A Practical Guide to Working 

with Health-Care Systems 

on Tobacco-Use Treatment 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment Centers for Disease Control and Prevention

Ordering Information

To order a copy of this publication, contact:

Centers for Disease Control and Prevention

Office on Smoking and Health

Mail Stop K-50, Publications

4770 Buford Highway, NE

Atlanta GA 30341-3717

Phone: 1-800-CDC-1311 (800-232-1311)

FAX Information Services: 1-888-CDC-FAXX (888-232-3299)

http://www.cdc.gov/tobacco/pubs.htm

Suggested Citation

Centers for Disease Control and Prevention. A Practical Guide to Working with Health-Care Systems 

on Tobacco-Use Treatment. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health; 2006. 

A Practical Guide to Working

with Health-Care Systems 

on Tobacco-Use Treatment 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

September 2006 

Table of Contents

Acknowledgments.........................................................................................................................................iii

Introduction...................................................................................................................................................... 1

Health-Care Systems Primer....................................................................................................................... 7

Ambulatory Care ............................................................................................................................................ 7

Government as Health-Care Clinician ........................................................................................................ 8

Hospitals .........................................................................................................................................................11

Health Plans .................................................................................................................................................. 13

Purchasers of Insurance............................................................................................................................... 17

Effective Tobacco-Control Interventions and 

the Health-Care System’s Role................................................................................................................. 21

Individual Treatment.................................................................................................................................... 21

Clinicians........................................................................................................................................................ 25

Systems Changes to Support Clinician Intervention............................................................................... 32

Reducing Patient Out-of-Pocket Costs for Tobacco-Use Treatment...................................................... 37

Community Policy and Mass Media ......................................................................................................... 40

Building Relationships Within Health-Care Systems...................................................................... 43

Reasons to Collaborate................................................................................................................................. 43

Keys to Successful Collaboration ............................................................................................................... 43

Beginning a Collaboration........................................................................................................................... 44

Roles Within the Collaboration................................................................................................................... 44

The Public Health Contribution ................................................................................................................. 45

Implementation Strategies....................................................................................................................... 47

Lessons Learned............................................................................................................................................ 47

Measuring Progress...................................................................................................................................... 48

Increasing Systems-Change Effectiveness ................................................................................................ 48

Case Studies................................................................................................................................................... 51

Conclusion ....................................................................................................................................................... 69

References........................................................................................................................................................ 71

Appendixes...................................................................................................................................................... 77

A. Glossary of Terms................................................................................................................................... 78

B. Essential Elements of an Effective Practice-Based Tobacco-Cessation System ............................. 80

C. Essential Elements of an Effective Pediatric Practice-Based Tobacco-Control System................ 81

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | i
D. Making the Business Case for Tobacco Control................................................................................. 83

E. For More Information............................................................................................................................ 84

F. Practice Assessment Document ........................................................................................................... 90

G. Coverage for Tobacco-Use Cessation Treatments ............................................................................. 95

H. Reducing the Burden of Smoking on Employee Health and Productivity ................................. 101

I. Tobacco Quitlines ................................................................................................................................ 109

J. QuitWorks .............................................................................................................................................113

K. Minimal Data Set Intake Questions....................................................................................................115

L. Medicaid Model Language ................................................................................................................ 125

M. Promotion of Tobacco Cessation in the Health-Care System: Suggested Strategies ................. 127

ii | Table of Contents
Acknowledgments

Abby C. Rosenthal, M.P.H.

Cessation Strategic Coordinator 

Office on Smoking and Health 

Centers for Disease Control 

and Prevention 

Atlanta, Georgia

Corinne G. Husten, M.D., M.P.H.

Acting Director

Office on Smoking and Health 

Centers for Disease Control 

and Prevention 

Atlanta, Georgia

We thank the following individuals who served as members of the Health-Care Systems Workgroup 

and who contributed their expertise and experience in developing and reviewing this document.

Marc W. Manley, M.D., M.P.H.

Workgroup Chair

Executive Director

Center for Tobacco Reduction and

Health Improvement

BlueCross and BlueShield of Minnesota

St. Paul, Minnesota

Anna Berkowitz, M.P.H. 

Program Consultant

Office on Smoking and Health

Centers for Disease Control and Prevention

Atlanta, Georgia

Wendy Bjornson, M.P.H.

Smoking Cessation Center

Oregon Health & Science University

Portland, Oregon

Nancy G. Clarke

Health System Liaison

Oregon Department of Human Services,

Health Promotion, and Chronic

Disease Prevention

Portland, Oregon 

Jack F. Hollis, Ph.D.

Associate Director 

Kaiser Permanente Center for Health Research

Portland, Oregon

Carolyn C. Link, M.P.H.

Workgroup Lead Writer

Center for Tobacco Reduction and 

Health Improvement

BlueCross and BlueShield of Minnesota

St. Paul, Minnesota

Nicola Majchrzak, M.P.H., M.S.W.

Project Director

Massachusetts General Hospital Tobacco 

Research and Treatment Center

Boston, Massachusetts

Tim McAfee, M.D., M.P.H.

Chief Medical Officer

Free and Clear, Inc.

Seattle, Washington 

Cathy Melvin, Ph.D., M.P.H.

Director, Smoke-Free Families

National Dissemination Office

Cecil G. Sheps Center for Health

Services Research

University of North Carolina at Chapel Hill

Chapel Hill, North Carolina

Nancy Rigotti, M.D.

Director,Tobacco Research and 

Treatment Center

Massachusetts General Hospital

Boston, Massachusetts

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | iii
Leif Solberg, M.D.

Associate Medical Director for

Care Improvement Research

Health Partners Research Foundation 

Minneapolis, Minnesota 

Jessica Spraggins, M.P.H.

ORISE Fellow 

Office on Smoking and Health 

Centers for Disease Control and Prevention 

Atlanta, Georgia

Tracey Strader, M.S.W.

Executive Director

Oklahoma Tobacco Settlement

 Endowment Trust Fund

Oklahoma City, Oklahoma

Susan Swartz, M.D.

Medical Director

Center for Tobacco Independence

Maine Medical Center

Portland, Maine

Jonathan P. Winickoff, M.D., M.P.H. 

Chair, American Academy of Pediatrics

Tobacco Consortium

Assistant Professor of Pediatrics

Harvard Medical School

Boston, Massachusetts

Reviewers

Christopher M. Anderson, B.A.

Program Director

California Smoker’s Helpline

Dept. of Family and Preventive Medicine

University of California, San Diego

La Jolla, California

Scott Sherman, M.D., M.P.H.

Smoking Cessation Coordinator 

VA Greater Los Angeles HealthCare System 

Professor of Medicine 

UCLA/San Fernando Valley Program

Sepulveda, California

Donna Warner, M.B.A., M.A., C.A.C.

Director, Planning and Program

Development

Massachusetts Tobacco Control Program

Massachusetts Department of Public Health 

Boston, Massachusetts

Case Study Contributors

Charles J. Bentz, M.D., F.A.C.P. 

Wendy Bjornson, M.P.H.

Nancy Clarke

Sally Carter, M.S.W. 

D’Anne Gilmore 

Joy L. Leuthard, M.S., L.S.W.A.

Nicola Majchrzak, M.P.H., M.S.W.

Tim McAfee, M.D., M.P.H.

Lynn Mitchell, M.D., M.P.H. 

Lezli Redmond, M.P.H.

Dawn Robbins

Tracey Strader, M.S.W. 

Susan Swartz, M.D.

Judith Van Osdol, B.S.N., R.N., M.H.S.A.

Donna Warner, M.B.A., M.A., C.A.C.

We also acknowledge the contributions of the following Northrop Grumman IT contractor staff: 

Maxine Forrest, Technical Writer; Jody Gan, Research Associate; Samantha Helfert, Medical 

Librarian; and Jeffrey Roussel and Catherine Ignacio, Graphic Designers.

iv | Acknowledgments
Introduction

T

Treating Tobacco Use and Dependence: 

Clinical Practice Guideline

Promoting widespread use of treatment for tobacco dependence is one of 

the primary goals in improving public health (U.S. Department of Health 

and Human Services, 2000). Tobacco use, and smoking in particular, causes 

many of the chronic and debilitating diseases that affect the population 

and stress the health-care system. Such diseases include heart disease, 

stroke, multiple cancers, and respiratory diseases, as well as complications 

of pregnancy such as preterm delivery and low infant birth weight (U.S. 

Department of Health and Human Services, 1989, 2001, and 2004; National 

Cancer Institute, 1999). 

State health departments 

and businesses are uniquely 

positioned to expand 

the provision of tobaccodependence treatment 

through partnerships and 

purchasing strategies. Insurance coverage can be expanded 

for state employees and 

Medicaid recipients. Business 

partnerships can be developed 

to initiate or expand coverage 

for self-insured or indemnity 

populations. Comprehensive 

benefits must be appropriately 

promoted, and their use should 

be monitored.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 1

obacco dependence shows many features of a chronic disease. Although a 

minority of tobacco users achieves permanent abstinence in an initial quit 

attempt, the majority persist in tobacco use for many years and typically 

cycle through multiple periods of relapse and remission. A failure to appreciate the 

chronic nature of tobacco dependence may undercut clinicians’ motivation to treat 

tobacco use consistently (Fiore et al., 2000).
This guide will review what is known about implementing comprehensive 

tobacco-control and treatment strategies within health-care systems. 

Provided within are examples of effective partnerships between public 

health agencies, health-care systems, and the business community. Also 

included is a primer designed to promote a better understanding of 

health care for those not familiar with systems operations. The reader 

should be aware that this guide uses the term “patient” in the broadest 

sense—therefore, users of this guide should not exclude opportunities 

for providers to treat tobacco use among relatives, such as parents of 

infant, child, and adolescent patients; other patient family members; 

and any other individuals with whom providers have contact through 

interactions with patients. 

Approximately 28% of adolescents in this county currently use tobacco, 

22% of whom are smokers (Centers for Disease Control and Prevention 

[CDC], 2005a). Additionally, more than one in five adults in this country 

currently smoke (CDC, 2004b), but most want to quit. In 2002, 70% of 

smokers reported that they wanted to quit, and 41% attempted to quit 

for at least 24 hours in the past year. However, only about 5% of smokers 

maintained abstinence for 3 to 12 months (CDC, 2005b).

Safe and effective tobacco-use treatments that greatly enhance success in 

quitting are available, but many smokers do not or cannot access these 

treatments (Fiore et al., 2000). Most who try to quit may not be successful 

because they do not use effective treatments (American Cancer Society, 

2003; Zhu et al., 2000). 

In terms of efficacy, cost effectiveness, and impact, tobacco-use treatment 

has been ranked in the top three preventive services and has been specified 

as cost saving (Maciosek et al., 2006). Experts agree that reducing the 

number of new smokers and helping current smokers quit plays a critical 

role in improving public health (Peto et al., 2000). Reducing tobacco use 

is a key component of Healthy People 2010—the nation’s action plan for 

improving public health in the first decade of the 21st century. This plan 

includes 21 objectives related to tobacco and a goal to reduce smoking 

prevalence by more than half (to 12%) by 2010. Current smoking prevalence 

in the United States is 20.8% (CDC, 2005b).

2 | Introduction
Projected Mortality Patterns

Cumulative Deaths (millions) 

22 

20 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 

2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 

Years 

Current Course 

Prevention Effect 

Prevention and Treatment Effect 

Source: Henningfield JE, Slade J. Tobacco-dependence medications: public health and regulatory issues. 

Food and Drug Law Journal 1998;53(suppl):75–114. 

The chart below illustrates the importance of including cessation in primary 

tobacco-control efforts. 

Promoting quitting among tobacco users is one of the key recommendations in several recent major reports. The CDC recommends the following 

comprehensive tobacco-control strategies: 

U.S. Public Health Service (PHS) Guideline for 

Treating Tobacco Use and Dependence

■ Ensure that all smokers are offered effective tobacco-use treatment at all 

clinical encounters.

■ Increase access to and participation in effective tobacco-use counseling.

■ Increase access to and appropriate use of effective tobacco-treatment 

medications.

■ Reduce patient out-of-pocket costs for tobacco-use treatment.

■ Create a social and economic environment that promotes quitting 

(Fiore et al., 2000).

Guide to Community Preventive Services

■ Increase the unit price for tobacco products.

■ Implement sustained mass media campaigns.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 3
■ Implement provider reminder systems in health-care settings.

■ Reduce patient out-of-pocket costs for tobacco-use treatment. 

■ Initiate multicomponent interventions that include patient telephone 

support (Hopkins et al., 2001). 

Interagency Committee on Smoking and Health,

Cessation Subcommittee Goals, 2003

■ Mobilize health insurers, employers, and others to foster evidence-based 

tobacco-dependence coverage for all covered lives.

■ Mobilize health systems to implement system-level changes to foster 

effective utilization of tobacco-dependence treatments.

■ Mobilize national quality assurance and accreditation organizations, 

clinicians, health systems, and others to establish and measure the 

treatment of tobacco dependence as part of the standard of care 

(www.cdc.gov/tobacco/ICHS).

■ Mobilize communities to ensure that policies and programs are in place 

to increase demand for services and to ensure access to such services, 

especially for underserved populations (Fiore et al., 2004). 

The Cochrane Collaboration, 2005

■ Health insurance that pays the full cost of smoking-cessation treatments 

can increase quit rates compared to benefit plans that only partially 

cover cessation treatment or that offer no cessation benefits (Cochrane 

Collaboration, 2005).

■ Programs to stop smoking delivered during hospitalization that include 

a 1-month follow-up are most effective (Cochrane Collaboration, 2005).

■ Proactive telephone counseling can be effective compared to an 

intervention without personal contact. Successful interventions generally 

involve multiple contacts timed around a quit attempt (Cochrane 

Collaboration, 2005).

■ All of the commercially available forms of nicotine replacement therapy 

(gum, transdermal patch, nasal spray, inhaler, and sublingual tablets/

lozenges) are effective as part of a strategy to promote smoking cessation 

(Cochrane Collaboration, 2005).

■ Standard self-help materials may increase quit rates compared to 

no intervention, but the effect is likely to be small (Cochrane 

Collaboration, 2005).

4 | Introduction
Establishing new relationships, particularly with people in health-care 

systems and the business community, is essential to achieving success. 

By themselves, public health agencies have insufficient funding and 

capacity to deliver tobacco-use treatment services, create an environment 

that supports tobacco-use treatment, and manage other aspects of a 

comprehensive tobacco-use treatment program. These tobacco-use 

treatment objectives may be best achieved by developing new partnerships. 

The primary purpose of this guide is to increase public health professionals’ 

(in state and local health departments) comfort with and skill in establishing 

collaborative relationships with leaders in health-care systems and working 

with these partners on activities to promote effective system-wide tobaccouse treatment. The goal is to provide key information and practical advice 

that will help public health professionals improve their understanding of 

health-care systems and develop better skills in building relationships and 

working with health-care professionals. 

This guide is also intended as a vehicle for public health agencies to assist 

health-care systems in increasing their use of effective tobacco-dependence 

treatments. The guide can also serve as a resource for the business/

employer sector, which is adversely affected by tobacco use through 

absenteeism, loss of productivity, and higher health-care costs. Businesses 

and employers also have a vested interest in encouraging and supporting 

health-care systems to promote and implement effective tobaccodependence treatment and cessation services. 

Two primary sources of evidence inform this guide: the PHS clinical 

practice guidelines, Treating Tobacco Use and Dependence, and the CDC’s 

Guide to Community Preventive Services (the Community Guide). The evidence 

base from those resources is supplemented by the opinions and experiences 

of a national panel of experts who contributed to this effort and served as 

technical reviewers.

This guide includes four major sections: 

■ Health-Care Systems Primer provides an overview of the major 

organizations that make up the health-care system and summarizes 

the challenges that each component faces for implementing effective 

tobacco-cessation initiatives. As noted above, public health professionals 

and members of the business/employer sector who are less familiar 

with these organizations should review this section before reading the 

next sections. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 5
■ Effective Tobacco-Control Interventions and the Health-Care System’s 

Role discusses effective tobacco-use treatments and strategies for 

increasing access to these treatments. Professionals from each part 

of the public and private health-care system—clinics, hospitals, 

health plans, insurers, insurance purchasers, and the public health 

community—have roles to play in implementing these strategies. 

Some of their key roles are described in this section. Because the section 

presumes a working knowledge of health-care systems, readers who 

are less familiar with these organizations should first review the HealthCare Systems Primer, which begins on page 7. Case studies of successful 

partnerships between public health agencies and health-care systems are 

integrated throughout the document. 

■ Building Relationships Within Health-Care Systems describes 

strategies for collaboration on achieving tobacco-treatment–related 

objectives and how different agencies have used collaborative efforts 

to achieve specific goals.

■ Implementation Strategies describes initiatives for incorporating 

recommended evidence-based strategies into practice. 

The appendixes provide additional resources, such as detailed information 

on selected topics and sample materials that can be adapted or duplicated 

by clinics and clinicians. A listing of additional sources of information 

(e.g., publications, Web sites) is also included. 

6 | Introduction
Health-Care Systems Primer 

The influence of health-care system administrators, insurers, and purchasers 

could, in theory, be used to encourage and support the consistent and 

effective identification and treatment of tobacco users. These agents could 

craft and implement supportive systems, policies, and environmental prompts that 

render tobacco-use treatment an integral part of the health-care system. Indeed, 

research clearly shows that systems-level change can reduce smoking prevalence 

among enrollees of managed health-care plans (Fiore et al., 2000). 

Treating Tobacco Use and Dependence: 

Clinical Practice Guideline

In a very simplified view of the health-care system, there are four major 

components:

■ Service delivery (inpatient through hospitals and outpatient/ambulatory 

through clinics or providers’ offices).

■ Administration (via health plans or insurers). 

■ Finance (through commercial and governmental purchasers).

■ Quality care (compliance with quality-assurance standards).

It is useful to understand the basic organizational forms and concerns of 

ambulatory care, hospitals, health plans, and purchasers before approaching 

these organizations with a tobacco-use treatment agenda. This knowledge 

can increase confidence, help identify opportunities, and demonstrate 

a commitment to understanding potential partners’ capabilities and 

constraints. 

Ambulatory Care

Providers’ offices are the main point of contact between tobacco users and 

the health-care system because 70% of smokers visit a clinician each year 

(Tomar et al., 1996). (In this document we use the term clinic to describe all 

sites where patients receive outpatient ambulatory care. We use the term 

clinician to refer to all health-care providers, including physicians; nurses; 

physical, occupational, and respiratory therapists; pharmacists; etc.) Clinics 

range in size and focus, from solo practices to small- and large-group 

practices or medical groups, and from specialty to multispecialty clinics 

and outpatient surgery centers. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 7
Increasingly, clinics and practices are joining together to form larger medical 

groups. An organization that includes services like home health care or 

physical therapy as well as clinic and hospital services is referred to as 

an integrated delivery system. In some communities these large systems 

also are major employers that play a significant role in the local business 

community.

While autonomy has always been important to clinicians, aggregation 

provides certain advantages, such as greater leverage when negotiating 

contracts with health plans, joint marketing opportunities, resource sharing, 

and financial stability for smaller practices.

Tobacco-use treatment efforts have traditionally targeted primary care

clinics, but in recent years these efforts have been expanded to reach 

specialty clinics and inpatient settings.

Government as Health-Care Clinician

Government-funded and -operated clinics are an important part of the 

health-care safety net. These include county health departments, clinics, 

and hospitals; Women, Infants, and Children (WIC) clinics; Federally 

Qualified Health Centers (FQHC); the Veterans’ Administration hospitals 

and clinics; and the Department of Defense and Indian Health Service 

community health clinics and centers. In each of these settings, clinicians 

should be encouraged to deliver treatments that are recommended in the 

Public Health Service (PHS) guidelines. Strategies described in the Guide 

to Community Preventive Services should be supported as systems-change 

initiatives (Hopkins et al., 2001). These clinical settings provide an excellent 

opportunity for reaching low-income populations, which have the highest 

smoking rates.

Challenges Clinics Face

Public health professionals should be aware of typical concerns affecting 

the energy, interest, and capacity of clinicians in integrating tobacco-use 

treatment strategies into regular practice.

Change pressures

In one study of clinical quality improvement in the mid-1990s, researchers 

noted that during a single year, 64% of 44 participating clinics underwent 

a change in ownership or affiliation, 77% experienced a major change in 

internal systems, and almost every clinic experienced personnel turnover 

among managers or key clinicians (Magnan et al., 1997). While clinicians 

may value tobacco-use treatment, such turmoil makes it difficult for clinic 

staff and management to focus on new or non-acute issues. 

8 | Health-Care Systems Primer
Economic pressures 

Health plan or Medicaid reimbursement may be absent or insufficient to 

adequately reimburse providers for services, which can be a disincentive 

for providing “free service.” This adds to time pressures. Health plan cost 

increases have also added economic pressures. 

Clinician time and stress

A standard 12- to 15-minute office visit actually involves about 10 minutes 

of clinician–patient time. The priority for clinicians is to address patient 

concerns as well as potential acute medical needs during this limited time. 

Clinicians are also under pressure to provide patients with a wide range 

of preventive services and comprehensive care for an increasing number 

of chronic medical conditions. So although clinicians generally want their 

patients to stop smoking, they often believe that they do not have the time 

or expertise to address this issue, or they may not consider tobacco-use 

treatment to be a top priority for the time-limited office visit. Patients 

rarely make an appointment specifically for or request assistance with 

quitting smoking. To address the time constraints, referrals can be made 

to telephone counseling/quitlines, which are present in almost every state, 

or to community-based cessation programs to provide ongoing counseling 

and support for quitting.

Reimbursement

Although there are effective evidence-based treatments for smokers, 

clinicians usually are not reimbursed for providing these services. The 

lack of reimbursement, while not the main driver of care delivery, may 

negatively affect treatment patterns (Fiore et al., 2000; Manley et al., 2003). 

Payment methods are shifting back 

to fee-for-service arrangements and 

away from capitation. Under feefor-service reimbursement systems, 

the incentives point more toward 

procedures and tests and away from 

services that are harder to quantify 

(and bill), such as intensive tobaccouse treatment counseling (Fiore et al., 

2000; Manley et al., 2003).

Staffing

Clinic staffs vary widely in their 

number, capacity, skill level, and 

expertise. However, clinics can 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 9
2002 HEDIS 

measures related 

to smoking report 

three rates:

■ Advising smokers 

to quit (as in 

prior years). 

■ Offer of smoking 

cessation 

medications.

■ Offer of strategies 

for support and 

assistance with 

quitting. 

improve their tobacco-cessation efforts for patients who use tobacco. 

The important factors in successfully implementing interventions are 

(a) any staff member can be involved, (b) assigning specific roles and 

tasks makes it happen, and (c) making referrals to state quitlines may 

reduce the counseling burden.

Quality of care

Clinicians in all settings are concerned with delivering high-quality care, 

and many employ quality improvement (QI) techniques to plan, implement, 

measure, and improve care strategies. Many clinics emphasize the use of 

evidence-based care guidelines, which are readily available for tobacco-use 

treatment (Fiore et al., 2000). This may be a challenge if the PHS guideline 

was not used to develop the QI measures or if the measures are not being 

monitored. 

Clinicians who have limited access to information technology may use a 

paper-based system, which limits system-wide data collection and affects 

their ability to measure quality improvement. A number of health systems 

have or are moving toward electronic medical records, which will enable 

them to collect more comprehensive information. 

About 90% of the nation’s health plans use the Health Employer Data 

Information Set (HEDIS) measures to assess their performance. HEDIS 

is sponsored, supported, and maintained by the National Committee for 

Quality Assurance (NCQA), a nonprofit organization that assesses and 

measures the quality of health plans. NCQA assesses health plans in 

three ways: 

1. Accreditation through an on-site review of key clinical and 

administrative processes.

2. Use of HEDIS to measure performance in key areas.

3. A comprehensive satisfaction survey of plan members.

Prior to 2002, the HEDIS measure related to tobacco use was called 

“Advising Smokers to Quit” and one rate was reported: the percentage 

of health plan members 18 and older who were continuously enrolled 

during the measurement year, were either current smokers or recent 

quitters, were seen by a managed care organization (MCO) practitioner 

during the measurement year, and received advice to quit smoking. 

In 2002, rates were added for discussion or recommendation of tobacco-use 

treatment medications and support or assistance with quitting. The measure 

was renamed “Medical Assistance with Smoking Cessation” (NCQA, 2003a).

10 | Health-Care Systems Primer
HEDIS data are collected using a mailed patient-satisfaction survey 

developed by the Consumer Assessment of Health Plans (CAHPS®), a 

5-year project funded by the Agency for Healthcare Research and Quality 

(AHRQ) to help consumers identify the best health plans and services to 

meet their needs (AHRQ, 1998). Information on tobacco use is collected as 

part of a general patient-satisfaction survey of randomly selected health 

plan members. Respondents who report recent smoking and a visit to the 

doctor during the previous year are asked whether their clinician advised 

them to quit, offered medication, or provided assistance with quitting 

during the visit. The most recent survey found the mean for medication 

and assistance to be 35%. Plans in the top 90th percentile were providing 

medications and assistance in the 46% range. 

HEDIS data can be used as a rough estimate of smoking prevalence 

in the health plan population. If a health plan mails 1,500 surveys and 

receives 500 returned surveys, and 100 respondents report being smokers, 

it is reasonable to estimate a 20% smoking prevalence rate among plan 

members. However, because smokers are somewhat less likely to respond 

to surveys, the estimate may be somewhat low (Solberg et al., 2003). These 

data can be compared to state prevalence data to validate the estimate. 

Hospitals

Like clinics, hospitals can operate as independent entities, as part of a 

system, or as part of a network of hospitals. Also like clinics, the trend 

is toward greater integration and affiliation with other parts of the healthcare system. 

There are four major types of hospitals: 

■ General medical and surgical.

■ Specialty (specialty hospitals treat a specific population like children 

or mothers or specialize in the treatment of certain conditions, such as 

heart disease).

■ Psychiatric.

■ Rehabilitation and chronic disease.

Each of the major types of hospitals also can be characterized by their 

tax status (for-profit or not-for-profit), affiliation with a health professional 

training school or teaching hospital, and the range of services provided 

(Pacific Business Group on Health, 2004). Teaching hospitals and those 

receiving public funding may be more willing to initiate tobacco-control 

programming (Conroy et al., 2005). 

Some hospitals 

are interested in 

providing tobaccouse treatment 

services and 

education to the 

community. Others 

may engage in 

tobacco-control 

activities, such as 

clean indoor air 

campaigns. Still 

others may be 

interested in doing 

all of the above. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 11
JCAHO’s tobaccorelated measures: 

■ Acute myocardial 

infarction.

■ Congestive 

heart failure.

■ Pneumonia 

(formerly 

communityacquired 

pneumonia).

The measure 

assesses the 

percentage of 

smokers with these 

conditions who are 

given tobacco-use 

treatment advice 

and treatment 

during their 

hospital stay. 

Hospitalized patients may be particularly motivated to try to quit smoking 

for two reasons. First, the illness resulting in hospitalization may have been 

caused or exacerbated by tobacco use, highlighting the patient’s personal 

vulnerability to the health risks of smoking. Second, every hospital in the 

United States must now be smoke-free to gain accreditation by the Joint 

Commission on Accreditation of Healthcare Organizations (JCAHO). As 

a result, every hospitalized smoker is temporarily housed in a smoke-free 

environment. For both these reasons, clinicians should use hospitalization 

as an opportunity to promote tobacco-use treatment among their patients 

who smoke (Fiore et al., 2000; Cochrane Collaboration, 2005).

Challenges Hospitals Face

Like clinics, hospitals are faced with complex and competing pressures 

that can influence their tobacco-use treatment activities.

Length of stay

The average length of stay (i.e., number of days that patients remain in the 

hospital) is growing shorter, and the inpatient population is increasingly 

acutely ill (Hall and DeFrances, 2003). These acutely ill patients require 

complex medical care that affords little time or attention for chronic issues, 

including tobacco-use treatment. The new JCAHO requirements are 

beginning to change this picture (see below).

Staffing

Many hospitals experience shortages of skilled nursing staff. Professional 

nurses have less time to spend with individual patients who are increasingly 

acutely ill.

Accreditation

Hospitals are accredited by JCAHO, which evaluates the quality and safety 

of care for more than 16,000 health-care organizations. To maintain and 

earn accreditation, organizations must have an extensive on-site review at 

least once every 3 years. Tobacco-related measures are included in three of 

JCAHO’s core measures (see left sidebar) (JCAHO, 2003). Hospital staff may 

be more interested in tobacco-use treatment activities for selected patients 

who are covered by the standards.

Hospitals are also assessed by Quality Improvement Organizations (QIOs) 

that are under contract with the federal government to assess and improve 

the hospital-based care provided to Medicare patients. Quality measures 

are used to identify areas with the greatest potential for improvement. Like 

12 | Health-Care Systems Primer
JCAHO, QIOs use three measures that pertain to tobacco. These measures 

assess the percentage of smokers (patients who have smoked in the year 

prior to hospital admission) with acute myocardial infarction, congestive 

heart failure, and pneumonia who are provided tobacco-use treatment 

advice and offered counseling and medication, if appropriate (Medicare 

Quality Improvement Clearinghouse, 2005). 

Quality of care

Hospitals are concerned with quality of care and patient safety—both 

of which can be affected by the patient’s tobacco use. To improve both 

elements, evidence-based guidelines exist for the treatment of tobacco 

use among hospitalized smokers (Fiore et al., 2000).

Health Plans

Health plans provide and manage administrative services for the healthcare system. For the purposes of this document, a health plan is the 

organization that offers a variety of health insurance products and may 

take responsibility for coordinating and improving the delivery of care. 

The insurance product is the insurance policy or benefit coverage offered 

to a group or individual by the health plan.

Health plans vary substantially in their approaches to managing health care, 

the types of insurance products offered, and the populations served. Today 

it is common for health plans to offer both indemnity and managed care

plans, to serve both fully insured and self-insured customers, and to serve 

both government and commercial purchasers.

To work effectively with health plans of all types, it is not necessary for 

public health professionals to understand the numerous variations. Instead, 

they can focus on the major points outlined below.

Assignment of Risk

The concept of financial risk is central to understanding insurance. The 

entity that bears the risk for a population is financially responsible for 

paying the cost of health-care claims incurred by that population. 

A fully funded or fully insured product is one under which the health 

plan bears the financial responsibility (American’s Health Insurance Plans, 

2003). Most small employers are fully insured. Health plans typically offer 

a defined set of benefits, sometimes with different options and potential 

“a la carte” additions, for these subscribers. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 13
Health plans have 

greater control 

over tobaccouse treatment 

medication and 

counseling benefits 

for their fully 

insured members. 

State and federal 

legislation 

mandating 

standards and 

benefits for fully 

insured plans and 

members often do 

not apply to selfinsured plans.

