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Clinical Journal of Oncology Nursing logoLink to Clinical Journal of Oncology Nursing
. 2026 Jun 1;30(3):199–205. doi: 10.1188/26.CJON.199-205

Implementing an Evidence-Based Smoking Cessation Referral Tool Kit in a High-Risk Lung Cancer Screening Clinic

Kris Mathey 1,✉, Diane Von Ah 1
PMCID: PMC13239587  PMID: 42227788

Abstract

BACKGROUND

Smoking cessation is a healthcare priority, particularly for those at high risk for lung cancer; however, referrals to smoking cessation programs remain inconsistent.

OBJECTIVES

This quality improvement project implemented a provider-driven smoking cessation referral tool kit to increase smoking cessation referrals and improve billing practices in a lung cancer screening clinic.

METHODS

A smoking cessation referral tool kit, including provider education, communication training, and sample scripting aids, was implemented. Smoking cessation referrals and billing practices were assessed prior to and after implementation.

FINDINGS

In January, referrals rose from 13% in 2024 to 33% in 2025, and in February, referrals rose from 16% to 34%, representing gains of 20% and 18%, respectively. Eligible patients billed increased in January from 70% in 2024 to 85% in 2025, and in February from 76% in 2024 to 100% in 2025. Nurses can implement this tool kit to improve smoking cessation referrals and standardize billing practices.

Keywords: smoking cessation, tool kit, referral, high-risk lung cancer, tobacco cessation

LUNG AND BRONCHUS CANCERS ARE THE THIRD MOST COMMON cancer diagnoses in the United States, with estimates of 26,640 new cases and 124,730 deaths in 2025 alone (Siegel et al., 2025). Tobacco smoking is the primary causal factor in lung cancer, accounting for 90% of all lung cancer diagnoses (Centers for Disease Control and Prevention [CDC], 2025). In addition, tobacco smoking in patients with cancer has been linked to increased treatment-related toxicities, morbidities, and overall and cancer-specific mortality, as well as increased risk of second primary cancers (CDC, 2020). Quitting smoking at the time of cancer diagnosis can reduce the risk of dying of cancer by 30%–40% (Sheikh, 2024). Therefore, smoking cessation has been identified as a healthcare priority, particularly in patients at high risk for lung cancer (CDC, 2020).

In an effort to detect lung cancer earlier, the U.S. Preventive Services Task Force (2021) has recommended annual screening for lung cancer with low-dose computed tomography for individuals at high risk for the disease. In line with this recommendation, the Centers for Medicare and Medicaid Services (2022) mandated that all patients seen for lung cancer screening receive counseling on the importance of maintaining cigarette abstinence and requires current smokers to receive counseling on the importance of smoking cessation and, if appropriate, information about smoking cessation interventions. Researchers have shown that smoking cessation can improve immediate and long-term health outcomes, reduce cancer occurrence, including lung cancer, and reduce overall mortality (Davis et al., 2020). Thus, referring patients to a smoking cessation program is a critical step in promoting smoking cessation, particularly among those at high risk for lung cancer (Davis et al., 2020).

Although best practices for smoking cessation referral programs exist, clinic processes may vary. Researchers have identified that less than half of those who smoke are being offered evidence-based smoking cessation interventions (Himelfarb-Blyth et al., 2021). Although providers recognize the importance of referring patients for smoking cessation, systems are often insufficient to support the implementation and maintenance of these programs. Systems that incorporate provider communication and streamline smoking cessation referrals have proven to be more effective in engaging smokers in smoking cessation opportunities (Davis et al., 2020). In addition, optimizing medical coding and billing practices ensures the financial stability and sustainability of healthcare practices in the long term, such as smoking cessation (Burks et al., 2022). The Centers for Medicare and Medicaid Services requires explicit documentation of smoking cessation for the hospital system to bill for services. Specifically, counseling and education regarding smoking cessation must be discussed for at least five minutes, at which point an advanced practice provider (APP) can enter the Current Procedural Terminology (CPT) code (99406) for the counseling visit in the medical record (Jensen et al., 2022). Therefore, to effectively implement and sustain best practices within smoking cessation programs, healthcare providers must be knowledgeable about billing and coding practices. Burks et al. (2022) recommend that providers participate in formal educational sessions on billing practices to enhance their knowledge and apply accurate billing, ultimately improving the sustainability of best practices. Without adequate training and consistency in referring patients to smoking cessation clinics, organizations may miss opportunities to financially support these programs in the long term. Therefore, programs must be developed to implement best practices to ensure smoking cessation screening referrals are made and counseling is adequately documented, particularly for high-risk patient populations, such as those in the lung cancer screening clinic.

