Tobacco cessation is a journey of repeated efforts to quit, sometimes with frequent relapses. The 2020 Surgeon General’s Report on Smoking Cessation stated that people who smoke cigarettes can make up to twenty attempts to stop over a period of several years before they are successful. With each quit attempt, smokers learn how to better cope with the triggers that prompt them to go back. This journey can be shortened by counseling and the use of medications to prevent relapses. Counseling can be provided by staff in the doctor’s office, a booklet, a website, an App, or, best of all, a trained Tobacco Treatment Specialist. More counselling sessions, longer counseling sessions, and sessions over a longer period are all associated with better outcomes. Just one follow-up session with the doctor after a quit attempt doubles the effectiveness of any quit attempt.
All of the medications available for tobacco cessation were approved based on comparison with placebo treatment which included counseling. Placebo groups did fairly well in all the studies that led to FDA approval. In the case of Chantix (varenicline), 17.6 % of the placebo group were able to quit after twelve face-to-face sessions of counseling. Efficacy of Varenicline, an α4β2 Nicotinic Acetylcholine Receptor Partial Agonist, vs Placebo or Sustained-Release Bupropion for Smoking Cessation: A Randomized Controlled Trial | Lifestyle Behaviors | JAMA | JAMA Network. The FDA approved medications are minimally effective when used without counseling and follow-up.
Although medications for tobacco cessation are far less effective without counselling, in the real-world counselling is either not available or not provided. The North American Quitline Consortium provides leadership and organizational support to the state Quitlines. They report that the annual volume of unique engaged users continues to decline over the past five years and in 2021 was 283,000, less than 1% of tobacco users. https://www.naquitline.org. Physicians may be providing some counselling services, but they certainly don't bill for it. A Multi-Institutional Evaluation of Billing for Tobacco Cessation Services: Opportunities to Improve Quality and Enhance Revenue Capture - ScienceDirect. My (unpublished) review of Aetna claims data, the average number of sessions for people who received counseling was 1.1, which suggests that scheduled follow-up is rare.
In office settings, any person in a white coat can provide an effective, billable service.
The American Academy of Family Practice has developed a program to engaged non-professional staff in coordinating tobacco treatment called Office Champions. Office Champions | AAFP
Ideally, Tobacco Treatment Specialists (TTS) are the most qualified. A TTS is a health professional specifically trained and certified in the treatment of tobacco use. TTS staff the state Quitlines and work for health plans, Accountable Care Organization and large group practices helping patients navigate the process of quitting. Microsoft Word - What is a TTS 2011_12_1.docx
To train current staff in counseling, there are many online programs available from the Council for Tobacco Treatment Training Programs
Many clinicians refer to the state Quitline as part of tobacco treatment. They provide a handout or brochure with the national number, 1-800-QUIT-NOW, which will refer to the local number. One of the most effective ways of coordinating access to the state quitlines is automated EMR referral. Tobacco users identified can be referred directly to the state quit line: Enhancing eReferral Capacity - North American Quitline Consortium Contact your state Quitline for details.