The simple answer to how to quit tobacco is that there is no simple answer. Different methods work for different people, and no two paths to quitting are the same. Often, several attempts are needed before the right method is found. However, as a healthcare provider, the best thing you can do for your patients is to recommend they quit, point them in the direction of proven cessation methods, and provide the encouragement and inspiration needed to help them stick with it.
Talk To Your Patient
APPROACHING PATIENTS ABOUT TOBACCO CESSATION
Though primary care providers are in an excellent position to provide tobacco cessation interventions with their patients who use tobacco products, it can be difficult and sometimes uncomfortable to approach the topic. We recommend treating tobacco use as a vital sign so that a patient’s tobacco use status is readily apparent upon their entrance into the exam room. This is an easy way to integrate conversations about tobacco use into the clinic visit. Tobacco use can be a chronic, relapsing condition that at times requires varying levels of intervention. We encourage you to go as far as you can with each patient at each visit as you help lay the groundwork for tobacco cessation.
In order to assess your patient’s level of nicotine dependence, we suggest using the test in Fagerström Test for Nicotine Dependence. The level of your patient’s nicotine dependence has important indications for the regimen that should be suggested for treatment.
It can be difficult to know what to say to your patient, here are some simple scripts for your use.
THE UTAH TOBACCO QUIT LINE
Believe it or not, telephone counseling is one of the most effective ways to help people quit smoking or chewing tobacco. In contrast to in-person counseling, it eliminates the need for transportation and childcare, as a person can access services from wherever there’s a telephone. Help can be obtained on the person’s own timetable and terms, and critical assistance is just a phone call away.
When someone calls the Utah Tobacco Quit Line, they can:
- Be connected with a trained coach who will help them develop a personalized quit plan, and guide them through the quitting process.
- Receive up to five individually tailored sessions with a coach.
- Get a self-help booklet and information about online resources.
- Opt in for text messaging reminders and support.
- Receive information about how to help a friend or family member to quit.
- Be able to discuss options for medications, including free Nicotine Replacement Therapy (NRT) to eligible callers (youth are not eligible for NRT).
Quit line services are completely confidential and available in English and Spanish. Translation is also available into more than a hundred other languages. All services are free to Utah residents.
Check here to determine if free promotional materials are available at your local health department.
Online Coaching is a free, internet-based service designed to help individual tobacco users through the quitting process. Its interactive tools and features can be used 24 hours a day, seven days a week, for as long as needed. At any time, tobacco users can log on for information and support. Utah online coaching members can take advantage of:
- Tools to help them through the quitting process
- Smoking cessation tips and answers to frequently asked questions
- Access to medication guides
- Interaction with quitting experts
All these services are free to Utah users. Online coaching can be used alone or in combination with other services, like the Utah Tobacco Quit Line, for added support.
UTAH TOBACCO CESSATION RESOURCE DIRECTORY
The Utah Tobacco Cessation Resource Directory is provided as a public service by the Utah Department of Health Tobacco Prevention and Control Program. The purpose of the directory is to assist tobacco users and health professionals in locating tobacco cessation resources in their local area. We encourage you to contact these agencies or programs if you are interested in more specific information about the length, content and cost (if any) of programs.
In Utah, the Medicaid system is part of the Department of Health. Medicaid clients tend to have higher smoking rates than average, so the Tobacco Prevention and Control Program (TPCP) partners with Medicaid to offer quitting services to its clients. The program offers services through the Utah Tobacco Quit Line and includes coverage of tobacco cessation medications, as well as additional help for pregnant women. To learn more, contact TPCP at 1-877-220-3466.
QUITTING SERVICES FOR THE UNINSURED
Through a grant from the TPCP, participating Association for Utah Community Health (AUCH) community health centers offer Zyban and Chantix free of charge for their uninsured clients. To be eligible for these services, the client must be uninsured, a tobacco user, and an established client with a primary care provider at a participating community health center. If you are uninsured but do not currently go to a community health center for your primary care, you must become a client of the community health center for all of your primary care needs before you will be eligible to participate in this program. Contact your nearest community health center for more information.
