Better Screening: Electronic medical records consistently under-report tobacco use. Identification of all forms of tobacco use is an essential first step in treatment.

Consistent advice to quit, every visit: Physician billing for tobacco cessation for 3 minutes (CPT 99406) is not commonly used yet can be billed up to eight times a year, even if patients are not making a quit attempt.

Offer evidence-based treatment at every visit. Medication and counseling are available at no cost. Varenicline is 50% more effective than other medications

Offer a trial of quitting: Many clinicians ask their patients about “readiness to change”. Patients who say they are not ready are not provided treatment. The “stages of Change” theory has been challenged by new literature that demonstrates the outcomes of a “trial of quitting” where patients sample the medications. Varenicline will reduce cravings to the point where some patients surprise themselves by quitting.

Consider the role of self-medication for underlying mental illness as a reason for relapse. Patients with serious mental illnesses have higher rates of relapse. Nicotine acts as an anti-depressant. Many patients who fail repeatedly but remain motivated will accept a referral to a behavioral health practitioner.

Schedule a follow-up visit for patients making a quit attempt. Most people trying to stop smoking relapse within the first week. A follow-up session or phone call can help get patients back on the plan and can double the effectiveness of any intervention.

Consider using two or more medications for patients who relapse.

Refer to a center of excellence: Most major medical centers have clinics specializing in the treatment of tobacco. They are able to provide counselling by Tobacco Treatment Specialists coordinated with use of multiple medications.

Consider a quit attempt using a nicotine product authorized for sale by the FDA. Vaping is as effective as nicotine replacement for smoking cessation.

Consider Harm Reduction: for adults who have consistent difficulty in quitting. Vaping products and pouches that have been authorized for sale by the FDA are safer than smoking.

Adopt Systems Change for Tobacco Treatment. A comprehensive assessment of how clinicians provide treatment for tobacco will reveal numerous opportunities to improve workflow, initiate and sustain treatment, and measure outcomes.