Purpose

This quality improvement project was designed to implement a provider-driven smoking cessation referral tool kit to increase smoking cessation referrals and billing practices in a high-risk population. The tool kit included standardized evidence-based communication techniques and counseling regarding smoking cessation and general and specific provider education regarding the benefits of smoking cessation, and implemented standardized documentation requirements, which included sample scripting. The education and training targeted the APPs who manage the high-risk lung cancer screening clinic.

Methods

This quality improvement project was conducted at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, a part of the Ohio State University Wexner Medical Center in Columbus, Ohio. This hospital has a dedicated lung cancer screening clinic, which serves those who are at risk for lung cancer. The lung cancer screening clinic was seen as an optimal setting to implement this provider-driven smoking cessation tool kit, as these patients are deemed at greatest risk for lung cancer. In addition, researchers have shown that more than 50% of people who seek lung cancer screening are active smokers (Shelley et al., 2022). Therefore, providing support for those seen in this clinic may result in not only smoking cessation but also reducing deaths from lung cancer (Shelley et al., 2022).

Intervention Development Phase

The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care guided the overall project (Buckwalter et al., 2017). The Society for Research on Nicotine and Tobacco and the Association for the Treatment of Tobacco Use and Dependence developed the guidelines, which present the evidence for smoking cessation health benefits in this high-risk group and provide initial clinical recommendations for integrating evidence-based smoking cessation treatment with lung cancer screening (Fucito et al., 2016). Based on this evidence and a comprehensive literature review, three major provider-driven intervention components were identified that have been shown to improve smoking cessation referrals. These components included enhanced communication techniques and counseling, provider education regarding the benefits of smoking cessation, and standardized documentation including the need for formulizing sample scripting for providers’ notes (Blocker et al., 2020; Boe & Ridner, 2021; Chavarria et al., 2019; Davis et al., 2020; Etteldorf et al., 2020; Gibson et al., 2021; Giuliani et al., 2019; Himelfarb-Blyth et al., 2021; Kendra et al., 2022; Khanna et al., 2021; Kotti et al., 2023; Tong et al., 2023; van Westen-Lagerweij et al., 2023; Wadlin et al., 2022; Young et al., 2023). In addition, the literature provided recommendations for best practices in improving system infrastructure, which included provider education on billing procedures to sustain the program (Burks et al., 2022). These three main recommendations and rationale will be briefly described.

ENHANCED COMMUNICATION AND TECHNIQUES COUNSELING

Enhancing provider communication skills is an essential approach to increasing smoking cessation. The 5As Behavioral Counseling Framework focuses on provider communication (Himelfarb-Blyth et al., 2021). There are multiple steps for the provider to interact with the client. Providers using the 5As Behavioral Counseling Framework should ask patients if they smoke, which provides an initial screening. If patients are found to be current tobacco smokers, they are advised to modify their behavior for the benefit of their health. This is then followed by assessing the patient’s interest in quitting, and if readiness is established, the provider assists by providing counseling. The provider completes this framework by arranging appropriate follow-up and referral (Etteldorf et al., 2020). The 5As Behavioral Counseling Framework has been modified to the 3As framework and focuses on the three steps of ask, advise, and act. The 3As approach is an evidence-based and validated behavioral counseling framework that simplifies the steps and streamlines the implementation process for clinicians (Himelfarb-Blyth et al., 2021). This modified framework has been used successfully to increase referrals and promote smoking cessation (Himelfarb-Blyth et al., 2021).