Billing & Reimbursements
As of January 2014, the Affordable Care Act (ACA) requires insurance plans to cover many clinical preventive services. Some of the covered preventive services include:
- Tobacco use screening for all adults
- Tobacco cessation counseling for adults who use tobacco, and expanded counseling for pregnant women
Click here for chart explaining 2014 Medicare Benefits on Tobacco Cessation Counseling
Medicare Part B covers both intermediate and intensive levels of tobacco cessation counseling for symptomatic and asymptomatic patients: intermediate and intensive.
Two cessation attempts are covered per year, and both coinsurance and deductibles are waived. Each attempt may include a maximum of four intermediate or intensive counseling sessions. The total annual benefit covers up to eight smoking cessation counseling sessions in a 12-month period. The patient may receive another eight counseling sessions during a second or subsequent year after 11 months have passed since the first Medicare-covered cessation counseling session.
To qualify for payment from Medicare, the following criteria must be met at the time of service:
- Patients must be competent and alert.
- Counseling must be provided by a physician or other Medicare-recognized practitioner.
Use the following CPT codes for patients who use tobacco and have been diagnosed with a recognized tobacco-related disease or exhibit symptoms consistent with tobacco-related disease:
|CODE||Type of Counseling||Description|
|99406||Intermediate||Smoking and tobacco-use cessation counseling visit greater than three minutes but not more than 10 minutes.|
|99407||Intensive||Smoking and tobacco-use cessation counseling visit greater than 10 minutes.|
Use the following CPT codes for patients who use tobacco but do not have symptoms of tobacco-related disease:
|CODE||Type of Counseling||Description|
|G0436||Intermediate||Smoking and tobacco use cessation counseling visit greater than 3 minutes but not more than 10 minutes.|
|G0437||Intensive||Smoking and tobacco use cessation counseling visit greater than 10 minutes.|
- The ICD-9 CM codes 305.1 (nondependent abuse of drugs; tobacco use disorder; tobacco dependence) and/or V15.82 (history of tobacco use) should be used with the above CPT codes.
- For counseling less than three minutes, service is considered as bundled into the appropriate evaluation and management (E/M) visit code and should not be reported separately.
- Tobacco cessation codes can be used separately or along with E/M codes (99201-99215). However, a -25 modifier should be appended to the E/M code. When tobacco cessation codes are billed with E/M codes, E/M services have to be provided on the same day and separately identifiable from smoking cessation counseling.
*For each patient receiving smoking and tobacco-use cessation counseling or counseling to prevent tobacco use, medical record documentation must show and include standard information along with sufficient patient history to adequately demonstrate that Medicare coverage conditions were met.
Medicare Part D covers FDA-approved cessation drug therapies. However, over-the-counter therapies are typically excluded.
Many states offer some payment for individual tobacco cessation and treatment counseling for Medicaid patients. However, providers are encouraged to contact their state Medicaid office for coverage information in their specific state.
As of January 1, 2014, all state Medicaid programs are required to support all FDA-approved smoking cessation medications without requiring co-pays or other financial barriers.
PRIVATE / COMMERICAL INSURANCE CARRIERS
Private insurers are required to provide evidence-based tobacco cessation counseling and interventions to all adults and pregnant women. Private payer benefits are subject to specific plan policies. Providers need to check with insurance plans to determine what specific interventions are included and the extent to which they are covered.
|CODE||Type of Counseling||Description|
|99406||Intermediate||Smoking and tobacco-use cessation counseling visit greater than three minutes but not more than 10 minutes (Short Descriptor: Smoke/tobacco counseling 3-10).|
|99407||Intensive||Smoking and tobacco-use cessation counseling visit greater than 10 minutes (Short Descriptor: Smoke/tobacco counseling greater than 10).|
|S9075||Smoking Cessation Treatment|
|S9453||Smoking Cessation Classes (nonphysician provider, per session)|
|99381-99397||Preventive Medicine Services|
|99078||Physician Educational Services in Group Setting|
Various E/M services (associated with acute or chronic care) may be coded. When providing an E/M service, if greater than 50 percent of face-to-face time with patient is spent on counseling, time may be used as a basis for selection of level of service.
|ICD-9 DIAGNOSIS CODE||Description|
|649.0x||Tobacco-use disorder complicating pregnancy, childbirth or puerperium|
|989.84||Other substances, chiefly nonmedicinal as to source, tobacco*|
- List additional code to specify nature of toxic effect. Excludes localized toxic effects classified elsewhere and respiratory conditions due to external agents and, if applicable, any diagnosis code(s) for condition(s) evaluated and managed in the same encounter.*
- All codes with .x or .xx require fourth or fifth digits. See the ICD-9 manual for complete descriptions.