A self-funded or self-insured product is one under which an employer or 

other group sponsor, rather than the health plan, is financially responsible 

for paying expenses, including claims (America’s Health Insurance Plans, 

2003). Large employers (over 500 employees) are frequently self-insured, 

and they select a benefits package for their employees. Self-insured 

companies usually contract with a health plan or independent company 

(known as third-party administrators) to process claims and handle other 

administrative needs.

If a health department wants to increase the percentage of people with 

insurance coverage for effective tobacco-use treatment medications and 

counseling, they must work with health plans, large self-insured employers, 

and broader government agencies (e.g., county, city) to structure benefits 

appropriate for supporting cessation (see Appendix G).

Reimbursement System

Under a fee-for-service payment system, a health plan (indemnity) 

reimburses the member or pays the health-care clinician directly for each 

covered medical expense after the expense has been incurred (America’s 

Health Insurance Plans, 2003). By contrast, under capitation (managed 

care), the clinician is paid a fixed amount for each patient served, regardless 

of the actual number or nature of services provided.

Types of Health Plans

Health plans can be categorized by whether they offer indemnity or 

managed care insurance products to their customers. It is common for 

health plans to offer multiple insurance products, and the differences 

between the various products are becoming less clear over time, as more 

hybrid options become available.

Indemnity

Sometimes called “traditional” health insurance policies, indemnity 

products provide coverage for health-care services on a fee-for-service 

basis. These policies typically include a deductible, which is an amount 

that a member must pay out of pocket each year. Most also charge a 

co-payment for covered services and have maximum overall benefit 

limitation or limitations on specific services. 

Unlike managed care plans, members of an indemnity plan can generally 

receive care from any licensed health-care clinician at any location and 

time they choose. But these broader choices are typically accompanied by 

increased out-of-pocket expenses and more administrative procedures for 

the members.

14 | Health-Care Systems Primer
Managed care

Managed care plans and products typically involve a network of clinicians 

from whom a subscriber can receive care, some type of limitation on benefits 

to subscribers who choose to use clinicians outside of that network, and 

some type of authorization or approval system (Essentials of Managed 

Care). There are three major types of managed care plans: Preferred 

Provider Organizations (PPOs); Point of Service (POS) plans; and 

Health Maintenance Organizations (HMOs). 

PPOs are companies that arrange for lower fees with a network of healthcare clinicians, giving policyholders a financial incentive to seek care within 

that network. Members pay higher rates for services obtained from a 

clinician who is not part of their network.

POS refers to a type of coverage that allows plan members to choose a 

clinician within the plan’s network or one outside the network at the time 

that the care is needed. Choosing an out-of-network clinician usually 

involves higher costs.

HMOs are the oldest form of managed care (AHRQ, 2002; Health Insurance 

Association of America, 2002). They offer members a range of health 

benefits, including preventive care, for a set monthly fee. The health plan 

pays for services for members in advance, rather than as they are provided 

(AHRQ, 2002). There are many kinds of HMOs, distinguished in large part 

by their different relationships 

with clinicians.

Public health professionals 

have tended to assume that 

managed care organizations, 

especially HMOs, are more 

likely to be receptive to efforts 

to decrease tobacco use. The 

theory is that because they 

use capitation, HMOs have 

a clearer incentive to control 

costs and provide preventive 

care. This has proven to be 

partially true, with surveys 

of insurers finding that 

HMOs are more likely than 

other insurance plans to 

cover tobacco-use treatment 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 15
counseling and medication and to systematically identify tobacco users 

(Rigotti et al., 2002). However, some traditional indemnity plans have 

proven to be very interested in and effective at addressing tobacco-use 

treatment, while some HMOs have virtually ignored it (Manley et al., 2003). 

Indemnity plans may actually be able to document savings from decreases 

in utilization that result from tobacco-use treatment more easily than HMOs.

Challenges Health Plans Face

Health plans face several challenges that may negatively or positively 

affect their capacity and interest in working on tobacco-use treatment. 

Public health professionals will be more effective in working with health 

plans on tobacco control if they understand these pressures.

Rising health-care costs 

Nationally, private health insurance premiums increased 13.9% in 2003 

and 11.2% in 2002 (Kaiser Family Foundation, 2004). Health plans are 

increasingly being challenged by purchasers to control rising costs resulting from expensive new drugs and medical technologies. Tobacco-use 

treatment is cost-effective; although it results in higher short-term expenses, 

it will yield long-term benefits in lower overall costs (Winer, 1994). (See 

Appendix H for a detailed discussion of reimbursement issues.) 

Competition and purchaser demand

In many markets, health plans are concerned for their economic survival. 

In response to rising health-care costs and purchaser demand, low-cost 

insurance options are being offered by new companies that are entering 

the market as well as by existing companies. These options may cover 

only major medical expenses, not routine clinic visits. They are attractive 

to employers who are faced with annual premium increases that are often 

in the double digits, but these low-cost plans may also result in fewer 

reimbursed opportunities for tobacco treatment. New products such as 

“medical savings accounts” and “consumer-directed health policies” are 

also emerging. Their effect on tobacco-use treatment is still unknown.

Quality of care and accountability

Many health plans see achievement of accredited status from the NCQA

as a necessity for attracting employer/purchaser business in a competitive 

environment. In 2002, the focus of the HEDIS tobacco measures expanded 

from providing documentation of smoking status and giving advice to quit 

to providing medications and support and assistance with quitting. JCAHO 

has implemented an additional measure for hospitals that assesses the 

16 | Health-Care Systems Primer
provision of tobacco-dependence treatment for heart disease and 

pneumonia. Establishing goals and monitoring service provision within 

health plans and hospitals is important for creating change over time.

Purchasers of Insurance

Purchasers are important and often-overlooked players in the health-care 

system. Purchasers include companies, government agencies, or other 

consortia that purchase health-care benefits for a group of individuals 

(U.S. Department of Health and Human Services, 2005).

As the major purchasers of health insurance plans for the U.S. workforce, 

employers determine whether their employees and the employees’ 

dependents have access to tobacco-use treatment benefits. More than 

60% of Americans receive their health coverage through their employer 

(Partnership for Prevention, 2002). Of employers who provide coverage, 

currently only 24% provide any coverage for tobacco-use treatment and 

only 5% provide coverage for both medication and counseling (Partnership 

for Prevention, 2002).

Government Purchasers 

Local, state, and federal governments finance health insurance coverage 

for groups such as seniors (Medicare), the poor and disabled (Medicaid), 

veterans (Veterans Administration or VA), government employees, and 

others. Government purchasers pay for plans that cover 25% of all insured 

people (Mills and Bhandari, 2003). Public health professionals can make 

substantial gains in reducing out-of-pocket costs for tobacco-cessation 

treatments by focusing on changing the purchasing behavior of state 

governments and working with larger employers or business–health 

coalitions. State and county officials should ensure that tobacco-dependence 

treatment is covered by the insurance they provide. The provision of 

comprehensive coverage is a first step in reducing tobacco dependence 

among government employees at the state and county levels. If prevalence 

is high in this group, initiating coverage, along with creating tobacco-free 

campuses and ties to the state quitline, will help reduce tobacco-use rates 

(Cochrane Collaboration, 2005).

In 2000, approximately 32 million people in the United States received 

health insurance coverage through a state Medicaid program (Kaiser Family 

Foundation, 2000). Of these, about 11.5 million—or 36%—were smokers 

(CDC, 2004a), making smoking prevalence in this population much 

Medicare currently 

covers tobaccodependence 

counseling and 

prescription 

medications.

Over-the-counter 

medications are 

not covered at 

this time. 

Counseling: 

■ Medicare will 

cover two 

cessation 

attempts per 

year.

■ Each attempt 

may include a 

maximum of four 

intermediate or 

intensive sessions.

■ Total annual 

benefits cover up 

to eight counseling 

sessions in a 

12-month period.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 17
Medicare 

reimbursement 

for eligible 

providers: 

■ Physicians/

dentists.

■ Physician 

assistants.

■ Nurse 

practitioners.

■ Clinical nurse 

specialists.

■ Nurse midwives.

■ Other Medicarerecognized 

practitioners.

Larger companies, 

particularly those 

with dedicated 

employee health 

staff and lower 

employee turnover 

rates, may be 

more interested 

in and capable of 

offering tobaccouse treatment 

interventions. 

higher than that in the general population. In 2002, a total of 36 Medicaid 

programs (71%) reported offering coverage for at least one form of tobaccodependence treatment for all Medicaid recipients. Of these, 12 states offered 

some form of tobacco-use treatment counseling services, and 36 covered 

pharmacotherapy treatments (CDC, 2004a). One of the national health 

objectives for 2010 is for all 50 states and the District of Columbia to provide 

Medicaid coverage for nicotine-dependence treatments.

In 2003, only three states’ Medicaid benefits packages included comprehensive coverage for tobacco-use treatment medications and counseling 

(Halpin, Bellows, and McMenamin, 2006). Public health professionals 

should become aware of the current level of coverage and programming 

provided through state-administered programs like Medicaid and work 

to move toward the provision of comprehensive coverage where it does 

not exist. 

Extending tobacco-treatment insurance coverage to all federally 

covered lives would ensure that a large proportion of the U.S. population 

(approximately 100 million people and their families) has effective and 

comprehensive insurance coverage for the treatment of tobacco dependence. 

Covered lives would include Medicaid and Medicare beneficiaries, 

Department of Defense beneficiaries, persons covered by the Department 

of Veterans Affairs, federal employees enrolled in the Federal Employee 

Health Benefits Program, and individuals receiving health care at federally 

funded clinics (Fiore et al., 2004). 

To encourage implementation of more comprehensive Medicaid coverage, 

Medicaid purchasing specifications were developed by CDC’s Office on 

Smoking and Health in conjunction with George Washington University. 

These provide contract language based on the PHS guideline and the 

Community Guide to assist states in purchasing coverage for tobaccodependence treatment (George Washington University, 2002; Hopkins 

et al., 2001).

Commercial Purchasers

Both large and small employer groups purchase health-care benefits. As 

discussed earlier, many large employers are self-insured and design their 

own benefits and manage their own financial risk, while smaller employer 

groups are typically fully insured. Some groups engage brokers who act 

as agents licensed by the state to sell and service contracts for multiple 

health plans.

18 | Health-Care Systems Primer
Purchasing Groups 

These groups usually offer affordable group health coverage to businesses 

with fewer than 100 employees. They are also known as health insurance 

purchasing co-ops, employer-purchasing coalitions, and purchasing 

coalitions. Most are locally or regionally based and funded through 

voluntary agencies, grants, and membership dues (America’s Health 

Insurance Plans, 2003). Public health professionals can be more efficient 

by educating the leaders of purchasing groups on tobacco-use treatment 

issues than by working one on one with small employers.

Union Trust Funds

Union trust funds (sometimes referred to as Taft-Hartley funds after the 

1947 Labor Management Relations Act, which governs relations between 

employers and labor unions) may be used to provide health insurance to 

union members (American Federation of State, County, and Municipal 

Employees, 2000; Barbeau et al., 2001). Union trust funds typically insure 

members for their entire working career, even when a member changes 

employers. Therefore, the union may have a longer-term perspective in 

considering their return on investment for tobacco-use treatment.

Challenges Purchasers Face

Cost 

As described in Section 3, healthcare costs are rapidly increasing. 

Cost is a leading barrier to providing 

comprehensive health insurance 

coverage (Partnership for Prevention, 

2002); however, concerns about cost 

due to tobacco-related disease may also 

help convince employers to provide 

tobacco-use treatment coverage. 

Employers and insurers sometimes 

neglect to assess the extent of the cost 

of tobacco-related diseases. It may be 

valuable to assist them in determining 

these costs in relation to the cost of 

expanded benefits (Pacific Center on 

Health and Tobacco, 2002 ).

Brokers can be 

a key audience 

for public health 

professionals 

seeking to 

influence 

purchasing 

decisions and 

influence the 

products offered 

by health plans 

and businesses

(Pacific Center 

on Health and 

Tobacco, 2003a).

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 19
Quality 

A focus group study of employers revealed multiple factors influencing 

purchasers’ health plan selection. These include cost, quality and breadth 

of benefits, reputation, and level of customer service (Partnership for 

Prevention, 2002). 

Productivity

Employers/purchasers are concerned about their workforce’s health and 

productivity. Employers with less employee turnover may have greater 

interest in the longer-term payoff that investing in reducing tobacco use 

provides. See Issues Brief in Appendix H.

Insurance mandates 

Not all insured individuals are affected by state health mandates because 

Medicare and self-insured employer health plans may not be subject to 

state regulation. Even so, in 1997 health mandates influenced coverage for 

more than 60 million insured people. From the employer and health plan 

perspective, there are strong arguments both in favor of and in opposition 

to health mandates. Some mandates may improve worker productivity and 

protect small businesses, but at the same time mandates can increase costs to 

health plans, consumers, and employers (Partnership for Prevention, 2002). 

20 | Health-Care Systems Primer
Effective Tobacco-Control Interventions 

and the Health-Care System’s Role 

Over the years the harmful effects of smoking have been well documented. 

Although great progress has been made, a challenging struggle remains. 

We all need to strengthen our efforts to prevent young people from ever 

starting to smoke and to encourage smokers of all ages to quit (U.S. Department of 

Health and Human Services, 2004).

Richard Carmona, M.D., M.P.H., F.A.C.S., U.S. Surgeon General 

The Health Consequences of Smoking: A Report of the 

Surgeon General, Executive Summary

The scientific literature shows broad agreement that tobacco-use treatment interventions are effective as well as cost-effective (Fiore et al., 

2000; Warner et al., 1996; Coffield et al., 2001; Maciosek et al. 2006). Tobaccouse treatment interventions that have been proven to be effective can be 

categorized in a number of different ways. In this section, we describe four 

categories of effective interventions:

■ Individual treatment, including behavioral counseling and 

pharmacotherapy.

■ Health-systems changes that support clinician intervention.

■ Reducing patient out-of-pocket costs for tobacco-use treatment. 

■ Community policy changes and mass media campaigns.

We also present specific tobacco-use treatment objectives for each of these 

categories, ways to achieve those objectives (strategies), and examples 

of tactics for implementation (service delivery, coordinated initiatives, 

administration) and specific roles that professionals from each component 

of public and private health-care systems (health plan administrators, 

purchasers, etc.) can play in achieving the tobacco-use treatment objectives. 

Individual Treatment

The U.S. Public Health Service (PHS) clinical practice guideline, Treating 

Tobacco Use and Dependence, found counseling and medication to be safe 

and effective in increasing a person’s chances of quitting smoking 

(Fiore et al., 2000). Studies show that tobacco-use treatment counseling 

and pharmacotherapy treatment each double quit rates (Cochrane 

Collaboration, 2005; Fiore et al., 2000). 

Objective:

Increase the delivery 

of effective tobaccouse treatment 

counseling and 

FDA-approved 

medications.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 21
Case Study #1

QuitWorks: Linking Hospitals in 

Massachusetts to the Quitline

Objective:

Illustrate how public health officials can collaborate with health plan 

managers to promote institutional adoption of the PHS guidelines and 

use of the state’s Quitline.

In 2002, the Massachusetts Department of Public Health, in collaboration with all 

major health plans, launched QuitWorks, a cessation service for all Massachusetts 

residents operated by the Try to STOP Tobacco Resources Center (Quitline) in 

Boston. QuitWorks is a program for use by any provider with any patient regardless 

of health insurance status. 

At the heart of QuitWorks is a simple fax enrollment form. Upon receipt (by fax) 

of a completed form, the quitline calls the patient and offers free confidential 

tobacco-treatment counseling by telephone and describes the full range of the 

state’s evidence-based treatment programs. Referring providers receive a fax-back 

status report on each patient enrolled and, at 6 months, an outcome report on the 

patient’s quit attempts and quit status. 

The initiative was initially introduced to more than 4,000 physician practices 

statewide. In 2003, hospitals in Massachusetts began expressing a need for 

the program, in part to meet Joint Commission on Accreditation of Health 

Organizations (JCAHO) core measures. In response, QuitWorks for Hospitals 

was launched, creating a continuum of effective treatment interventions from 

admission to post-discharge or post-outpatient visit. More than 22 of 62 hospitals 

in Massachusetts have adopted the QuitWorks program or are in the process of 

doing so. 

More than 20 hospitals have implemented the PHS guidelines and many have 

purchased training for their staff. Hundreds of clinicians have received training in 

QuitWorks or brief interventions. Some hospitals have added in-house tobaccotreatment specialists and have sent them to the University of Massachusetts Medical 

School (UMMS) certification training or participated in obtaining online training 

in basic cessation-treatment skills. Several hospitals have initiated a system-wide 

program to screen for tobacco-use status, including in the emergency room. 

It takes a dedicated team of hospital executives and clinic managers from 3 to 

6 months to integrate QuitWorks into patient care. A QuitWorks Guide for Hospitals 

and Health Centers directs the hospital team to consider the systems-level changes 

needed and to create and sustain tobacco-free campuses and provide counseling 

and nicotine replacement therapy (NRT) for patients and staff members. 

22 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
Case Study #1, continued

QuitWorks for Hospitals has had important partners: Massachusetts General 

Hospital, Tobacco Research and Treatment Center, and Tufts New England Medical 

Center helped design QuitWorks for Hospitals, while Massachusetts’s health plans 

and the Massachusetts Peer Review Organization contributed training and financial 

support. Opening a new and important arena for QuitWorks, BlueCross/BlueShield 

of Massachusetts recently awarded a grant to the UMMS to adapt QuitWorks for 

community health centers serving cultural and linguistic minorities. 

Lessons Learned:

■ Effective relationships can be developed between quitlines and hospitals. 

■ Hospitals and health-care systems may be willing to pay for staff training in 

using the system and receiving data feedback from the quitline.

■ Quitlines cannot implement a system of this magnitude alone. Public health 

department involvement is needed in convening all partners. 

■ Endorsement by all major health plans, and any funding they provide, has 

helped QuitWorks achieve legitimacy, credibility, effectiveness, and a sense of 

permanence.

■ Follow-up and reporting of client outcomes also adds to program credibility.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 23
Recommendations 

related to 

pregnancy:

■ Although quitting in 

the first trimester is 

preferred, quitting at 

any time during the 

pregnancy will yield 

benefits. Clinicians 

should offer effective 

interventions at the 

first prenatal visit 

and throughout the 

pregnancy.

■ Pregnant smokers 

should be offered 

extended or 

augmented psychosocial interventions 

that exceed minimal 

advice to quit.

■ Many pregnant 

women are reluctant 

to admit they smoke. 

Careful and supportive 

questioning may be 

needed.

■ Pharmacotherapy 

should be considered 

when a pregnant 

woman is otherwise 

unable to quit. In such 

cases, the clinician 

and the pregnant 

smoker must contrast 

the risks and benefits 

of the medication 

against the risk 

of continued 

tobacco use. 

(Fiore et al., 2000)

Counseling can be provided in a number of different venues, including 

face to face (individual or in a group) or by telephone. The effectiveness of 

counseling services increases as their intensity (i.e., the number and length 

of sessions) increases. Counseling can be provided effectively by many 

different kinds of health-care clinicians. Even brief counseling for tobacco 

cessation (i.e., 1–3 minutes) can be beneficial (Fiore et al., 2000). 

The U.S. Food and Drug Administration (FDA) has approved six medications to help smokers quit (see medications chart in Appendix G). 

Five are nicotine replacement therapies that relieve withdrawal 

symptoms. These include nicotine gum, patches, inhalers, nasal sprays, 

and lozenges (CDC, 2004a). The sixth medication, which is not a nicotine 

replacement product, is the oral medication bupropion. Bupropion is an 

antidepressant that is thought to reduce the urge to smoke by affecting 

the same chemical messengers in the brain that are affected by nicotine 

(Fiore et al., 2000). Except in the presence of identified contraindications, 

all patients attempting to quit should be encouraged to use FDA-approved 

pharmacotherapies. Long-term tobacco-use treatment pharmacotherapy 

should be considered as a strategy to reduce the likelihood of relapse (Fiore 

et al., 2000). Most people use these medications for a period of 4–6 weeks. 

Specific Populations

Although smoking prevalence is higher among men than women, the PHS 

guideline indicates that the same tobacco-use treatments are effective for 

both sexes, with the exception of pregnant women (Fiore et al., 2000). The 

guideline outlines specific recommendations for pregnant women because 

of the serious risk of smoking to these women and their unborn children 

(see sidebar). 

There are well-documented differences between racial and ethnic groups 

in the United States in terms of smoking prevalence, smoking patterns, 

and quitting behaviors (CDC, 2005b). The PHS guideline concludes that 

treatments identified in the scientific literature as safe and effective should 

be offered to patients across all racial and ethnic groups and states that it is 

essential for the treatments to be conveyed in a language that is understood 

by the smoker. Using culturally appropriate models and examples may 

also increase the smoker’s acceptance of treatment. Clinicians also should 

remain sensitive to individual differences and health beliefs that may affect 

treatment acceptance and success (Fiore et al., 2000). 

24 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
Clinicians

Strategies

A number of strategies have been shown to increase clinicians’ delivery of 

effective tobacco-use treatment counseling and appropriate medication.

These include 

■ Using clinician prompts and reminder systems (Hopkins et al., 2001).

■ Providing education, resources, and feedback to promote clinician 

intervention in conjunction with provider reminder systems 

(Hopkins et al., 2001; Fiore et al., 2000).

■ Dedicating staff to provide tobacco-dependence treatment and 

assessing the delivery of this treatment in staff performance evaluations 

(Fiore et al., 2000).

■ Providing telephone counseling support as an adjunct to other 

interventions by using health plan or state-based quitlines

(Hopkins et al., 2001; Cochrane Collaboration, 2005).

■ Coding for tobacco dependence (305.1) in both inpatient and outpatient settings (Fiore et al., 2000).

Tactics

There are many ways in which a variety of people in the health-care system 

can promote access to effective tobacco-dependence treatment. Examples 

of effective actions for clinicians, hospital staff members, administrators, 

insurance purchasers, and public health professionals are presented below.

Service delivery (clinicians)

■ Provide brief counseling to 

patients who use tobacco or 

have recently quit and refer 

patients to quitlines and other 

available cessation resources 

(Revell, 2005).

■ Offer FDA-approved firstline tobacco-dependence 

pharmacotherapies to all 

tobacco users who are trying 

to quit (Fiore et al., 2000).

■ Provide intensive counseling 

or refer to telephone quitlines 

(Fiore et al., 2000; Revell, 2005; 

Cochrane Collaboration, 2005). 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 25
■ Recommend pharmacotherapy if appropriate for pregnant smokers 

(Fiore et al., 2000).

■ If hospital-based, provide inpatient tobacco-dependence consultation 

services and medication and ensure that discharged patients are referred 

to a quitline or other services for ongoing counseling and follow-up 

(Solberg et al., 2004). 

Administration (insurance providers)

■ Provide annual coverage for at least two courses of all first-line FDAapproved pharmacotherapies (including over-the-counter medications) 

and two courses of counseling (George Washington University, 2002). 

■ Collaborate with public health professionals in establishing quitlines as 

an adjunct to treatment services.

■ Ensure access to comprehensive cessation coverage benefits and monitor 

benefit utilization.

■ Integrate tobacco-use treatment counseling into all case management 

services, including those for pregnancy as well as chronic disease.

■ Participate in quitline oversight to ensure quality service and promote 

collaboration between the health plan and the quitline. 

■ Assess and report on Health Employer Data and Information Set 

(HEDIS) Consumer Assessment of Health Plans (CAHPS) measures for 

the provision of medication and the provision of support and assistance 

in quitting; set targets to improve to 90th percentile rates (National 

Committee for Quality Assurance [NCQA], 2003b). 

■ Eliminate or minimize co-pays or deductibles for counseling and 

medications.

■ Advocate for sustained state quitline funding.

Health plans/hospitals/quality assurance

■ Develop procedures to identify smokers at health plan or at hospital 

admission and refer them to tobacco-use treatment services.

■ Expand formularies to include first-line FDA-approved tobaccodependence pharmacotherapies. 

■ Encourage clinicians to prescribe first-line medications to reduce a 

patient’s nicotine withdrawal symptoms, even if the patient is not 

intending to quit following his or her hospital stay.

■ Monitor adherence to JCAHO tobacco-treatment standards and consider 

broadening these to all tobacco users admitted to the hospital.

■ Communicate results of tobacco-use treatment interventions to clinicians 

and health-care staff and primary care providers following discharge.

26 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
■ At discharge, refer patients who smoke to a quitline or other local 

services for follow-up.

■ Include tobacco-use treatment in community wellness programs. 

■ Promote hospital and clinic policies that support tobacco-use treatment 

and provide for in- and outpatient tobacco-dependence services and 

post-discharge follow-up (Fiore et al., 2000).

■ Review HEDIS scores on tobacco measures, set targets, and monitor 

progress.

Quality promotion (public health)

■ Work with quality improvement organizations (QIOs) to support and 

monitor existing tobacco-control standards (e.g., Medicaid standards).

■ Ensure that the state quitline represents the needs of the community 

and health-care systems (hospitals, clinics, health plans, etc.). Public 

health professionals could invite a representative of the quitline to talk 

with health-care systems and could offer feedback from the service to a 

business or health plan (Tobacco Technical Assistance Consortium, 2003). 

■ Act as a neutral convening body for collaborative tobacco-centered 

quality improvement initiatives between state health plans or clinics.

■ Consider clinical and health plan quality measures related to tobacco 

use when selecting networks, health insurance products, and health 

plans (George Washington University, 2002; NCQA, 2003a; JCAHO, 

2003). 

■ Ensure that all public health programs such as Title V (Maternal and 

Child Health Block Grant), Title X (The National Family Planning 

Program), and others address tobacco cessation. 

Public health

■ Actively promote tobacco-use treatment interventions to health-care 

employers and health insurers.

■ Coordinate with employers to contract with quitlines to provide tobaccouse treatment counseling for employees. (This strategy would apply 

primarily to larger employers.) 

■ Fund, promote, or administer a statewide quitline. 

■ Promote or support tobacco-use treatment services for uninsured and 

underinsured people in public clinics.

■ Proactively seek health system participation in quitline promotion and 

referral systems as well as implementing quality improvement efforts to 

ensure that the quitline is meeting health-care system needs. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 27
■ Promote implementation of tobacco-free campuses for health-care 

systems and employers. 

■ Serve as an advocate for funding (e.g., advocate for monies received 

from a tobacco tax to be dedicated for tobacco-use treatment) (Tobacco 

Technical Assistance Consortium, 2003). 

■ Encourage health-care systems and employers to provide funding to 

state quitlines or funding for promotional initiatives.

■ Promote tobacco-use treatment counseling and medication coverage to 

self-insured groups.

Health-Care Systems Strategies

Individual 

Treatment 

Service Delivery

Administration Quality Assurance 

(Health Plans/

Hospitals)

Quality Promotion

(Public Health)

Public Health

Provide brief counseling 

to patients who smoke 

or have recently quit 

and refer patients to 

quitlines and other 

available resources 

for more intense 

counseling.

Provide annual 

coverage for at least 

two courses of all firstline FDA-approved 

pharmacotherapies 

(including over-thecounter medications) 

and two courses of 

counseling. 

Develop procedures 

to identify smokers 

at health plan or at 

hospital admission 

and refer them to 

tobacco-use treatment 

services.

Work with quality 

improvement 

organizations (QIOs) 

to support and monitor 

existing tobacco control 

standards. 

Actively promote 

tobacco-use treatment 

services to health-care 

employers and health 

insurers.

Offer FDA-approved 

first-line tobaccodependence 

pharmacotherapies to 

all tobacco users who 

are trying to quit. 

Collaborate with public 

health professionals in 

establishing quitlines 

as an adjunct to 

treatment services.

Expand formularies 

to include firstline FDA-approved 

tobacco-dependence 

pharmacotherapies.

Ensure that the state 

quitline represents 

the needs of the 

community and 

health-care systems 

(hospitals, clinics, 

health plans, etc.).

Coordinate with 

employers to contract 

with quitlines to 

provide tobacco-use 

treatment counseling 

for employees.

Provide intensive 

counseling or refer to 

telephone quitlines. 

Ensure access to 

cessation coverage 

benefits and monitor 

benefit utilization.

Encourage clinicians 

to prescribe first-line 

medications to reduce 

a patient’s nicotine 

withdrawal symptoms, 

even if the patient is 

not intending to quit 

following his or her 

hospital stay.

Act as a neutral 

convening body for 

collaborative tobaccocentered quality 

improvement initiatives 

between state, health 

plans, or clinics.

Fund, promote, and/or 

administer a statewide 

quitline.

Recommend 

pharmacotherapy 

if appropriate for 

pregnant smokers.

Integrate tobaccouse treatment 

counseling into all 

case management 

services, including 

those for pregnancy 

as well as chronic 

disease.

Monitor adherence 

to JCAHO tobaccotreatment standards 

and consider broadening these to all tobacco 

users admitted to the 

hospital.

.

28 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
Health-Care Systems Strategies, continued

Individual 

Treatment 

Service Delivery

Administration Quality Assurance 

(Health Plans/

Hospitals)

Quality Promotion

(Public Health)

Public Health

If hospital-based, 

provide inpatient 

tobacco-dependence 

consultation services 

and medication and 

ensure that discharged 

patients are referred 

to a quitline or other 

services for ongoing 

counseling and 

follow-up. 

Participate in quitline 

oversight to ensure 

quality service and 

promote collaboration 

between the health 

plan and the quitline.

Communicate results 

of tobacco-use 

treatment interventions 

to clinicians and healthcare staff and primary 

care providers following 

discharge.

Consider clinical and 

health plan quality 

measures related to 

tobacco use when 

selecting networks, 

health insurance 

products, and 

health plans. 

Promote or support 

tobacco-use treatment 

services for uninsured 

and underinsured 

people in public 

clinics.

Assess and report on 

Health Employer Data 

and Information Set 

(HEDIS) Consumer 

Assessment of Health 

Plans (CAHPS) measures 

for the provision of 

medication and of 

support and assistance; 

set targets to improve 

to 90th percentile rates. 

At discharge, refer 

patients who smoke to 

a quitline or other local 

services for follow-up.

Ensure that all public 

health programs such 

as Title V (Maternal 

and Child Health 

Block Grant), Title X 

(The National Family 

Planning Program), and 

others address tobacco 

cessation.

Proactively seek health 

system participation in 

quitline promotion and 

referral systems as well 

as implementing quality 

improvement efforts to 

assure that the quitline 

is meeting health-care 

systems needs.

Eliminate or minimize 

co-pays or deductibles 

for counseling and 

medications.

Include tobaccouse treatment in 

community wellness 

programs.

Promote 

implementation of 

tobacco-free campuses 

for health-care systems 

and employers.

Advocate for quitline 

funding.

Promote hospital and 

clinic policies that 

support tobacco-use 

treatment and provide 

for in- and outpatient 

tobacco-dependence 

services and postdischarge follow-up. 

Serve as an advocate 

for funding.

