Tobacco Use Counseling

Fact Sheet and Resources

Tobacco use is the number one preventable cause of death, resulting in over 400,000 deaths annually from diseases such as cardiovascular disease, respiratory disease and cancer.

Smoking during pregnancy accounts for 20 to 30% of low–birth weight babies, up to 14% of preterm deliveries and about 10% of all infant deaths.

Pregnancy appears to motivate women to stop smoking: 46% of pre–pregnancy smokers quit smoking directly before or during pregnancy.

Tobacco use screening and cessation counseling is rated among the three most effective and efficacious preventive health actions that can be undertaken in a clinical setting.

U.S. Preventive Services Task Force (USPSTF) Grade: A
USPSTF Recommendation:
Ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.¹

Ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.²

Tobacco use Counseling - Provider Fact Sheet (PDF - 396.76 KB)

• Why is this important?
• How frequently is this preventive service being provided?
• What are the best screening practices identified in the literature?
• What are the best interventions identified in the literature?
• What barriers exist for providers?
• What are some ideas to address these barriers?
• What does the Affordable Care Act cover?
• What does Medicaid cover?
• References

For More Information

• Provider Implementation Tools
• Other Resources

Why is this important?

Overall
Smoking is the leading preventable cause of premature death, resulting in about 480,000 deaths annually from diseases such as cardiovascular disease, respiratory disease, and cancer.³

Pregnancy
During pregnancy, tobacco use results in roughly 1,000 infant deaths annually and is associated with an increase in the risk of premature birth and intrauterine growth retardation.⁴

Smoking during pregnancy causes an estimated:

• 5-8% of preterm deliveries
• 13-19% of term deliveries with low birth weight
• 23-34% cases of sudden infant death syndrome (SIDS)
• 5-7% of preterm-related infant deaths

Smoking during pregnancy increases this risk of childhood asthma and obesity, and infantile colic.⁵

Pregnancy appears to motivate women to stop smoking. Over half, 55%, of women who smoke prior to pregnancy quit smoking by the last 3 months of pregnancy.⁶

It is also important to note that of those who quit smoking during pregnancy, 40% relapse within 6 months after delivery.⁷

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How frequently is this preventive service being provided?

Overall
A nationally representative survey conducted from 2005-2010 found that adults were screened for tobacco use during 65.6% of all ambulatory care adult visits. Of those who were identified as tobacco users, roughly 20.7% received tobacco cessation counseling.⁸

Screening for tobacco use was lower among Hispanic patients than among non-Hispanic white patients.

Outpatient visits that were >20 minutes were more likely to include tobacco counseling compared to shorter visits.⁹

Pregnancy
A study conducted in New Jersey found that 92.7% of women who smoked before pregnancy were asked about tobacco use by their prenatal care provider and that 56.7% of women who were smoking when they entered prenatal care received smoking cessation counseling.¹⁰

According to a nationally representative study, fewer physicians are currently doing all five major smoking intervention steps for pregnant patients (the 5-As), compared to a sample from 1988.¹¹

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What are the best screening practices identified in the literature?

The USPSTF identifies the 5-As behavioral counseling framework as a good strategy to begin conversations with patients about smoking cessation.¹² Also recommended by The American College of Obstetricians and Gynecologists (ACOG), the 5-As include:

1. Ask about tobacco use.
2. Advise to quit using clear, personalized messages.
3. Assess willingness to make a quit attempt.
4. Assist in quit attempt.
5. Arrange follow-up and support.

When the 5-As is integrated into existing routines, the time commitment is usually 7 to 10 minutes.¹³

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What are the best interventions identified in the literature?

A meta-analysis, focused on the general population of smokers, found that teams of physicians and non-physicians using multiple intervention modalities on multiple occasions produce the best results. Providers can improve intervention success by increasing the number of contacts, types of contacts, and number of people making contacts. The duration of contact is the strongest predictor of quitting.

A second meta-analysis found that self-help strategies alone are ineffective and reinforced the effectiveness and importance of clinicians treating tobacco use/dependence with a combination of counseling and (unless contraindicated) pharmacotherapies. It also highlighted that nicotine gum is an important aid for cessation (on average more than doubling odds of cessation).¹⁴

Although combination therapy (i.e. counseling and medication) has been found to be most effective in general populations, the USPSTF found inadequate evidence to evaluate the use of pharmacotherapy in pregnant women.¹⁵ However, If women are unable to quit on their own or with counseling, ACOG recommends that nicotine replacement therapies be considered under the close supervision of a provider.¹⁶

Evidence suggests that, a 5-As office-based protocol that systematically identifies pregnant women who smoke and offers treatment or referral increases quit rates.¹⁷

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What barriers exist for providers?

