Tobacco Dependence Treatment, Including Health Coaching or Counseling

In this model, clinicians provide patients with or refer patients to cessation treatments. The 2008 update of the Clinical Practice Guidelines for Treating Tobacco Use and Dependence strongly recommends that providers offer effective tobacco dependence counseling and cessation medication to patients who use tobacco. The guidelines state that the combination of medication and counseling is more effective than using tobacco cessation medication or receiving counseling alone. The U.S. Preventive Services Task Force also recommends screening for tobacco use and offering behavioral interventions in addition to pharmacotherapy.

The recommended counseling framework for tobacco cessation is called the “5 As” and involves:

• Asking about tobacco use
• Advising patients to quit through clear personalized messages
• Assessing their willingness to quit
• Assisting them to quit
• Arranging follow-up and support

The Quick Reference Guide for Clinicians summarizes the recommendations of the Clinical Practice Guidelines and is organized around the 5As. In addition, the Guidelines state that seven medications have been shown to promote long-term tobacco abstinence:

• Non-nicotine-based medications:
  • Bupropion SR
  • Varenicline
• Nicotine-based medications:
  • Nicotine gum
  • Nicotine inhaler
  • Nicotine lozenge
  • Nicotine nasal spray
  • Nicotine patch

Examples of Tobacco Dependence Treatment Programs

• The Mississippi Rural Health Association (MRHA) and the Community Health Center Association of Mississippi are both conducting tobacco cessation projects in collaboration with the Mississippi State Department of Health Office of Tobacco Control. Both projects are training providers in rural areas to deliver brief, evidence-based tobacco screening and assessment to their patients using a curriculum based on the 5As.
• Na Pu`uwai, a Native Hawaiian organization on the island of Molokai, offers evidence-based tobacco cessation services to patients. The behavioral health staff provides brief interventions based on the 5As model, as well as more intensive tobacco cessation interventions for patients that require additional support. In addition, Na Pu`uwai provides patients with nicotine replacement therapy free of charge and helps facilitate access to other medications for smoking cessation. As access to transportation can be limited in this rural community, Na Pu`uwai offers telephone counseling and provides culturally-tailored “quick kits” during the first counseling session to encourage long-term cessation efforts. These kits include materials that support exercise, including water bottles and pedometers, and oral alternatives to tobacco, such as sunflower seeds.
• The Iowa City Veterans Affairs (VA) Healthcare System, through support from the VA Office of Rural Health, is developing a tobacco treatment model for rural veterans who have issues accessing care. While state quitlines can be beneficial to many rural tobacco users, outside quitline providers cannot access VA records and some veterans prefer to receive services directly from the VA.
  
  In this program, electronic health records are reviewed to identify current or recent tobacco users, who are then contacted by mail and offered access to the program. VA nurses review and summarize patients' health history for a physician, clinical pharmacist, or nurse practitioner, who makes a decision about appropriate smoking cessation medication options. An interventionist then engages the patient in shared decision making over the telephone to identify an appropriate medication to treat tobacco dependence.
  
  The VA pharmacy further facilitates access to tobacco cessation services by mailing the medication to the patient. In addition, an interventionist provides participants with six telephone-based counseling sessions based on the recommendations of the U.S. Public Health Service's Clinical Practice Guidelines. Finally, the project team screens patients for comorbid conditions including elevated depressive symptoms, risky alcohol use, and concerns about post-cessation weight gain and offers concomitant behavioral counseling to address these issues. Patients requiring more extensive assistance for these issues are linked to appropriate treatment programs within the VA.
• The Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program is an evidence-based intervention that prenatal providers can use to help pregnant women decrease or eliminate tobacco use.

Considerations for Implementation

The most recent update of the U.S. Preventive Services Task Force also recommends that providers offer tobacco counseling services to adolescents. The CDC has prepared a fact sheet that describes special considerations for treating adolescent patients. Specifically, providers should offer interventions that are developmentally appropriate and that respect the confidentiality of the patient.

In addition, the U.S. Preventive Services Task Force recommends that providers screen and counsel all pregnant women who use tobacco, preferably with tailored materials that discuss the effects of tobacco on maternal and fetal health.

Rural providers who cannot access tobacco counseling training or have staffing constraints may wish to explore the option of contracting with a certified tobacco counselor via telemedicine. Medicare covers telehealth for both brief and intensive tobacco cessation counseling sessions. However, because best practices recommend consistently identifying and treating every tobacco user, this option may only be feasible for small practices that do not have significant counseling demands. Some rural clinics also collaborate with local partners to provide patients with access to tobacco cessation services. For example, the Upper Peninsula Health Care Network in Michigan encourages patient referrals to group counseling sessions at local health departments.

Many rural providers find that they need to address comorbid conditions while treating patients for tobacco use. Comorbid conditions can include depression, mood disorders, cancer, heart disease, and chronic obstructive pulmonary disease, among others. The Clinical Practice Guidelines indicate that integrating tobacco dependence treatment into chronic disease management programs may be an effective way to provide cessation services to populations with comorbid conditions.

Rural providers should consider educating staff members about the importance of providing tobacco cessation treatment to every identified tobacco user. Provider's offices may need to designate one staff member to coordinate referral or treatment plans for patients. Rural primary care providers should be aware that non-physician personnel may be able to directly provide tobacco counseling to patients as well. Medicare covers smoking cessation counseling services for qualified smokers, as long as these services are provided by a Medicare-recognized practitioner (for example, clinical nurse specialists and clinical psychologists, among others).

Providers may need to assess which type of counseling will best benefit their patients. Some rural practices report that patients are reluctant to join group counseling sessions due to a perceived lack of privacy or confidentiality in small communities. However, some community members may appreciate the support of their peers in their efforts to quit. Rural providers may also consider offering telephone counseling sessions to accommodate patients with limited access to transportation.

Program Clearinghouse Examples

• Altura Centers for Health
• Na Pu'uwai

Resources to Learn More

Comparative and Cost Effectiveness of Telemedicine Versus Telephone Counseling for Smoking Cessation
Document
This article describes a study conducted in rural Kansas that compares the cost effectiveness of an integrated telemedicine counseling intervention to telephone counseling.
Author(s): Richter, K.P., Shireman, T.I., Ellerbeck, E.F., Cupertino, A.P., Cox, L.S., Preacher, K.J., et al.
Citation: Journal of Medical Internet Research, 17(5), e113
Date: 5/2015

Helping Smokers Quit: A Guide for Clinicians
Document
This brief pocket guide for clinicians summarizes the 5As and suggested medications for tobacco dependence treatment.
Organization(s): U.S. Department of Health and Human Services, Public Health Service
Date: 5/2008

Strengthening Health Systems for Treating Tobacco Dependence in Primary Care: Part III – Training for Primary Care Providers
Document
This training guide includes guidance for developing and implementing tobacco-focused health systems policies, systems changes, and interventions. The audiences include policy makers, primary care service managers, primary care providers, and future trainers.
Organization(s): World Health Organization
Date: 2013

Treating Tobacco Use and Dependence: 2008 Update
Document
This report is an update to the 2000 Clinical Practice Guideline was published that describes new and effective clinical treatments for tobacco.
Organization(s): Tobacco Use and Dependence Guideline Panel, U.S. Department of Health and Human Services
Date: 5/2008