Review HEDIS and 

JCAHO scores on 

tobacco measures, set 

targets, and monitor 

progress.

Encourage healthcare systems and 

employers to provide 

funding to state 

quitlines or funding for 

promotional initiatives.

Promote coverage of 

tobacco-use treatment 

counseling and 

medication coverage 

to self-insured groups.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 29
Case Study #2

Use of Outreach in Tobacco-Control 

Training and Assistance

Objective:

To increase understanding of tobacco dependence and the use of effective 

tobacco-dependence treatments through a collaborative outreach program. 

The Wisconsin Department of Health has closely partnered with the Center 

for Tobacco Research and Intervention, University of Wisconsin–Madison 

(UW-CTRI), which focuses on improving the understanding of tobacco 

dependence and increasing the use of effective treatments to help smokers 

quit for good. Partnerships with health-care systems, insurers, and employers 

have increased tobacco-use treatment coverage in the state.

The CTRI outreach program provides academic detailing to office practices. 

Academic detailing* supports providers in implementing effective tobaccodependence treatment by providing training to health-care providers, clinics, 

and health-care delivery systems. The six Wisconsin outreach specialists conduct 

on-site trainings with a CME credit option, provide guides and materials, and 

conduct specialized technical assistance for integrating tobacco-dependence 

treatment within each clinic’s unique care-delivery system. The outreach program 

has reached more than 10,000 clinicians in at least 500 different organizations 

through trainings, materials, and consultative services. 

The outreach staff members offer health-care providers direct access to the 

Wisconsin Tobacco Quit Line, a proactive, individualized counseling service that 

has helped approximately 40,000 callers from its inception in 2001 until June 2005. 

The Quit Line and UW-CTRI recently began the “Fax to Quit” program, which has 

increased the number of clients served by the quitline by faxing a referral to the 

quitline and having the quitline make a proactive call to the client. Health-care 

providers generate a steady stream of referrals to the Quit Line—approximately 

500 each month. 

UW-CTRI coordinates with 45 federally funded clinics, health departments, and 

other organizations that treat low-income patients on training for clinic staff, 

linkages to the Quit Line, and the provision of free nicotine patches to uninsured or 

underinsured smokers. In addition, UW-CTRI partners with First Breath, a program 

of the Wisconsin Women’s Health Foundation, to promote smoking cessation 

among pregnant women. 

* Academic detailing is similar to detailing used by the pharmaceutical industry, but 

it brings a training/systems-change message to office practices.

30 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
Case Study #2, continued

UW-CTRI also partnered with the Wisconsin Hospital Association to disseminate 

a recently developed “hospital packet.” This effort provides on-site technical 

assistance to help hospitals implement key tobacco-dependence treatment 

recommendations. 

Supporting strategies for change is difficult. Quality standards such as HEDIS, 

JCAHO, coding systems, and organizing elements (e.g., electronic medical 

records) can be used to support integration of tobacco-dependence treatment 

within health-care systems. Tracking and evaluation should be used to monitor 

the implementation and delivery process and provide feedback to clinicians. 

Lessons Learned:

■ Outreach staff can be effective in promoting integration of tobacco-control 

strategies within the practice setting.

■ Encouraging providers to fax referrals to the quitline improves care outcomes. 

■ Partnering with key health-care and business organizations can improve 

coverage for tobacco-dependence treatment.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 31
Objective:

Ensure that all 

tobacco users are 

offered effective 

tobacco-use 

treatment at all 

clinical encounters.

Systems Changes to Support Clinician Intervention

Clinicians and health-care systems play an important role in encouraging 

patients who use tobacco products to attempt to quit and in helping 

ensure the success of these attempts. The PHS guideline indicates that 

even minimal intervention by a clinician (i.e., as little as 3 minutes of faceto-face counseling) can increase overall abstinence rates, and both the PHS 

guideline and the Community Guide recommend strategies to encourage 

health-care clinicians to assume an active role in helping patients quit. 

Working with systems to incorporate the range of effective strategies will 

promote improved treatment. The guidelines advocate five key steps to 

intervention in the primary care setting that are collectively known as the 

5A’s (Fiore et al., 2000). They involve

■ Asking if patients smoke.

■ Advising them to quit.

■ Assessing readiness to quit.

■ Assisting with counseling and pharmacological treatments.

■ Arranging for follow-up.

An alternative to the 5 A’s has been proposed by Dr. Steven Schroeder and 

the Smoking Cessation Leadership Center at the University of California, 

San Francisco. One of their central strategies is Ask-Advise-Refer (i.e., to a 

quitline or other effective program) (Schroeder, 2003). 

Not every patient who is identified as a smoker or other tobacco user will 

be ready to make a quit attempt. Therefore, after asking about tobacco use, 

advising the smoker to quit, and assessing his or her current readiness to 

quit, it is important to provide a motivational intervention known as the 

5R’s for those not currently ready to quit. Its steps emphasize

■ Relevance—Encourage the patient to consider how quitting or not 

quitting specifically affects them and their loved ones.

■ Risks—Suggest and highlight relevant risks of continued tobacco use.

■ Rewards—Help the patient identify potential benefits of stopping 

tobacco use. 

■ Roadblocks—Identify barriers or impediments to quitting and ways 

these can be addressed.

■ Repetition—Repeat this intervention each time the patient visits 

the clinic.

32 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
Strategies 

Strategies to promote clinician intervention could include

■ Adopting a clinical system that identifies smoking or other tobacco-use 

status in conjunction with the collection of vital signs (Fiore et al., 2000).

■ Using a centralized system that features clinician reminder elements 

and a clinician education component to encourage clinicians to address 

tobacco use and to assist them in helping their patients quit (Hopkins, 

2001).

■ Implementing office-wide systems to support delivery of the 5A’s to 

patients who are willing to quit, followed by documentation of the 

treatment services provided, and encouraging follow-up with the 5R’s 

motivational intervention for patients who are currently unwilling to 

quit smoking (Fiore et al., 2000). 

■ Including tobacco-dependence treatment in the defined duties of 

clinicians (Fiore et al., 2000).

■ Using electronic medical records to support and document tobaccodependence treatment (Bentz, Davis, and Bayley, 2002). 

■ Coding for tobacco dependence 

using the 305.1 ICD-10 code 

(Fiore et al., 2000).*

■ Providing quitline linkages to 

support treatment intervention 

and follow-up (Pacific Center on 

Health and Tobacco, 2003b).

■ Reimbursing for treatment of 

tobacco use as a chronic disease 

(Fiore et al., 2000). 

■ Implementing a centralized system 

to identify and treat tobacco users 

who are hospitalized for any 

reason (Rigotti et al., 2002).

* Some systems are also using the following CPT codes: 0002F: Tobacco use, 

smoking assessed; 0003F: Tobacco use, nonsmoking assessed; G0375: Smoking 

and tobacco use cessation counseling visit, Intermediate, greater than 3 minutes 

up to 10 minutes; G0367: Smoking and tobacco use cessation counseling 

visit, Intensive, greater than 10 minutes; 99383–99387: Preventive Medicine 

Examination; 99393–99397: Established Patient Periodic preventive medicine 

evaluation; 99401–99412: Preventive Medicine, Individual Counseling; 90804–

90809: Office or other outpatient facility—behavior modification; 90816–90822: 

Inpatient hospital, partial hospital or residential care facility; 01320: Dental code.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 33
Tactics

Examples of effective roles that each component of the health-care system 

plays in promoting use of the 5A’s and the 5R’s and achieving a greater level 

of clinician intervention are described below.

Service delivery

■ Promote state-run or other quitline services to clinicians, health plans, 

and insurers (Fiore et al., 2000).

■ Coordinate with quitlines to provide post-discharge follow-up (Pacific 

Center on Health and Tobacco, 2003b). 

■ Integrate tobacco-use treatment in programs administered by health 

departments, including services for children with special health-care 

needs; Maternal and Child Health Block Grant (Title V) programs; 

family planning grants (Title X); Medicaid; and Special Supplemental 

Nutrition Program for Women, Infants, and Children (WIC) programs 

(Fiore et al., 2000).

Quality assurance/quality improvement

Quality assurance/quality improvement staff or other designated 

individuals within the health-care system should coordinate the following:

■ Provide feedback to individual clinicians and groups on their 

effectiveness in delivering medications and referrals to counseling 

or quitline services (Hopkins et al., 2001).

■ Become champions and, along with committed team members 

(physicians, nurses, medical assistants, and others), provide training 

for clinicians in evidence-based treatment.

■ Initiate a system where tobacco users can be referred to state or health 

plan tobacco-cessation quitlines.

■ Ask health plans for NCQA HEDIS data that report rates of clinician 

advice to quit, provision of medication, and support and assistance 

with quitting. (Information on HEDIS measures related to tobacco 

use is provided on page 10 of this document [NCQA, 2003a].) 

■ Monitor benefit utilization and feed results back to health-care systems 

and clinicians providing services and use to determine if quality 

indicators are being met. 

34 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
Administration

■ Implement office-based reminder systems that trigger clinical staff to 

ask all patients about tobacco use, provide chart documentation of 

tobacco-use status, and offer and document quitting assistance to 

users (Fiore et al., 2000). 

■ Encourage office practices to define roles among clinical staff to ensure 

that counseling and medications are systematically provided and their 

provision documented in medical charts or electronic records. 

■ Implement a system to identify and document the tobacco-use status 

of all clinic and hospitalized patients.

■ Develop inpatient treatment systems, referral networks, and quality 

assurance mechanisms to support such systems. 

■ Provide incentives and support to clinician groups that want to set up 

systems for implementing the PHS guidelines and increase treatment 

rates (America’s Health Insurance Plans, 2003).

Finance

■ Provide annual coverage for at least two courses of both counseling and 

FDA-approved medications with minimal or no co-payments (George 

Washington University, 2002). 

■ Coordinate with state Medicaid programs to ensure comprehensive 

coverage of counseling and medication (George Washington University, 

2002).

■ Collaborate with the business sector to promote comprehensive coverage 

and quitline services.

Quality care

■ Assess JCAHO scores relating to tobacco-use treatment and set targets 

for improvement. 

■ Provide “quality surveillance” by sharing data within and between 

clinician groups that allow comparisons of their own performance on 

tobacco-related indicators with others (e.g., provision of medication 

by assessing pharmacy data, referral to telephone counseling through 

feedback from the quitline service).

■ Assess HEDIS scores for provision of medication and support and 

assistance with quitting (counseling). 

■ Identify “best practices” for tobacco-use cessation interventions within 

health systems and promote successful models and structures. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 35
Systems Changes to Support Clinician Intervention

Service Delivery Quality 

Assurance/Quality 

Improvement

Administration Finance Public Health

Provide feedback to 

individual clinicians 

and groups on their 

effectiveness in 

delivering medications 

and referrals to 

counseling and/or 

quitline services. 

Assess JCAHO/HEDIS 

scores relating to 

tobacco-use treatment 

and set targets for 

improvement.

Implement office-based 

reminder systems that 

trigger clinical staff to 

ask all patients about 

tobacco use, provide 

chart documentation of 

tobacco-use status, and 

offer and document 

quitting assistance to 

users.

Provide annual 

coverage for at least 

two courses of both 

counseling and FDAapproved medication 

with minimal or no 

co-payments. 

Coordinate with 

quitlines to provide 

post-discharge 

follow-up.

Provide “quality 

surveillance” by 

sharing data within 

and between clinician 

groups that allow 

comparisons of their 

own performance 

on tobacco-related 

indicators with others.

Define roles among 

clinical staff to ensure 

that counseling and 

medications are 

systematically provided 

and their provision 

documented.

Coordinate with state 

Medicaid programs to 

ensure comprehensive 

coverage of counseling 

and medication.

Promote state-run or 

other quitline services 

to clinicians, health 

plans, and insurers. 

Become champions 

and, along with 

committed team 

members (physicians, 

nurses, medical 

assistants, etc.), provide 

training for clinicians 

in evidence-based 

treatment.

Implement a system to 

identify and document 

the tobacco-use status 

of all hospitalized 

patients.

Initiate a system where 

tobacco users can 

be referred to state 

tobacco cessation 

quitlines.

Assess HEDIS scores for 

provision of medication 

and support and 

assistance with quitting 

(counseling).

Collaborate with 

the business 

sector to promote 

comprehensive 

coverage and quitline 

services.

Integrate tobacco-use 

treatment in programs 

administered by 

health departments, 

including services for 

children with special 

health-care needs; 

Maternal and Child 

Health Block Grant 

(Title V) programs; 

family planning grants 

(Title X); Medicaid; and 

Special Supplemental 

Nutrition Program 

for Women, Infants, 

and Children (WIC) 

programs. 

Develop inpatient 

treatment systems, 

referral networks, 

and quality assurance 

mechanisms to support 

such systems.

Identify “best practices” 

for tobacco-use 

cessation interventions 

within health systems 

and promote successful 

models and structures.

Ask health plans for 

NCQA HEDIS data that 

report rates of clinician 

advice to quit, provision 

of medication, and 

support and assistance 

with quitting. 

Provide incentives and 

support to clinician 

groups that want to 

set up systems for 

implementing the PHS 

guidelines and increase 

treatment rates. 

36 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
Reducing Patient Out-of-Pocket Costs 

for Tobacco-Use Treatment 

As previously noted, smoking cessation treatments are not only clinically 

effective, but also are extremely cost-effective relative to other commonly 

used disease prevention interventions and medical treatments (e.g., treatment of elevated cholesterol, mammography screening) (Fiore et al., 2000). 

Reducing or eliminating patient out-of-pocket costs for tobacco-dependence 

treatments increases treatment rates (CDC, 2000; Curry et al., 1998; 

Cochrane Collaboration, 2005).

Strategies 

Approaches for increasing tobacco-use treatment by reducing patient costs 

include 

■ Providing effective tobacco-dependence treatments (both counseling 

and pharmacotherapy) as paid or covered services for all subscribers 

or members of public and private health insurance packages (Fiore et 

al., 2000; George Washington University, 2002; Cochrane Collaboration, 

2005).*

■ Encouraging initiation of reimbursement mechanisms to compensate 

clinicians for delivery of effective tobacco-dependence treatments 

and including these interventions in the defined duties of clinicians 

(Fiore et al., 2000).

Tactics

There are a variety of tactics that health plan administrators, purchasers, 

and public health professionals can employ to promote implementation of 

these strategies. 

Service delivery

■ Provide medication and counseling (e.g., state-run quitlines or other 

counseling services) for uninsured or underinsured populations (George 

Washington University, 2002).

■ Promote quitline services and collaborate with Medicaid, health-care 

systems, and employers to provide low- or no-cost services (George 

Washington University, 2002). 

■ Ensure maximal utilization of services (George Washington University, 

2002). 

* As of March 2005, Medicare began reimbursing physicians for tobaccodependence treatment counseling. Medicare also began providing coverage 

for prescription tobacco treatment medications in January 2006.

Objective:

Reduce or eliminate 

patient out-of-pocket 

costs for tobacco-use 

treatment.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 37
Public health

State public health and/or large public health agencies need to coordinate 

the following:

■ Work with insurance agents and brokers, health consultants, sales 

staff, and purchasing coalitions to promote the inclusion of tobacco-use 

treatment services, including counseling and medication coverage, in 

benefit contracts. 

■ Ensure that purchasers understand the financial benefits of tobacco-use 

treatment interventions. 

■ Negotiate tobacco-use treatment benefits as part of union contracts.

■ Provide and promote tobacco-use treatment benefits for employees 

through insurance contracts, self-insurance, and work-site programs.

■ Consult with federal, state, and local government decision makers to 

provide and promote tobacco-use treatment benefits for government 

employees and people who receive health-care benefits through 

Medicare, Medicaid, the Indian Health Service, Community Health 

Centers, the Veterans Administration, the Department of Defense, and 

the Bureau of Prisons.

■ Encourage employers to learn how benefits they already have can be 

used for tobacco-use treatment and to promote their use by employees 

(Tobacco Technical Assistance Consortium, 2003; Pacific Center on Health 

and Tobacco, 2002).

■ Demonstrate to employers that coverage of tobacco-use treatment is 

cost effective and cost saving (Coffield et al., 2001; Tobacco Technical 

Assistance Consortium, 2003; Cochrane Collaboration, 2005; Maciosek 

et al., 2006). 

Administration

■ Support coding for tobacco dependence (ICD-10, Code 305.1) within the 

health-care system to assist in identifying tobacco users and to assess 

costs of tobacco-related diseases.

■ Remove or minimize barriers to accessing tobacco-use treatment benefits 

by decreasing or eliminating co-pays and removing utilization caps 

(Hopkins et al., 2001).

■ Inform clinicians and office managers of coverage availability.

■ Understand current coverage levels. Ask insurers about all products 

or services (e.g., benefits, riders, discounts) that address tobacco-use 

treatment (Pacific Center on Health and Tobacco, 2003a). 

■ Promote coverage of tobacco-use treatment counseling and medication 

coverage to self-insured groups.

■ Provide disease management and treatment for tobacco-related diseases 

and conditions.

38 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
Reducing Patient Out-of-Pocket Costs for Tobacco-Use Treatment

Service Delivery Quality 

Assurance/Quality 

Improvement

Administration Finance Public Health

Provide medication 

and counseling for 

insured, uninsured, 

or underinsured 

populations. 

Monitor benefit 

utilization and feed 

results back to healthcare systems providing 

services.

Support coding for

tobacco-dependence

(ICD-10, Code 305.1)

within the health-care

system to assist in

identifying tobacco users

and to assess costs of

tobacco-related diseases.

Include tobacco-use 

treatment counseling 

and medications as a 

standard part of all fully 

insured contracts.

Work with insurance 

agents and brokers, health 

consultants, sales staff, 

Medicaid, and purchasing 

coalitions to promote 

the inclusion of tobaccouse treatment services, 

including counseling and 

medication coverage, in 

benefit contracts.

Promote quitline

services and collaborate with Medicaid,

health-care systems,

and employers to

provide low- or nocost services.

Remove or minimize 

barriers to accessing 

tobacco-use treatment 

benefits by decreasing 

or eliminating co-pays 

and removing utilization 

caps.

Reimburse for tobacco 

use treatment in the 

same way that clinicians 

are reimbursed for other 

chronic diseases.

Ensure that purchasers 

understand the financial 

benefits of tobacco-use 

treatment interventions.

Ensure maximal 

utilization of services 

by reducing or 

eliminating co-pays. 

Inform clinicians and 

office managers of 

coverage availability.

Include coverage for 

office visits to treat 

“tobacco-use disorder” 

as a standard benefit.

Negotiate tobacco-use 

treatment benefits as part 

of union contracts.

Understand current 

coverage levels. Ask 

insurers about all 

products or services 

(e.g., benefits, riders, 

discounts) that address 

tobacco-use treatment.

Cover at least two 

courses of counseling 

and medication per year 

to support the quitting 

process. 

Provide and promote 

tobacco-use treatment 

benefits for employees 

through insurance 

contracts, self-insurance, 

and work-site programs.

Promote coverage of 

tobacco-use treatment 

counseling and 

medication to selfinsured groups.

Offer health 

benefits that include 

comprehensive 

counseling and 

medications for 

employees.

Consult with federal, state, 

and local government 

decision makers to provide 

and promote tobacco-use 

treatment benefits for 

government employees and 

people who receive healthcare benefits through 

Medicare, Medicaid, the 

Indian Health Service, 

Community Health Centers, 

the Veterans Administration, 

the Department of Defense, 

and the Bureau of Prisons.

Provide disease 

management and 

treatment for tobaccorelated diseases and 

conditions.

Work with self-insured 

employers (including 

states) to ensure that 

their health plans 

provide coverage for 

both tobacco-use 

treatment counseling 

and pharmacotherapies. 

Encourage employers to 

learn how benefits they 

already have can be used 

for tobacco-use treatment 

and to promote their use 

by employees.

Demonstrate to employers 

that coverage of tobaccouse treatment is costeffective. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 39
Objective:

Create social 

and economic 

environments that 

promote tobaccouse treatment.

Finance

■ Include tobacco-use treatment counseling and medications as a standard 

part of all fully insured contracts.

■ Reimburse for tobacco-use treatment in the same way that clinicians are 

reimbursed for treatment of other chronic diseases.

■ Include coverage for office visits to treat “tobacco-use disorder” as a 

standard benefit (305.1 IDC-10 code). 

■ Cover at least two courses of counseling and medication per year to 

support the quitting process (George Washington University, 2002).

■ Offer health benefits that include counseling and medications for 

employees. 

■ Work with self-insured employers (including states) to ensure that their 

health plans provide coverage for both tobacco-use treatment counseling 

and pharmacotherapies (Tobacco Technical Assistance Consortium, 2003). 

Community Policy and Mass Media

Mass media campaigns, when part of multicomponent interventions, 

also are effective in increasing the number of tobacco users who seek 

treatment. Such campaigns do not necessarily have to be focused on 

tobacco-use treatment (CDC, 2000). Increasing the unit price of tobacco, 

primarily through an increase in excise tax, also helps people seek treatment 

and decreases smoking prevalence and tobacco consumption (Hopkins 

et al., 2001). Data show that a 10% increase in the price of tobacco products 

generally results in a 4% decrease in the amount of tobacco used by the 

general population (Hopkins et al., 2001). Research findings also show 

that legislation that bans smoking in the workplace creates an environment 

favorable to tobacco cessation (Cochrane Collaboration, 2005). Workplace 

smoking bans decrease daily tobacco consumption while increasing 

quit attempts and the success of these attempts (Center for Tobacco 

Cessation, 2004).

Like the general population, pregnant women and racial and ethnic 

minority groups benefit from a comprehensive approach to tobaccouse treatment that includes increases in the price of tobacco and the 

establishment of smoke-free workplace policies. Tax increases are 

especially helpful in promoting cessation among pregnant women, 

adolescents, and low-income individuals, thereby increasing the need 

for adequate coverage for and access to cessation services for these 

groups (CDC, 2000; Hopkins et al., 2001). 

40 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
Strategies 

Effective methods for using policy changes and the media to promote 

tobacco-use treatment include the following:

■ Implementing smoking bans and restrictions to reduce exposure to 

environmental tobacco smoke (Hopkins et al., 2001).

■ Increasing the unit price for tobacco products to reduce the initiation of 

tobacco use and prevalence, increase cessation attempts, and increase the 

use of tobacco-use treatment (Hopkins et al., 2001).

■ Combining mass media education (campaigns) with other interventions 

to reduce tobacco-use initiation and prevalence, increase cessation, and 

increase tobacco-use treatment (Hopkins et al., 2001).

■ Marketing quitlines to encourage their use (and unaided quit attempts as 

well) (Zhu et al., 2000).

Stakeholders

In the policy and media categories, the roles of the various health system 

players are similar. A willing organization could play one or more of the 

roles identified below.

■ Coalition member: Representatives of clinics, hospitals, and health plans 

can be powerful members of coalitions that promote policy change and 

the maintenance of funding for tobacco-control programs, including 

quitlines.

■ Bridge to employers: Health plans and large clinic or hospital systems 

are businesses as well as health-care organizations. They can provide 

a link to the business sector that public health professionals and 

advocacy organizations may lack. Senior executives of large health-care 

organizations can reach out to other business leaders and involve them 

in policy changes. 

■ Effective lobbyist: Health system lobbyists with key legislative 

relationships may be able to open doors previously closed to traditional 

tobacco-control advocates.

■ Funder: Health systems can be dues-paying members of organizations or 

coalitions that promote policy change or work-site health initiatives and 

may be able to financially support media campaigns.

■ Champion: Clinicians are trusted sources of health-care advice and 

credible tobacco policy messengers at the state and local levels. Rural 

health-system organizations and leaders often have even greater 

influence than their metropolitan peers because they may have more 

direct relationships with legislators, or their organizations may carry 

substantial clout as employers. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 41
■ Defender: Effective media campaigns and policy initiatives are 

vulnerable to attack from opponents of tobacco control. Health 

systems leaders can support a program under attack—or better yet, 

proactively educate decision makers about the importance of tobaccodependence treatment and the key role media campaigns and public 

policies play in encouraging and supporting quitting.

■ Business health coalition: A number of larger communities have 

business health coalitions with valuable relationships in both the 

health-care and business communities that may be an asset in moving 

an agenda forward. A business health coalition typically comprises 

health-care system and business members who collaborate to address 

key health issues in the community. 

Business health coalitions can

• Encourage members to initiate or expand coverage for tobaccodependence treatment.

• Increase members’ awareness of the state quitlines and promote 

financial support.

• Support smoke-free policies among businesses and in the community.

For additional information on effective coalitions and campaigns, 

refer to the following Pacific Center on Health and Tobacco documents: 

Health Insurance Benefits for Treatment of Tobacco Dependence: Summary and 

Invest in Tobacco Cessation for a Healthy, Productive Workforce, available at 

www.ttac.org/leadership/resources.html. Also, please visit the Centers 

for Disease Control and Prevention’s Media Campaign Resource Center at 

www.cdc.gov/tobacco/mcrc and the Tobacco-Free Coalition of Oregon’s 

site at www.tobaccofreeoregon.org. The Make It Your Business campaign 

(available at www.tobaccofreeoregon.org) is another valuable resource. 

(See Case Study #6 on page 56.)

42 | Effective Tobacco-Control Interventions and the Health-Care System’s Role
Building Relationships 

Within Health-Care Systems

Tobacco control seeks to end the death and disease caused by tobacco use 

and by exposure to secondhand smoke. But, unlike diphtheria, pertussis, or 

tetanus, there is no vaccine to inoculate people against tobacco’s harmful 

effects. Instead, individuals, agencies, and organizations must work together to 

take on a complex mix of social, cultural, economic, and political issues which 

encourage tobacco use (Tobacco Technical Assistance Consortium, 2004).

Communities of Excellence Plus in Tobacco Control: 

Training and Resource Manual 

Informed by a basic understanding of the structure and concerns of 

health-care system organizations, public health professionals can more 

knowledgeably approach potential partners and begin the important 

process of building relationships. The challenge is to move beyond 

simple cooperation and coordination to create a spirit of collaboration 

and partnership to address tobacco as a community issue (Winer and 

Ray, 1994). 

When a comprehensive and complex set of goals will be pursued over a 

longer period of time, the more intensive approach of collaboration may be 

the best investment. This can result in systems change to impact tobaccodependence treatment and thereby reduce rates of illness and death. 

Reasons to Collaborate

Organizations collaborate to achieve some result or results that one 

organization cannot achieve alone (Ray, 2002). Whether your goal is to 

increase access to effective tobacco-use treatment counseling or to create 

smoke-free environments that support tobacco-use treatment, it is unlikely 

that a single organization can achieve that objective alone. 

Keys to Successful Collaboration

Several factors support successful collaborations, including mutual trust, 

shared decision making, open communication, and having a skilled 

convener (Winer and Ray, 1994). In addition, having committed leaders, 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 43
Getting Started:

Selecting Appropriate 

Public Health Staff

The “right” person to 

initiate contact with a 

health system organization 

depends on your 

objectives. If you are 

trying to increase clinician 

referrals to a quitline, you 

may need to work with 

someone other than your 

community policy contact. 

You should be prepared to 

talk to a number of people 

before finding the right 

person. 

Health department staff 

members who have 

previous experience with 

community organizing 

or coalition development 

may be a good choice to 

assist in building a new 

tobacco-use treatment 

coalition and anticipating 

and addressing potential 

problems.

a common purpose, dedicated resources, external accountability, and clear 

time lines increases the chances for success (Solberg, 2000).

Tobacco-control collaborations are prone to experiencing the same barriers 

as other collaborations: disparate visions, flawed communications, lack 

of role definition, and unclear responsibilities. In addition, tobacco-use 

treatment collaborations are often challenged by competition over tobaccocontrol resources and attempts by outside forces to divide health coalitions. 

Beginning a Collaboration

Collaboration between public health systems and the nongovernmental 

health-care system involves the coming together of distinct cultures. Early 

on, participants must develop trust, and to do so, they must rely on each 

other’s honesty, integrity, and fairness. Developing relationships takes 

time, effort, and persistence. It is also very helpful at the beginning to take 

the time to develop a common vocabulary so everyone is communicating 

effectively. 

In addition to having potentially different educational backgrounds and 

work experience, public health professionals and health-care systems 

professionals work for organizations with different missions and cultures. 

Experienced collaborators emphasize the primacy of personal relationships. 

Successful development is more likely to grow out of individual contacts 

and relationships that turn eventually into a small cooperative project over 

time. Only then is there sufficient trust to start thinking about shared values 

and mission. 

An interagency collaboration works best if there is sponsorship by senior 

leaders in participating organizations. If the health department director 

contacts the health-care system CEO and obtains buy-in, the initiative 

frequently begins with a solid base. 

Roles Within the Collaboration

In any given state, there may be multiple collaborations that are relevant 

to tobacco control—a purchasers’ coalition, a Medicaid benefits task force, 

a clinical guideline-focused collaborative, and others. In each, certain 

roles must be filled. These include convenor, facilitator, funder, technical 

assistance provider, and active participant. The right organizations to 

perform each of those roles depends on the specific situation. 

44 | Building Relationships Within Health-Care Systems
The Public Health Contribution

To be effective collaborators, public health professionals must identify what 

they can contribute to the collaboration. Skills and resources that public 

health professionals can contribute might include

■ Knowledge of effective tobacco-control strategies.

■ Common ground and the ability to foster cooperation and agreement 

among competitors for shared efforts.

■ Group facilitation and management skills. 

■ Technical support.

■ Leadership in tobacco-control policy advocacy, if appropriate. 

■ Experience in reaching specific populations (e.g., pregnant smokers, 

low-income populations, populations with health disparities).

■ Data collection, analysis, and reporting.

■ Funding to support the collaboration and its work; recognition of the 

skills and resources that health-care systems and professionals bring and 

the importance of focusing on tobacco control as a strategy for improving 

quality of care. 

■ A clear mission. Public health groups can be more mission-driven and 

help keep the work going. 

■ Relationships with existing programs in the voluntary sector (American 

Heart Association, American Lung Association, American Cancer Society, 

pregnancy programs, etc.) that may be of assistance in supporting 

tobacco-control initiatives. 

Health-care systems may have a different culture than that of public health. 

Using the contacts discussed on the previous page, the health-care systems 

may appreciate public health support in establishing internal committees 

within the system. Having representation from management, nursing, 

benefits, respiratory therapy, pharmacy, quality improvement, legal, and 

other departments will be helpful in planning the initiative and ensuring 

that key departments integrate tobacco-control strategies into their system 

components (see Health-Care Systems Primer, pp. 7–20, for additional 

details.)

Next Steps:

Finding a Health-Care 

Systems Contact

Differing program needs 

will require contact with 

different health-care 

systems contacts. The 

following are suggestions 

for developing contacts 

to meet specific program 

needs:

Some clinics, hospitals, 

and health plans employ 

medical and nursing 

staff with specific quality 

improvement (QI) 

accountabilities. Look for 

a “QI medical director” 

or “Director of QI” when 

searching for a contact for 

clinical systems or individual 

treatment efforts. 

