Standard-of-Care Tobacco Use Treatment
Most people who use tobacco want to quit and try to quit each year.(1) However, without help from counseling or medications (also known as quitting “cold turkey”), less than 5% of folks who try are successful.(2) Fortunately, we know what works in tobacco use treatment from years of research and experience.
Integrating standard-of-care tobacco use treatment is essential to improving client outcomes and successful tobacco-free policy implementation.(1,2)
North Carolina Tobacco Treatment Standard of Care for Adults’
Check out the North Carolina Tobacco Treatment Standard of Care:
Adolescent Treatment & Prevention
Above is the standard of care for adults. More research is needed to define a standard of care for adolescents. However, the American Academy of Pediatrics recommends screening, brief interventions, considering motivational interviewing, counseling, and considering medications for adolescents with moderate to severe tobacco use disorder. Learn more from the American Academy of Pediatrics’ fact sheet: Supporting Youth Who Are Addicted to Nicotine: Advice for Pediatricians.
All children, adolescents and younger, should be screened for secondhand smoke exposure, while caregivers who use tobacco are referred to QuitlineNC for support with quitting. Work with the caregivers to reduce smoke and vape exposure as much as possible as there is no safe level of secondhand smoke(4).
All youth should receive messages about prevention(5). For evidence-based prevention resources, check out the Stanford Tobacco Prevention Toolkit and the CATCH my Breath Curriculum that can be implemented at schools or by service providers. Your regional and local tobacco prevention and control staff can assist with this as well.(5)
Tobacco Use Treatment Integration: Health Systems Change
Tobacco use treatment is not the responsibility of any single provider or team. Tobacco use treatment must be integrated into agency practice and procedures through health systems change. Health systems change is a change in organizational policies or in environmental supports that encourages and channels improvement(s) in systems, community, and individual-level health outcomes.(6)
Examples of health systems changes:
- Tobacco-free policy implementation
- Ensuring every clinician screens all clients for tobacco use
- Automatically offering all clients who use tobacco medications and counseling
You can assess your organization’s level of tobacco use treatment integration with the American Lung Association’s online, on-demand Tobacco Treatment Integration Assessment Tool.
Your regional and local tobacco control staff can partner with you to implement or improve tobacco use treatment at your agency. They are a free resource from your local public health department.
You Quit, Two Quit also offers free technical assistance and training and publishes a North Carolina specific Practice Bulletin, as well as Going Tobacco-Free: Implementing Tobacco-Free Policies and Cessation Efforts in Women’s Substance Use Disorder Treatment Settings
The Million Hearts Tobacco Cessation Change Package has resources for any type of health systems change you might pursue related to tobacco use treatment. Also, Dimensions: Tobacco-Free Policy Toolkit is a step-by-step guide to policy implementation.
Children who experience adverse childhood experiences (known as ACEs) are much more likely to start using tobacco products.(7,8) These ACEs can also be known as trauma. Therefore being trauma-informed is vital for tobacco use treatment providers.
Trauma-informed care shifts the focus from “What’s wrong with you?” to “what is strong with you” and “what happened to you?” A trauma-informed approach seeks to realize the widespread impact of trauma in patients, families, and staff, and makes changes to clinical practice and policy to avoid triggering trauma responses.(9) Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness.(9) Being trauma-informed is the responsibility of all agency personnel: clinical providers, front desk staff, security, and leadership.
What does this mean for tobacco use treatment and policy? Trauma can involve a breach of trust by authority figures. As healthcare providers, we must work to repair that trust by creating a positive, safe, and respectful environment. Judgmental or punitive responses to tobacco use are not trauma-informed and will make offering tobacco use treatment and maintaining a policy harder. Instead:
- Relationship should be collaborative and mutually respectful
- The client is the expert
- Have shared decision making, offer choices
Learn about trauma-informed care from the Trauma-Informed Care Implementation Resource Center.
