The Top Priority
Building a Better System for Tobacco-Cessation Counseling
C. Tracy Orleans, PhD*, Steven H. Woolf, MD, MPH*, Stephen F. Rothemich, MD, MS,
James S. Marks, MD, MPH, George J. Isham, MD, MS
United States and accounting for more than $167
billion in healthcare costs and lost productivity.1Find-
ings from the National Commission on Prevention
Priorities (NCPP), reported in this issue by Maciosek et
al.2and Solberg et al.,3underscore the enormous
potential health and economic benefits of addressing
this behavior in routine clinical care. Extrapolating
from evidence that one-time, brief primary care cessa-
tion counseling has a 12-month effectiveness of 2.4%
(5.0% when combined with pharmacotherapy), Sol-
berg et al.3estimate a 23.1% quit rate from repeated
annual screening and brief intervention for tobacco
users. Extended over the lifetimes of smokers, the
intervention would save 2.47 million quality-adjusted
life years at a cost savings of $500 per smoker and
billions of dollars for the nation.
The NCPP updates its previous 2001 effort to rank
the relative effectiveness of clinical preventive services
recommended by the U.S. Preventive Services Task
Force.4In 2001 and again in the current update, the
identification and counseling of smokers surged to the
top of the list. Its clinical impact and cost effectiveness
surpass that of other important preventive services,
such as mammography, colorectal cancer screening,
and pneumococcal and influenza vaccination of se-
niors. The NCPP identified tobacco-use screening and
intervention for adults, along with childhood immuni-
zation and aspirin chemoprophylaxis for high-risk
adults, as the three most consequential and cost-effec-
tive preventive services that clinicians can provide.2
Delivery of this top-priority service remains inade-
quate, however. According to 2004 Health Plan Em-
ployer Data and Information Set (HEDIS) perfor-
mance data reported by the National Committee for
Quality Assurance (NCQA), although 69% of smokers
in commercial health plans received some advice to
obacco use remains the nation’s leading pre-
ventable cause of disease and death, each year
claiming an estimated 438,000 lives in the
quit, only 37% and 38%, respectively, went on to
receive counseling about cessation strategies or medi-
cations.5The NCQA reports similar, but lower, rates for
smokers enrolled in Medicaid plans. The recom-
mended components of effective smoking-cessation
counseling are the “5A’s”: ask about tobacco use at
every visit (A1), advise to quit (A2), assess willingness to
make a quit attempt (A3), assist with counseling and
pharmacotherapy (A4), and arrange follow-up support
and assistance (A5).6A recent survey of more than 4000
smokers in nonprofit staff-model health plans found
that rates for A1 and A2 were favorable (90% and 71%,
respectively), but that follow-through on A3 to A5 was
inadequate (56%, 38% to 49%, and 9%, respectively),
even though most of the surveyed smokers wanted to
quit and wanted their physician’s help.7Recent studies
of interventions to improve the identification of smok-
ers (A1), such as checking smoking status as a “vital
sign,” have reported little improvement in A2 to A5,
pointing to the need for broader systems changes.8–10
Multicomponent systems changes consistent with the
planned care or chronic care model by Wagner et al.11
can facilitate the delivery of all 5A’s.3,12,13Helpful
systems-level strategies include measurement, perfor-
mance reports and incentives for provider adherence
to cessation practice guidelines, computer-based pa-
tient enrollment and tracking systems, computer-gen-
erated telephone counseling calls and feedback on
outcomes, cessation specialist office-staff support, re-
duced patient co-payments for counseling services,
referral to community resources for additional support,
and clinician/health plan support for community pol-
icies that support quitting and maintenance (e.g., in-
creased tobacco taxes, tobacco control funding, clean
indoor air laws, media campaigns and promotions of
quit lines, and other cessation services).2,3,12,14–16
Using a combination of these strategies, several
health plans have reported dramatic success. For in-
stance, within 10 years, Group Health Cooperative in
Seattle reduced the prevalence of adult smoking from
25% to 15% (the state average was 21%).12,17Provident
Health Systems in Portland OR, Kaiser Permanente of
Northern California, and HealthPartners in Minnesota
achieved similar results.18–20Fisher et al.21used partic-
ipatory approaches to change systems of care in two
federally qualified health centers serving a low-income
From the Robert Wood Johnson Foundation (Orleans, Marks),
Princeton, New Jersey; School of Medicine, Virginia Commonwealth
University (Woolf, Rothemich), Richmond, Virginia; and HealthPart-
ners (Isham), Minneapolis, Minnesota
Address correspondence and reprint requests to: C. Tracy Orleans,
PhD, Robert Wood Johnson Foundation, College Road East, Prince-
ton NJ 08543. E-mail: firstname.lastname@example.org.