In the policy and media 

arenas, key contacts include 

health system lobbyists, 

communications directors, 

market researchers, 

and medical directors 

who might serve as 

spokespeople. If the health 

system has a philanthropic 

arm, such as a foundation 

or community relations 

department, you might 

want to try that area, too. 

Try contacting the hospital’s 

community relations 

department or marketing 

departments about offering 

tobacco-use treatment 

services at the hospital or 

work sites or developing 

relationships that will 

provide quitline referrals. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 45

Implementation Strategies 

Results from community-based interventions and statewide programs show 

that a comprehensive approach to tobacco control is needed to curtail the 

epidemic (U.S. Department of Health and Human Services, 2000).

Donna E. Shalala, former Secretary of Health and Human Services

In beginning to work with health-care systems, selecting appropriate staff 

and developing initial relationships between the leaders of all organizations 

lays the foundation in which the collaboration can be developed to improve 

tobacco-use cessation. Changing systems is a long-term process that requires 

working with health-care systems to determine perceived problems, gaps 

in care, and willingness to change. Identifying a champion’s willingness to 

commit resources and develop opportunities for systems change is a good 

starting point. Potential opportunities include the following:

■ Is a health-care system looking to create a tobacco-free campus before 

insurance coverage for tobacco cessation is expanded? 

■ Are there practices or components of the system that have effectively 

implemented Public Health Service (PHS) guidelines for treating tobacco 

dependence? 

■ Would these providers or health-care practices be willing to provide 

leadership? 

■ What are the barriers to effective implementation of provider reminders? 

■ What current programming is in place that could potentially be used as a 

model for tobacco-use treatment (e.g., diabetes, hypertension)?

Lessons Learned

The most progressive health plans have used a number of strategies and 

components in successful tobacco-control initiatives (Rigotti et al., 2002). 

Some of their lessons learned include the following:

■ Establish evaluation mechanisms up front. This is important for 

demonstrating the effectiveness of the initiative. 

■ Work with partners to establish an internal committee, which is critical 

for developing reasonable time lines, setting feasible goals and objectives, 

and obtaining buy-in and support for the implementation process. Key 

players might include

• Medical director.

• Benefits manager.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 47
• Health promotion representative.

• Pharmacists.

• Nurses.

• Quality assurance personnel.

Measuring Progress

The plan may be willing to share its Health Employer Data Information 

Set (HEDIS) and JCAHO scores on these measures, or the state insurance 

commissioner’s office may have the scores. Because insurers make multiple 

coverage plans available to purchasers, determine the extent of tobaccodependence treatment coverage provided within the more popular plans. 

Public health staff can view the coverage and provide feedback comparing 

coverage to PHS and Community Guide recommendations. (See Coverage 

document, Appendix G.) If current coverage for tobacco-dependence 

treatment is not in line with the PHS guidelines, recommendations as 

to what steps might be taken to increase coverage for medication and 

counseling could be provided. Establishing baselines in tobacco cessation 

facilitates goal setting. One baseline measure could be the current level of 

medications being provided to treat tobacco dependence. Health systems 

often closely track the provision of pharmacotherapy. 

The HEDIS measures have three components. The “advice to quit” measure 

is the first indicator. Plans at the highest levels in the country are scoring in 

the 70% range. Second, the HEDIS scores relate to the provision of support 

and assistance in quitting, which is a proxy for counseling. The highest rate 

in 2004 was 45%. The HEDIS “offer of medication” question is a third source 

of information (NCQA, 2003a), also with the highest rate around 45%.

Increasing Systems-Change Effectiveness

A plan identifying implementation components, time lines, and evaluation 

criteria should be developed.* Data collection and analyses are also 

integral parts of effective systems change. If health-care systems are 

interested, public health staff could share practice assessments, which 

assists in identifying strengths and opportunities at the practice level and 

provides support for implementing evidence-based practices. (See Practice 

Assessment document, Appendix F.) 

*The National Business Coalition on Health (NBCH) also conducts an annual 

assessment of health plans—eValue8. This tool requests treatment information 

from plans that is compared to national data and fed back to the plans in terms 

of strengths and opportunities. Tobacco-use treatment information is collected in 

the prevention section of the tool.

48 | Implementation Strategies
Public health departments could also assist health-care systems in 

identifying and using baseline data to develop implementation targets. 

If medication prescriptions are at the 20% level, this is in line with current 

practice. A 10 percentage point increase (to 30%) over the next 1 to 2 years 

might be a reasonable target. System pharmacies usually have excellent data 

systems for tracking medication dispensing. These data can then be used to 

show change over time. 

One example of work in this area is from Oregon. The Oregon Department 

of Health assessed which health plans were most likely to have a high 

percentage of tobacco users and then worked closely with the plans to 

enhance coverage and treatment strategies. 

Other questions to consider when addressing these issues include: Can a 

mechanism be instituted with the quitline vendor to provide feedback to 

the health plan and individual providers on patient enrollment progress, 

and can a system of fax referrals to the quitline be established? For example, 

Wisconsin has developed a mechanism for providers to fax referrals to the 

quitline, which accounts for 35% of all referrals. What additional strategies 

can be developed to integrate tobacco control into existing systems? If 

electronic medical records are in use, tobacco-use status should be logged 

into the system and any treatment provided should be documented. These 

data should then be collected, analyzed, and fed back to providers on a 

regular basis as a means to measure progress toward reaching treatment 

targets set by the system. 

Another strategy is to develop coordination between health plans. Health 

plans within a geographic area are frequently staffed by the same clinicians. 

If health plans promote the same message across plans, providers may be 

more likely to implement effective tobacco-control treatment. The state 

health department could assist in supporting health plan implementation 

of strategies coordination in tobacco control, including

■ Identification of tobacco-use status.

■ Advice to quit.

■ Offer of medication.

■ Referral to a quitline or other counseling services. 

State Examples

In Minnesota, health plans were encouraged to improve medication 

coverage and alleviate the quitline burden of providing medications to 

otherwise insured individuals, thus assuring state funding to provide 

medications for the underinsured and uninsured. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 49
The California Next Generation Alliance developed an office practice guide, 

the Health Care Provider’s Tool Kit for Delivering Smoking Cessation Services, that 

is designed to promote effective office-based tobacco-cessation practices 

(Next Generation California Tobacco Control Alliance, 2003).

The Pacific Center on Health and Tobacco in Oregon developed a Linking 

Health Care Systems and Quitlines document that contains a number of case 

studies illustrating successful strategies (Pacific Center on Health and 

Tobacco, 2003b).

In Michigan, the Michigan Association of Health Plans took a leadership 

role in coordinating health plan change efforts, establishing minimum 

suggested standards for coverage of tobacco-use treatment and bringing 

implementation staff together to share strategies and materials to improve 

treatment. The states of Oregon, Maine, and Wisconsin and the Columbia 

University Dental School have provided academic detailing to office 

practices promoting science-based tobacco-control activities within the 

office setting (Swartz et al., 2002). 

Educating purchasers about the importance of coverage and enlisting their 

assistance in implementing comprehensive coverage for their employees 

has also been an effective strategy. For example, the Tobacco-Free Coalition 

of Oregon (TOFCO) has developed a business health document, Make It Your 

Business, which provides examples of working with businesses to improve 

coverage of tobacco-use treatment (TOFCO, 2003). 

Several tactics for systems change are as follows:

■ The Arizona Health Department works with WIC clinics to support 

faxed referrals to the quitline.

■ Prescription pads listing the quitline telephone number can be 

distributed to promote referrals. 

■ A video could be shown for providers and their patients to familiarize 

them with the quitline service. 

■ Quality-assurance strategies can be developed that will assess the 

extent of 

• Provision of medication.

• Referrals to the quitline or other counseling services.

• Coding for tobacco dependence (305.1).

The next section provides case studies to more fully illustrate effective 

implementation strategies.

50 | Implementation Strategies
Case Studies 

Case Study #3

Connecting Private Clinics 

to State-Level Quitlines

Providence Health System, Oregon

Objective:

To increase compliance with the PHS guidelines on clinician–quitline 

collaboration, updated tobacco-use tracking systems, and efficient 

clinician feedback methods.

Providence Health System in Portland, Oregon, implemented a project to increase

compliance with the Public Health Service (PHS) guidelines for the 5 A’s intervention

in 20 local primary care clinics. This project featured three unique health-care

delivery components designed to increase clinicians’ ability to consistently deliver

tobacco-cessation and other preventive health services: 1) a direct link from the clinic

to a statewide tobacco-cessation quitline; 2) an electronic medical record (EMR)

charting system that prompted providers to consistently screen for tobacco users

and manage them appropriately; and 3) a provider feedback system that motivated

providers to increase compliance with the PHS tobacco-cessation guidelines.

In a 1-year study, 100,000 unique outpatient visits were documented in the 

20 Providence clinics (Bentz, 2002). Fifteen percent of patients (15,000) were 

identified as tobacco users, and 4.3% of tobacco users (643) were referred to 

the quitline either through direct fax referral from the clinic or via self-referral 

after receiving a brochure. The effect of provider performance feedback had a 

significant, positive influence on the documentation of Asking, Advising, Assessing, 

and Assisting in the EMR. The total Assistance rate (referrals to the quitline or to a 

Providence tobacco program, provision of written cessation materials by clinic staff, 

prescriptions for and counseling on medications, etc.) in clinics receiving feedback 

was almost double that of the clinics that received no feedback (controls). 

The costs per quitline connection were very reasonable (between $21 and 

$35 per patient) during the first year of the study. After the start-up costs 

were paid, the cost per quitline connection dropped significantly (down to less 

than $6 per patient) during the second year. This compares favorably to the costs 

that are typically incurred when using media connections to drive quitline uses 

($100 to $400 per patient connected). 

Lessons Learned:

Connecting smoking patients in physicians’ offices directly to state-level quitlines 

is feasible, effective, and well accepted by clinicians and patients. This method 

may prove to be an economical way for public health advocates to promote 

quitline usage. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 51
Case Study #4

Involving Health Systems Promotes 

Public Health Programs’ Success 

Oklahoma State Medical Association

Objective:

To form a partnership that will meet public health needs by promoting 

relationships with clinicians.

The partnership between the Oklahoma State Department of Health (OSDH) and 

the Oklahoma State Medical Association (OSMA) resulted in a successful bid for a 

3-year grant to develop a best-practice prenatal smoking-cessation intervention. 

OSMA served as the lead agency on the grant application. Traditionally, the health 

department would have assumed the role of lead agency and sought OSMA 

endorsement, but OSDH staff understood that clinicians would be more likely 

to welcome the best-practice intervention if it were introduced and promoted 

by other clinicians. 

To date, the program has reached 26 private-practice sites, including private 

physician practices, residency programs, and Native American tribal clinics, 

and is coordinating the provision of technical assistance, grant-writing support, 

training, and consultation by OSDH staff with expertise in prenatal tobacco-use 

treatment. OSMA, representing nearly 5,000 providers, contributed its credibility 

among clinicians, access to a significant number of doctors and various health 

systems statewide, and the strong infrastructure of the clinician-developed and 

-led Physician’s Campaign for a Healthier Oklahoma. The purpose was to improve 

tobacco-dependence treatment for prenatal smokers in the state. 

To date, the program has reached 17 private practices and is coordinating with 

two health-care systems. Providers and staff are encouraged to

■ Assess prenatal cessation practices using a modified chronic disease assessment 

tool. (See assessment tool, Appendix F.)

■ Identify areas of tobacco-dependence treatment needing improvement.

■ Establish strategies to move toward more effective practice over time.

The OSDH found that when it takes advantage of opportunities to involve health 

system leadership in public health initiatives, the health system responds by 

leveraging resources, strengthening partnerships, extending the reach of public 

health initiatives, and further investing in public health outcomes. Although these 

opportunities may place health systems in new roles or unfamiliar territory, their 

success can be considerable if the initiatives build on the health system’s strengths.

52 | Implementation Strategies
Case Study #4, continued

Results:

The following preliminary results have been identified through independent 

evaluation of the project. Comprehensive data will not be available until late 2006. 

■ Familiarity with the 5 A’s in practice sites showed an overall increase. 

■ Self-reported advice to quit, assessing willingness to quit, and assisting patients 

to quit all increased. 

■ More resources became available within practices to assist women in quitting. 

■ Use of the statewide cessation HelpLine has increased dramatically. 

■ Confidence, on the part of providers and their staff, in implementing the 

5 A’s intervention increased from the baseline data to the post-implementation 

survey. 

■ Practices indicated more awareness of important factors related to 

comprehensive tobacco-cessation program implementation. 

■ Self-reported ability to implement the program was high. 

■ All tasks related to the program implementation were reported as “easy.” 

■ Satisfaction with the Practice Enhancement Assistants (PEAs) was rated 

very high. 

■ 100% of practice sites said that they would recommend the PEA implementation 

process and participation in the Smoke Free Beginnings program to other 

practices. 

■ One limitation of the project evaluation: when the baseline and postimplementation surveys were completed by the providers, the same 

person did not complete the survey in all cases. 

Lessons Learned:

■ Medical society involvement was invaluable in reaching health-care providers.

■ A peer-to-peer approach proved effective in reaching clinicians. 

■ Using a practice assessment tool helped identify areas of strength and 

opportunity and provided a guide for selecting targets for change. 

■ Many practices were able to show changes in office practice as a result of the 

intervention. However, this will be better quantified as time progresses.

Funding for this project was provided by the Smokefree Families Dissemination 

Program, Robert Wood Johnson Foundation.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 53
Case Study #5

Public–Private Quitline Collaboration

Oregon Medicaid 

Objective:

To build an effective partnership to support a broad-based quitline.

The state of Oregon created a successful public–private partnership for telephonebased quitting assistance as a way to support the tobacco-use treatment efforts of 

health plans. This partnership is a collaboration of three public agencies operating 

at the state level:

■ The Public-Health Tobacco Prevention and Education Program (TPEP).

■ The Tobacco-Free Coalition of Oregon (TOFCO).

■ The Office of Medical Assistance Program (OMAP).

TPEP selected a vendor for its statewide telephone-based (single-call) tobaccouse treatment support program that could also provide a proactive multiple-call 

program to health plans at a reasonable cost. Participation by health plans is 

voluntary, and advantages include proactive enrollment, free promotion, volume 

price discounts, and free evaluation.

OMAP modeled the partnership by contracting with the vendor for its fee-forservice members. It also used its managed care contracting mechanisms and 

quality improvement forum to encourage its health plans to use this program 

or a comparable one.

Five of OMAP’s (Medicaid) 14 health plans elected to participate in the shared 

program. Through a Health Systems Task Force, TOFCO convened the plans’ 

tobacco-use treatment staffs to create common guidelines, provide outreach to 

clinicians and clinics, promote the program to members, and monitor results.

The TPEP policy decision to make the telephone support program a shared 

public–private responsibility ensured that area health plans would continue their 

existing financial contributions to tobacco-use treatment programs. But voluntary 

participation has its limits. Although the combined resources and influence of the 

prevention program, the Medicaid agency (OMAP), and the advocacy group made 

it easy for health plans to participate, only the state Medicaid plans expanded 

their tobacco-treatment offerings as a result of this effort. Prior to the initiative, 

one Medicaid health plan and three commercial plans provided their members 

with telephone counseling for quitting tobacco use. Afterwards, four additional 

54 | Implementation Strategies
Case Study #5, continued

Medicaid plans added telephone counseling as a benefit. Now, half of all callers to 

the Oregon quitline are Medicaid clients.* No additional commercial plans added 

telephone counseling as a benefit; however, two of the three plans that already 

offered telephone counseling switched to the common carrier. 

Data show that a “help is here” campaign to promote the quitline generated 

700 calls within a 3-week period. Quit rates, though lower than those published 

in clinical trials, are comparable to those reported in published literature for 

“real world” applications. 

Lessons Learned:

■ Coordination with Medicaid is an effective strategy for reaching low-income 

populations.

■ Medicaid enrollees may be harder to reach at follow-up for determination 

of quit rates. 

* El-Bastawissi A, McAfee T, Zbikowski SM, et al. The uninsured and Medicaid 

Oregon tobacco user experience in a real world, phone based tobacco use 

treatment programme. Tobacco Control 2003;12(1):45–51.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 55
Case Study #6

Building Business Champions

Tobacco-Free Coalition of Oregon, 

Make It Your Business Campaign

Objective:

Develop business partnerships to support comprehensive coverage 

for tobacco-dependence treatment.

In Oregon, about 40% of tobacco users get health-care benefits from their 

employers, but only about one-third of them are covered for tobacco-dependence 

treatment. A key to increasing benefit coverage is getting access to large healthcare purchasers to make a strong business case for adding these benefits. 

Through a series of surveys and focus groups, the Tobacco-Free Coalition of Oregon 

(TOFCO) identified key audiences needing information about the cost-effectiveness 

of providing reimbursement for tobacco-use treatment. At the top of the list were 

the large purchasers as well as insurers and consultants who broker contracts 

between the purchasers and insurers. To help gather information and gain access 

to these key groups, staff with the Oregon Department of Human Services Tobacco 

Prevention and Education Program assisted TOFCO in developing a partnership 

with the Oregon Coalition of Health Care Purchasers (OCHCP). OCHCP, which 

prefers system-wide rather than single health issue projects, allowed TOFCO to 

conduct a survey of its members about tobacco-addiction treatment resources 

and to assist with member follow-up. 

The director of the OCHCP subsequently agreed to serve on a high-level 

advisory committee for the “Make It Your Business” campaign, a statewide 

campaign sponsored by TOFCO to involve businesses in providing tobaccouse treatment services for employees. The chairman of the advisory committee 

is the Oregon Health and Science University (OHSU) medical school president, 

and other members include representatives from health insurers, businesses, and 

labor unions. The advisory committee developed a strategic outreach plan and 

successfully generated earned media through editorials and press releases of survey 

information. In the process, advisory committee members became advocates for 

expanding coverage for tobacco-dependence treatment in their own organizations. 

The medical school president reviewed benefit coverage for the more than 10,000 

employees of the university’s hospital, clinics, and research departments. He also 

met with the executives of the largest health plans in the area to advocate for 

inclusion of tobacco-dependence treatment as a standard benefit in these health 

plans. OHSU now provides coverage for employees. 

56 | Implementation Strategies
Case Study #6, continued

Projects that challenge businesses and insurers to examine their benefit packages 

for tobacco-use treatment coverage and make the business case for adding these 

benefits can result in significant progress. The Make It Your Business Campaign tools 

to help approach businesses and insurers are available at www.tobaccofreeoregon.

org. Getting access to the decision makers, while difficult, can be facilitated by 

recruiting high-level advisors and using targeted media channels such as popular 

business journals. To build the momentum needed for this change to occur, 

campaigns to increase consumer demand are also needed. 

Lessons Learned:

■ Purchasers, employers, and the media were more receptive to providing and 

promoting benefits for tobacco-use treatment than assumed. 

■ Businesses often do not know if their health plans cover tobacco-use treatment. 

They may assume their plans provide this coverage when they do not. 

■ Though many businesses may see the benefits to providing coverage for 

tobacco-use treatment, there may still be resistance to adding coverage 

because of the added costs and perceived low demand for these services. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 57
Case Study #7

Health Systems Contribute Support 

in the Face of Funding Cuts

Oregon Tobacco Prevention and Education Program

Objective:

To build an effective partnership to support a broad-based quitline.

Because of limited funds, the tobacco-use treatment component of Oregon’s 

Tobacco Prevention and Education Program (TPEP) was designed as a public–

private partnership. The state quitline is a cornerstone of this partnership. Successful 

relationships between the state program and the health plans’ and health systems’ 

tobacco coordinators, quality improvement coordinators, health promotion staff, 

and clinician champions have been created as a result of this collaboration. 

When funding for TPEP was cut by the legislature because of a severe state budget 

shortfall, the day-to-day partners were quick to react. Several of the health systems’ 

medical directors testified at legislative hearings to explain the delivery systems’ 

interconnected dependence on the state program for tobacco-use treatment 

services. But when sustained funding for the tobacco program was pitted against 

the need to fund low-income health care, allegiances were split. The primary 

mission of those with the most influence—that is, the top executives and lobbyists 

for the health plans and health systems—is health care. So in this situation, the 

executives and lobbyists’ case in favor of protecting health care won over the 

medical directors’ concern about the loss of the state quitline. 

Lessons Learned:

■ The political positions of health systems are quite complex, which makes it very 

important for tobacco-control programs to work at multiple levels within the 

insurer and clinician organizations. 

■ To better withstand state budget crises, a separate strategy is needed to build 

stronger alliances with leaders at the highest levels of the health systems that 

exert the strongest political clout.

A strong coalition effort was able to gain renewed reimbursement for the quitline 

following a short period of extremely limited service. 

58 | Implementation Strategies
Case Study #8

Partnership Extends and Improves Tobacco-Use 

Treatment in Oklahoma

Oklahoma Health Care Authority, Oklahoma State Department 

of Health, Oklahoma Tobacco Settlement Endowment Trust, 

Oklahoma Medicaid

Objective:

Build partnerships with professional organizations to increase provider 

provision of tobacco-use treatment. 

A 4-year strategic partnership brought improved access to tobacco-use treatments 

to the state of Oklahoma. The Oklahoma State Department of Health (OSDH), the 

Oklahoma Health Care Authority (OHCA), Medicaid, and the Oklahoma Tobacco 

Settlement Endowment Trust (TSET) created a formula for success that resulted in 

better information exchange, stronger interagency relationships, a convincing case 

for improved access to tobacco-use treatment medications based on health and 

economic data, and leverage of Master Settlement Agreement (MSA) resources 

that helped create a statewide helpline for tobacco users.

From 1999 to the present, each partner has contributed resources and support. 

OSDH staff provided technical assistance to OHCA by

■ Presenting the Public Health Service’s Clinical Practice Guideline: Treating Tobacco 

Use and Dependence to health plan medical directors.

■ Providing model Medicaid contract language that OHCA could use as a guide. 

In 2003, TSET funded the statewide Oklahoma Tobacco Helpline, which is provided 

at no cost to all state residents regardless of their insurance status. OHCA, in 

turn, built its capacity in tobacco-dependence treatment issues and subsequently 

moved from providing limited coverage to providing comprehensive coverage that 

includes tobacco-dependence treatment medications. 

To achieve the goal of increasing access to medical coverage for tobacco 

dependence treatment, OHCA reviewed utilization data and model Medicaid 

contract language, coordinated training events, and participated in a tobacco-use 

treatment systems strategy session that was facilitated by a resource staff member 

from CDC’s Office on Smoking and Health. Once OHCA’s Drug Utilization Review 

Committee, Medical Advisory Committee, and Board of Directors better understood 

potential utilization of the benefit, they approved a policy to lift a preauthorization 

requirement and covered both prescription and over-the-counter tobacco-use 

treatment medications for Medicaid clients. This policy also allows medications 

for a second quit attempt if the client receives counseling from the Oklahoma 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 59
Case Study #8, continued

Tobacco Helpline or other approved tobacco-use treatment program. Furthermore, 

these medications do not count against the six-prescriptions-per-month limit that 

normally applies to Medicaid clients. 

The administrative rules of this policy were passed on November 13, 2003, and 

the expanded coverage took effect on January 1, 2004. Data show an increase in 

tobacco-use treatment claims in January of approximately 20% to 30% above the 

2003 calendar year averages. In February, when the preauthorization requirement 

was waived for the first 90 days of therapy, there was an increase of more than 60% 

over the January claims. Data available for March 2004 indicate that the number 

of paid claims will either increase slightly over February or at least remain relatively 

constant. 

Approximately 40% of the Medicaid population is made up of smokers. By 

removing the prior authorization requirement, Medicaid was able to double the 

percentage of smokers receiving medications, but this continues to be a small 

fraction of tobacco users in the program. 

For the period of July 2003 through June 2004, a total of 732 clients received 

smoking-cessation products through the Medicaid fee-for-service program (due to 

computer problems, Oklahoma is assuming that the data presented below underrepresents demand).

Product 

(unit)

# of

Claims

Total

Units

Total

Days

Units/

Day Total Cost Total

Clients

Per

Diem

Zyban® 

(ea) 209 12,686 6,783 1.87 $24,129.78 165 $3.56

Spray (ml) 28 1,325 591 2.24 $4,900.24 15 $8.29

Inhalers 

(cart) 271 27,734 4,571 6.07 $23,073.65 162 $5.05

Patches 

(ea) 749 16,774 16,846 1.00 $64,307.65 540 $3.82

Gum (ea) 15 2,340 267 8.76 $924.87 12 $3.46

Lozenges 

(ea) 25 2,532 281 9.01 $1,282.96 9 $4.56

TOTAL 

FY 03 1,297 63,391 29,339 2.16 $118,619.15 732 $4.04

In summary, 

■ 165 clients received Zyban®.

■ 540 clients received nicotine replacement patches.

■ 162 clients received inhalers.

■ 732 individuals received medications.

■ The standard course of medication was 90 days.

60 | Implementation Strategies
Case Study #8, continued

1 claim 2 claims 3 claims 4 claims 5 claims ≥ 6 claims 

Claims* per Client 

461 

144 

63 

28 23 13 

500 

450 

400 

350 

300 

250 

200 

150 

100 

50 

0 

For the period of July 2004 through June 2005, a total of 2,531 clients received 

smoking cessation products through the Medicaid fee-for-service program.

Product 

(unit)

# of

Claims

Total

Units

Total

Days

Units/

Day Total Cost TotalClients

Per

Diem

Zyban® 

(ea) 461 26,977 14,381 1.88 $44,893.99 319 $3.12

Spray (ml) 91 5,860 1,353 4.33 $18,376.53 34 $13.58

Inhalers 

(cart) 737 120,364 15,965 7.54 $89,288.40 476 $5.59

Patches 

(ea) 3,341 78,692 77,810 1.01 $300,178.23 2,449 $3.94

Gum (ea) 57 8,359 1,147 7.29 $3,532.78 47 $3.08

Lozenges 

(ea) 100 16,160 1,768 9.14 $8,050.70 50 $4.55

TOTAL 

FY 05 4,787 256,412 112,424 2.28 $464,320.63 2,531** $4.13

* A claim should be considered a full course of treatment. Only the first claim is a 

“free ride.” The second and subsequent claims require a preauthorization and a 

cessation program (helpline or other).

** Total unduplicated clients for FY05.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 61
Case Study #8, continued

1,500 

535 

270 

110 50 100 

0 

200 

400 

600 

800 

1000 

1200 

1400 

1600 

1 claim 2 claims 3 claims 4 claims 5 claims ≥ 6 claims 

Claims* per Client 

In summary, 

■ 319 clients received Zyban®.

■ 2,449 clients received nicotine replacement patches.

■ 476 clients received inhalers.

■ 2,531 individuals received medications.

■ The standard course of medication was 90 days.

Lessons Learned:

■ Multiple-organization involvement was key in improving coverage under 

Medicaid.

■ Medicaid was willing to consider policy change when evidence demonstrated 

that benefit utilization was severely limited by the requirement for prior 

authorization.

■ Having an informed public health champion in the Medicaid office facilitated 

policy change. 

* A claim should be considered a full course of treatment. Only the first claim is a 

“free ride.” The second and subsequent claims require a preauthorization and a 

cessation program (helpline or other).

62 | Implementation Strategies
Case Study #9

Integrated Statewide Program Provides 

Spectrum of Services to Maine Citizens

Partnership for a Tobacco-Free Maine

Objective:

Support a comprehensive tobacco-control program with a quitline and 

provision of medication as core elements.

The Partnership for a Tobacco-Free Maine (PTM), a program of the Maine Bureau 

of Health, was created in 1997 with $3.5 million in funding from an increase in 

the state’s tobacco excise tax. In 2000, Master Settlement Agreement monies were 

placed into the Fund for a Healthy Maine, which supports programs to lower health 

risks, including programs to promote tobacco control, dental health, substance 

abuse prevention, and school health clinics, among others. Allocation from this 

fund increased revenues for PTM to $17.25 million in fiscal year 2001; however, 

since that time, annual funding has been reduced to about $13 to $15 million. 

The Tobacco Treatment Initiative, launched in 2001 by PTM, focuses on access 

to tobacco-use treatments. The initiative comprises

■ The Maine Tobacco HelpLine.

■ A medication voucher program.

■ Tobacco-treatment training to educate health professionals about tobacco 

use and to train and certify tobacco-control specialists.

The HelpLine offers a total of four counseling sessions to any resident. HelpLine 

callers who have no insurance or benefits for nicotine replacement therapy 

(NRT) can receive up to an 8-week supply of nicotine gum or patches. Through 

collaboration with a pharmacy benefit manager, the HelpLine electronically 

submits voucher information authorizing callers to obtain NRT products at 

a Maine pharmacy of their choice. The voucher program is also expanding 

access to NRT products for patients of primary care clinics in several Maine 

communities. 

Maine works to integrate statewide tobacco-treatment services with the 

medical community, using an academic detailing model to conduct clinical 

outreach (Swartz et al., 2002). Across the state, practice-based educational 

sessions are provided to engage clinicians, nurses, and other clinical 

and administrative staff in implementing clinical quitlines to improve 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 63
Case Study #9, continued

tobacco-dependence treatment. The target audience includes staff of primary 

care and prenatal clinics, as well as medical specialty, dental, chiropractic, and 

nonallopathic practices. The sessions aim to increase the following:

■ Knowledge about tobacco dependence.

■ Awareness of the impact of supportive messages from health-care providers.

■ Use of PTM treatment resources and knowledge of Medicaid benefits for 

tobacco-use treatment. 

■ Support for integration and monitoring of evidence-based practice. 

In practices providing prenatal care, outreach consultants also promote the 

Every Mother’s Wish program. This program, which is tailored to pregnant 

smokers, provides self-help materials, a quitline video filmed in Maine, and 

referral by fax to the Maine Tobacco HelpLine. The HelpLine calls women who 

are referred for services and sends them an Every Mother’s Wish T-shirt. After 

completion of counseling sessions, a silver necklace is mailed to the participating 

expectant mother.

As a result of conducting extensive clinical outreach, offering medication through 

the HelpLine, and using pharmacies to provide NRT, Maine has seen significant 

upward trends in population-based use of its tobacco-treatment services. In the first 

2 years, HelpLine use climbed from about 1.5% of adult smokers in Maine to about 

3% (from 3,300 to 6,800 per year). In 2003, 31% of callers reported hearing about 

HelpLine services through a doctor or other health professional. Half of all callers 

who received counseling were given a voucher for nicotine patches or gum. Just 

over half of HelpLine callers either had no insurance or were Medicaid beneficiaries. 

Finally, when use of services across geographic regions was examined, the volume 

of calls was found to be proportional to the total number of adult smokers residing 

in each region.

