Modern medicine can transplant organs, cure hepatitis C, and deploy artificial intelligence to read radiology scans. Yet one of the most effective life-saving interventions in clinical medicine, treatment for tobacco dependence, is still delivered inconsistently. More than 28 million Americans continue to smoke cigarettes. Evidence-based treatments are widely available, inexpensive, and highly cost-effective. But across health systems, physicians rarely deliver them in a systematic way. By every measure, physicians are not consistently providing evidence-based treatment to people who use tobacco. This is evident whether one looks at the National Health Interview Survey, NCQA CAHPS surveys, studies of medical claims, or electronic medical records. The barriers are well understood, and many effective solutions are available. The first step is to measure your own performance and resolve to do better.
Better screening
Electronic medical records consistently underreport tobacco use. Identifying all forms of tobacco use is an essential first step in treatment. Simply asking about tobacco use is itself an effective intervention. If you do not ask, that omission becomes a form of tacit acquiescence. Best practices in effective screening were described by Kaiser Permanente of Northern California.
Provide consistent advice to quit at every visit
Clinical practice guidelines outline evidence-based treatment that can be provided at every visit, regardless of readiness to change. Treatment can be provided and documented by trained clinical staff under a physician’s supervision. Billing for tobacco cessation counseling of at least 3 minutes (CPT 99406) is not commonly used, yet it can be billed up to eight times per year, even when patients are not actively making a quit attempt.
Offer evidence-based treatment at every visit
Medication and counseling, used separately or together, significantly increase the likelihood of successful quitting. Varenicline is approximately 50 percent more effective than other cessation medications. For patients with insurance, all cessation medications are available without copay or deductible. For patients without insurance, varenicline is available from Cost Plus Drugs for about $10 per month. Counseling is available at no charge through 1-800-QUIT-NOW (1-800-784-8669) or through many health plans.
Schedule follow-up
Many patients attempting to quit smoking relapse within the first week. A scheduled follow-up visit or phone call can help patients get back on track and can double the effectiveness of any intervention.
Offer a trial of quitting
Many clinicians ask patients about their “readiness to change.” This is an application of the “stages of change” model which outlines the process for self-motivated behavior change. In this model, patients who say they are not ready to change at the time of the clinic visit often receive no treatment at that time or even on subsequent visits. This is a missed opportunity, because there is fluidity between stages and a patient may respond to many of the motivational messages available. In addition, the model has been challenged by newer research demonstrating the effectiveness of a “trial of quitting,” in which patients try cessation medications without committing to an immediate quit date. The medications, especially varenicline, can reduce cravings to the point that some patients surprise themselves by remaining nicotine-free for extended periods and ultimately quitting.
Consider the role of mental health
Some patients use nicotine to self-medicate for underlying mood disorders. For example, patients with serious mental illness have much higher prevalence as well as higher relapse rates. Nicotine can act as an antidepressant. When nicotine use ends, depression reappears. Patients who repeatedly attempt to quit but remain motivated may benefit from referral to a behavioral health practitioner.
Refer to a center of excellence
Most major medical centers have clinics specializing in tobacco treatment. These programs provide counseling by tobacco treatment specialists and coordinate the use of multiple medications.
Consider harm reduction
For adults who have persistent difficulty quitting, harm-reduction approaches may play a role. Nicotine products authorized for sale by the FDA, such as certain vaping products or nicotine pouches, are substantially less harmful than smoking combustible cigarettes.
Adopt systems change for tobacco treatment
A comprehensive assessment of how clinicians deliver tobacco treatment will reveal many opportunities to improve workflow, initiate and sustain treatment, and measure outcomes.
Evaluate the economics
Evaluate the economics of tobacco treatment within your practice. As an increasing proportion of patients are covered under value-based contracts, the financial impact of smoking cessation can be calculated and measured.
In conclusion
There is much that can be done to improve performance in tobacco treatment. We have effective medications, proven counseling strategies, and decades of evidence showing what works. The remaining challenge is not scientific; it is organizational. Health systems need to treat tobacco dependence with the same seriousness they apply to hypertension, diabetes, or heart disease. That means identifying every patient who uses tobacco, offering treatment at every visit, supporting quit attempts with medication and counseling, and measuring performance in a systematic way. Follow the links in this article for more detailed information. The data needed to improve performance already exist within your electronic medical record system. All that is required is the decision to begin. If we want better outcomes, we need to stop treating tobacco cessation as an optional conversation and start treating it as a core responsibility of clinical care.
Edward Anselm is a board-certified internist with a long-standing focus on public health, tobacco control, and preventive care. He earned his medical degree from the Chicago Medical School at Rosalind Franklin University and completed his internal medicine residency at Montefiore Medical Center in New York. Over the past three decades, Dr. Anselm has served in senior leadership roles across clinical, corporate, and managed-care settings, including chief medical officer positions at HIP Health Plan of New York, FidelisCare, and Health Republic Insurance of New York.
Recently retired from his role as medical director at Aetna, Dr. Anselm continues to teach at the Icahn School of Medicine at Mount Sinai as a clinical assistant professor. His current work focuses on strengthening reimbursement pathways for tobacco cessation and preventive services, helping clinicians integrate evidence-based care that improves patient outcomes while supporting practice sustainability. His research has been published in the American Journal of Accountable Care, the American Journal of Preventive Medicine, AJPM Focus, and Health Affairs Forefront, including articles on tobacco control in accountable care, underbilling of cessation services, and the financial and quality benefits of treating tobacco use as a clinical priority.
Dr. Anselm’s educational and policy work is shared through EdwardAnselmMD.com and The Anselm Nicotine Prescription, with professional updates available on LinkedIn.