The brief intervention for tobacco use treatment is known as the 5As, and it mirrors screening, brief intervention, and referral to treatment or SBIRT, an evidence-based behavioral health brief intervention.(2)
|Screening||Ask||Screen for all forms of tobacco use|
|Brief Intervention||Advise*||Explore how tobacco use fits with what client values, highlight discrepancies, tailor information to how quitting/treatment may benefit client|
|Assess||Where you can meet client with evidence-based treatment|
|Assist||With evidence-based treatment (medications & counseling)|
|Referral to Treatment||Arrange||For follow-up care, either in-house or with resources like QuitlineNC|
*Medical professionals may be more accustomed to advising clients on what to do or prescribing treatment plans, while behavioral health professionals are accustomed to collaborative treatment planning. It is more powerful to have a person-centered and trauma-informed conversation with the client, evoking the reasons why they might want to make a change in their tobacco use. Clients identifying their own reasons makes your advice moot, this becomes the client’s goal, and you are there to help. Learn more about how to evoke clients’ reasons for quitting through counseling.
Ensure that time to have these conversations, or at the least personalized advice to quit, and each of the 5As is institutionalized into workflows. Change individual or group curricula to educate clients about the harms of tobacco use, benefits of becoming tobacco free, and evidence-based treatment.
Screening, NC-TOPPS, & Assessing for Nicotine Dependence
Screen all adults and adolescents for all forms of tobacco use (including vaping) through self-assessment in advance and at the visit.(1) Screen all children for secondhand smoke or vape exposure. The Million Hearts Tobacco Cessation Change Package and You Quit Two Quit have excellent screening resources available.(1)
The North Carolina Treatment Outcomes and Program Performance System [NC-TOPPS] has tobacco use screening, product use, and (for children) secondhand smoke/vape questions. NC-TOPPS is the required data collection and outcomes measure for many behavioral health programs serving people with Medicaid or who are uninsured. Learn more here.
Screening for tobacco use is not the same as assessing use and nicotine dependence. Document all the forms of tobacco clients use, the frequency, and quantity. Here is sample tobacco use screening and documentation form for: pregnant clients, clients who had a baby in the past year, and all other clients.
The Fagerström test for nicotine dependence is an evidence-based way to assess nicotine dependence in adults. The Hooked on Nicotine Checklist (HONC) is evidence-based for adolescents and comes in a smoking and vaping version.
It is vital to train staff in evidence-based tobacco use treatment and how to promote a tobacco-free policy, prior to implementation of both. Your regional and local tobacco control staff and You Quit, Two Quit offer training and can help you plan one at no cost to your agency.
You can also attend one of these upcoming trainings!:
|Date||Training & Link||Organization||Type|
|1/17/2023||Prioritizing Tobacco Treatment in Substance Use and Recovery Masterclass||National Behavioral Health Network for Tobacco and Cancer Control||Treatment Integration|
|2/22/2023||Making Shift Happen: An Overview of Motivational Interviewing||AREA L AHEC||Skills Training|
|4/17/2023||Tobacco and E-Cigarette Use: Evidence-Based Treatment and Prevention||TPCB and WAKE AHEC||Treatment Integration and Skill Training|
Justice in the Air: Framing for Tobacco-Free Behavioral Health Initiatives (Any time, prerecorded training – Online Self-Paced Module)
Duke-UNC Tobacco Treatment Specialist Training Program (a comprehensive nationally accredited program that can help you become a Nationally Certified Tobacco Treatment Provider)
Check out even more training resources at QuitlineNC.com
Million Hearts Tobacco Cessation Change Package also has a list of training resources.
Become a Nationally Certified Tobacco Treatment Provider
Receiving certified tobacco treatment provider training helps you to put all of these pieces together; you will learn about: tobacco products, screening, assessment, finding motivations, medications, and counseling.
NAADAC- the national association for addiction professionals oversees the national certification for tobacco treatment providers. The Council for Tobacco Treatment Training Programs accredits the programs, a list of accredited programs for the Nationally Certified Tobacco Treatment Provider (NCTTP) certification can be found here.
The nationally accredited program in North Carolina is the Duke-UNC Tobacco Treatment Specialist Training Program. It is a partnership between Duke Smoking Cessation Center, UNC Tobacco Treatment Program, and the NC Division of Public Health Tobacco Prevention and Control Branch.