The Maine Tobacco Treatment Initiative plans to continue focusing on increasing 

treatment capacity across the state. The Center for Tobacco Independence (CTI), 

the Treatment Initiative contractor, will train tobacco specialists each year, and 

the American Lung Association of Maine will oversee their certification. CTI, in 

collaboration with the Maine Coalition on Tobacco and Health, will advocate for 

insurers (including public payers) to cover services delivered by certified tobacco 

specialists. And as previously mentioned, the medication voucher program will 

be expanded to provide access to NRT through public health clinics and other 

community sites.

64 | Implementation Strategies
Case Study #9, continued

Challenges and Opportunities:

■ Only one health insurance company provided medication coverage to Maine 

residents.

■ Coordinating with the business community to increase medication coverage so 

that state funding could be reserved for medications for the underinsured and 

uninsured required active HelpLine documentation of callers’ insurance status 

and name of insurance carrier (if any).

■ The state health department partnered with the large medical center to develop 

and implement the program.

■ Active collaboration between partners was necessary to develop a common 

language to overcome cultural differences among partner organizations. 

Lessons Learned:

■ Coordinating with a Pharmacy Benefits Manager (PBM) facilitates the 

distribution of medications in a predominantly rural state.

■ Referring pregnant women to the HelpLine via fax provides greater access 

to this population.

■ Active data collection and reporting provides ongoing program support.

■ A scientific advisory board provides expertise and support for innovative 

programming. 

A Practical actical Guide to Working with Health-Car Health-Care Systems Systems on Tobacco-Use obacco-Use Treatment eatment | 65
Case Study #10

State-Level Tobacco-Control Policy Activity: 

Sometimes a Health Plan Can Help

Group Health Cooperative, The Center for Health Promotion, Inc.

Objective:

Build an effective partnership to ensure allocation of Master Settlement 

Agreement (MSA) funding for tobacco control. 

The Group Health Cooperative (GHC) in Washington State partnered with seven 

other community-based organizations, the Governor’s Office, the Office of the 

Attorney General, and the Washington State Department of Health to ensure that 

state legislators in Washington appropriated tobacco settlement dollars to fund 

health-care priorities, including tobacco-initiation prevention and tobacco-use 

treatment. Steps involved in securing this funding included developing a strong 

coalition of organizations to advocate for public policy aimed at reducing tobacco 

use. GHC served as a founding member of the coalition. Efforts were also made to 

establish a sound network of tobacco-control advocates at the grassroots level.

Primary strategies employed in pursuit of public policy support for this funding 

included

■ Direct lobbying of members of the legislature.

■ Conducting a highly visible media campaign.

■ Emphasizing grassroots organizing and advocacy.

A GHC lobbyist assisted with appeals to the legislature, and more than one-third 

of GHC clinicians signed tailored letters encouraging their legislators to support 

the use of tobacco settlement funds for tobacco control and other public health 

priorities. The health plan also provided funds for the media campaign. In addition, 

GHC representatives served on advisory councils to the attorney general and the 

department of health.

As a result of these strategies, Washington became the first state in the nation 

to commit all funding from the master tobacco settlement to tobacco control 

and other public health priorities. To solidify this commitment, the partnering 

organizations then worked to ensure the continuity of tobacco-control funding 

and increase funding levels by

■ Drafting an initiative that would increase the tobacco tax and guarantee more 

than $28 million per year in tobacco-control funding.

■ Creating a coalition of voluntary organizations, tobacco-control groups, national 

advocacy organizations, and health groups concerned with the uninsured in 

close communication with the state department of health.

66 | Implementation Strategies
Case Study #10, continued

■ Obtaining signatures and conducting an effective campaign in support of 

the tobacco tax initiative.

GHC remained very active in the coalition and provided significant funding for 

lobbying in support of the tobacco tax initiative. The GHC Board of Directors 

formally endorsed this initiative, and its Governmental Affairs Office worked to 

support it. Other GHC contributions included

■ Providing linkages between groups working on obtaining insurance for the 

uninsured and preventing tobacco use. 

■ Speaking and writing opinion pieces or editorials in support of the tobacco 

tax initiative.

■ Mobilizing member support for the initiative.

As a result of the coalition members’ efforts, including GHC, the tobacco tax 

initiative was passed in July 2005, receiving more than 60% of votes. 

Lessons Learned:

■ Partnerships between health-care systems, clinicians, and state agencies can 

be effective in obtaining funding.

■ Using health-care system support to lobby for an initiative can be effective.

■ Media campaigns add considerable visibility to the initiative. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 67
Case Study #11

Achieving Seamless Continuation of 

Tobacco-Use Treatment Services from 

Inpatient to Outpatient Settings

Massachusetts General Hospital, Quit Smoking Service

Objective:

Electronically identify patient smoking status upon hospital admission to 

efficiently and effectively meet the needs of inpatient smokers and encourage 

post-discharge tobacco-use treatment.

Many acute-care hospital patients are admitted because they have a smoking-related 

illness. A hospital admission is an opportunity for a smoker to try to quit. Getting sick 

often motivates patients to reconsider their life choices and motivates smokers to 

think about quitting, making the hospital stay a “teachable moment” for tobacco-use 

treatment. Because a hospital is a smoke-free environment, smokers may undergo 

nicotine withdrawal symptoms during their stay, including anxiety, irritability, 

impatience, restlessness, and difficulty concentrating and sleeping. These symptoms 

often go untreated because they are not recognized as nicotine withdrawal 

symptoms. The Joint Commission on Accreditation of Healthcare Organizations 

(JCAHO) standards mandate documentation of inpatient tobacco-use treatment 

counseling for all smokers admitted with myocardial infarction, congestive heart 

failure, and pneumonia. To address this, hospitals have expressed increasing interest 

in implementing system changes to comply with the accreditation standards. 

To meet the needs of inpatient smokers and encourage post-discharge tobaccouse treatment, Massachusetts General Hospital’s Quit Smoking Service (MGH QSS) 

is working with the admissions department to electronically record each patient’s 

smoking status upon admission to the hospital. The MGH QSS envisions a seamless 

process in which a coordinator identifies a list of inpatient smokers daily and a trained 

QSS counselor offers state-of-the-art counseling and drug treatment. All actions are 

then documented in the patient’s medical record, which helps the hospital improve 

compliance with JCAHO measures. Subsequently, and when appropriate, a referral 

is made to “Quitworks,” the Massachusetts state quitline. This proactive telephonebased counseling program provides up to five counseling calls to a patient after 

discharge. Quitworks also provides feedback to the MGH QSS on the status and 

outcome of all referrals. The MGH QSS then contacts the patients’ primary care 

clinicians to provide updated information on the patient’s smoking status.

Lessons Learned:

■ Having specific systems in place is imperative for a seamless tobacco-treatment 

process from admission to post-discharge. 

■ Reliable identification of a patient’s smoking status upon hospital admission is key 

to reaching the largest number of smokers.

■ Once a clinical service is developed, referral to the state quitline supports smoking 

cessation following discharge. 

68 | Implementation Strategies
Conclusion

Effective treatments can more 

than double a person’s chances 

of successfully quitting smoking 

(Fiore et al., 2000). Smokers 

whose benefits cover tobaccouse treatment are more likely 

to undergo treatment and to 

quit successfully (Curry et al., 

1998; Cochrane Collaboration, 

2005). Data from businesses 

that have included tobacco-use 

treatment benefits as part of their 

health insurance also show that 

providing this coverage is costeffective over time (Fiore et al., 

2000; Wagner et al., 1995; Warner 

et al., 1996). 

In the Clinical Practice Guideline: 

Treating Tobacco Use and Dependence, the U.S. Public Health Service presents 

recommendations aimed at improving access to effective treatment. 

Specifically, the guidelines recommend that every patient who uses tobacco 

should be offered at least brief treatment. Insurers and purchasers should 

include tobacco-dependence treatments as a benefit so clinicians can be 

reimbursed for providing these services (Fiore et al., 2000). 

A systematic review of published studies on tobacco-use treatment was 

conducted on behalf of the Task Force on Community Preventive Services 

(Hopkins et al., 2001). This review, along with the PHS guidelines, reports 

that approaches used by health-care systems—where clinicians identify 

patients who use tobacco and discuss with them the importance of quitting, 

and where the clinicians receive information to assist them in helping their 

patients understand the risks associated with tobacco use—effectively 

increase both the number of clinicians who address tobacco use with their 

patients and the number of tobacco users who attempt to quit. Based on 

these findings, the Task Force recommends that interventions to increase 

tobacco-use treatment should include reminder systems for clinicians and 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 69
clinician education programs in conjunction with systems-change strategies, 

sustained media campaigns, availability of quitlines, reduction of patient 

out-of-pocket costs for treatment, and increases in excise taxes on tobacco 

(Centers for Disease Control and Prevention, 2000). 

To be successful advocates, public health professionals and others who are 

interested in and have opportunities to promote tobacco-use treatment or 

reimbursement for these services must understand what types of treatment 

have proven successful, why reimbursement is such an important issue, 

and how providing this benefit affects the business sector in both the short 

and long term. They must also understand how the various components 

of the health-care system operate, the challenges they face, and their role 

in tobacco-use treatment. Armed with a comfortable level of knowledge 

about tobacco-use treatment and the ever-changing health-care arena, 

they can effectively approach health-care clinicians, health plans, insurers, 

and purchasers to educate them about effective strategies, assist them in 

identifying common goals, and plan a strategy for working successfully 

together to achieve those goals. 

Developing effective relationships between public health and health-care 

systems will require time, effort, and persistence. Providing support and 

assistance for incremental change, with an effective evaluation system, will 

be key components in supporting implementation of effective tobaccocontrol initiatives. 

Although the PHS and Community Guide recommendations are not fully 

implemented, nor are desirable levels of service and coverage for tobaccouse treatment in place, progress is being made, and a foundation has been 

laid. A strong science base exists for the treatment of tobacco dependence, 

and additional efforts are required to more effectively translate research 

into practice. We can now see that the needs and desires of health plans, 

clinicians, purchasers, and consumers—particularly as they relate to quitting 

tobacco—often overlap. As demonstrated in the case studies presented in 

this tool kit, progress often is achieved through collaborative efforts, and 

these efforts are resulting in significant achievements in tobacco cessation. 

Implementation of the strategies contained in this guide, along with 

establishing strong partnerships with health-care insurers, purchasers, and 

businesses, will provide opportunities to increase the availability and use of 

effective treatments for tobacco use. Integration of comprehensive treatment 

strategies in health-care settings will result in decreases in the prevalence of 

tobacco use and reduce the public health burden of tobacco-related diseases 

in the United States.

70 | Conclusion
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on health care use. Archives of Internal Medicine 1995;155:1789–1795.

Warner KE, Smith RJ, Smith DG, et al. Health and economic implications 

of a work-site smoking cessation program: a simulation analysis. Journal 

of Occupational and Environmental Medicine. 1996.

Winer M, Ray K. Collaboration Handbook: Creating, Sustaining, and Enjoying the 

Journey. St. Paul, MN: Wilder Foundation; 1994.

Zhu S, Melcer T, Sun J, et al. Smoking cessation with and without assistance: 

a population based analysis. American Journal of Preventive Medicine 2000; 

18(4):305–311.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 75

Appendixes
Appendix A

Glossary of Terms

Academic detailing: Detailing similar to that used by the pharmaceutical 

industry, but it brings a training systems change message to office practices.

Broker: A person who is licensed by the state to sell and service contracts 

for multiple health plans.

Capitation: A method of payment for health services in which the clinician 

is paid a fixed amount for each patient served regardless of the actual 

number or nature of services provided. 

Copayment: A specified amount that the insured pays out of pocket at the 

time services are provided or prescription medications are purchased. 

Deductible: An amount the insured pays before insurance plan coverage 

is in effect. 

Earned media: Coverage of a story without paying for media placements. 

Examples include a letter to the editor, op-eds, coverage of press conferences, appearance on talk shows or local news programs, and on-air or 

print interviews. Such coverage is called “earned media” because you 

have to develop materials, work with reporters, and expend resources 

to get it; however, you do not have to pay for the placement of the messages 

in the stories. 

Fee-for-service: A method of payment in which the health-care clinician 

is paid for services rendered instead of receiving a salary or receiving 

capitated payments (see above). In fee-for-service plans, the insurer may 

reimburse the plan member or pay the clinician directly after services have 

been provided. 

Fully insured: A type of coverage in which the insurance company is paid 

a monthly premium to assume complete risk for covered charges after the 

deductible and copayments are satisfied. 

Health insurance products: The specific types of health-care coverage 

that are offered by health plans and insurers and may contain differing 

coverage available for purchase. 

Health plan: An organization that offers a variety of health insurance 

products and may take responsibility for coordinating and improving the 

delivery of care. 

Health Plan Employment Data and Information Set (HEDIS): A

set of standardized performance measures developed by the National 

Committee on Quality Assurance (NCQA) that is designed to ensure that 

purchasers and consumers have the information they need to reliably 

compare the performance of managed health-care plans. 

Indemnity products: Policies that provide coverage for health-care services

on a fee-for-service basis. Often referred to as “traditional insurance,” these

plans typically include a deductible and often also require a co-payment.

78 | Appendixes
Integrated delivery system: A health-care service organization provides 

a full range of health-care services, including clinician services, hospital 

services, and outpatient and ancillary services. 

Joint Commission on Accreditation of Healthcare Organizations 

(JCAHO): An independent, not-for-profit organization that sets standards 

and accredits health-care organizations and programs in the United States. 

Managed care: A type of health plan or product that typically involves a 

network of clinicians from whom members can receive care, some limitation 

on benefits to members who choose to use clinicians outside the network, 

and some type of authorization or approval system that must be used when 

securing services.

National Committee for Quality Assurance: The NCQA is a not-forprofit managed care accreditation organization that is designed to improve 

patient care and health plan performance in three ways: (1) through 

accreditation achieved through a rigorous, on-site review of key clinical 

and administrative processes that are performed at health plans’ requests; 

(2) through HEDIS, a tool used to measure performance in key areas; and 

(3) through a comprehensive member satisfaction survey. 

Point of service (POS): A type of coverage that allows plan members 

to choose a clinician within the plan’s network or one outside the network 

at the time that the care is needed. Choosing an out-of-network clinician 

usually involves higher costs.

Preferred provider organizations (PPOs): Companies that arrange for 

lower fees with a network of health-care clinicians, giving policyholders a 

financial incentive to seek care within that network. Members pay higher 

rates for services obtained from a clinician who is not part of their network.

Primary care: General medical care that focuses on preventive care and 

the treatment of routine injuries and illnesses. 

Quality improvement organizations (QIOs): A group of clinicians 

and other health-care experts who are paid by the federal government 

to assess the care given to Medicare patients and to plan improvements. 

QIOs review complaints about the quality of care provided by hospitals 

(inpatient, outpatient, and emergency room care), skilled nursing facilities, 

and ambulatory surgical centers. They also assess services provided by 

home health agencies and private fee-for-service plans. QIOs usually 

serve on a statewide basis and may be valuable partners in monitoring the 

implementation of tobacco-control initiatives. 

Self-insured: A plan in which an employer or other group sponsor, 

rather than the health plan, is financially responsible for paying expenses, 

including claims. Most large employers are self-insured, and they select 

a benefits package for their employees. Self-insured companies usually 

contract with a health plan or independent company (known as third-party 

administrators) to process claims and handle other administrative needs.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 79
Appendix B

Essential Elements of an Effective 

Practice-Based Tobacco-Cessation 

System*

1. Identification of All Tobacco Users

■ Nursing staff or aides ask all patients with unknown status about 

their tobacco use when patients are placed in the examining room. 

(Children with daily secondhand smoke exposure are also identified.)

■ Charts are labeled to identify current use, recent (past year) use, 

former use, and nonuse.

■ At subsequent visits, patients identified as current or recent users of 

tobacco are asked about use.

2. Clinician Reminders

■ Information is provided about current use.

■ Prominent flags call attention to this information, for example, using a 

colored identification sticker or stamp (current, former, never).

■ Electronic medical records can prompt providers to obtain status and 

provide brief advice. 

3. Clinician Message

Clinicians are reminded to

■ Assess patient’s interest in quitting (i.e., ask if ready to make a quit 

attempt now).

■ Advise patient of the importance of quitting.

■ Negotiate a quit date if interested in quitting.

■ Offer assistance and follow-up (medication and counseling).

■ Refer to state or National Network of Quitlines access numbers 

(1-800-QUIT NOW). 

They also are reminded that it is very difficult for smokers to quit.

4. Assistance

Provide

■ Counseling resources, preferably on-site or phone-based.

■ Medication (unless contraindicated). 

■ Educational materials.

5. Follow-up 

■ Provide follow-up at all office visits, based on #1 and #2 above.

■ Telephone patient soon after quit date to assess progress and reinforce 

action.

* Solberg LI. Incentivising, facilitating, and implementing an office tobacco cessation 

system. Tobacco Control 2000;9(Suppl 1):i37–i41.

80 | Appendixes
Appendix C

Essential Elements of an Effective

Pediatric Practice-Based TobaccoControl System

In addition to addressing tobacco-use treatment with adults in primary 

care or specialty settings, it is important to recognize the opportunities to 

intervene in pediatric settings. The pediatric setting provides an opportunity 

to prevent and eliminate tobacco use by young people and adults. Tobacco 

control in pediatric health care has three primary aims: (1) to eliminate 

childhood secondhand smoke (SHS) exposure, (2) to eliminate tobacco 

use by parents and guardians of pediatric patients, and (3) to prevent 

and eliminate tobacco use by pediatric patients. Steps to accomplish 

these goals are 

1. Systematically identify all tobacco users in the household.

■ Ask the parents and guardians of all pediatric patients about the 

smoking status of household members; this can be done at the front 

desk, during the recording of vital signs, or during the visit with 

the clinician.

■ Confidentially ask all adolescent and pre-adolescent patients about 

their tobacco use.

2. Systematically document smoking status in the medical record.

■ In the child’s medical record, document the smoking status of all 

smokers, including pediatric patients, their parents, and other 

household members.

3. Inform and prompt child health-care clinicians about the 

child’s SHS exposure or tobacco use.

■ Use stickers or other indicators on the problem list or visit note to cue 

clinician inquiry and 5 A’s counseling on tobacco issues. 

■ Electronic medical records can systematically prompt clinicians to 

inquire and follow up on the tobacco issues of pediatric patients and 

household members.

4. Intervene directly and indirectly.

■ Create a smoke-free office that includes posters, brochures, and 

information on enrolling smokers in evidence-based smokingcessation counseling, creation of smoke-free environments, and 

preventing smoking initiation.

i. Advise: “I strongly advise that you establish a no-smoking policy 

in your home and car and that you quit smoking yourself. I can 

help you.”

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 81
ii. Prescribe medications for parent and adolescent tobacco 

dependence if appropriate.

iii. Link smokers to quitlines and other tobacco-treatment services.

iv. Provide more extensive office counseling if possible.

5. Follow up.

■ Address tobacco use with all smoking members of the household 

at future visits.

■ Remind nonsmoking families about smoke-free policies and the 

dangers of initiating tobacco use.

Citation: Winickoff JP, Berkowitz AB, Brooks K, et al. State-of-the-art interventions for 

office-based parental tobacco control. Pediatrics 2005;115(3):750–760.

82 | Appendixes
Appendix D

Making the Business Case 

for Tobacco Control*†

States may find it helpful to develop a fact sheet containing some or all of 

the following elements as a means of having key information in one place 

when beginning to work with health-care systems. 

■ Provide state-specific and, if possible, organization-specific data on 

smoking prevalence.

■ Provide state-specific data on the cost of tobacco use in terms of direct 

and indirect health-care costs.

■ Use HEDIS data to estimate the percentage of smokers in a health plan.

■ Gather organization-specific HEDIS data on rates of advice to quit and 

assistance with quitting, and provision of medication (may be available 

from the state insurance office).

■ Assess JCAHO data on rates of providing tobacco-dependence treatment 

for specified diagnostic categories (pneumonia, cardiovascular disease, 

lung disease).

■ Provide a clear description of the health benefits of tobacco cessation. 

(See consumer materials from the 2004 publication The Health 

Consequences of Smoking: A Report of the Surgeon General at

www.cdc.gov/tobacco.)

■ Describe the effectiveness of available treatments. (See PHS Web site.)

■ Describe the cost-effectiveness of available treatments. (See PCHT finance 

document.)

■ Describe short- and long-term costs and cost savings. (See Make It Your 

Business Campaign, www.TOFCO.org, and PACT Employer Document, 

www.endsmoking.org.)

■ Describe specific case examples of similar organizations that have 

adopted tobacco-control policies and programs. 

■ Encourage self-insured businesses and health plans to use the www.

businesscaseROI.org Web site for assessing costs for tobacco use and 

benefit implementation. 

■ Use the CDC document Coverage for Tobacco Use Treatments to supplement the sheet you have developed. Available at www.cdc.gov/tobacco/

educational_materials/cessation/ReimbursementBrochureFull.pdf

* The information in this resource sheet was adapted from: Pacific Center on Health 

and Tobacco. Build a Financial Infrastructure: Health Plan Benefits and Clinician 

Reimbursement. Portland, OR: The Center; 2003. Available at http://www.

paccenter.org/public/reports_folder/reimbursement_web.pdf.

†See State Highlights for state-specific tobacco-control data, www.cdc.gov/tobacco.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 83
Appendix E

For More Information

Listed below are Web sites where you can find the primary sources of 

information cited in this tool kit, as well as other policies and practices 

related to implementing tobacco-use treatment in the health-care setting. 

Guidelines and Key Documents

■ Treating Tobacco Use and Dependence is a U.S. Public Health Service 

(PHS)-sponsored clinical practice guideline that contains evidencebased strategies and recommendations to support effective treatment 

for tobacco use and nicotine addiction. Available at http://www.

surgeongeneral.gov/tobacco.

■ The Guide to Community Preventive Services provides information 

on the effectiveness of community-based interventions in three 

areas of tobacco-use prevention and control: (1) initiation of tobacco 

use, (2) tobacco-use treatment, and (3) reduction of exposure to 

environmental tobacco smoke. Articles, slide sets, and commentaries 

can be found at http://www.thecommunityguide.org/tobacco.

■ Crossing the Quality Chasm: A New Health System for the 21st Century is 

one in a series of reports developed by the Institute of Medicine’s Quality 

Initiative, which has focused on assessing and improving the nation’s 

quality of care. This report, which is the second of two published in the 

third phase of the initiative, presents key steps to promote evidencebased practice and strengthen clinical information systems. Ordering 

information and access to online text is available at http://books.nap.

edu/catalog/10027.html?onpi_newsdoc030101. 

■ Surgeon General’s reports related to tobacco are available on the Centers 

for Disease Control and Prevention Web site at http://www.cdc.gov/

tobacco/sgrpage.htm. These include the reports cited as sources for 

this document. The PHS guidelines and related consumer and clinician 

materials also can be found at http://www.surgeongeneral.gov/tobacco. 

■ A National Action Plan for Tobacco Cessation outlines a series of 

science-based action steps to reduce tobacco consumption and promote 

tobacco-use treatment, especially among minority and lower-income 

Americans. This report, sponsored by the American Legacy Foundation, 

the University of Wisconsin Center for Tobacco Research and 

Intervention, and the Journal of American Public Health, is available 

at http://www.ctri.wisc.edu/home/NatActionPlan%2002-04.pdf.

■ Preventing 3 million premature deaths and helping 5 million smokers 

quit: a national action plan for tobacco cessation, by Michael C. Fiore and 

colleagues at CDC, was published in the American Journal of Public Health

in February 2004 (Vol. 94, No. 2, pages 205–210). 

84 | Appendixes
Data

■ Data on tobacco-use prevalence, morbidity, and mortality are available at 

the Centers for Disease Control and Prevention Web site at http://www.

cdc.gov/tobacco/data.htm and http://www.cdc.gov/nchs.

■ Data on insurance status and type (national and by state) from a survey 

conducted jointly by the Bureau of Labor Statistics and the Bureau of 

the Census are available at http://ferret.bls.census.gov/macro/032002/

health/toc.htm.

Pregnancy

■ A Cost-Benefit/Cost-Effectiveness Analysis of Smoking Cessation for 

Pregnant Women, by J.S. Marks, J.P. Koplan, C.J.R. Hogue, et al. American 

Journal of Preventive Medicine 1990; 6(5):282–289.

■ The Partnership for Smoke-Free Families Program (PSF), which focuses 

on tobacco-use treatment for pregnant women and reducing exposure 

to tobacco smoke for infants and young children, has created a technical 

assistance manual that provides other health-care organizations with 

the information they need to create similar programs in their own 

health-care settings. Included are lessons learned, recommendations 

for program implementation, and samples of program materials. The 

manual is available in PDF format at http://www.smokefreefamilies.

org/documents/PSFManual.pdf.

Quality Assurance 

■ The National Committee on Quality Assurance (NCQA) Web site 

provides information to help consumers, including representatives of 

large employers, make more informed decisions when choosing a health 

plan. The site also provides pages for health-care professionals that detail 

NCQA programs and NCQA publications, including publications on 

HEDIS. Available at http://www.ncqa.org/index.asp.

■ Accelerating Quality Improvement in Health Care: Strategies to Speed 

the Diffusion of Evidence-Based Innovations explores the reasons why 

clinicians and systems are slow to adopt many medical and health-care 

innovations, best practices, and ways to speed the diffusion of proven 

treatments and tools that improve the quality of health care. This report, 

commissioned papers, and related conference proceedings are available 

at http://www.nihcm.org.

Finance and Business

■ Build a Financial Infrastructure: Health Plan Benefits and Clinician 

Reimbursement combines evidence-based recommendations and the 

experiences of the Pacific Center on Health and Tobacco (PCHT), a 

consortium of five western states (California, Oregon, Washington, 

Arizona, and Hawaii) concerning tobacco-cessation benefits and clinician 

reimbursement. The report is designed to guide planning and decision 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 85
making by states and other groups that are working to implement 

tobacco-cessation programs. Also available are two summaries based 

on this report: (1) Health Insurance Benefits for Treatment of Tobacco 

and (2) Invest in Tobacco Cessation for a Healthy, Productive Workforce

(see next entry). Visit the PCHT Web site at http://www.paccenter.org. 

■ Implementing Tobacco Interventions in the Real World of Managed Care, 

by J.F. Hollis, R. Bills, E. Whitlock, et al. Tobacco Control 2000; 9(Suppl I):

i18-i24. 

■ Invest in Tobacco Cessation for a Healthy, Productive Workforce is a brochure 

designed to help employers determine the cost of smoking to their 

businesses and estimate the cost of providing a tobacco-use cessation 

benefit for their employees. This brochure, developed by the PCHT, is 

available at http://www.paccenter.org/public/reports_folder/cess_in_

wp_web.pdf.

■ Employers’ Smoking Cessation Guide: Practical Approaches to a Costly 

Workplace Problem, a guide published by the Professional Assisted 

Tobacco Cessation Therapy (PACT) consortium for large and 

small employers interested in enacting an affordable, effective 

smoking-cessation treatment program, is available at http://www.

endsmoking.org.

■ Reimbursement for Smoking Cessation Therapy: A Health Care Practitioner’s 

Guide, a guide published by the PACT consortium for clinicians on how 

to obtain reimbursement for tobacco-use treatment services that also 

is helpful to employers in the implementation of a tobacco-cessation 

benefit. Available at http://www.endsmoking.org

■ A guide to purchasing prevention benefits that was developed for 

employers by North Carolina Prevention Partners contains information 

that may be helpful to employers in other states. The guide can be found 

at http://www.ncpreventionpartners.org/basic/eguide.htm.

■ Information on the costs of tobacco use to employers and information 

on smoke-free policies can be found in the publication Making Your 

Workplace Smokefree: A Decisionmaker’s Guide. The entire guide or selected 

chapters are available in PDF format at http://www.cdc.gov/tobacco/

research_data/environmental/etsguide.htm. 

■ Making the Business Case for Smoking Cessation is a Web site that 

assists businesses in calculating the costs of smoking and the benefits 

of cessation in terms meaningful to health-care delivery organizations 

and purchasers. Available at www.ahip.org.

■ The Oregon Make It Your Business Campaign encourages businesses 

to voluntarily help employees become tobacco-free and urges health 

insurers to include, as a standard benefit, the medications and programs 

to help people quit smoking or chewing tobacco. The tool kit provides a 

step-by-step guide for businesses that want to “make it their business” 

to ensure a tobacco-free workforce. The tool kit also provides checklists, 

worksheets, and fact sheets. Available at http://www.tobaccofreeoregon.

org/projects/miyb.

86 | Appendixes
■ www.businesscaseROI.org is a Web-based modeling tool that has been 

developed for managed care organizations to assess their tobacco-related 

disease costs and project potential costs for adding tobacco-dependence 

treatment benefits. 

■ “Coverage of Smoking Cessation Treatment by Union Health and 

Welfare Funds” (Barbeau E., Li Y., et al., American Journal of Public 

Health 2001;91(9):1412–1415) presents the results of a survey to determine 

the level of insurance coverage for smoking-cessation treatment and 

factors associated with coverage among health and welfare funds 

affiliated with a large labor union. Information on purchasing a copy of 

this article is available at http://www.ajph.org/cgi/reprint/91/9/1412. 

Quitlines 

■ Linking a Network: Integrate Quitlines with Health Care Systems describes 

the role that tobacco quitlines play within health-care systems that 

deliver cessation services. The report combines emerging evidence on 

the efficacy of quitlines with practical experience from case studies 

to provide a view of the value of partnerships between quitlines and 

health-care systems in developing a comprehensive statewide tobacco 

program. This brochure, developed by PCHT, is available at http://www.

paccenter.org/public/reports_folder/linking_broch_web.pdf.

■ The North American Quitline Consortium is a forum designed to 

facilitate communication among leaders representing state and 

provincial health departments, quitline vendors, researchers, and 

national organizations in the United States and Canada in an effort to 

better understand quitline operations, promotion, and effectiveness. 

Information about the Consortium is available at http://ctcinfo.org.

Medicaid 

■ Links to data from a study conducted by the Center for Health and 

Public Policy Studies at the University of California, Berkeley, to track 

changes in coverage of tobacco-dependence treatments by state Medicaid 

programs and to publications concerning health insurance policy and 

tobacco control are available in two MMWR issues, January 30, 2004, 

and May 30, 2003. Available at www.cdc.gov/tobacco. 

■ Medicaid Purchasing Specifications provide valuable contract language 

that can be used by employers and purchasers to structure benefits 

related to tobacco-use prevention and tobacco-use treatment and 

are included in the sample purchasing specifications developed by 

CDC in conjunction with George Washington University Center 

for Health Services Research and Policy. Designed to assist states in 

implementing evidence-based tobacco-dependence treatment and 

improve Medicaid contracts, these specifications are available at 

http://www.gwhealthpolicy.org/newsps/tobacco.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 87
Databases and Information Services

■ The Center for Tobacco Cessation (CTC) serves as a source of sciencebased information on tobacco-use treatment and works with national 

partners to expand the use of effective tobacco-dependence treatment 

and activities. CTC is jointly funded by the American Cancer Society 

and the Robert Wood Johnson Foundation. For resource tools, policy 

information, helpful links, and publications such as A Quick Reference 

Guide to Effective Tobacco Cessation Treatments and Activities, visit the 

CTC Web site at http://www.ctcinfo.org. 