PROVIDER EDUCATION REGARDING THE BENEFITS OF SMOKING CESSATION

Education of providers as well as patients is another essential approach to increasing smoking cessation referrals. Evidence-based approaches to educating providers have many benefits, such as improving communication and increasing provider confidence in their practice. Provider education can offer strategies to improve communication techniques with patients as well as reinforce the underlying pathophysiology and benefits of quitting. Provider education about not only the benefits of smoking cessation but also the referral processes for smoking cessation can support improved smoking cessation referral outcomes.

STANDARDIZED DOCUMENTATION

System-level approaches increase smoking cessation referrals. Sample scripting can lead to consistency in practice for documentation as well. Himelfarb-Blyth et al. (2021) used scripting with a line reading, “As part of your care today, I am going to refer you to . . .” (p. 1199). This scripting encouraged providers to use open-ended language, which supported patients in declining a referral instead of making a decision about accepting one. However, current workflows could be more efficient regarding who, how, and when smoking cessation advice and referrals are implemented. Overall, streamlining practice using evidence-based approaches with communication techniques, education of providers, and sample scripting for documentation can lead to improved smoking cessation referral outcomes (Etteldorf et al., 2020).

Intervention

This quality improvement project involved creating a smoking cessation referral tool kit for providers serving a high-risk lung cancer population. It began with an internally developed educational session, “EBP Practices to Streamline APP Lung Cancer Screening Practice and Tobacco Cessation Referrals,” geared toward the APPs who work in the lung cancer screening clinic. This one-hour educational session was delivered virtually to APPs who work in the lung cancer screening clinic (see Figure 1). Nursing continuing professional development credit for 1.0 contact hour was awarded to participants who completed the educational session and evaluation forms. This educational offering was recorded to ensure standardization, allow those who could not attend to receive the information, and provide participants the opportunity to review it at any time after the session as a reminder of best practice.

FIGURE 1.

FIGURE 1

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USING THE 3As FRAMEWORK FOR COMMUNICATION FOR TOBACCO CESSATION REFERRAL DISCUSSIONS

After completion of the educational session, APPs were granted access to the electronic progress note template for patient visits. The progress note emphasized the importance of including smoking cessation discussions during visits, recommending the required duration of at least three to five minutes for these conversations, and offering referral for a tobacco cessation clinic.

An opportunity to gather feedback was used to gain valuable insights from providers, which was essential for the acceptance and adoption of this standardized provider documentation. This process also improved the final implementation script and encouraged its use. Finally, a centralized digital repository to store resources accessible to providers was created to ensure access to exemplars. Follow-up emails summarizing the initiative and offering reminder cues to use the tool kit were sent to all APPs in the lung cancer screening clinic.

Project Implementation and Data Analysis

The lung cancer clinic coordinator used a standardized audit tool to collect the data from the electronic health record. Data abstraction from the electronic health record was done by the clinic coordinator, who had knowledge of the data source but was not a part of the project overall, to ensure neutrality. The data and data analysis were reviewed by both authors. The outcomes of this project were as follows: (a) attendance and evaluation of an educational session on smoking cessation, (b) evaluation of the number and percentage of referrals to the smoking cessation clinic, and (c) assessment of accurate documentation, billing, and use (number and percentage) of the CPT code 99406 for smoking cessation counseling. Data compiled were analyzed using descriptive statistics (counts and frequencies). A comparison of data from January and February 2024 (prior to the intervention) and January and February 2025 (after the intervention) regarding smoking cessation referrals and CPT code use was recorded. The medical record system recorded the referral rate and billing codes in an electronic format, ensuring accuracy of the data retrieved.

Results

All six APPs in the lung cancer screening clinic completed the educational session (four synchronously and two asynchronously), with all providing evaluation feedback. All participants reported that the program met the objectives and enhanced their professional development. The evaluations featured a write-in response that asked, “How will this program change or influence the care you deliver or impact your practice?” Respondents indicated that they believed the exemplar scripts “would improve their documentation and billing practices,” the overall education “heightened their awareness of the importance of smoking cessation,” and the training would result in “more purposeful discussions with patients regarding smoking cessation.” Overall, comments reflected that documentation would be “easier” and “more consistent.” These responses reinforced that the objectives of the educational session were achieved.