Documentation, Evaluation, and Billing
Documentation is important for both evaluation and billing purposes. It is important to make any changes to your electronic health record to record tobacco use treatment data and the outcomes you want to track. You can track both clinician activities and client outcomes.
Client outcomes could include – quit rates at 3 months, 6 months, and one year; client satisfaction with treatment; self-efficacy for a future quit attempt; and many more.
Clinician activities to evaluate could include – screening all clients for tobacco use, number of clients who were offering counseling or medications, number of clients with tobacco use treatment goals or interventions documented in treatment plans, and many more.
Excellent resources for how to create your documentation and evaluation plan are –
NC Medicaid covers tobacco use treatment brief interventions provided by advanced practice providers (physicians, nurse practitioners, and physician assistants) in medical and behavioral health settings. Ensure that the CPT codes in the chart below are included in your contracts with Medicaid managed care organizations.
|CPT Codes||Preventive Counseling Codes:|
|99406||Tobacco cessation counseling, 3-10 min., intermediate|
|99407||Tobacco cessation counseling, >10 min., intensive|
Tobacco use treatment counseling should be integrated into more intensive services in behavioral health settings with clients who have co-occurring behavioral health conditions. Behavioral health professionals would then bill for those services under the co-occurring mental health or substance use disorder diagnosis and include documentation of how tobacco use impacts client mental health or other substance use treatment goals.
All 7 FDA approved tobacco use treatment medications are also covered by NC Medicaid with a prescription, including over the counter nicotine replacement therapy. Prior authorization is required for nicotine nasal spray, nicotine inhaler and more than 6 months of varenicline. Learn more about medications and which brands are covered here.
Clinicians should use ICD-10 codes and document medical necessity and the treatment provided. Coding is not sufficient to clearly establish medical necessity and ensure payment for services, clinician notes should establish this. Learn more about what to include in notes and billing for tobacco use treatment from the following sources –
- U.S. Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General. Atlanta, GA; 2020.
- US Department of Health and Human Services. Treating Tobacco Use and Dependence: 2008 Update [Internet]. Rockville, MD: US Department of Health and Human Services; 2008 [cited 2021 Jun 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK63952/
- Groner JA, Hoshaw-Woodard S, Koren G, Klein J, Castile R. Screening for children’s exposure to environmental tobacco smoke in a pediatric primary care setting. Archives of Pediatrics and Adolescent Medicine [Internet]. 2005 May 1 [cited 2021 Jun 17];159(5):450–5. Available from: https://jamanetwork.com/journals/jamapediatrics/fullarticle/486010
- Centers for Disease Control and Prevention (US), U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General [Internet]. Publications and Reports of the Surgeon General. Centers for Disease Control and Prevention (US); 2006 [cited 2021 May 18]. 727. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44324/
- U.S. Department of Health and Human Services. Executive Summary—Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General [Internet]. Atlanta, GA; 2012 [cited 2021 May 18]. Available from: http://www.cdc.gov/tobacco
- VanFrank B, Graff K, Adsit R, Schauer G, Owens L, Babb S, et al. Million Hearts Tobacco Cessation Change Package [Internet]. 2019 [cited 2021 Jun 17]. Available from: https://millionhearts.hhs.gov/files/tobacco_cessation_change_pkg.pdf
- Edwards V. Adverse Childhood Experiences and Smoking Persistence in Adults with Smoking-Related Symptoms and Illness. The Permanente Journal [Internet]. 2007 Apr 1 [cited 2021 May 19];11(2):5. Available from: /pmc/articles/PMC3057738/
- Alcalá HE, von Ehrenstein OS, Tomiyama AJ. Adverse Childhood Experiences and Use of Cigarettes and Smokeless Tobacco Products. Journal of Community Health [Internet]. 2016 Oct 1 [cited 2021 May 19];41(5):969–76. Available from: /pmc/articles/PMC5011440/
- Trauma-Informed Care Implementation Resource Center. What is Trauma-Informed Care? [Internet]. 2021 [cited 2021 Jun 17]. Available from: https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/