■ Information on tobacco-cessation counseling can be found on the 

American Cancer Society Web site located at http://www.cancer.org. 

Type “cancer AND counseling” in the search box located in the upper 

right corner of the home page.

■ Information on tobacco cessation and the effects of tobacco use on 

specific populations can be found on the American Lung Association 

Web site located at http://www.lungusa.org. 

■ Information on tobacco cessation, including how to access state 

quitlines and patient self-help materials, can be found at http://

www.smokefree.gov.

■ The ttac exchange is an online newsletter produced by the Tobacco 

Technical Assistance Consortium at the Rollins School of Public Health 

at Emory University. This technical assistance tool is designed to bring 

information, strategies, and other tools to the tobacco-control community 

and to serve as a gateway to resources on current tobacco-control issues. 

For details, go to http://www.ttac.org.

■ Reaching Higher Ground: A Guide for Preventing, Preparing for, and 

Transforming Conflict for Tobacco Coalitions provides coalition leaders, 

members, and facilitators creative ways to address differences within 

a coalition and work successfully to achieve common goals. The guide 

is available online at http://www.ttac.org/products/pdfs/Higher_

Ground.pdf.

■ University of Michigan Hospital offers a CD discussing the development 

of smoke-free campuses for hospitals. To order this CD contact: UMHS 

Tobacco Consultation Service, 300 N. Ingalls 2D19/0430, Ann Arbor, MI 

48109-0430, Phone: 734-936-5988, Fax: 734-647-1516, quitsmoking@med.

umich.edu, http://www.naquitline.org.

■ QuitWorks is a free statewide cessation resource program that was 

developed by the Massachusetts Department of Health in collaboration 

with all major health plans in Massachusetts. This guide was developed 

to help hospitals and health centers to integrate the comprehensive 

QuitWorks program into their practices. The document provides an 

overview of the QuitWorks program, the scientific evidence supporting 

it, and the resources necessary to implement this type of program in 

other states. This document is available at http://www.quitworks.org.

88 | Appendixes
Partners

■ Centers for Medicare and Medicaid Services. Glossary. Available at 

http://www.cms.hhs.gov/glossary. 

■ Next Generation California Tobacco Control Alliance. A Statewide Strategy 

for Smoking Cessation in California. Sacramento, CA: The Alliance; 2002. 

Available at http://www.tobaccofreealliance.org/Resources.htm. 

■ Quality Mapping Solutions Web site. Available at http://qmsonline.com/

jcaho.htm. 

Centers for Disease Control and Prevention

■ The Centers for Disease Control and Prevention’s Office on Smoking and 

Health (OSH) has a Web site for Tobacco Information and Prevention 

Source (TIPS) that contains a wealth of information about tobacco use, 

economic costs, and policies. The TIPS Web site can be found at http://

www.cdc.gov/tobacco.

■ The Cessation Resource Center Web site contains cessation-focused 

resources developed and tested by state tobacco-control programs, 

OSH partner organizations, and other federal agencies. These cessation 

resources are available to registered state and organizational tobaccocessation programs. Available at http://apps.nccd.cdc.gov/crc.

■ Designing and Implementing an Effective Tobacco Counter-Marketing 

Campaign. Atlanta, Georgia: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking 

and Health. First Edition October 2003. Available at www.cdc.gov/

tobacco.

■ Telephone Quitlines: A Resource for Development, Implementation, 

and Evaluation is a guide that discusses the role of quitlines in a 

comprehensive tobacco-control program and provides detailed 

information on quitline needs and resources. Available at http://

www.cdc.gov/tobacco/quitlines.htm.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 89
Part I: Organization of the Health-Care Delivery System

Appendix F

Practice Assessment Document

This document was adapted for the Smoke-Free Families dissemination 

project and can be further adapted for general adult populations by 

removing the pregnancy references. 

Components

Support from 

leadership in 

our practice for 

addressing tobacco 

use in pregnancy...

Score 0 1 2 3 4 5 6 7 8 9 10 11

Little Support

...does not exist, or 

there is a little interest.

Basic Support

...is reflected in 

vision statements 

and business plans, 

but no resources are 

specifically earmarked 

to execute the work.

Good Support

...is reflected by senior 

leadership and specific 

dedicated resources 

(dollars and personnel).

Full Support

...is part of the system’s 

long-term planning 

strategy, receives 

necessary resources, 

and specific people 

are held accountable.

Organizational goals 

incorporated into 

overall activities 

in our practice for 

addressing tobacco 

use in pregnancy...

Score

...do not exist.

0 1 2

...exist but are not 

actively reviewed.

3 4 5

...are measurable and 

reviewed.

6 7 8

...are measurable, 

reviewed routinely, and 

incorporated into plans 

for improvement.

9 10 11

Quality improvement strategies for 

addressing tobacco 

use in pregnancy in 

our practice...

Score

...are ad hoc and not 

organized or supported 

consistently.

0 1 2

...utilize ad hoc 

approaches for targeted 

problems as they 

emerge.

3 4 5

...utilize a proven 

improvement strategy 

such as academic 

detailing or systems 

changes for addressing 

targeted problems.

6 7 8

...include a proven 

improvement strategy 

and use it proactively in 

meeting organizational 

goals.

9 10 11

External (state, 

health plans, etc.) 

financial incentives 

for addressing 

tobacco use in 

pregnancy...

Score

...are not used to 

influence clinical 

performance goals.

0 1 2

...are used to influence 

utilization and costs of 

tobacco screening and 

treatment.

3 4 5

...are used to support 

patient care goals.

6 7 8

...are used to motivate 

and empower providers 

to support patient care 

goals.

9 10 11

Senior leaders 

in our practice 

(e.g., CEO, Medical 

Director, Director 

of Operations)...

Score

...do not encourage 

enrollment of pregnant 

smokers into smoking 

cessation programs.

0 1 2

...do not make 

improvements 

related to smoking in 

pregnancy a priority.

3 4 5

...encourage 

improvement efforts in 

addressing smoking in 

pregnancy.

6 7 8

...visibly participate in 

improvement efforts in 

addressing smoking in 

pregnancy.

9 10 11

Adapted from the MacColl Institute for Healthcare Innovation, Group Health Cooperative © 2000.

90 | Appendixes
Part III: Self-Management Support 

Part II: Community Linkage 

Components

Linking pregnant 

patients who smoke 

to resources outside 

our practice...

Score 0 1 2 3 4 5 6 7 8 9 10 11

Little Support

...is not done 

systematically.

Basic Support

...is limited to a list of 

identified community 

resources in an 

accessible format.

Good Support

...is accomplished 

through a designated 

staff person or resource 

responsible for ensuring 

providers and patients 

make maximum use of 

community resources.

Full Support

...is accomplished 

through active 

coordination between 

the health system, 

community service 

agencies, and patients.

Components

Assessment and 

documentation of 

self-management 

needs and activities 

to help pregnant 

patients who smoke 

avoid tobacco use...

Score

Little Support

...are not done.

0 1 2

Basic Support

...are expected.

3 4 5

Good Support

...are completed in a 

standardized manner.

6 7 8

Full Support

...are regularly assessed 

and recorded in 

standardized form 

linked to a treatment 

plan available to 

practice and patients.

9 10 11

Self-management 

support for the 

pregnant woman 

who smokes and is 

interested in 

stopping...

Score

...is limited to 

the distribution 

of information 

(pamphlets, booklets).

0 1 2

...is available by referral 

to self-management 

classes or educators.

3 4 5

...is provided by trained 

clinical educators who 

are designated to 

do self-management 

support, affiliated with 

the practice, and see 

patients on referral.

6 7 8

...is provided by clinical 

educators affiliated with 

the practice, trained in 

patient empowerment 

and problem-solving 

methodologies, and 

see most patients with 

chronic illness.

9 10 11

Support and 

addressing concerns 

of patients and 

families regarding 

smoking in 

pregnancy as 

they are raised...

Score

...is not consistently 

done.

0 1 2

...is provided for 

specific patients and 

families through 

referral.

3 4 5

...is encouraged, 

and peer support, 

groups, and mentoring 

programs are available.

6 7 8

...is an integral 

part of care and 

includes systematic 

assessment and routine 

involvement in peer 

support, groups, or 

mentoring programs.

9 10 11

Effective behavior 

change interventions 

such as counseling 

and assistance for 

quitting smoking...

Score

...are not available.

0 1 2

...are limited to 

the distribution of 

pamphlets, booklets, 

or other written 

information.

3 4 5

...are available only by 

referral to specialized 

centers staffed by 

trained personnel.

6 7 8

...are readily available 

and an integral part of 

routine care.

9 10 11

Adapted from the MacColl Institute for Healthcare Innovation, Group Health Cooperative © 2000.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 91
Part IV: Decision Support

Components

Evidence-based 

guidelines for 

prenatal smoking 

cessation...

Score

Little Support

...are not available.

0 1 2

Basic Support

...are available but are 

not integrated into 

care delivery.

3 4 5

Good Support

...are available and 

supported by provider 

education.

6 7 8

Full Support

...are available, 

supported by provider education, and 

integrated into care 

through reminders and 

other proven behavior 

change methods.

9 10 11

Involvement 

of specialists in 

addressing smoking 

in pregnancy...

Score

...is primarily through 

traditional referral.

0 1 2

...is achieved through 

specialist leadership to 

enhance the capacity 

of the overall system 

to routinely implement 

guidelines.

3 4 5

...includes specialist 

leadership and 

designated specialists 

who provide clinical 

care team training.

6 7 8

...includes specialist 

leadership and specialist involvement in 

improving the care 

of pregnant patients.

9 10 11

Education related to 

effective methods 

to address smoking 

in pregnancy for 

individuals involved 

in providing care 

to patients...

Score

...is provided 

sporadically.

0 1 2

...is provided 

systematically through 

traditional methods.

3 4 5

...is provided using 

optimal methods (e.g., 

academic detailing).

6 7 8

...includes training 

all practice teams in 

regard to smoking 

cessation methods such 

as population-based 

management and selfmanagement support.

9 10 11

Informing patients 

about guidelines 

and risks associated 

with smoking in 

pregnancy...

Score

...is not done.

0 1 2

...happens on request 

or through developed 

protocols.

3 4 5

...is done through 

specific patient 

education materials.

6 7 8

...includes specific 

materials developed for 

patients that describe 

their role in achieving 

guideline adherence.

9 10 11

Adapted from the MacColl Institute for Healthcare Innovation, Group Health Cooperative © 2000.

92 | Appendixes
Part V: Delivery System Design

Components

Our practice 

functioning as a

team...

Score

Little Support

...is not addressed.

0 1 2

Basic Support

...is addressed by 

assuring the availability 

of individuals with 

appropriate training 

in key elements of 

smoking cessation.

3 4 5

Good Support

...is assured by regular 

team meetings to 

address guidelines, roles 

and accountability, and 

problems in addressing 

smoking in pregnancy.

6 7 8

Full Support

...is assured by teams 

who meet regularly and 

have clearly defined 

roles including patient 

self-management 

education, proactive 

follow-up, and resource 

coordination and 

other skills in smoking 

cessation.

9 10 11

Practice team 

leadership...

Score

...is not recognized in 

the practice or by the 

system. 

0 1 2

...is assumed by 

the organization 

to reside in specific 

organizational roles.

3 4 5

...is assured by the 

appointment of a 

team leader, but the 

individual roles in 

smoking cessation are 

not defined.

6 7 8

...is guaranteed by 

the appointment of 

a team leader who 

assures that roles and 

responsibilities for 

addressing smoking in 

pregnancy are clearly 

defined.

9 10 11

The system we use 

for appointments...

Score

...can be used to 

schedule a variety of 

appointment types.

0 1 2

...assures scheduled 

follow-up with prenatal 

patients.

3 4 5

...is flexible and 

can accommodate 

innovations such as 

customized visit length 

or group visits.

6 7 8

...includes organization 

of care that facilitates 

the patient seeing 

multiple providers in a 

single visit.

9 10 11

Follow-up treatment 

for pregnant patients 

who smoke...

Score

...is scheduled by 

patients or providers in 

an ad hoc fashion.

0 1 2

...is scheduled by the 

practice in accordance 

with guidelines.

3 4 5

...is assured by the 

practice team by 

monitoring patient 

utilization.

6 7 8

...is customized to 

patient needs, varies 

in intensity and 

methodology (phone, 

in person, email), 

and assures guideline 

follow-up.

9 10 11

Collaborating with 

other providers the 

patient has regarding 

tobacco cessation...

Score

...is not a priority.

0 1 2

...depends on written 

communication 

between primary 

care providers 

and specialists, 

case managers, or 

disease management 

companies.

3 4 5

...between primary care 

providers and specialists 

and other relevant 

providers is a priority 

but not implemented 

systematically.

6 7 8

...is a high priority, 

and smoking cessation 

interventions include 

active coordination 

between primary care, 

specialists, and other 

relevant groups.

9 10 11

Adapted from the MacColl Institute for Healthcare Innovation, Group Health Cooperative © 2000.

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 93
Part VI: Clinical Information Systems

Components

A list of patients who 

have been identified 

as pregnant patients 

who smoke...

Score

Little Support

...is not available.

0 1 2

Basic Support

...includes name, 

diagnosis, contact 

information, and date 

of last contact either on 

paper or in a computer 

database.

3 4 5

Good Support

...allows queries to sort 

sub-populations by 

clinical priorities.

6 7 8

Full Support

...is tied to guidelines 

that provide prompts 

and reminders about 

needed services.

9 10 11

Reminders to 

providers (stickers, 

flow sheets, etc.) 

about delivering 

information 

related to smoking 

cessation...

Score

...are not available.

0 1 2

...include general 

notification of smoking 

during pregnancy 

but does not describe 

needed services at time 

of encounter.

3 4 5

...include indications 

of needed service for 

populations of patients 

through periodic 

reporting.

6 7 8

...include specific 

information for the 

team about guideline 

adherence at the time 

of individual patient 

encounters.

9 10 11

Feedback to your 

team on the status 

of success related 

to approaches 

implemented to 

address smoking 

in pregnancy...

Score

...is not available or 

is non-specific to the 

team.

0 1 2

...is provided at 

infrequent intervals 

and is delivered 

impersonally.

3 4 5

...occurs at frequent 

enough intervals to 

monitor performance 

and is specific to the 

team’s population.

6 7 8

...is timely, specific to 

the team, routine, and 

personally delivered 

by a respected opinion 

leader to improve team 

performance.

9 10 11

Patient treatment 

plans for pregnant 

women who smoke...

Score

...are not expected.

0 1 2

...are achieved 

through a standardized 

approach.

3 4 5

...are established 

collaboratively 

and include selfmanagement as 

well as clinical goals.

6 7 8

...are an established 

collaborative approach 

that includes selfmanagement as well as 

clinical management. 

Follow-up occurs and 

guides care at every 

point of service.

9 10 11

Process Used:

Briefly describe the process you used to fill out the form (e.g., reached consensus in a face-to-face meeting; filled out by the team leader in consultation 

with other team members as needed; each team member filled out a separate form and the responses were averaged). 

Adapted from the MacColl Institute for Healthcare Innovation, Group Health Cooperative © 2000.

94 | Appendixes
Appendix G

Coverage for Tobacco-Use Cessation Treatments

COVERAGE FOR TOBACCO

USE CESSATION TREATMENTS 

Why Is Health Insurance Coverage for Tobacco Use Treatments So 

Important? 

• Smoking is costly to employers both in terms of smoking-related medical expenses and lost 

productivity. 

– Ten percent of smokers alive today are living with a smoking-related illness.

1 

– Men who smoke incur $15,8002 (in 2002 dollars) more in lifetime medical expenses and are 

absent from work 4 days more per year than men who do not smoke.

3 

– Women who smoke incur $17,5002 (in 2002 dollars) more in lifetime medical expenses and are 

absent from work 2 days more each year than nonsmoking women.

3 

– In 1999, each adult smoker cost employers $1,760 in lost productivity and $1,623 in excess 

medical expenditures.

4 

– Smoking causes heart disease, stroke, multiple cancers, respiratory diseases, and other costly illnesses. Secondhand smoke causes lung disease and lung cancer.

5, 6 

– Smoking increases costly complications of pregnancy, such as pre-term delivery and low birthweight infants.

7 

• Smoking is the leading preventable cause of death in the United States.

8, 9 Smokers who quit will, 

on average, live longer and have fewer years living with disability.

10 

• About 23% of American adults and 28% of teens smoke.

11, 12 More than 70% want to quit, but few 

succeed without help.

11 Tobacco use treatment doubles quitting success rates.9 

What Treatments Are Available? How Effective Are They? 

Smoking cessation treatments have been found to be safe and effective. These include counseling and 

medications, or a combination of both.

9 

• Face-to-face counseling and interactive telephone counseling are more effective than services that 

only provide educational or self-help materials. 9, 16 

• The effectiveness of counseling services increases as their intensity (the number and length of 

sessions) increases.

9 

• Smokers are more likely to use telephone counseling than to participate in individual or group 

counseling sessions.

16, 17 

Why,

What,

and

How

Paying for tobacco use cessation treatments is the single most cost-effective 

health insurance benefit for adults that can be provided to employees.13, 14, 15 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 95
Coverage for Tobacco 

Use Cessation Treatment: 

Why, What, and How 

• The Food and Drug Administration has approved six first-line medications to help smokers quit: 

– Five are nicotine replacement therapies that relieve withdrawal symptoms. They include nicotine 

gum, patch, nasal spray, inhaler, and lozenge.9 

– The sixth medication, bupropion SR (sustained release), is a non-nicotine medication that is 

thought to reduce the urge to smoke by affecting the same chemical messengers in the brain that 

are affected by nicotine.9 

Type Form Common Brand Name(s) Availability 

Nicotine 

Replacement 

Therapy 

Gum Nicorette® Over-the-counter (OTC) 

Patch Nicoderm®, Habitrol®, 

Prostep®, Nicotrol® 

OTC and prescription 

Inhaler Nicotrol® Prescription 

Nasal Spray Nicotrol® Prescription 

Lozenge Commit®** OTC 

Bupropion SR Pill Zyban®, Wellbutrin® Prescription 

Prescription and Over-the-Counter Tobacco Cessation Medications* 

* Approved by the Food and Drug Administration (FDA) and addressed in the 2000 PHS Guidelines. 

** Received FDA approval on October 31, 2002, therefore not addressed in the 2000 PHS Guidelines. 

Scientifically proven treatments can double a person’s chances of quitting smoking.9 

How Should Benefits Be Designed? 

Benefits for proven tobacco-use cessation treatments have been shown to increase treatment use and the 

number of successful quitters; therefore, both the Public Health Service-sponsored Clinical Practice 

Guideline, Treating Tobacco Use and Dependence, and the Community Preventive Services Task Force 

recommend that all insurers provide tobacco cessation benefits that do the following: 

• Pay for counseling and medications, together or separately.9 

– Cover at least four counseling sessions of at least 30 minutes each,9 including proactive telephone 

counseling and individual counseling. While classes are also effective, few smokers attend them.19 

– Cover both prescription and over-the-counter nicotine replacement medication and bupropion 

(see medication table).9 

– Provide counseling and medication coverage for at least two smoking cessation attempts per year.20, 21 

– Eliminate or minimize co-pays or deductibles for counseling and medications, as even small 

copayments reduce the use of proven treatments.18, 19 

What Is the Role of Health Insurance Coverage in Tobacco-Use 

Cessation? 

• Health insurance coverage of medication and counseling increases the use of effective treatments.18 

• Although 66% of Americans under the age of 65 are insured through an employer,22 only 24% of

employers offer any coverage for tobacco-use treatment.23

Coverage of tobacco-use cessation treatment increases both use of effective treatment 

and the number of successful quit attempts.18 

96 | Appendixes
How Much Do Cessation Benefits Cost? Are They Cost-Effective? 

• Tobacco cessation is more cost-effective than other common and covered disease prevention 

interventions, such as the treatment of hypertension and high blood cholesterol.14 

• Cost analyses have shown tobacco cessation benefits to be either cost-saving or cost-neutral.3, 20 

Overall, cost/expenditure to employers equalizes at 3 years; benefits exceed costs by 5 years.3 

• It costs between 10 and 40 cents per member per month to provide a comprehensive tobacco 

cessation benefit (costs vary based on utilization and dependent coverage).19, 24 

• In contrast, the annual cost of tobacco use is about $3,400 per smoker or about $7.18 for each 

pack of cigarettes sold.4 

• Neonatal health care costs related to smoking are equivalent to $704 for each maternal smoker.4 

Randomized controlled trials indicate that a smoking cessation program for pregnant women can 

save as much as $6 for each $1 spent.25 

What Is the Experience of Companies and Health Plans Providing 

This Benefit? 

Businesses that have included a tobacco cessation 

benefit report that this coverage has increased 

the number of smokers willing to undergo 

treatment and increased the percentage that 

successfully quit.24, 26 

• Union Pacific Railroad has experienced a 

decrease smoking prevalence among its 

employees from 40% to 25% in the 7-year 

period that it has offered a cessation benefit as 

part of a comprehensive cessation program.26 

• At the Group Health Cooperative in Seattle, 

enrollees offered full coverage for smoking 

cessation treatments were four times as likely to 

try to quit and four times as likely to succeed.24 

How Do I Get More Information? 

Listed below are Web sites where you can find additional information on tobacco-use cessation or 

reimbursement for cessation treatment. 

Smoking Cessation Treatment Effectiveness 

• Treating Tobacco Use and Dependence is a Public Health Service-sponsored clinical practice 

guideline that contains evidence-based strategies and recommendations to support effective treatment for tobacco use and nicotine addiction. The guideline and related consumer and clinician 

materials also can be found at http://www.surgeongeneral.gov/tobacco/. 

• The Guide to Community Preventive Services provides information on the effectiveness of community-based interventions in three areas of tobacco-use prevention and control: (1) initiation of 

tobacco use, (2) cessation, and (3) reduction of exposure to environmental tobacco smoke. Articles, 

slide sets, and commentaries can be found at http://www.thecommunityguide.org/tobacco/. 

• Surgeon General’s Reports related to tobacco are available on the Centers for Disease Control and 

Prevention Web site at http://www.cdc.gov/tobacco/sgrpage.htm. 

• Data on tobacco-use prevalence and tobacco-related morbidity and mortality rates can be found 

at two Centers for Disease Control and Prevention Web sites: http://www.cdc.gov/tobacco/data.htm 

and http://www.cdc.gov/nchs/. 

Coverage for Tobacco 

Use Cessation Treatment: 

Why, What, and How 

– Reduced life insurance costs 3, 28 

How Tobacco Cessation Cuts Cost 

• Over time, tobacco-use cessation benefits 

generate financial returns for employers in 

four ways: 

– Reduced health care costs 3, 27 

– Reduced absenteeism 3, 28, 29 

– Increased on-the-job productivity 3, 28, 29 

• Benefits realized more immediately include: 

– Increases in employee productivity 3, 29 

– Reductions in smoking-attributed 

neonatal health care costs 25 

• Employers who provide a smoke-free workplace may also realize savings on fire insurance 

and costs related to items such as ventilation 

services and property repair and upkeep.3, 28 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 97
98 | Appendixes

Designing Health Insurance Benefits 

• Sample purchasing specifications, which provide valuable contract language that can be used by 

employers and purchasers to structure benefits related to tobacco-use prevention and cessation, are 

available to assist states in implementing evidence-based tobacco-dependence treatment and 

improve Medicaid contracts. These sample specifications, developed by CDC in conjunction with 

George Washington University Center for Health Services Research and Policy, are available at 

http://www.gwhealthpolicy.org/newsps/tobacco. 

• Build a Financial Infrastructure: Health Plan Benefits and Provider Reimbursement combines 

evidence-based recommendations with the experiences of the Pacific Center on Health and Tobacco 

(PCHT), a consortium of five western states (California, Oregon, Washington, Arizona, and Hawaii) 

concerning tobacco cessation benefits and provider reimbursement. The report is designed to guide 

planning and decision-making by states and other groups that are working to implement tobacco 

cessation programs. Also available are two summaries based on this report: (1) Health Insurance 

Benefits for Treatment of Tobacco Dependence and (2) Invest in Tobacco Cessation for a Healthy, 

Productive Workforce. Visit the PCHT Web site at http://www.paccenter.org. 

• Employers’ Smoking Cessation Guide: Practical Approaches to a Costly Workplace Problem, a 

guide published by the Professional Assisted Cessation Therapy (PACT) consortium for large and 

small employers interested in enacting an affordable, effective smoking cessation program, is available at http://www.endsmoking.org. 

• Reimbursement for Smoking Cessation Therapy: A Health Care Practitioner’s Guide, published 

by the Professional Assisted Cessation Therapy (PACT) consortium for health care providers on how 

to obtain reimbursement for cessation services can be helpful to employers in the implementation of a 

tobacco cessation benefit. It is available at http://www.endsmoking.org. 

• Data on insurance status and type (national and by state) from a survey conducted jointly by the 

Bureau of Labor Statistics and the Bureau of the Census are located at 

http://ferret.bls.census.gov/macro/032002/health/toc.htm. 

• Coverage of Smoking Cessation Treatment by Union Health and Welfare Funds [Barbeau E, Li 

Y, et al. American Journal of Public Health 2001; 91(9):1412-1415]. This article presents the results 

of a survey to determine the level of insurance coverage for smoking cessation treatment and factors 

associated with coverage among health and welfare funds affiliated with a large labor union. 

Information on purchasing a copy of this article is located at 

http://www.ajph.org/cgi/reprint/91/9/1412. 

• Data concerning changes in coverage of tobacco-dependence treatments by state Medicaid 

programs from a study conducted by the Center for Health and Public Policy Studies at the 

University of California, Berkeley, and links to publications addressing health insurance policy and 

tobacco control are available at http://chpps.berkeley.edu/smoking/index.htm. 

• A guide to purchasing prevention benefits that was developed for employers in North Carolina 

by North Carolina Prevention Partners contains information that may be helpful to employers in 

other states. The guide can be found at http://www.ncpreventionpartners.org/basic/eguide.htm. 

Resources Useful for Employers 

• Making Your Workplace Smokefree: A Decisionmaker’s Guide provides information on the costs 

of tobacco use to employers. The entire guide or selected chapters are available in PDF format at 

http://www.cdc.gov/tobacco/research_data/environmental/etsguide.htm. 

• Quitline Resource Guide, published by CDC’s Office on Smoking and Health, provides 

information on contracting for quitline services and key components of quitline services, such as 

counseling, staffing, quality assurance, promotion, and evaluation. The guide (in press when 

this document was published) will be available at http://www.cdc.gov/tobacco. 

Coverage for Tobacco 

Use Cessation Treatment: 

Why, What, and How 
A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 99

• Linking a Network: Integrate Quitlines with Health Care Systems, published by the Pacific 

Center on Health and Tobacco, describes the importance of linking state quitlines with health care 

systems and presents case studies describing linkages with health care systems. This resource (in press

when this document was published) will be available at http://www.paccenter.org. 

• A Quick Reference Guide to Effective Tobacco Cessation Treatments and Activities and other 

resources are available from the Center for Tobacco Cessation’s (CTC) Web site at 

http://www.CTCinfo.org. CTC, which is jointly funded by the American Cancer Society and 

The Robert Wood Johnson Foundation, serves as a source of science-based information on cessation 

and works with national partners to expand the use of effective tobacco dependence treatment and 

activities. 

• Information on tobacco cessation counseling can be found on the American Cancer Society Web 

site located at http://www.cancer.org. Type “cancer AND counseling” in the search box located in 

the upper right corner of the home page. 

• Information on tobacco cessation and the effects of tobacco use on specific populations can be 

found on the American Lung Association Web site located at http://www.lungusa.org. 

Sources

1 Centers for Disease Control and Prevention. Cigarette smoking-attributable mortality—United States 2000. Morbidity 

and Mortality Weekly Report 2003;52(35):842–44. 

2 Hodgson T. Cigarette smoking and lifetime medical expenditures. The Milbank Quarterly 1992;70(1):81–125. 

3 Warner KE, Smith RJ, Smith DG, Fries BE. Health and economic implications of a work-site smoking-cessation 

program: a simulation analysis. Journal of Occupational and Environmental Medicine 1996;38(10):981–92. 

4 Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and 

economic costs—United States, 1995–1999. Morbidity and Mortality Weekly Report 2002;51(14); 300–03. 

5 U.S. Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress: A 

Report of the Surgeon General: 1989 Executive Summary. Atlanta, GA: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health; 1989. 

6 National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke. The Report of the California 

Environmental Protection Agency. Smoking and Tobacco Control Monograph 10. U.S. Department of Health and 

Human Services, National Institutes of Health, National Cancer Institute. NIH Pub. No. 99–4645, 1999. 

7 U.S. Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Atlanta, GA: 

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2001. 

8 McGinnis JM, Foege WH. Actual causes of death in the United States. Journal of the American Medical Association 

1993;270:2207–12. 

9 Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, 

MD: U.S. Department of Health and Human Services, Public Health Service; 2000. 

10 Nusselder WJ, Looman CW, Marang-van de Mheen PJ, et al. Smoking and the compression of morbidity. Journal of 

Epidemiology and Community Health 2000;54(8):566–74. 

11 Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2000. Morbidity and 

Mortality Weekly Report 2002;51(29):642. 

12 Centers for Disease Control and Prevention. Trends in cigarette smoking among high school students–United States, 

1991-2001. Morbidity and Mortality Weekly Report 2002;51(19):410. 

13 Warner KE. Cost effectiveness of smoking-cessation therapies. Interpretation of the evidence and implications for coverage. Pharmacoeconomics 1997;11(6):538–49. 

14 Cummings SR, Rubin SM, Oster G. The cost-effectiveness of counseling smokers to quit. Journal of the American 

Medical Association 1989;261(1):75–79. 

15 Coffield AB, Maciosek MV, McGinnis JM, et al.. Priorities among recommended clinical preventive services. American 

Journal of Preventive Medicine 2001;21(1):1–9. 

16 McAfee T, Sofian N, Wilson J, Hindmarsh M. The role of tobacco intervention in population-based health care. 

American Journal of Preventive Medicine 1998;14:46–52. 

17 McAfee T. Increasing the population impact of quitlines. Paper presented at the North American Quitline Conference, 

Phoenix, AZ, 2002. 

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Why, What, and How 
100 | Appendixes

18 Hopkins DP, Briss PA, Ricard CJ, et al. Task Force on Community Preventive Services. American Journal of Preventive 

Medicine 2001;20(2 Suppl):16–66. 

19 Schauffler HH, McMenamin S, Olsen K, Boyce-Smith G, Rideout JA, Kamil J. Variations in treatment benefits 

influence smoking cessation: results of a randomized controlled trial. Tobacco Control 2001;10:175–80. 