*Senior authorship equally shared.
Am J Prev Med 2006;31(1)
© 2006 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/06/$–see front matter
minority population. Within 2 years, tobacco-use
screening increased from 2% to 94%, and provider quit
advice and offers of cessation assistance rose to 80%
and 61% to 64%, respectively. Systems changes in each
of these four examples combined internal and external
quitting resources to reduce the burden on busy office
staff and ensure treatment delivery. Apart from being
more likely to quit, there is growing evidence that
smokers express greater satisfaction with their doctors
and their care when they receive the interventions
offered by these systems.7,22
The vast majority of clinicians work outside such sys-
tems, however. Most primary care is delivered by small
independent practices, which are struggling to deliver
essential care and maintain economic viability.23Office
visits average only 14.5 minutes and must address diverse
patient needs.24,25The ordinary clinician lacks the time,
reimbursement, skills, and staff to deliver all 5A’s to all
smokers in their care.26,27These clinicians require alter-
native models to connect patients with high-quality assis-
tance outside the practice.6,19,28Such models call on
clinicians to do what is feasible in a busy office visit: to
identify smokers (A1), offer a few minutes of brief advice
(A2), and refer patients elsewhere for more extended
assistance (A3 to A5). Clinicians are thereby involved in
what they do best—adding their imprimatur to the im-
portance of quitting29and anchoring their quit advice in
the context of the patient’s health needs and history30—
but the model turns elsewhere for more effective assis-
tance.31For example, proactive telephone counseling
achieves higher quit rates than brief physician advice and
counseling.14,32Several initiatives—a variety of state pro-
grams, the “Ask, Advise, Refer” campaign of The Ameri-
can Dental Hygienists’ Association and the National Ces-
sation Leadership Center, and the “Ask and Act”
campaign of the American Academy of Family Physi-
cians—encourage clinicians to perform A1 and A2 in
their offices and to refer patients to quit lines and other
external cessation services for further assistance.16,19,33
Under the best of these models, quit line counselors work
with primary care clinicians in a team approach, provid-
ing feedback reports on smokers’ progress with counsel-
ing, which clinicians can reference in discussions with
patients at follow-up visits, and counselors can alert phy-
sicians when cessation medications are indicated.17,34A
randomized trial is currently testing whether such an
Whether it is referring patients to quit lines or to
other community services outside the practice, an ef-
fective system for helping smokers to quit can rarely be
cobbled together by the practices themselves. Although
clinicians are capable of modifying internal operations
to support a cessation counseling program36—such as
adopting a vital sign intervention or refining the brief
advice they give smokers—other ingredients for cessa-
tion counseling require engagement and leadership
from the larger institutions and delivery systems within
which practices operate. For example, where practices
are owned by a health system with a common electronic
health record, senior management must authorize the
necessary reprogramming to create electronic prompts
to identify smokers. Most clinicians lack the time,
talent, and contacts to design a convenient referral
system that is easy to use, limits imposition on the
practice, and provides a seamless transfer of patients
and their information to an offsite counseling program.