• Time constraints
• Competing priorities
• Inadequate institutional support for providers
• Lack of skills in addressing smoking
• Lack of time for meaningful interventions
• Personal smoking habits¹⁸
• Provider perception that cessation interventions are ineffective
• Patient willingness to engage in intervention or provide accurate information
• Both providers and patients need to know what services are actually covered

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What are some ideas to address these barriers?

• Smoking Cessation For Pregnancy And Beyond: A Virtual Clinic provides a thorough step-by-step resource in how to have an effective conversation about smoking with pregnant patients.
• Some women may be heavily addicted to nicotine and continue to smoke during pregnancy. Therefore providers should repeat and continue efforts to achieve tobacco cessation, as well as screening for other substance use, throughout the pregnancy.¹⁹
• Develop office routines and practice patterns that could improve management of patients that smoke or use tobacco.
• Provide a workflow process for billing and reimbursement methods.

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What does the Affordable Care Act cover?

All Marketplace plans and many other plans must cover tobacco use screening for all adults and cessation interventions for tobacco users without charging a copayment or coinsurance. This is true even if the patient has not met their yearly deductible. This applies only when these services are delivered by a network provider.²⁰

The Departments (Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury) will consider a group health plan or health insurance issuer to be in compliance with the requirement to cover tobacco use counseling and interventions, if, for example, the plan or issuer covers without cost-sharing:²¹

1. Screening for tobacco use; and,
2. For those who use tobacco products, at least two tobacco cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for:
   • Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and
   • All Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization.

The Centers for Medicare and Medicaid Services (CMS) also provides information about the Coverage of Preventive Services.

HealthCare.gov provides lists of preventive care benefits for all adults and those specific to women.

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What does Medicaid cover?

Each state has its own plan for Medicaid coverage. To find out more about Medicaid and CHIP eligibility and coverage in your state, please visit Medicaid.gov.

NOTE: Section 4107 of the ACA, P.L. 111-148, amended Title XIX (Medicaid) of the Social Security Act to provide for Medicaid coverage of comprehensive tobacco cessation services for pregnant women, including both counseling and pharmacotherapy, without cost sharing. This is only one of a number of important ACA provisions that impact tobacco cessation coverage for tobacco users in general, including pregnant tobacco users.²²

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For more information

Provider Implementation Tools

AHRQ Five Major Steps to Intervention (The "5 A's") provides a description of the five major steps to intervention; the "5 A's": Ask, Advise, Assess, Assist, and Arrange.

Smoking Cessation For Pregnancy And Beyond: A Virtual Clinic is an interactive Web-based program designed for health care professionals to hone their skills in assisting pregnant women to quit smoking.

ACOG Smoking Cessation During Pregnancy, A Clinician's Guide to Helping Pregnant Women Quit Smoking is a free CME-accredited, self-instructional guide and tool kit that describes evidence-based methods for screening and counseling pregnant and postpartum women who use tobacco.

University of North Carolina's You Quit Two Quit Project includes tools and information for health care professionals to provide smoking cessation counseling for pregnant and postpartum women.

Substance Abuse During Pregnancy: Guidelines for Screening and Management (Revised Edition 2015) provides information and help for all health care professionals working with pregnant women enhance their skills and improve care for women and infants.

Treating Tobacco Use and Dependence: 2008 Update is a Public Health Service-sponsored Clinical Practice Guideline that contains strategies and recommendations designed to assist clinicians; tobacco dependence treatment specialists; and health care administrators, insurers, and purchasers in delivering and supporting effective treatments for tobacco use and dependence.

The Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program from the Society for Public Health Education (SOPHE) is an evidence-based program shown to be effective in helping pregnant women quit smoking. SCRIPT is component of a patient education program for prenatal care providers based on the 5 A's and outlines a self-evaluation process to help build women's smoking cessation success over a seven-day period; written in the 5-6th grade reading level. SOPHE also offers Adopting SCRIPT in your Organization Training which trains health professionals to promote, implement, and evaluate SCRIPT.

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Other Resources

SAMHSA Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs.

CDC Smoking & Tobacco Use Best Practices for Comprehensive Tobacco Control Programs – 2014 report is an evidence-based guide to help states plan and establish effective tobacco control programs to prevent and reduce tobacco use. The report contains a cessation intervention section that addresses health systems change.

CDC Tobacco Use and Pregnancy provides basic information, data and interventions for health care providers and public health professionals.

Smokefree Women provides information and resources on quitting smoking targeted at women; it includes a pregnancy and motherhood section.

The Community Guide Reducing Tobacco Use and Secondhand Smoke Exposure is a free resource to help choose programs and policies to improve health and prevent disease in your community.

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