20 Harris JR, Schauffler HH, Milstein A, Powers P, Hopkins DP. Expanding health insurance coverage for smoking 

cessation treatments: experience of the Pacific Business Group on Health. American Journal of Health Promotion 

2001;15(5):350–6. 

21 George Washington University Center for Health Services Research and Policy. Sample Purchasing Specifications 

Related To Tobacco-Use Prevention And Cessation: a Technical Assistance Document. October 2002. Available at: 

http://www.gwhealthpolicy.org/newsps/tobacco/tobacco-prevent.html. Accessed 06/24/03. 

22 U.S. Bureau of the Census. Current Population Survey: Annual Demographic Survey Supplement—Detailed Insurance 

(P60) Package. Available at: http://ferret.bls.census.gov/macro/032002/health/toc.htm. Accessed 10/18/02. 

23 Partnership for Prevention. Insurance Coverage of Clinical Preventive Services in Employer-sponsored Health Plans: 

Preliminary Results of a Partnership for Prevention/William M. Mercer National Survey, 2001. Washington, DC. 

Partnership for Prevention In press. 

24 Curry SJ, Grothaus MA, McAfee T, Pabiniak C. Use and cost effectiveness of smoking-cessation services under four 

insurance plans in a health maintenance organization. New England Journal of Medicine 1998; 339(10):673–79. 

25 Marks JS, Koplan JP, Hogue CJR, Dalmat ME. A cost-benefit/cost-effectiveness analysis of smoking cessation for 

pregnant women. American Journal of Preventive Medicine 1990;6(5):282–9. 

26 Professional Assisted Cessation Therapy (PACT). Employers’ Smoking Cessation Guide: Practical Approaches to a 

Costly Workplace Problem. Available at: 

http://www.endsmoking.org/resources/employersguide/pdf/employersguide.pdf. Accessed 03/26/03. 

27 Wagner EH, Curry SJ, Grothaus L, Saunders KW, McBride CM. The impact of smoking and quitting on health care 

use. Archives of Internal Medicine 1995;155(16):1789–95. 

28 Centers for Disease Control and Prevention, American Cancer Society, and Wellness Councils of America. 

Making Your Workplace Smokefree—A Decision Maker's Guide. 1996. Available at: 

http://www.cdc.gov/tobacco/research_data/environmental/etsguide.htm. Accessed 04/05/03. 

29 Halpern MT, Shikiar R, Rentz AM, Khan ZM. Impact of smoking status on workplace absenteeism and 

productivity. Tobacco Control 2001;10:233–8. 

Coverage for Tobacco 

Use Cessation Treatment: 

Why, What, and How 
Appendix H

Reducing the Burden of Smoking on 

Employee Health and Productivity

Center for Prevention 

and Health Services 

ISSUEBrief 

Volume I, Number 5 

Reducing the Burden of Smoking on 

Employee Health and Productivity 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment

This issue brief summarizes information presented during the fifth in a series of Business Consultations 

sponsored by the Centers for Disease Control and Prevention (CDC). The National Business Group on 

Health and the CDC convened Reducing the Burden of Smoking on Employee Health and 

Productivity, a consultation with business and health leaders, on May 28, 2003, in Washington, DC. 

Statistics and figures that are not annotated with a source were presented by the speakers. 

Why Employers Promote Tobacco Use Cessation 

The human and financial costs associated with tobacco use are enormous. In addition 

to the incalculable physical and emotional distress brought on by tobacco related 

diseases and deaths, tobacco use exacts a high price from employers via greater costs 

for health care and life insurance, increased absenteeism and lower rates of 

presenteeism and productivity. 

Employers can combat the negative health 

and economic effects of tobacco use by 

integrating tobacco cessation treatment 

into their mix of employee benefits. In 

fact, paying for an employee’s tobacco 

cessation treatment provides more return 

on investment than any other adult 

treatment or prevention benefit. 

The National Business Group on Health 

is committed to providing employers with 

practical information about the 

advantages of covering tobacco cessation 

benefits. This issue brief is one such 

resource. Here you will find information 

on the prevalence and health impact of 

smoking, proof of the economic cost of 

tobacco related illnesses, guidelines for designing and implementing the most effective 

tobacco cessation benefits, and examples from several large employers who have 

benefited from offering coverage for tobacco use treatment. 

Calculating the Cost of Smoking 

To calculate the cost of smoking for an individual company, consider the following: 

• The overall prevalence of tobacco use is about 25% of the total population, 

which can be generalized to any workplace population. 

• The CDC estimates that companies spend $3,856 per smoker per year in 

direct medical costs and lost productivity. 

(Number of employees) x (0.25) x ($3,856 per year) = Estimated cost per 

year in excess medical expenditures and lost productivity 

Example: 

• (10,000 employees) x (0.25) = 2,500 employees who use tobacco 

• (2,500) x ($3,856) = $9,640,000 per year in business borne costs 

associated with smoking 

| 101
Volume I, Number 5 ISSUEBrief 2

Smoking costs lives, time and money 

• Smoking claims more than 440,000 lives each year, making it the leading 

preventable cause of death in the United States (see chart below). In fact, 

smoking kills more people each year than AIDS, drugs and alcohol, homicide, 

suicide and motor vehicle accidents combined. 

• Since the 1960s, research has linked more than 50 painful and costly diseases 

and conditions to smoking, and it is estimated that 10 percent of smokers, or 

approximately 8.6 million people, are currently living with one or more of these 

smoking-related illnesses. 

• A significant amount of 

time is lost from business 

due to smoking breaks and 

the illnesses and fatalities 

that are caused by smoking, 

as smokers are more likely 

to suffer a disability, are 

more likely to miss work 

and are less productive than 

nonsmokers. 

• Female smokers incur 

$17,500 more in lifetime 

medical expenses and miss 

an average of two more 

days of work than 

nonsmoking women. 

• Male smokers incur 

$15,800 more in lifetime 

medical expenses and miss 

an average of four more 

days of work than 

nonsmoking men. 

• On average, direct medical expenses and lost productivity resulting from 

premature death for people with smoking-related diseases cost a staggering 

$157 billion each year or $3,856 per smoker per year. 

From CDC. (2002). Annual smoking-attributable mortality, years of potential life 

lost, and economic costs—United States, 1995–1999. MMWR, 51(14), 300–303. 

Annual U.S. Deaths 

Attributable to Cigarette Smoking 

Secondhand Smoke 

38,000

Other Cancers 

31,000

Ischemic 

Heart Disease 

82,000

Stroke 

17,500 Chronic Lung Disease 

82,000

Other 

Diagnoses 

82,000

Lung Cancer 

125,000

102 | Appendixes
3 ISSUEBrief Volume I, Number 5 

• Additional costs to the economy include those related to permanent or 

temporary disability, absenteeism, or decreased productivity among living 

employees who smoke. Other business-related costs of smoking include workers 

compensation claims and occupational health awards, indoor air pollution, 

accidents, fires, and cleaning and maintenance. 

Employer Strategies For Promoting 

Tobacco Use Cessation 

Smoking is an addiction that often requires repeated attempts and professional 

intervention to overcome. Because the most successful interventions require medical 

attention, it is necessary for most employees to have these services covered as part of their 

health benefit. For businesses, making an investment in tobacco cessation benefits not 

only improves employee health but also reduces the significant direct and indirect costs 

associated with tobacco use. In fact, paying for tobacco use treatment is regarded as the 

single most cost-effective health insurance benefit for adults and it is also considered the 

benefit with the most positive impact on health. 

• Request or select health plans that cover effective treatment of smoking (see 

“Evaluating Your Health Plan’s Coverage” on p.4). 

• Ensure that health care providers (those in on-site medical clinics and those 

with larger health care plans) adhere to Health Employer Data Information Set 

(HEDIS®) requirements. HEDIS® measures whether providers screen all 

patients for smoking, counsel smokers to quit and recommend FDA approved 

medications. 

• Design benefits to cover a variety of treatments (i.e., counseling and prescription 

as well as over the counter medications) and allow individuals to choose their 

preferred approach. 

• Consider the delivery of telephone counseling, as it is one of the most successful 

and cost-effective forms of cessation counseling (see “Evaluating Telephone 

Counseling Programs” on p.5). 

• Ensure that smoking cessation counseling emphasizes problem-solving and 

social support to enhance the likelihood of abstinence. 

• Remove fees, co-pays, and other restrictions intended to limit use of benefits. 

Programs that offer counseling and medications free of charge are more effective 

than those that require cost sharing. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 103
Volume I, Number 5 ISSUEBrief 4

• Communicate to employees the types of cessation benefits that are covered 

under their health plans. 

• Take a long-term approach to smoking cessation and structure benefits to 

support multiple quit attempts. 

• Offer smoking cessation treatment to employees’ spouses and dependents. 

• Promote a healthy workplace that discourages smoking and values the well being 

of all employees. Institute workplace bans on smoking to reduce tobacco use 

and protect nonsmokers from secondhand smoke. 

• Offer incentives to achieve and maintain healthy lifestyles (see “Incentives Add 

Up for Bank One Employees” on p.6). 

• In states that offer telephone counseling “quitlines” or “helplines,” consider 

contracting with the state to provide this service to your employees (many states 

lack sufficient funding to cover smokers who have insurance). If the state does 

not have such a service, consider contracting directly with a quitline vendor to 

provide services to employees. 

Evaluating Your Health Plan’s Coverage 

Performance data is an invaluable tool to help identify high quality health care. Most 

managed care plans have data on HEDIS® measures and will provide the data on request. 

This information is collected through the Consumer Assessments of Health Plans Survey 

(CAHPS), which added questions to its 2003 survey to determine whether providers 

recommended medications to help patients quit smoking and/or offered assistance in 

quitting beyond advice. The results will be published in 2004, but health plans can access 

the data before it is publicly reported. 

The National Business Coalition on Health’s eValue8 initiative also assesses health care 

plans on their efforts to promote smoking cessation. In addition to consulting these 

resources, purchasers should ask prospective health care plans whether their providers 

actively try to identify smokers, what smoking initiatives are in place, and what support is 

provided to former smokers to prevent relapse. 

104 | Appendixes
5 ISSUEBrief Volume I, Number 5 

The effectiveness of tobacco cessastion counseling services 

increases as the number and length of sessions increases. 

Telephone counseling services vary in the number of contacts 

they provide, the duration of the calls, the type of information 

they offer and the training required of counselors. When 

evaluating these services, the following criteria should 

be considered: 

• Is the counseling consistent with the strategies 

described in the Public Health Service’s Treating 

Tobacco Use and Dependence—Clinical Practice 

Guideline? Visit www.surgeongeneral.gov/tobacco/ for a 

copy of the Public Health Service’s report outlining best 

practices for the treatment of tobacco dependence or 

reference the Quitline Resource Guide, which will be 

available in 2004 at www.cdc.gov/tobacco. 

• Does the service allow more than one contact? 

Multiple contacts are generally more effective than a 

single contact, but there are no data to suggest an 

optimal number of contacts. 

• How long has the service been in business? 

A long history in business does not necessarily equate to 

quality service. However, you can learn a great deal 

about a company by examining its track record, 

including quit rates. 

• How are data collected, evaluated, and provided to 

the purchaser? Reference the Quitline Resource Guide 

at www.cdc.gov/tobacco for criteria. 

• What is the service’s 6-month quit rate? 

12-month quit rate? How is the quit rate calculated? Is 

everyone who has agreed to counseling included? 

counseling is paired with medications, smokers 

experience substantially greater cessation success rates. 

Consider contracting with a service that has experience 

integrating counseling with one or more medications. 

• Does the service offer an option to link counseling 

with medications? Research has shown that when 

• Can the service provide references? As you would 

with a new employee or vendor, always insist on 

references and invest the time in several quality 

telephone calls to check the service’s cessation record 

and customer service. Make sure to ask about the 

service’s record with call hang ups and any issues 

related to the service’s hours of operation. 

• How are telephone counselors trained and 

evaluated? Reference the Quitline Resource Guide at 

www.cdc.gov/tobacco for criteria. 

• How does the service evaluate its own success? 

While there is no system of accreditation for counselors, 

there are quality assurance measures that the service 

should be tracking, including call monitoring, quit rates, 

and numbers of calls managed per hour. 

• Do the counselors seem knowledgeable and helpful? 

Make an unannounced call to the service to test your 

impression of the counselor’s expertise and the utility of 

the service. 

• Do counselors offer clients a “tool kit” to help them 

abstain from tobacco use? Smokers can benefit from 

educational materials including fact sheets and quit tips 

that complement medications and counseling. 

• How can the company help to promote its services? 

Find out if the service can help you to engage employees 

to use the service via advertising or other forms of 

promotion. Ongoing promotion is key to program 

success. 

Evaluating Telephone Counseling Programs 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 105
Volume I, Number 5 ISSUEBrief 6

Cost benefits of tobacco use cessation programs 

The minor cost of covering tobacco cessation benefits seems insignificant when compared 

to the major financial burden that tobacco use places on businesses. As health care 

costs due to tobacco related illnesses increase, they erode employer profits, which in 

turn creates a cycle of diminished health care coverage, salaries and other benefits 

for employees. 

• Tobacco cessation benefits are more cost-effective than more commonly 

covered disease prevention interventions, such as treatment for hypertension 

and high cholesterol. 

• Cost analyses prove that tobacco cessation benefits are either cost-saving 

or cost-neutral. 

• Comprehensive tobacco cessation benefits cost between $1.20 and $4.80 per 

employee per year. In contrast, the annual cost of tobacco use is about $3,400 

per smoker. 

• Overall, cost/expenditure to 

employers equalizes at three years 

and benefits begin to exceed costs 

by five years. 

• Because smoking cessation efforts 

are relatively inexpensive and yield 

a large, long-term benefit, they 

help to stem the rising cost of 

health care. Measures that keep 

health care costs in check are 

valuable because it is estimated that 

a one percent reduction in health 

care costs could increase retained 

profits by five percent. 

Incentives Add Up for 

Bank One Employees 

Through its 2002 health risk assessments, Bank One 

estimated that 11% of its employees are smokers and that 

the company lost more than $24 million annually to 

smoking. To address this issue, Bank One offers a variety of 

health plans, each with different benefits related to tobacco 

cessation. Smokers now pay $14 more per pay period than 

nonsmokers do for both health and life insurance ($336 

more per year). The additional fees paid by smokers fund 

wellness programs and offset higher health care costs. 

In addition, the company implemented a smoking cessation 

program that consists of four class sessions. Anyone who 

completes the program (regardless of whether they quit 

smoking) is eligible for the nonsmokers’ discount. In 2002, 

Bank One found that about 23% of those who took part in 

the program said they quit smoking for at least a year. 

106 | Appendixes
7 ISSUEBrief Volume I, Number 5 

Resources on Tobacco Use, Smoking Cessation, 

and Smoking-Related Diseases 

Pitney Bowes addresses health promotion and tobacco 

cessation on multiple fronts, including programs offering: 

• incentives (cash incentives for wellness program 

participation and discounted life insurance premiums 

for nonsmokers), 

• discouragement (no smoking inside the workplace 

since 1991 at any U.S. worksite), and 

• access (on-site medical clinics and prescription drug 

coverage that includes nicotine replacement therapy and 

bupropion). 

The company’s more focused efforts have also yielded highly 

beneficial results: 

• The on-site medical clinic in the Connecticut office 

created a successful smoking cessation program that 

offers nicotine replacement therapy and bupropion (free 

of cost through the clinic) as well as referrals for 

counseling as needed. The program also provides 

American Lung Association materials for education and 

measures lung capacity using a CO monitor to help 

individuals mark their progress. Although the results have 

not been studied scientifically, the program reports a 

50% quit rate after one year. 

• Pitney Bowes contracted with Group Health of Puget 

Sound to offer smoking cessation to all of its U.S. 

employees at no cost. The result was “Free and Clear,” 

a one year intervention that combines telephone 

counseling and educational materials. This program was 

also highly successful: 

— From 1999 to 2000, nearly 400 individuals 

participated. 

— Approximately 21% of participants quit for one year 

and 36% reduced their consumption. 

— Through the Free and Clear program, the company 

estimated a return on investment of 2.6:1. 

Pitney Bowes Meets Federal Health Targets 

Making Your Workplace Smokefree: 

A Decisionmaker’s Guide 

www.cdc.gov/tobacco/research_data/ 

environmental/etsguide.htm. 

Quitline Resource Guide (in press) 

Will be available in 2004 at 

www.cdc.gov/tobacco 

Coverage for Tobacco Use Cessation Treatments 

http://www.cdc.gov/tobacco/educational_ 

materials/cessation/index.html 

Health Insurance Benefits for 

Treatment of Tobacco Dependence 

www.paccenter.org/public/reports_

folder/insurance_flier_web.pdf 

Linking a Network: Integrate Quitlines 

with Health Care Systems 

www.paccenter.org 

American Cancer Society 

www.cancer.org 

American Lung Association 

www.lungusa.org 

National Cancer Institute 

www.nci.nih.gov 

National Center for Health Statistics 

www.cdc.gov/nchs 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 107
Center for

Prevention

and Health

Services

ISSUEBrief 

Volume I, Number 5 

Reducing the Burden of Smoking on 

Employee Health and Productivity 

About the Center for Prevention and Health Services (CPHS) 

The Center houses the Business Group’s projects and resources that relate to the delivery 

of preventive and other health services through employer-sponsored health plans and worksite 

programs. Through the Center, employers can find practical toolkits to address preventive 

health and health promotion issues at the worksite. Employers will find current information 

and recommendations from federal agencies and professional associations, model programs 

from other employers, and the latest clinical and health services research results. In addition, 

the Center provides opportunities for employer participation in teleconferences and in-person 

solutions workshops. Currently, the Center has initiatives in racial and ethnic disparities in health 

and health care, terrorism and public health emergency preparedness, maternal and child health, 

preventive services, health services research and quality, health and work performance, benefit 

design and wellness programs. 

For more information, visit www.wbgh.org/programs/cphs/ 

or contact Ron Finch, Ed.D., Director, at finch@wbgh.org. 

About the National Business Group on Health 

The National Business Group on Health, formerly the Washington Business Group on Health, 

is the national voice of large employers dedicated to finding innovative and forward-thinking 

solutions to the nation’s most important health care issues. The Business Group represents its 

185 members, primarily Fortune 500 companies and large public sector employers, who provide 

health coverage for more than 40 million U.S. workers, retirees and their families. The Business 

Group fosters the development of a quality health care delivery system and treatments based on 

scientific evidence of effectiveness. The Business Group works with other organizations to promote patient safety and expand the use of technology assessment to ensure access to superior 

new technology and the elimination of ineffective technology. 

Helen Darling, President 

National Business Group on Health 

50 F Street N.W., Suite 600 • Washington D.C. 20001 

Phone (202) 628-9320 • Fax (202) 628-9244 • www.wbgh.org 

Widmeyer Communications, Inc., Editing and Design 

108 | Appendixes
Appendix I 

Tobacco Quitlines

Tobacco Quitlines 

at a glance 

What are tobacco quitlines?

Sporadic availability, geographically and over time

Transportation difficulties

Childcare responsibilities

Financial cost of participating.

This map was produced by 

the Map Design Unit of The 

World Bank. The boundaries, 

colors, denominations and 

any other information shown 

on this map do not imply, on 

the part of The World Bank 

Group, any judgment on the 

legal status of any territory, 

or any endorsement or 

a c c e p t a n c e o f s u c h 

boundaries.

TOBACCO QUITLINES - DENMARK IBRD 33217 

THE NETHERLANDS May 2004 

GLOBAL PICTURE LUXEMBOURG NORWAY

ICELAND FINLAND

SWEDEN ESTONIA

BELGIUM 

CANADA UNITED KINGDOM BELARUS

IRELAND POLAND Channel Islands CZECH REP. GERMANY FRANCE SLOVAK REP.

UNITED STATES HUNGARY GEORGIA PORTUGAL SPAIN ITALY BOSNIA AND 

HERZEGOVINA ISLAMIC SWITZERLAND CROATIA REP. OF IRAN AUSTRIA MEXICO MALTA Taiwan 

Hong Kong 

THAILAND 

MALAYSIA 

SINGAPORE 

BRAZIL 

AUSTRALIA

SOUTH

AFRICA NEW

ZEALAND COUNTRIES AND AREAS WITH FUNCTIONING QUITLINES

COUNTRIES PLANNING/SETTING UP QUITLINES

Canadian, and U.S. states and provinces have publicly 

financed quitlines. Some employers and private health 

insurers provide quitlines for their employees and members.

Many new quitlines have been set up in recent years, as

evidence of their efficacy has become more solid and as

tobacco control programs worldwide have become more

common. Quitlines vary greatly in scale and sophistication.

Quitlines are telephone-based tobacco cessation services. 

Since the late 1980’s, quitlines have been established in many 

countries, states and provinces. Most are accessed through a 

toll-free telephone number and provide a combination of 

services including educational materials, referral to local 

programs, and individualized telephone counseling.

Counselors answer callers’ questions about the cessation

process and help them develop an effective plan for quitting. Why have quitlines become popular?

Reactive quitlines only respond to incoming calls. Proactive 

quitlines handle incoming calls and also follow up the initial 

contact with additional outbound calls, to help initiate a quit 

attempt or to help prevent relapse. In some cases, as when 

smokers give consent in their doctors’ offices to be called by 

a counselor, the contact is entirely proactive. Proactive

telephone counseling has been shown to have a marked 

effect on callers’ probability of success in quitting and in 

maintaining long-term abstinence from tobacco use,

comparable to the effects of pharmacotherapies. 

Easy access. Traditionally, tobacco users have faced

various barriers in accessing cessation services, including: 

Quitlines reduce these barriers by allowing users to access

service from their own homes at a time that is convenient 

for them, and usually at no cost to themselves. Partly for 

these reasons, surveys have shown that tobacco users are 

much more likely to use telephone-based services than face- Where are they available to-face programs. ?

Brazil, Iran, New Zealand, South Africa, many European 

countries, some countries in Asia, and most Australian, Benefits of centralization. Because it provides services 

over the telephone, a quitline can serve a large geographic 

May 2004 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 109
Economies of scale, leading to more efficient utilization of 

counseling resources 

Standardized training 

Better quality control 

Ease of evaluation. 

area from a single, centralized base of operations. So 

unlike traditional cessation programs in which it is common 

for participants to have to wait until a group forms, quitlines 

are able to operate year-round, often with extended hours 

of business and multilingual capabilities.

attempts, and found a strong dose-response relationship

between the level of intended treatment intensity (i.e.,

number of follow-up sessions) and the treatment effect (Zhu

et al. 1996). 

Further research has demonstrated the continued effectiveness 

of the California quitline after it scaled up to statewide 

operation (Zhu et al. 2002). Borland et al. (2001) found 

similar results for a quitline service in Victoria, Australia. 

These studies increase confidence that the efficacy found in 

clinical trials can carry over to “real world” settings. With the 

efficiencies inherent in centralized, telephone-based 

operations, quitlines appear to be a cost-effective way to 

deliver cessation assistance (McAlister et al. 2004). 

The benefits of centralization include: 

Ease of promotion. Most comprehensive tobacco control 

programs include a media component designed to counteract 

the effects of tobacco industry advertising. This key part of 

successful anti-tobacco programs can be very costly, 

necessitating prudent spending decisions. Media programs 

are a convenient way to promote cessation services, since 

advertisements can carry a single telephone number and air 

across a wide area. This is more efficient than promoting an 

array of local programs, each with its own method of 

accessing service. And quitlines can refer callers to local 

programs as appropriate, thus serving both as a direct 

cessation service provider and as a hub of coordinated 

services.

Quitlines as part of comprehensive

tobacco control programs 

Most quitlines are supported by state or national health 

agencies, through tobacco taxes or other public funds. They 

are often the government’s chief or only contribution to 

providing direct tobacco cessation services, with the rest of 

its tobacco control funding earmarked for other efforts such 

as educating people about the harm caused by tobacco 

use, preventing initiation of tobacco use among young 

people, and reducing exposure to second hand smoke. If 

resources were not available to make progress in these 

areas, it is doubtful that a quitline alone would be a 

worthwhile investment of public health funds. But in the 

context of comprehensive tobacco control efforts, a quitline 

can help to advance larger goals of the program, such as 

normalizing cessation and eliminating disparities in tobacco 

use or access to treatment. 

Strong evidence of quitline efficacy 

Reactive quitlines: Two studies support use of a reactive 

quitline in the context of a comprehensive tobacco control 

program. A California study found that a well-promoted 

quitline providing a single comprehensive counseling session 

of about 50 minutes increased quit attempts and reduced 

relapse, relative to an intervention of self-help materials 

alone (Zhu et al. 1996). Counties in New York State where 

a quitline was promoted had significantly higher quit rates 

than those without such promotion, even though the majority 

of evaluated quitters did not access the service, indicating 

that quitline promotion in itself may increase cessation on a 

population level (Ossip-Klein et al. 1991).

Practical considerations 

The range of services provided: Quitline callers have 

a wide range of expectations, so most well established 

quitlines offer a wide range of services. Adult smokers 

wanting help to quit are the most common callers, but there 

are also those who are not yet ready to quit, or who have 

already quit. There are smokers of cigarettes, cigars, and 

pipes, and callers who use chewing tobacco or other 

smokeless tobacco. There are callers of all ages, including 

minors, and callers who speak different languages. In all of 

these categories, some want counseling; others just want 

printed information or referral. Some callers have particular 

needs such as learning more about smoking while pregnant, 

or quitting tobacco while managing a psychological 

condition such as bipolar disorder or schizophrenia. There 

are non-tobacco-users calling on behalf of friends and family 

members, and health care professionals or others trying to 

decide whether to refer their patients, students, or neighbors. 

Comprehensive quitlines develop protocols, resources, and 

staff training for each situation. 

Proactive quitlines: The evidence for proactive quitlines 

is more thorough. Several meta-analytical reviews have 

established that proactive telephone counseling is an 

effective intervention for smoking cessation (Lichtenstein et al.

1996, Fiore et al. 2000, Hopkins et al. 2001, Stead et al. 

2004). The most recent of these examined 13 studies of 

proactive interventions and found that callers who received 

counseling were successful at least 50% more often than 

those who only received self-help materials (odds ratio of 

1.56) (Stead et al. 2004). The U.S. Public Health Clinical 

Practice Guideline and the Guide to Community Preventive 

Services recommend proactive quitlines as a way to help 

smokers quit (Fiore et al. 2000, Hopkins et al. 2001). 

A large randomized, controlled trial (n=3,030) that served 

as the basis for the California Smokers’ Helpline, the first 

publicly supported, statewide quitline, found that telephone 

counseling increased the percentage of smokers making a 

quit attempt and decreased the rate of relapse for those 

Evidence-based structured protocols guide the flow of 

counseling sessions and remind counselors of topics 

considered to affect quitting success. Counselors using 

clinically validated protocols help clients to: 

110 | Appendixes
Clarify and enhance their motivation to quit 

Boost their self-efficacy for quitting 

Identify situations that will trigger an urge to use tobacco, 

and plan effective strategies for getting through them 

without tobacco 

Identify ways to get the social support they need 

Commit to a quit date, often with counselor follow-up for 

accountability and extra support. 

The psychology of tobacco use and the process of habit 

formation, maintenance, and extinction 

General principles of counseling and motivational 

interviewing 

Effective counseling techniques for behavior modification 

Challenging counseling scenarios, such as crisis calls and 

callers with psychiatric issues 

Multicultural counseling 

Effective case management practices, including use of 

protocols 

Health issues related to tobacco use and cessation 

NRT and other quitting aids. 

What contribution is the quitline making to the overall 

tobacco control program?

Is it successful in reaching target populations, especially 

high-risk and underserved groups?

Are callers satisfied with services received?

What percentages of callers make a quit attempt, and 

maintain abstinence (e.g., for 6 months)?

Are the results comparable to other published outcomes?

Besides providing training, quitline supervisors and

managers oversee coverage of incoming calls, effective

case management, and productivity. They monitor and

debrief sessions and make sure the services provided are 

helpful, appropriate, and factually accurate. They also 

ensure the program’s compliance with applicable laws and 

ethical guidelines governing the provision of telephone 

counseling. 

Evaluation: Successful and sustainable quitline operation 

requires rigorous evaluation. Baseline data include, at a 

minimum, how callers heard about the quitline, 

demographic variables such as age, ethnicity, and 

education, type of tobacco used and level of consumption. 

Process data include percentage of calls answered live and 

number of callers (especially members of target populations) 

receiving each type of service. Follow-up data include quit 

status, length of abstinence, and satisfaction with quitline 

services. For quitlines serving large numbers of callers, 

following up a randomly selected sample is adequate. 

Staffing: Quitlines are staffed to meet demand, which is 

largely determined by the intensity and timing of promotion. 

Rather than staying open around the clock, most quitlines 

focus their resources on peak daytime and evening hours. 

The staffing plan must take into account both the overall 

demand for service over time, and the demand at any given 

moment, especially during the “bursts” of calls that occur 

when mass media advertisements are aired. For new 

quitlines, the number of staff required may be calculated by 

estimating the likely number of callers, which in turn may be 

done by comparing the promotional plan with similar 

campaigns elsewhere. Most quitlines require between 30 

minutes and two hours of counselor time per caller, 

depending on the intensity and number of counseling 

sessions provided. Maintaining a balance between 

counselors’ productivity and their availability for incoming 

calls is one of the main challenges of quitline operations, but 

one which becomes more manageable as the scale grows. 

It may not be feasible or even desirable for every quitline to 

conduct its own clinical trial to ensure efficacy, but all 

quitline funding should include an allocation for program 

evaluation to address key questions: 

When recruiting counselors, it is helpful to keep in mind 

that most of the evidence for the efficacy of quitlines is 

based on the work of paraprofessional counselors using 

structured protocols, indicating that postgraduate education 

and licensure are not necessary. Instead of graduate 

training, most quitlines look for candidates with natural 

counseling skills such as empathy, reflective listening, and 

the ability to guide clients through a structured problemsolving process. These skills are crucial to quitline quality 

and effectiveness. 

It is important when citing results to identify clearly any 

characteristics of the population that received service that 

may have had a bearing on their success, and to address 

whether and why any participants were excluded from the 

analysis. Training and supervision: A quitline’s training program 

is another key to assuring quality in its services. At a 

minimum, a good training program addresses: 

Promotion: Increasing public awareness of quitline 

services can be done in various ways. Mass media 

advertising—television, radio, newspapers, billboards, and 

other media—usually plays a central role in promotion. 

Successful mass media campaigns identify their target 

audience and do thorough marketing research before 

launching ads. Cultural and linguistic appropriateness is 

especially important. Low-cost promotional strategies have 

been successfully used in some countries, such as requiring 

manufacturers to print the quitline telephone number on 

cigarette packages. 

Health care providers are natural partners for quitlines and 

can play a major role in increasing their utilization. 

