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Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May.

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Treating Tobacco Use and Dependence: 2008 Update.

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5Systems Interventions—Importance to Health Care Administrators, Insurers, and Purchasers


Efforts to integrate tobacco intervention into the delivery of health care require the active involvement of clinicians, health care systems, insurers, and purchasers of health insurance. Such integration represents an opportunity to increase rates of delivering tobacco dependence treatments, quit attempts, and successful smoking cessation.201

In contrast to strategies that target only the clinician or the tobacco user, systems strategies are intended to ensure that tobacco use is systematically assessed and treated at every clinical encounter. Importantly, these strategies are designed to work synergistically with clinician- and patient-focused interventions, ultimately resulting in informed clinicians and patients interacting in a seamless way that facilitates the treatment of tobacco dependence.202204

Several considerations argue for the adoption of systems-level tobacco intervention efforts. First, such strategies have the potential to substantially improve population abstinence rates. Levy et al. estimated that, over time, widespread implementation of such strategies could produce a 2 percent to 3.5 percent reduction in smoking prevalence rates.205 Second, despite recent progress in this area, many clinicians have yet to use evidence-based interventions consistently with their patients who use tobacco.23,48,51 Some evidence indicates that institutional or systems support (e.g., adequate clinician training or automated smoker identification systems) improves the rates of clinical interventions.206208 Finally, agents such as administrators, insurers, employers, purchasers, and health care delivery organizations have the potential to craft and implement supportive systems, policies, and environmental prompts that can facilitate the delivery of tobacco dependence treatment for millions of Americans. For example, managed care organizations and other insurers influence medical care through formularies, performance feedback to clinicians, specific coverage criteria, and marketing approaches that prompt patient demand for particular services.139,209 Purchasers also have begun to use tobacco measures in pay-for-performance initiatives in which managed care organizations, clinics, and individual physicians receive additional reimbursement by achieving specific tobacco treatment-related goals. Indeed, research clearly shows that systems-level changes can reduce smoking prevalence among enrollees of managed health care plans.210212

Unfortunately, the potential benefits of a collaborative partnership among health care organizations, insurers, employers, and purchasers have not been fully realized. For example, treatments for tobacco use (both medication and counseling) are not provided consistently as paid services for subscribers of health insurance packages.213215 Although substantial progress has been made since the publication of the first Guideline in 1996,1,216218 neither private insurers nor state Medicaid programs consistently provide comprehensive coverage of evidence-based tobacco interventions.206,214,219 Findings such as these resulted in the Healthy People 2010 objective:

  • Increase insurance coverage of evidence-based treatment for nicotine dependency to 100 percent.220

In sum, without supportive systems, policies, insurance coverage, and environmental prompts, the individual clinician likely will not assess and treat tobacco use consistently. Therefore, just as clinicians must assume responsibility to treat their patients for tobacco use, so must health care administrators, insurers, and purchasers assume responsibility to craft policies, provide resources, and display leadership that results in a health care system that delivers consistent and effective tobacco use treatment.

Cost-Effectiveness of Tobacco Use Treatments

Tobacco use treatments are not only clinically effective, but are cost-effective as well. Tobacco use treatments, ranging from clinician advice to medication to specialist-delivered intensive programs, are cost-effective in relation to other medical interventions such as treatment of hypertension and hyperlipidemia and to other preventive interventions such as periodic mammography.194,221224 In fact, tobacco use treatment has been referred to as the “gold standard” of health care cost-effectiveness.225 Tobacco use treatment remains highly cost-effective, even though a single application of any effective treatment for tobacco dependence may produce sustained abstinence in only a minority of smokers. Finally, evidence-based tobacco dependence interventions produce a favorable return on investment from the perspective of both the employer and health plan due to reduced health care consumption and costs.226228 The cost-effectiveness of Guideline recommendations for tobacco use treatment is addressed in detail in Chapter 6.

Recommendations for Health Care Administrators, Insurers, and Purchasers

Health care delivery administrators, insurers, and purchasers can promote the treatment of tobacco dependence through a systems approach. Purchasers (often business entities or other employers, State or Federal units of government, or other consortia that purchase health care benefits for a group of individuals) should make tobacco assessment and coverage of treatment a contractual obligation of the health care insurers and/or clinicians who provide services to them. In addition to improving the health of their employees or subscribers, providing coverage for tobacco dependence treatment will result in lower rates of absenteeism229,230 and lower utilization of health care resources.229,231 Health care administrators and insurers should provide clinicians with assistance to ensure that institutional changes promoting tobacco dependence treatment are implemented universally and systematically. Various institutional policies would facilitate these interventions, including:

  • Implementing a tobacco user identification system in every clinic (Systems Strategy 1).
  • Providing adequate training, resources, and feedback to ensure that providers consistently deliver effective treatments (Systems Strategy 2).
  • Dedicating staff to provide tobacco dependence treatment and assessing the delivery of this treatment in staff performance evaluations (Systems Strategy 3).
  • Promoting hospital policies that support and provide tobacco dependence services (Systems Strategy 4).
  • Including tobacco dependence treatments (both counseling and medication) identified as effective in this Guideline as paid or covered services for all subscribers or members of health insurance packages (Systems Strategy 5).

