tobacco dependence interventions for pregnant women are especially cost-effective because they result in fewer low birth weight babies and perinatal deaths; fewer physical, cognitive, and behavioral problems during infancy and childhood; and yield important health benefits for the mother.406-407 One study found that interventions with U.S. pregnant smokers could net savings up to $8 million in direct neonatal inpatient costs given the cost of an intervention ($24-$34) versus the costs saved ($881) for each woman who quits smoking during pregnancy.408 Another study showed that, for each low-income pregnant smoker who quit, Medicaid saved $1,274.409 A simulation study found that a 1% point decrease in smoking prevalence among U.S. pregnant women would save $21 million (1995 dollars) in direct medical costs in the first year.406,410-411

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Tobacco-Dependence Treatment as a Part of Assessing Health Care Quality

Recommendation: Provision of Guideline-based interventions to treat tobacco use and dependence should remain in standard ratings and measures of overall health care quality (e.g., NCQA HEDIS). These standard measures should also include measures of outcomes (e.g., use of cessation treatment, short- and long-term abstinence rates) that result from providing tobacco dependence interventions. (Strength of Evidence = C)

The provision of tobacco dependence treatment should be increased by: (1) attention to health organization "report cards" (e.g., HEDIS, The Joint Commission, Physician Consortium for Performance Improvement, National Quality Forum, Ambulatory Quality Alliance),89,412-414 which support smoker identification and treatment; (2) accreditation criteria used by The Joint Commission and other accrediting bodies that include the presence of effective tobacco assessment and intervention policies; and (3) increasing the use of tobacco-related measures in pay-for-performance initiatives.

Future Research

The following topics regarding cost-effectiveness and health systems require additional research:

  • Cost-effectiveness of the various tobacco dependence treatments, both short- and long-term
  • Optimal ways to remove systemic barriers that prevent clinicians from effectively delivering tobacco dependence treatments
  • Systemic interventions to encourage provider and patient utilization of effective tobacco dependence treatments
  • Relative costs and economic impacts of different formats of effective treatments (e.g., proactive telephone counseling, face-to-face contact, medication).

Impact of using tobacco intervention performance measures on clinician intervention and patient outcomes, including the use of such measures in "pay for performance" programs.

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Providing Treatment for Tobacco Use and Dependence as a Covered Benefit

Recommendation: Providing tobacco dependence treatments (both medication and counseling) as a paid or covered benefit by health insurance plans has been shown to increase the proportion of smokers who use cessation treatment, attempt to quit, and successfully quit. Therefore, treatments shown to be effective in the Guideline should be included as covered services in public and private health benefit plans. (Strength of Evidence = A)

Multiple studies have assessed the impact of including tobacco dependence treatment as a covered health insurance benefit for smokers. Most studies have documented that such health insurance coverage increases both treatment utilization rates and the rates of cessation,210,212,391,415 although some research is not consistent with these findings.416 A recent Cochrane analysis(2005) concluded that health care financing systems that offered full payment for tobacco use treatment increased self-reported prolonged abstinence rates at relatively low costs when compared with a partial benefit or no benefit. Moreover, the presence of prepaid or discounted prescription drug benefits increases patients' receipt of medication and smoking abstinence rates.231,348,417 These studies emphasize that removing all cost barriers yields the highest rates of treatment utilization.

Three studies met criteria to be included in a 2008 Guideline Update meta-analysis of the effects of providing tobacco use treatments as a covered health insurance benefit. Three different outcomes were examined: rates of treatment provision, quit attempts, and quit rates. As can be seen in Tables 6.37 through 6.39, compared to not having tobacco use treatment as a covered benefit, individuals with the benefit were more likely to receive treatment, make a quit attempt and attain abstinence from smoking. 

Table 6.37. Meta-analysis (2008): Estimated rates of intervention for individuals who received tobacco use interventions as a covered health insurance benefit (n = 3 studies)

TreatmentNumber of
arms
Estimated odds ratio
(95% C.I.)
Estimated Intervention rate
(95% C.I.)
No intervention31.08.9
Clinician training32.3 (1.8-2.9)18.2 (14.8-22.3)

Select for the articles used in the Update's meta-analysis. 

Table 6.38. Meta-analysis (2008): Estimated rates of quit attempts for individuals who received tobacco use interventions as a covered health insurance benefit (n = 3 studies)

TreatmentNumber of
arms
Estimated odds ratio
(95% C.I.)
Estimated quit attempt rate
(95% C.I.)
No intervention31.030.5
Clinician training31.3 (1.01-1.5)36.2 (32.3-40.2)

Select for the articles used in the Update's meta-analysis. 

Table 6.39. Meta-analysis (2008): Estimated abstinence rates for individuals who received tobacco use interventions as a covered benefit (n = 3 studies)

TreatmentNumber of
arms
Estimated odds ratio
(95% C.I.)
Estimated abstinence rate
(95% C.I.)
No intervention31.06.7
Clinician training31.6 (1.2-2.2)10.5 (8.1-13.5)

Select for the articles used in the Update's meta-analysis.

It may be in the best interests of insurance companies, MCOs, purchasers, and governmental bodies within a specific geographic area to work collaboratively to ensure that tobacco dependence interventions are a covered benefit and enrollees are aware of these benefits. This would allow the financial benefits of the successful use of these services to be realized by all the health plans within a community.

Future Research

  • Impact of promotion or communication of tobacco dependence treatment benefits on utilization and resulting population health and economic effects.
  • Cost-effectiveness of specific elements of tobacco dependence treatment.
  • Appropriate level of payment needed to optimize clinician delivery of tobacco dependence treatment.

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Systems Change: Cost Effectiveness

Tobacco use treatments are not only clinically effective, but they are cost-effective as well. Tobacco use treatments ranging from clinician advice to medication to specialist-delivered intensive programs are cost-effective in relation to other medical interventions such as treatment of hypertension and hyperlipidemia and to other preventive interventions such as periodic mammography.194,221-224 In fact, tobacco use treatment has been referred to as the "gold standard" of health care cost effectiveness.225 Tobacco use treatment remains highly cost-effective, even though a single application of any effective treatment for tobacco dependence may produce sustained abstinence in only a minority of smokers. Finally, evidence-based tobacco dependence interventions produce a favorable return on investment from the perspective of both the employer and health plan due to reduced health care consumption and costs.226-228 The cost-effectiveness of guideline recommendations for tobacco use treatment is addressed in detail in Chapter 6.

New Recommendations in the PHS-Sponsored Clinical Practice Guideline—Treating Tobacco Use and Dependence: 2008 Update

Guideline Availability

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Page last reviewed December 2012
Internet Citation: Systems Change: Treating Tobacco Use and Dependence: Based on the Public Health Service (PHS) Clinical Practice Guideline—2008 Update. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/decisionmakers/systems/index.html