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
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:
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
Considerations for Implementation
The most recent update of the U.S. Preventive Services Task Force also recommends that providers offer tobacco
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.
covers telehealth for both brief and intensive tobacco cessation counseling sessions. However, because
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
services. For example, the Upper Peninsula Health Care
Network in Michigan encourages patient referrals to group counseling sessions at local health
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
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
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
Resources to Learn More
Comparative and Cost Effectiveness of
Telemedicine Versus Telephone Counseling for Smoking Cessation
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
Smokers Quit: A Guide for Clinicians
This brief pocket guide for clinicians summarizes the 5As and suggested medications for tobacco dependence
Organization(s): U.S. Department of Health and Human Services, Public Health Service
Health Systems for Treating Tobacco Dependence in Primary Care: Part III – Training for Primary Care
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
Treating Tobacco Use and Dependence: 2008
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