Through chart audits, a comparison of data from the same time points from the previous year, preintervention and postintervention, was conducted. In January, referrals increased from 13% (6 of 47 smokers) in 2024 to 33% (9 of 27 smokers) in 2025. In February, referrals rose from 16% (8 of 50 smokers) to 34% (10 of 29 smokers), representing gains of 20% and 18%, respectively (see Figure 2). This does not include the number of referrals offered but subsequently declined by the eligible patients and, thus, represents a conservative number.

FIGURE 2.

FIGURE 2

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REFERRAL PERCENTAGE TO TOBACCO CESSATION CLINICS

Note. Postintervention, referral rates increased by 20% in January 2025 and 18% in February 2025

From a comparison of historical data from the previous year, the percentage of eligible patients billed in January 2024 was 70% (33 of 47 current smokers), rising to 85% (23 of 27 current smokers) in January 2025. In February 2024, the percentage of eligible patients billed was 76% (38 of 50 current smokers), increasing to 100% (29 of 29 current smokers) in February 2025. These results demonstrate a substantial increase (15% and 24%, respectively) (see Figure 3). These initial findings suggest progress following the implementation of the provider-driven smoking cessation tool kit.

FIGURE 3.

FIGURE 3

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PERCENTAGE OF ELIGIBLE PATIENTS BILLED WITH CPT CODE 99406 FOR TOBACCO CESSATION COUNSELING

CPT—Current Procedural Terminology

Note. Percentage of eligible patients billed increased 15% postintervention in January 2025 and 24% postintervention in February 2025.

Discussion

The purpose of this quality improvement project was to implement a provider-driven smoking cessation referral tool kit to increase smoking cessation referrals and billing practices in a high-risk population. To accomplish this goal, APPs participated in an educational session, and, based on the feedback from this training, it was determined that the information provided was deemed to be crucial in enhancing their knowledge about smoking cessation. The APPs acknowledged the importance of recommending smoking cessation referrals for at-risk patients and identified that the standardized documentation would make documenting referrals more efficient and effective. In addition, the implementation of the provider-driven smoking cessation tool kit demonstrated the initial desired outcomes of increasing the percentage of smoking cessation referrals as well as improved billing practices of this counseling. Although more extended follow-up is necessary, there was an emerging trend suggesting that this project may be beneficial for enhancing smoking cessation referrals and improving billing practices and ultimately may address the smoking cessation needs of those at high risk for lung cancer.

Similar positive findings were noted by Etteldorf et al. (2020), who implemented a provider tool kit that was based on provider education and communication. In their study of 134 patients undergoing para-anesthesia, 50 (37.31%) accepted referral for smoking cessation counseling, treatment, or both. Similarly, these authors suggest that the evidence-based provider tool kit was instrumental in enhancing provider knowledge, supporting discussions of the implications of smoking with patients, and advising patients on referral services and opportunities to quit. Taken together, these findings suggest that implementing an evidence-based provider tool kit may be essential to improve smoking cessation.

In addition, provider billing for reimbursement improved substantially; the percentage of eligible patients billed rose from 70% to 85% in January and from 76% to 100% in February. This is important for the long-term sustainability of the program. Increasing referrals for smoking cessation has the potential to affect organizational resources. With a higher volume of referrals, organizations may incur increased costs and use of clinic resources; however, if documented sufficiently, this can lead to increased revenue, with increased patient volume increasing revenue from consultations, follow-up visits, and ancillary services. Previous process improvement studies have shown that smoking cessation referral programs are cost-effective, and the initial investment in these programs is typically outweighed by the long-term health and economic benefits (Davis et al., 2020).

Limitations

This project includes limitations. The most notable limitation of this quality improvement project was the limited evaluation period. This limited evaluation period makes it difficult to determine whether the improvements in referral and billing rates will be sustained over time. Further prospective assessments are needed to determine whether the improvement will be maintained, as well as to assess when and whether a “booster” educational session is necessary. In addition, although there was no way to measure the use of the templated scripts, referrals and billing practices improved. Finally, it should be noted that because of system issues, the project team was unable to directly track the actual number of successful referrals to smoking cessation visits (uptake) or those who quit smoking based on this project. Future improvement projects are needed to directly link these outcomes to fully evaluate these interventions.