These strategies are based on the evidence described in Chapter 6, as well as on Panel opinion.

Strategies for Health Care Administrators, Insurers, and Purchasers

Table 1Systems Strategy. Implement a tobacco user identification system in every clinic

ActionStrategies for implementation
Implement an office-wide system that ensures that for every patient at every clinic visit, tobacco use status is queried and documented.Office system change:
Expand the vital signs to include tobacco use, or implement an alternative universal identification system.

Responsible staff:
Nurse, medical assistant, receptionist, or other individual already responsible for recording the vital signs. These staff must be instructed regarding the importance of this activity and serve as nonsmoking role models.

Frequency of utilization:
Every visit for every patient, regardless of the reason for the visit.a

System implementation steps:
Routine smoker identification can be achieved by modifying electronic medical record data collection fields or progress notes in paper charts to include tobacco use status as one of the vital signs.

Blood Pressure: ______________________
Pulse: _______ Weight: _________
Temperature: ________________________
Respiratory Rate: _____________________
Tobacco Use (circle one): Current Former Never

Repeated assessment is not necessary in the case of the adult who has never used tobacco or who has not used tobacco for many years, and for whom this information is clearly documented in the medical record.

Table 2Systems Strategy. Provide education, resources, and feedback to promote provider intervention

ActionStrategies for implementation
Health care systems should ensure that clinicians have sufficient training to treat tobacco dependence, clinicians and patients have resources, and clinicians are given feedback about their tobacco dependence treatment practices.Educate all staff. On a regular basis, offer training (e.g., lectures, workshops, inservices) on tobacco dependence treatments, and provide continuing education (CE) credits and/or other incentives for participation.

Provide resources such as ensuring ready access to tobacco quitlines (e.g., 1-800-Quit-Now) and other community resources, self-help materials, and information about effective tobacco use medications (e.g., establish a clinic fax-to-quit service, place medication information sheets in examination rooms).

Report the provision of tobacco dependence interventions on report cards or evaluative standards for health care organizations, insurers, accreditation organizations, and physician group practices (e.g., HEDIS, The Joint Commission, and Physician Consortium for Performance Improvement).

Provide feedback to clinicians about their performance, drawing on data from chart audits, electronic medical records, and computerized patient databases. Evaluate the degree to which clinicians are identifying, documenting, and treating patients who use tobacco.

Table 3Systems Strategy. Dedicate staff to provide tobacco dependence treatment, and assess the delivery of this treatment in staff performance evaluations

ActionStrategies for implementation
Clinical sites should communicate to all staff the importance of intervening with tobacco users and should designate a staff person (e.g., nurse, medical assistant, or other clinician) to coordinate tobacco dependence treatments. Nonphysician personnel may serve as effective providers of tobacco dependence interventions.Designate a tobacco dependence treatment coordinator for every clinical site.

Delineate the responsibilities of the tobacco dependence treatment coordinator (e.g., ensuring the systematic identification of smokers, ready access to evidence-based cessation treatments [e.g., quitlines], and scheduling of followup visits).

Communicate to each staff member (e.g., nurse, physician, medical assistant, pharmacist, or other clinician) his or her responsibilities in the delivery of tobacco dependence services. Incorporate a discussion of these staff responsibilities into training of new staff.

Table 4Systems Strategy. Promote hospital policies that support and provide inpatient tobacco dependence services

ActionStrategies for implementation
Provide tobacco dependence treatment to all tobacco users admitted to a hospital.Implement a system to identify and document the tobacco use status of all hospitalized patients.

Identify a clinician(s) to deliver tobacco dependence inpatient consultation services for every hospital and reimburse them for delivering these services.

Offer tobacco dependence treatment to all hospitalized patients who use tobacco.

Expand hospital formularies to include FDA-approved tobacco dependence medications.

Ensure compliance with The Joint Commission regulations mandating that all sections of the hospital be entirely smoke-free and that patients receive cessation treatments.

Educate hospital staff that first-line medications may be used to reduce nicotine withdrawal symptoms, even if the patient is not intending to quit at this time.

Table 5Systems Strategy. Include tobacco dependence treatments (both counseling and medication) identified as effective in this Guideline as paid or covered services for all subscribers or members of health insurance packages

ActionStrategies for implementation
Provide all insurance subscribers, including those covered by managed care organizations (MCOs), workplace health plans, Medicaid, Medicare, and other government insurance programs, with comprehensive coverage for effective tobacco dependence treatments, including medication and counseling.Cover effective tobacco dependence treatments (counseling and medication) as part of the basic benefits package for all health insurance packages.

Remove barriers to tobacco treatment benefits (e.g., copays, utilization restrictions).

Educate all subscribers and clinicians about the availability of covered tobacco dependence treatments (both counseling and medication), and encourage patients to use these services.


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