*This list was formulated based on the 2004 Surgeon General’s Report on the Health Consequences of Smoking. It is not an all-inclusive list and may be subject to different interpretation of the report.
SELF-PAY PATIENTS AND UNINSURED PATIENTS
Resources for patients who do not have insurance coverage or who have limited coverage from their insurance carrier include the following:
- Quit lines (1-800-QUIT-NOW)
- Online cessation resources (Online Coaching)
- Flexible spending accounts if smoking cessation is an allowable expense
- Employee Assistance Programs (EAP); tobacco cessation may be covered by EAPs in some cases.
- Community resources and support groups
- Out-of-pocket spending
Visit the following recources for the most effective training and Continuing Medical Education (CME) courses to build your knowledge on tobacco use cessation and secondhand smoke exposure.
AMERICAN ACADEMY OF PEDIATRICS (AAP) TOBACCO TRAINING AND CME COURSES
PediaLink Course: Addressing Tobacco Use and Exposure
(click the ‘online courses’ option, and you will see it listed)
Available June 12, 2013 – June 12, 2016
AAP Credit = 1.00
AMA PRA Category 1 Credit(s)™ = 1.00
NAPNAP Credit = 1.00
Pharmacology Rx = 0.50
WEBINARS THROUGH THE AAP RICHMOND CENTER
The AAP Richmond Center hosts an ongoing webinar series to educate clinicians on child health issues related to tobacco control. Click here to view past webinars. Note that all of these webinars are presented free of charge.
Tobacco Training and CME Courses From Other Organizations:
- Become a Tobacco Treatment Specialist
- The Association for the Treatment of Tobacco Use and Dependence provides a listing of the different trainings that can assist in becoming a certified tobacco treatment specialist.
- Clean Air for Healthy Children and Families
- Training and materials to implement tobacco cessation in your practice. These materials are offered through the Pennsylvania Chapter of the American Academy of Pediatrics.
- Clinical Management of the Patient who Uses Tobacco
- This interactive curriculum is intended for use in a classroom by an instructor, but can also be used by small groups of students, or by an individual. Covered in the curriculum are the 5As (full and modified), as well as Motivational Interviewing, pharmacology, and the nature of addiction.
- Global Tobacco Control: Online Courses
- This site is an online resource that provides free online trainings, research-based reports and guides, and information on the capacity building programs of the Institute for Global Tobacco Control (IGTC) within the Johns Hopkins Bloomberg School of Public Health.
- Smoking Cessation: Effective Intervention Strategies
- This course is a collaborative effort of the Morehouse School of Medicine and the Mercer School of Medicine. It is intended primarily for medical students, who can register to receive academic curriculum credit.
- Tobacco Treatment Training
- This site uses Web-based programs that provide training in tobacco treatment that prepares physicians to provide clinical tobacco interventions for prevention and cessation.
- Tobacco Use and Dependence: An Updated Review of Treatments
- A free CME/CE credit course for physicians, nurses, and respiratory therapists developed by the University of Wisconsin Center for Tobacco Research and Intervention and focused on the Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update.
- Treatment of Tobacco Dependence
- This module, from the American Medical Association, is aimed to help learners describe approaches to determining the level of tobacco dependence and assessment of the patient’s readiness to attempt smoking cessation.
- University of Wisconsin Center for Tobacco Research and Intervention (CTRI)
- The CTRI combines tobacco control research with practical application in these videos and webinars. Providers of several disciplines are addressed, with videos for pharmacists, dental teams, and pulmonary providers.
- Center for Tobacco Cessation: Web-based Trainings
- This site lists several past trainings that have been held by the Center, and offers the presentation materials and webinars for several past trainings.
- Motivational Interviewing — Counseling Parents About Secondhand and Third Hand Smoke Exposure
- This presentation by Dr. Jonathan Winickoff will provide an overview of the health risks associated with secondhand and thirdhand smoke exposure, and explain motivational interviewing techniques to assist clinicians in counseling parents.
- ReachMD Features Thirdhand Smoke: Key Concerns for Infants and Children
- Dr. Jonathan Winickoff talks with host Dr. Jennifer Shu about how these chemicals, newly named thirdhand smoke, can affect our younger patients in particular.