Implications for Nursing

The implementation of this standardized provider-driven tool kit is transferable to other lung cancer screening clinics. It was designed to reduce participant burden and clinic demands, as it was implemented as part of a previously scheduled clinic visit to the lung cancer screening clinic, requiring no extra time or resources from the providers. Therefore, this provider-driven smoking cessation tool kit can be regarded as a low-cost intervention to reduce smoking and enhance overall health outcomes. In addition, by improving the documentation of the counseling visit, the system more accurately records the counseling session in the medical record and supports the recovery of costs associated with the counseling provided. This enhancement in documentation is significant for patient care and improved cost recovery.

Although longer-term follow-up is needed, this quality improvement project has implications for long-term improvements beyond the lung cancer clinic. The position from the International Society of Nurses in Cancer Care (2022), endorsed by the Oncology Nursing Society, is that nurses should be informed about and be supported to deliver evidence-based cessation interventions. This evidence-based educational provider tool kit could be adapted and implemented in other ambulatory oncology clinics as well as inpatient settings to improve smoking cessation referrals. The provider education is applicable for all oncology nurses, APPs, and nurses at the bedside, and could be part of continuing education programs focused on providing evidence-based information regarding the impact of smoking and improving smoking cessation.

Conclusion

These findings suggest that the APP, using a structured approach including provider education, communication strategies, and documentation tools, can affect smoking cessation referrals and optimize reimbursement opportunities. This can ultimately lead to improved patient outcomes with improvement in tobacco cessation. Substantial improvements were noted in referrals to tobacco cessation clinics as well as improvement in billing practices for tobacco cessation counseling. This project was a necessary and critical step toward achieving the longer-term outcomes of smoking cessation and improvement in overall health. This project represented initial outcomes rather than definitive evidence of causality. Future work can focus on linking these efforts over time, which includes incorporating ongoing education and potential electronic health record prompts to maintain referral consistency, as well as focusing on the uptake of tobacco cessation referrals leading to ultimate tobacco cessation.

IMPLICATIONS FOR PRACTICE.

  • ■ Implement evidence-based smoking cessation tool kits during routine lung cancer screening visits without adding extra clinic time or resources, supporting more consistent referrals and counseling.

  • ■ Use standardized scripts and templates to enhance documentation of smoking cessation counseling, which can increase reimbursement opportunities and ensure sustainability of smoking cessation programs.

  • ■ Transfer a low-cost, provider-driven intervention to other clinical settings, enabling nurses to address tobacco use more effectively, improve long-term health outcomes, and reduce the burden of lung cancer and tobacco use in high-risk populations.

PROFESSIONAL DEVELOPMENT ACTIVITY

EARN 1 CONTACT HOUR

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ONS members can earn free nursing continuing professional development (NCPD) for reading this article and completing an evaluation online. To do so, visit www.ons.org/publications-research/cjon/ncpd to link to this article and then access its evaluation link after logging in. ONS is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

Certified nurses can claim no more than 1 total ILNA point for this program. Up to 1 ILNA point may be applied to Care Continuum. See www.oncc.org for complete details on certification.

QUESTIONS FOR DISCUSSION

USE THIS ARTICLE FOR JOURNAL CLUB

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Journal club programs can help to increase your ability to evaluate the literature and translate those research findings to clinical practice, education, administration, and research. Use the following questions to start the discussion at your next journal club meeting.

  • ■ How can oncology advanced practice providers and oncology RNs influence patient and system outcomes via tobacco cessation conversations?

  • ■ Does your organization have a focus on high-risk lung cancer screening? How is tobacco cessation embedded within care?

  • ■ What next steps can you take to incorporate this evidence into practice or research?

Visit https://bit.ly/3JPMTkR for details on creating and participating in a journal club. Photocopying of this article for discussion purposes is permitted.

Footnotes

The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias.

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