A successful system for referrals and feedback often
requires staff from the quit line, or the community or
state cessation program, to work with counterparts in
the health system to work out the details.37Nor can
practices solve the problem of reimbursement for this
effort, which only purchasers and payers can rectify.
Thus, although clinicians can do much to improve
cessation counseling, creating a system to help smokers
obtain the quitting assistance that they need is an
undertaking best implemented at the level of policy-
makers: leaders of health systems, employers, payers,
and state tobacco control leaders. To be sure, decision
makers at this level face competing demands for limited
resources and require a compelling argument to un-
dertake the hard work and to pay the bills for creating
such systems.38However, the NCPP findings demon-
strate that healthcare decision makers, purchasers, and
policymakers standto achieve
turns—in extended lives and cost savings—by getting
serious about helping smokers to quit. The payoff is
made clear by the work of Maciosek et al.2and Solberg
et al.,3who demonstrated that more would be gained
by improving the delivery of cessation counseling than
by improving uptake of any other preventive service
reviewed by the NCPP. For example, improving uptake
of breast and colorectal cancer screening from current
delivery rates to 90% of eligible patients would save
91,000 and 340,000 quality-adjusted life years, respec-
tively, whereas doing the same for the identification
and counseling of smokers would save 1.3 million
quality-adjusted life years.2The economic implications
to public and private purchasers are equally compel-
ling. Knowing the projected savings of $500 per smok-
er3and the prevalence of tobacco use in their covered
population, payers and employers can “do the math,”
and quickly recognize the business case for adopting
system changes to support cessation. Few investments
could do more to control healthcare costs and increase
Policymakers and healthcare and tobacco control
leaders have made great strides in the last decade to
help clinicians to help smokers. Quit lines are available
in 45 states and now can be reached by one toll-free
number (1-800-QUIT NOW). Today, 41 state Medicaid
programs and 98% of U.S. health plans provide cover-
age for at least one form of recommended counseling
or pharmacotherapy, and both Medicare and the Vet-
American Journal of Preventive Medicine, Volume 31, Number 1www.ajpm-online.net
erans Health Administration (VHA) cover tobacco-
cessation counseling.39,40The proportion of U.S.
health plans using some system to identify smokers rose
from 15% in 1997 to 71% in 2002.40Advances in
e-health and health information technology are ex-
panding capacity for computerized provider reminders
and prompts.41The identification and assistance of
smokers is a key metric in several leading quality
improvement, pay-for-performance, and provider re-
certification initiatives.13Many national, state, and pro-
fessional groups offer cessation-related training tools
and supports for busy primary care clinicians. Major
tobacco control funders are collaborating with private
sector leaders to discover new ways to stimulate con-
sumer demand for proven cessation strategies.42Fi-
nally, growing nationwide support for comprehensive
clean indoor air laws (over 25% of the population is
now covered) and continued increases in combined
state and federal cigarette taxes (averaging $1.30 per
pack) are building stronger norms and support to help
These and other pieces of an effective system to help
clinicians assist smokers are coming into place, but
“assembly is required,” and so is leadership. Policy
leaders and stakeholders at all levels must take the
initiative to encourage health systems, the public health
community, and others who share an interest in to-
bacco control to work together to construct an inte-
grated system in which clinicians and community pro-
grams work synergistically to identify smokers and offer
high-quality assistance. Building the infrastructure for
such a collaboration will yield benefits that extend
beyond tobacco control to other areas of prevention
and chronic illness care.44As with cessation counseling,
clinicians need assistance from the outside to help
patients become physically active, change eating habits,
control their weight, and manage chronic illnesses.28,45
Investing in a “relationship infrastructure” that facili-
tates a more effective approach not only to tobacco use
but to the obesity epidemic and other threats to the
nation’s health and economy is increasingly urgent.
The findings of the NCPP could not be clearer: Build-
ing a better system for tobacco cessation counseling is
among the most important actions that we can take to
save lives and dollars and improve the quality of health
care for patients.
No financial conflict of interest was reported by the authors of
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