Providers who ask all patients whether they use tobacco, 

advise quitting, and refer patients to quitlines for 

comprehensive cessation counseling can have a profound 

impact on patient health. Therefore many quitlines make 

special efforts to build linkages with health care providers. 

As with mass media advertising, promoting quitlines 

through health care systems not only generates calls and 

Following up the initial training with a regular program of 

continuing education helps counselors continuously develop 

their skills and ensures that their knowledge of the field is 

up to date. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 111
Queue calls and route them to counselors according to

pre-established priorities 

Monitor calls 

Track and report on performance (e.g., percentage of

calls answered live) 

Expand capacity as needed. 

Assess the need for cessation services in the 

population, considering the prevalence of tobacco use 

in various communities and their readiness to respond 

to cessation messaging.

Determine how direct provision of service fits into the 

overall plan for decreasing tobacco use in the 

population. 

Identify a reliable funding source and determine a 

funding level appropriate to the quitline’s intended role 

in the overall tobacco control program. Tobacco taxes, 

where available, are a commonly used resource for 

quitlines.

Determine a budget and strategies for promotion. 

Promotional budgets that are roughly equivalent to

operational budgets are common.

Create a competitive process to select a quitline

operator. A Request for Proposals (RFP) process, in

which the funding agency provides a thorough

description of the quitline services to be provided and 

invites proposals from interested parties, is common. 

Create a similar process for selecting a media 

contractor. Require both contractors to coordinate their 

activities with each other. 

Write contracts with the selected providers that include 

firm deadlines for delivery of service. 

Closely monitor the contracts to ensure adherence to 

standards and deadlines. Perform ongoing evaluation 

to ensure the quitline’s effectiveness and continued 

relevance to the overall tobacco control program.

helps callers quit, but also increases cessation among 

people who do not call the quitline. 

Technology: A robust and scalable telephone system 

greatly facilitates operations by allowing quitlines to: 

Information systems are very important to the smooth 

functioning of proactive quitlines, which over time may 

serve hundreds of thousands of callers, each receiving 

service spread out over several calls, in some cases with 

different counselors. Computer networks and databases 

must be able to store sufficient information on all contacts 

with individual callers to ensure a seamless delivery of 

services. Integration of the communication and information 

systems, using off-the-shelf Computer Telephony Integration 

(CTI) software, can greatly enhance efficiency. Other 

technologies have the potential to expand the range of 

services offered. Interactive Voice Response (IVR) systems,

for example, allow callers to access personalized 

automated messages based on information they provide. 

Other emerging options include web-based interfaces,

integration with email, and sending text messages or even 

images and short films to cell phone users.

Careful planning, an adequate budget, and rigorous

evaluation will help ensure a successful quitline.

Key Resources for More Information

Anderson CM, Zhu SH. The California Smokers’ Helpline: A 

Case Study. Sacramento, CA: California Department of Health

Services; May 2000.

Costs: The costs of establishing and running a quitline 

can vary widely. Communications and information 

systems can be a significant start-up cost, although fairly 

inexpensive options with limited functionality are 

available. The two largest ongoing expenses are usually 

for promotion and staffing. The U.S. Centers for Disease 

Control and Prevention recommend that new quitlines 

spend as much money on promotion in the first couple of 

years as on all other direct costs combined. (Quitline 

promotion, it should be remembered, not only generates 

calls to the quitline but also promotes cessation in the 

general population.) Over time, the cost for promotion 

may stabilize or even decrease as the quitline builds 

referral relationships with organizations and individuals in 

the community. Staffing costs, on the other hand, tend to 

increase steadily over the years.

Borland R, Segan CJ, Livingston PM, Owen N. The effectiveness

of callback counselling for smoking cessation: a randomized

trial. Addiction. 2001;96:881-889.

Centers for Disease Control and Prevention. Quitline Resource

Guide: Strategies for Effective Development, Implementation,

and Evaluation. Atlanta: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health, 2004. 

European Network of Quitlines: Guide to Best Practice.

Available at www.enqonline.org.

Lichtenstein E, Glasgow RE, Lando HA, Ossip-Klein DJ, Boles SM.

Telephone counseling for smoking cessation: rationales and metaanalytic review of evidence. Health Education Research: Theory

and Practice 1996;1:243-257. 

Stead LF, Lancaster T, Perera R. Telephone counselling for 

smoking cessation (Cochrane Review). In: The Cochrane Library Steps in setting up a quitline Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd. 

Zhu SH, Anderson CM, Tedeschi GT, Rosbrook B, Johnson CE, 

Byrd M, Gutiérrez-Terrell E. Evidence of real-world effectiveness 

of a telephone quitline for smokers. New England Journal of 

Medicine 2002;347(14):1087-1093.

Zhu SH, Stretch V, Balabanis M, Rosbrook B, Sadler G, Pierce 

JP. Telephone counseling for smoking cessation: effects of singlesession and multiple-session intervention. Journal of Consulting 

and Clinical Psychology 1996;64:202-211. 

Expanded versions of the “at a glance” series, with e-linkages to resources and more information, are available on the 

World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp 

112 | Appendixes
Appendix J

QuitWorks

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 113
114

| Appendixes
Appendix K

Minimal Data Set Intake Questions

Approved February 2005 MDS Questions - FINAL

Phoenix, Arizona Updated July 19, 2005

MINIMAL DATA SET 

INTAKE QUESTIONS 

A. REASON FOR CALLING AND AWARENESS OF QUITLINE 

1. How can I help you? (Reason for Calling) 

Want help / information about quitting 

Want help / information about staying quit 

Want to refer someone for help 

Want general information or materials about quitline service 

Other___________________________________ 

2a. Are you: 

Calling for yourself (SKIP TO Q3) 

Calling on behalf of or to help someone else (CONTINUE TO Q2b) 

2b. Are you: 

A health professional 

A friend or family member 

A community organization, worksite, insurance 

Other___________________________________ 

3. How did you hear about the Quitline? (Do NOT read. CHECK ALL RESPONSES) 

(Optional

North American Quitline Consortium Page 1 of 10 

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CANADA: Do you currently smoke cigarettes daily, occasionally, or not at all? 

(CHECK ONE) 

Daily 

Occasionally (if less than 7 days per week or less than 1 cigarette per day) 

Optional if respond “Occasionally”: How many days did you smoke 

in the last 30 days? _____ 

Not at all 

When was the last time you smoked a cigarette, even a puff? -- / -- / ----

(if day is unknown, code as 15th of month.) dd/mm/yyyy 

(IF RESPONSE IS “NOT AT ALL” SKIP TO Q7) 

Approved February 2005 MDS Questions - FINAL 

Phoenix, Arizona Updated July 19, 2005 

4. Is this your first call to the quitline in the past year? 

Yes 

No Optional: How many times did you call the quitline in the past year? _____ 

(# of times) 

B. TOBACCO BEHAVIOURS 

5a. USA: Do you currently smoke cigarettes every day, some days, or not at all? 

(CHECK ONE) 

Everyday 

Some days (if less than 7 days per week or less than 1 cigarette per day) 

Optional if respond “Some Days”: How many days did you smoke in the last 30 

days? _____ 

Not at all 

When was the last time you smoked a cigarette, even a puff? -- / -- / ----

(if day is unknown, code as 15th of month.) dd/mm/yyyy 

(IF RESPONSE IS “NOT AT ALL” SKIP TO Q7) 

5b. How many cigarettes do you smoke per day on the days that you smoke? 

Cigarettes per day __ __ __ (If caller says over 100, confirm. 100 cpd = 5 packs 

per day; If caller says less than one per day, code 5a as Some Days/Occasionally) 

6. Cigarette smokers only: 

How soon after you wake up do you smoke your first cigarette? (DO NOT READ) 

within five minutes 

6 to 30 minutes 

31 to 60 minutes 

more than 60 minutes 

don’t know 

refused 

North American Quitline Consortium Page 2 of 10 

116 | Appendixes
 

Approved February 2005 MDS Questions - FINAL 

Phoenix, Arizona Updated July 19, 2005 

7. Do you currently use other tobacco products such as... (check all that apply) 

Cigars 

Pipes 

Chewing Tobacco or Snuff 

Other Tobacco Products (e.g. Bidis) Optional: (specify)___________________ 

 (IF Q5a = EVERYDAY/DAILY OR SOME DAYS/OCCASIONALLY AND Q7 =

NO OTHER TOBACCO, SKIP TO Q9) 

(IF Q5a = NOT AT ALL AND Q7 = NO OTHER TOBACCO, SKIP TO Q10) 

8. How much tobacco do you use per week? 

____ cigars (number per week) 

____ pipe bowls (number per week) 

____ chewing tobacco or snuff (number of pouches / tins per week) 

____ Other tobacco (amount per week) 

All current tobacco users (smokers and other tobacco users) 

9. Do you intend to quit within the next 30 days? (DO NOT READ) 

Yes 

No 

Don’t know 

Refused to answer 

10. Optional At what age did you start smoking regularly? ______ age in years 

C. CALLER CHARACTERISTICS (Ask of all eligible* callers) 

(* eligible is defined by each quitline and should be clearly described) 

11. First I need to verify are you male or female? 

Male 

Female 

Refused 

12. What year were you born? _ _ _ _ 

Refused 

Optional What is your date of birth? _ _/_ _ _ _ 

Mo./year

13. What is your zip code? (Canada = postal code) _ _ _ _ _ 

14. Optional: Do you have any health insurance? USA only 

Yes 

No 

Don’t know 

Refused 

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Approved February 2005 MDS Questions - FINAL

Phoenix, Arizona Updated July 19, 2005

15. What is the highest level of education you have completed? (DO NOT READ) 

USA Canada 

Less than grade 9 Less than high school 

Grade 9 to 11, no degree 

GED 

High school degree High school diploma 

some college or university 

 (includes any post-high school education,

 including technical or trade school, but not

 a degree.) 

Technical or trade school

college or university degree College or university degree 

(includes AA, BA, Masters, Ph.D.) 

16. USA Are you Hispanic or Latino? 

Yes (Hispanic or Latino) 

No (Not Hispanic or Latino) 

Refused 

Not ascertained (OPTIONAL) Reason: ______(include “don’t know” here) 

17. USA Which of these groups would you say best describes you? (READ) 

White1 

Black or African American2 

Asian3 

Optional if respond Asian: Which specific ethnicity or race do you identify with 

the most? (Do not read responses; code answer) 

Asian Indian 

Cambodian 

Chinese (except Taiwanese) 

Filipino 

Hmong 

Japanese 

Korean 

Laotian 

Pakistani 

Thai 

Taiwanese 

Vietnamese 

Other Asian (specify):___________________ 

don’t know/not sure 

Refused 

1 A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. 2 A person having origins in any of the black racial groups of Africa. Terms like Haitian or Negro can also

be used. 3 A person having origins in any of the original peoples of the Far East, Southeast Asian, or the Indian

subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the

Philippine islands, Thailand, and Vietnam.

North American Quitline Consortium Page 4 of 10 

118 | Appendixes
Approved February 2005 MDS Questions - FINAL 

Phoenix, Arizona Updated July 19, 2005 

Native Hawaiian or other pacific islander4 

Optional if respond Native Hawaiian or other pacific islander: Which specific 

ethnicity or race do you identify with the most? (Do not read responses; code 

answer) 

Native Hawaiian 

Samoan 

Tongan 

Tahitian 

Maori 

Guamanian or Chamorro 

Other Micronesian (e.g. Marshallese, Palauan, Pohnpeian, Chuukese, 

Yapese, Saipanese, Kosraean) 

Fijian 

Other (specify):_____________________ 

Don’t know/not sure 

Refused 

American Indian or Alaska native5 

DO NOT READ THE REST: 

THIS IS THE END OF THE INTAKE QUESTIONS REQUIRED BY THE MINIMAL 

DATA SET. 

4 A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. 5 A person having origins in any of the original peoples of North, Central, or South America, and who 

maintain tribal affiliation or community attachment. 

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A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 119

Other (specify)_____________ 

Don’t know 

Refused 

Canada To which of the following ethnic or cultural groups did your ancestors belong? 

(ancestor = great grandparents or further back) (READ; CAN CHECK MORE THAN 

ONE)

 Canadian (English or French Canadian) 

Aboriginal (Native Indian, Metis, Inuit) 

British (English, Irish, Scottish, Welsh) 

European (specify country __________________) 

Asian (specify country ___________________) 

Other (specify)_______________ (DON’T READ) 

None of the above (DON’T READ) 

Don’t know (DON’T READ) 

Refused (DON’T READ) 
 

Approved February 2005 MDS Questions - FINAL

Phoenix, Arizona Updated July 19, 2005

INTAKE ADMINISTRATIVE DATA

Counselor ID (Optional)

Caller ID 

Date of First Contact with Quitline _ /_ _ / _ _ _ _ 

day mo yr 

Intervention Provided to Caller (Check All That Apply) 

Basic information 

Literature and/or self-help materials 

Reactive counseling (one counseling session) 

Proactive counseling (more than one counseling session) 

Medications 

Referral 

Other 

North American Quitline Consortium Page 6 of 10 

120 | Appendixes
 

Approved February 2005 MDS Questions - FINAL

Phoenix, Arizona Updated July 19, 2005

MINIMAL DATA SET 

SEVEN MONTH FOLLOW-UP QUESTIONS 

7 MONTH FOLLOW-UP ADMINISTRATIVE DATA 

Evaluator ID 

Caller ID 

Date of First Contact with Quitline _ _ /_ _ / _ _ _ _ 

dd /mm/yyyy 

Date of Evaluation Interview: seven months after date of first contact with quitline 

_ _ /_ _ / _ _ _ _ 

dd/mm/yyyy 

. 

A. CALLER SATISFACTION 

1. Overall, how satisfied were you with the service you received from the Quitline? 

(READ ALL, CHECK ONE ONLY) 

very satisfied

mostly satisfied 

somewhat satisfied 

not at all satisfied

don’t know

refused

B. TOBACCO BEHAVIOURS 

2a. USA: Do you currently smoke cigarettes every day, some days, or not at all? 

(CHECK ONE) 

Everyday 

Some days (if less than 7 days per week or less than 1 cigarette per day) 

Optional if respond “Some Days”: How many days did you smoke in the last 30 

days? _____ 

Not at all 

When was the last time you smoked cigarettes daily? -- / -- / ----

(if day is unknown, code as 15th of month.) dd/mm/yyyy 

IF RESPONSE IS “NOT AT ALL” SKIP TO Q4 

North American Quitline Consortium Page 7 of 10 

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CANADA: Do you currently smoke cigarettes daily, occasionally, or not at all? 

(CHECK ONE) 

Daily 

Occasionally (if less than 7 days per week or less than 1 cigarette per day) 

Optional if respond “Occasionally”: How many days did you smoke 

in the last 30 days? _____ 

Not at all 

When was the last time you smoked cigarettes daily? -- / -- / ----

(if day is unknown, code as 15th of month.) dd/mm/yyyy 

(IF RESPONSE IS “NOT AT ALL” SKIP TO Q4) 

pipe bowls (number per week) 

Other tobacco (amount per week) Optional: (specify)___________________ 

Approved February 2005 MDS Questions - FINAL

Phoenix, Arizona Updated July 19, 2005

2b. How many cigarettes do you smoke per day on the days that you smoke? 

Cigarettes per day __ __ __ (If caller says over 100, confirm. 100 cpd = 5 packs 

per day; If caller says less than one per day, code as Some Days) 

3. Cigarette smokers only: 

How soon after you wake up do you smoke your first cigarette? (DO NOT READ) 

within five minutes 

6 to 30 minutes 

31 to 60 minutes 

more than 60 minutes 

don’t know 

refused 

4. Do you currently use other tobacco products such as... (check all that apply) 

Cigars 

Pipes 

Chewing Tobacco or Snuff 

Other Tobacco Products (e.g. Bidis) 

 (IF Q2a = EVERYDAY/DAILY OR SOME DAYS/OCCASIONALLY AND Q4 =

NO OTHER TOBACCO, SKIP TO Q6) 

(IF Q2a = NOT AT ALL AND Q4 = NO OTHER TOBACCO, SKIP TO Q8) 

5. How much tobacco do you use per week? 

____ cigars (number per week) 

____ 

____ chewing tobacco or snuff (number of pouches / tins per week) 

____ 

North American Quitline Consortium Page 8 of 10 

122 | Appendixes
Approved February 2005 MDS Questions - FINAL 

Phoenix, Arizona Updated July 19, 2005 

All current tobacco users (smokers and other tobacco users) 

6. Do you intend to quit within the next 30 days? (DO NOT READ) 

Yes 

No 

Don’t know 

Refused to answer 

7. Since you first called the Quitline on (Date of first contact), seven months ago, did 

you quit using tobacco for 24 hours or longer? (DO NOT READ, CHECK ONE 

ONLY) (Note: collect number of intentional quit attempts only) 

Yes

No

Don’t know

Refused to answer 

Optional: How many times did you quit using tobacco for 24 hours or longer? ____ 

(Note: collect number of intentional quit attempts only) 

8. When was the last time you smoked a cigarette, even a puff? -- / -- / ----

(if day unknown, code as 15th of month) dd/mm/yyyy 

Don’t know 

Refused to answer 

9. Have you smoked any cigarettes or used other tobacco, even a puff, in the last 7 days? 

Yes 

No 

Don’t know 

Refused 

10. Have you smoked any cigarettes or used other tobacco, even a puff, in the last 30 

days? 

Yes 

No 

Don’t know 

Refused 

11. Since your call to the quitline on (Date of first contact), seven months ago, have you 

used anything to help you quit? For example, nicotine replacement (gum or patch), 

pills (Zyban), group cessation, advice from a health professional, self-help materials? 

Yes

No

Don’t know

Refused

North American Quitline Consortium Page 9 of 10 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 123
Approved February 2005 MDS Questions - FINAL 

Phoenix, Arizona Updated July 19, 2005 

12. Optional What kind of treatments or health professionals? 

(Check all that apply – do not read) (Quitlines can expand these categories as necessary)

Medication Zyban 

NRT patches 

NRT gum 

NRT lozenges 

other medications as desired 

Advice from Physician 

Pharamacist 

Nurse 

Group cessation program 

Self-help materials 

Other ______________ 

THIS IS THE END OF THE 7 MONTH FOLLOW-UP QUESTIONS REQUIRED BY 

THE MINIMAL DATA SET. 

North American Quitline Consortium Page 10 of 10 

124 | Appendixes
Appendix L

Medicaid Model Language

A Summary of the Sample Purchasing Specifications 

Related to Tobacco-Use Prevention and Cessation

Medicaid populations have been shown to have smoking rates of 36% 

(almost double that of the population as a whole) (MMWR 11/9/01). 

Tobacco use is the most preventable cause of death and disability in the 

United States (McGuinnis). Tobacco use results in $92 billion in excess 

health-care costs annually (MMWR 2005).

To address this considerable health-care cost and to promote the provision 

of tobacco-dependence treatment for this population, the Centers for 

Disease Control and Prevention’s Office on Smoking and Health has 

coordinated with the Center for Health Services Research and Policy 

at the George Washington University School of Public Health to develop 

sample “Purchasing Specifications Related to Tobacco-Use Prevention 

and Cessation.”

These draft specifications are in the form of proposed contract language 

and are designed to be used by state Medicaid agencies as they develop 

their Medicaid managed care contracts. Ideally this language would be 

incorporated in an RFP or contract between the state and HMOs covering 

Medicaid enrollees. 

Several state Medicaid agencies and health departments have reviewed the 

Specifications and provided input to ensure applicability. The document has 

also been through a vetting process with selected state Medicaid directors. 

This process is part of a larger initiative to assist states in standardizing 

contract language around the most common chronic diseases, such as 

asthma, hypertension, and cardiovascular disease management.

The Public Health Service (PHS) Clinical Practice Guideline, Treating 

Tobacco Use and Dependence, summarizes a literature review and, along 

with the Community Preventive Services Task Force, makes a strong case 

for implementation of effective tobacco-control treatment and provision of 

comprehensive coverage (Fiore, Hopkins). The Partnership for Prevention 

has ranked tobacco-dependence treatment second overall (and first among 

adults) among proven preventive treatments (based on cost, 

cost effectiveness, and impact) (Coffield).

Lack of access to tobacco-use treatment and the costs of treatment are major 

barriers for low-income people trying to quit smoking. At present only 3 

states provide comprehensive tobacco treatment coverage under Medicaid, 

36 states and the District of Columbia provide a range of partial coverage 

for counseling and pharmacotherapy, and 15 states provide no coverage 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 125
(MMWR 1/30/04). The specifications were developed to improve the level 

of care available to this vulnerable population and create a higher level of 

uniformity among services available to the Medicaid population.

The specifications attempt to translate the PHS guideline findings into 

contract language to support the process. The specifications address

■ Systems components to support the treatment process.

■ The scope of the benefit.

■ Diagnostic and Treatment Services for enrollees who use tobacco or have 

recently quit, including 

• Pharmacotherapy.

• Counseling.

■ Services for pregnant women.

■ Services for adolescents and pre-teens.

■ Tobacco use treatment under chronic disease management programs.

■ Guidelines.

■ Coverage determination standards and procedures.

■ Relationship with state (or local) public health agency.

Quality measurement, quality improvement, and data reporting

Quality measures (such as implementation of the HEDIS measure) and 

regular reporting on sample chart audits, prescription drug monitoring, and 

interface with telephone counseling services, if available, are suggested to 

ensure effective implementation.

Medicaid Model Language Summary 8/05

126 | Appendixes
Appendix M

Promotion of Tobacco Cessation 

in the Health-Care System: 

Suggested Strategies

The following was created by the Veterans Administration (VA) and the 

Department of Defense for their Tobacco Use Cessation Clinical Practice 

Guideline. It was not used for the actual guideline, but is being reprinted 

with permission from the VA author of the document.

Objective

■ Increase to 100 percent any beneficiary’s access to evidence-based 

tobacco use and dependence treatment services in the DoD/VA system.

■ Remove barriers to providers, staff, clinical settings, and administrators 

from the DoD/VA system, so as to increase provision and utilization of 

tobacco use and dependence treatment services.

Background

In the health care system, treatment for tobacco use and dependence often 

begins with brief advice provided by a health care provider that advises 

the patient to quit, followed by possible interaction with counseling and 

pharmacotherapy. Considerable research shows that many evidencebased tobacco use and dependence treatments are effective in addition 

to health care provider advice and follow-up (Levy & Friend, 2002). With 

this evidence, the DoD/VA health care system administrators must ensure 

changes in the DoD/VA systems that develop, support, and sustain a range 

of evidence-based tobacco use and dependence treatment services. Based on 

system changes that remove barriers to evidence-based treatment services, 

the greater the access that DoD/VA beneficiaries have to this range of 

services, the greater the potential to increase treatment use and quit rates.

Smoking cessation is the “gold-standard” for cost-effectiveness among 

medical/preventive interventions. Smoking cessation has been called 

the “gold standard of health care cost effectiveness” (Eddy, 1992). Few 

interventions, with the exception of vaccinations for children and older 

adults, offer better value. Compared with other routine preventive 

interventions, smoking cessation is extremely cost-effective, comparing 

favorable with other health care interventions such as screening for 

hypertension and yearly mammography. Coronary bypass graft surgery 

costs roughly 10 times as much per quality-adjusted year of life saved 

(Cromwell et al. 1997). A return on the investment made on smoking 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 127
cessation can be made relatively quickly. A study by the Group Health 

Cooperative suggests that 4 years after quitting, smokers who quit have 

significantly lower health care utilization than smokers who continue 

(Wagner et al. 1995). 

In a systematic assessment of the value of clinical preventive services 

recommended by the US Preventive Services Task Force, smoking cessation 

services for adults was one of the highest ranked services (in terms of 

disease burden and cost-effectiveness) with one of the lowest delivery 

rates of all preventive services (Coffield et al. 2001). These and other 

findings would suggest that despite knowledge of the health benefits of 

tobacco use cessation and availability of cost-effective treatments, many 

health care providers and health care systems still fail to treat tobacco 

use adequately.

Recommendations

Main recommendations – “Top 10 system changes”

Changes at the organization level

1. National and local leadership should fully endorse and support the 

goal of reducing tobacco use and make it an organizational and 

institutional priority.

2. Tobacco use cessation treatment (both counseling and pharmacotherapy) 

should be provided as a covered benefit with no co-payment.

3. Clinical sites should dedicate staff to provide tobacco dependence 

treatment and assess the delivery of this treatment in staff performance 

evaluations. 

4. The Veterans Health Administration and Department of Defense should 

each implement standardized data collection to allow tracking and 

management of tobacco users.

5. The Veterans Health Administration and Department of Defense 

should establish national Quitlines for smoking cessation, which 

include provision of smoking cessation medications. Mechanisms 

should be developed to facilitate provider referral to Quitlines.

Changes at the clinic level

6. Treatment and referral for smoking cessation, (as well as their 

documentation) should be as convenient as possible, since it increases 

the likelihood that patients will receive appropriate treatment.

7. Every clinic should implement a tobacco-user identification system 

(e.g., use nicotine dependence ICD code).

128 | Appendixes
8. The Veterans Health Administration and Department of Defense should 

each use clinical reminders (electronic, if possible) that are tailored to the 

specific treatment setting.

Changes at the provider level

9. Every facility should develop and adopt strategies to increase provider’s 

adherence to the guideline (e.g., academic detailing, provider profiling, 

education outreach).

10.All providers and other health care team members should be trained 

in providing smoking cessation treatment, as patients who see trained 

providers are more likely to receive appropriate treatment.

Additional recommendations

Changes at the organization level

11. The Veterans Health Administration and Department of Defense should 

establish an Internet-based smoking cessation web site, to provide 

broader access to treatment for smokers and a central resource location 

for staff.

12.The Veterans Health Administration and Department of Defense should 

make all installations and campuses smoke-free.

13.Each institution’s policies should support and promote the provision of 

tobacco use cessation services. 

14.All facilities should initiate environmental and policy changes that 

discourage tobacco use among staff personnel, as staff who use tobacco 

are less likely to assist patients in quitting.

Changes at the clinic level

15.Tobacco users should be offered treatment at all clinical settings, as 

repeated advice from multiple providers increases the likelihood that 

they will quit.

16.Barriers to receiving smoking cessation treatment should be eliminated, 

so that patients can access treatment at any time and place.

Changes at the provider level

17.The Veterans Health Administration and Department of Defense should 

develop methods to reward clinicians and specialists for delivery of 

effective tobacco dependence treatments. 

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 129
Discussion

System changes are one of the most important aspects of tobacco control. 

Health care providers and staff universally acknowledge the importance 

of tobacco use cessation, but often fail to advise tobacco users to quit and 

assist them in quitting. This is in part due to the many competing demands 

placed on providers (Chernof et al., 1999) and health care institutions. 

System changes help to reduce barriers, increase knowledge and skills, 

and modify attitudes with respect to smoking cessation, which in turn 

increases the provision of effective tobacco cessation services. The 

changes are broken down into three levels for convenience and clarity 

(the organization, the clinic, and the provider), although many of the 

recommendations act at multiple levels.

Organization Level Changes

Changes at the organization level focus on modifying the culture with 

respect to tobacco use cessation and providing services or resources that 

are too large or complex for one facility to develop. Making tobacco use 

cessation a top organizational priority is one of the most important changes, 

as that makes all other changes much easier to effect. Tobacco use cessation 

treatment (both counseling and pharmacotherapy) should be a covered 

benefit, as it dramatically increases the rate of provision of these services 

(Curry et al., 1998; Fiore et al., 2000). Co-payments for treatment should be 

eliminated. Curry and colleagues found that elimination of all co-payments 

led to higher total costs but also to an increased number of non-smokers, 

through much higher levels of provision of tobacco use cessation treatments. 

Despite some people’s concerns, having smoking cessation treatment 

available as a covered benefit did not lead to profligate use. When costfree access of up to four 30-day trials of NRT was provided for over a 

year, 73 percent used this benefit once, 20 percent used it twice, and only 

3 percent and 5 percent used it three and four times, respectively (Harris 

et al., 2001). On a separate note, telephone Quitlines should be available 

to all tobacco users, as these are effective and greatly increase access 

to treatment.

While there is not yet evidence that Internet-based smoking cessation 

programs are effective, several studies are currently examining this issue.

In the absence of data, these programs provide a reasonable and efficient 

way to support patients who have Internet access. In addition, the 

Internet provides an efficient way to allow providers to access up-todate information, including guidelines, handouts, and other materials.

Clinic-Level Changes

Changes at the clinic level focus on making it as easy as possible to provide 

tobacco use cessation treatment to patients. Providers have many other 

competing obligations and demands on their time (Chernof et al., 1999), 

and the more difficult it is to help tobacco users quit, the less likely it is 

that it will happen. Therefore, clinics should review the entire process for 

tobacco use cessation, with an eye to making it as simple and easy 

130 | Appendixes
as possible. Patients often say that the provider’s advice is a particularly 

important motivating factor in helping them quit (Fiore et al., 2000). Clinics 

should therefore ensure there is a system for helping remind the provider 

to advise the patient to quit and then for assisting the provider in assisting 

the patient to quit. As an example, a typical set-up might include tobacco 

use status as part of the vital signs, with a reminder (electronic or paper) 

for the provider if the patient uses tobacco. After the provider advises the 

patient to quit, another staff member (e.g., nurse, pharmacist) might provide 

more detailed instructions on medication use and cessation tips, along with 

one or more follow-up contacts. Specific tasks that a clinic should think 

about in this regard are: 1) identification of tobacco users in a systematic 

way, 2) provision of detailed information about cessation, 3) ongoing 

management of tobacco cessation pharmacotherapy, and 4) follow-up 

counseling.

Provider Level Changes

At the provider level, changes focus on training and encouraging the 

provider and making tobacco use cessation treatment the standard of 

care. Therefore, systems should ensure that all health care providers 

receive adequate training in counseling tobacco users and providing 

pharmacotherapy. Training includes both initial training (which focuses 

on improving everyone’s knowledge and skills) and ongoing, follow-up 

training (which focuses on refining skills and removing barriers). Several 

ongoing studies are examining the use of provider profiling, whereby the 

performance of individual providers is audited and providers are given 

individual feedback. Additional studies are examining the effectiveness 

of educational outreach (also known as academic detailing). In a typical 

implementation of this approach, a respected local peer (an opinion leader) 

might briefly “detail” providers with specific information about tobacco use 

cessation. Not only does this efficiently give providers helpful information, 

it also sends the unspoken message that someone they know believes in 

tobacco use cessation and practices it with their own patients (thereby 

targeting cultural norms for providers). No studies have examined the use 

of incentives (either positive or negative) as a way to modify providers’ 

behavior with respect to tobacco use cessation, and studies examining 

their use in other areas (e.g., increasing immunization rates) have had 

mixed results (Giuffrida et al., 2000).

[Additional data on strategies for designing the health care system 

to promote tobacco use cessation can be found in Evidence Report 

Question #18]

A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment | 131