Tobacco Cessation and Quality Cancer Care

Short abstract

Oncologists are critical to tobacco cessation efforts by providing education and resources to patients to help them quit. ASCO is working to strengthen its tobacco control advocacy and promote better funding for tobacco-related cancer prevention research.

Figure u1.

Tobacco use is the leading preventable cause of disease and death in the United States, and is associated with increased risk of at least 15 types of cancer. It accounts for 30% of all cancer deaths, including 87% of all lung cancer deaths. In addition, there is growing evidence that smoking may compromise the effectiveness of treatment, reduce the tolerance of patients for treatment, increase the risk of complications, and increase the risk of patients for a secondary primary cancer.¹

Oncologists play a vital role in tobacco cessation by providing education and resources to patients to help them quit. During the last year, ASCO has worked to more clearly define the Society's role in tobacco control, and refine its agenda by focusing on initiatives that play to its strengths in advocacy and providing practical and reliable information to the oncology community—both caregivers and patients—to enable patients to quit smoking. An important component of this effort is to significantly improve the availability, awareness, and accessibility of tobacco cessation information to the membership. In addition, ASCO is working toward other long-term initiatives that will strengthen the Society's tobacco control advocacy and promote better funding for research on tobacco-related cancer prevention and control.

Where Has ASCO Been?

ASCO has been engaged in tobacco control advocacy for 15 years. A statement on tobacco control policy was among the Society's first official position papers when the ASCO Government Relations Office was established. The updated 2003 ASCO statement, “Tobacco Control: Reducing Cancer Incidence and Saving Lives,” reaffirmed the Society's commitment to cancer prevention and support for the elimination of tobacco products.² ASCO continued its advocacy for a fundamental reform of United States and international policy toward addictive tobacco products. ASCO's goal continues to be the immediate reduction of tobacco use and ultimate achievement of a tobacco-free world.

ASCO has worked collaboratively with the cancer and public health community on legislative and regulatory efforts related to tobacco control. Since 1993, these efforts have focused on legislation to significantly raise federal excise taxes on tobacco products as well as supporting efforts by the US Food and Drug Administration (FDA) to regulate tobacco products. Attempts by the FDA to regulate tobacco through the rules process were rejected by the courts. Legislative proposals have fallen short of final passage by Congress. However, there have been measured successes. The 1998 Master Settlement between 46 state attorney generals and major tobacco manufacturers settled the states' lawsuits against the companies and provided funding for more than 25 years to compensate states for past, current, and future smoking-related costs. In addition, states have become very active in passing laws regarding smoke-free workplaces and raising excise taxes. Public awareness has improved through major advertising campaigns, and more information is available about cessation counseling through quit lines and other mechanisms. A number of new pharmacologic treatments are also now available to help smokers successfully quit.

During the last year, ASCO has worked to more clearly define the Society's role in tobacco control, and refine its agenda by focusing on initiatives that play to its strengths in advocacy and providing practical and reliable information to the oncology community—both caregivers and patients—to enable patients to quit smoking.

On a global level, an international treaty, the WHO Framework Convention on Tobacco Control (FCTC), took effect in February 2005, after years of negotiation.³ The treaty represents the first coordinated global effort to reduce tobacco use, the world's leading preventable cause of death. Ratifying countries must implement scientifically proven measures to reduce tobacco use and its terrible toll on health, lives, and money. The treaty is intended to give governments greater access to scientific research and examples of best practices; motivate national leaders to rethink priorities as they respond to an ongoing international process; raise public awareness about the strategies and tactics employed by the multinational tobacco companies; make it politically easier for developing countries to resist the tobacco industry; and mobilize nongovernmental organizations to support stronger tobacco control.

It has been signed by 168 countries and at press time has been ratified by 160 countries. ASCO has provided written testimony during treaty negotiations supporting international efforts to control tobacco use, and is a member of the Framework Convention Alliance. The Alliance is composed of nearly 300 organizations representing more than 100 countries, and supports the development, ratification, and implementation of the WHO FCTC. The Society has urged ratification by the United States, but, despite signing the treaty, the current administration has not put forth any effort toward ratification.

ASCO's Agenda Moving Forward

Providing Resources for the Oncology Community on Tobacco Cessation

Given the significant impact of smoking on cancer incidence and death, as well as the growing body of research on smoking's effect on treatment outcomes, it is incumbent on the cancer care community to incorporate effective tobacco cessation as an integral component of quality cancer care. In order to encourage and improve the integration of tobacco cessation in oncology practices, it is vital that the Society provide the tools and resources for cancer care providers to be able to effectively offer these services. In addition, ASCO must advocate for improved coverage by public and private payers for tobacco cessation counseling as well as approved pharmacotherapies.

Under the auspices of the Cancer Prevention Committee, ASCO has recently issued a policy statement on “Risk Assessment and Cancer Prevention,” which highlights tobacco cessation as a core prevention activity for oncologists. In its statement, ASCO recommends that “smoking cessation treatment by oncologists be tailored to the specific needs of cancer patients.” A basic element of that treatment should be education about the link between cancer and smoking because higher cessation rates are associated with patient awareness of the relationship between smoking and the cancer diagnosis. The time of cancer diagnosis has been described as a teachable moment for intervening with smokers and providing cessation treatment.⁴ Oncologists must take advantage of that teachable moment.

The Centers for Medicare and Medicaid Services (CMS) will pay for two cessation attempts per year. Each attempt may include up to four intermediate or intensive sessions, with the total annual benefit covering up to eight sessions in a 12-month period (see sidebar). These counseling services will be covered for outpatient and hospitalized beneficiaries who are smokers and have a disease or adverse health effect that is tobacco-related or who are taking a medication whose metabolism or effect is affected by tobacco use.⁵ Although Medicare coverage for this service went into effect in 2005, preliminary data indicate that few claims have been submitted by oncologists for this service.⁶ It is not clear if oncologists are providing this service but are not aware of the ability to bill Medicare for this service or have not updated billing systems to include this code, or if oncologists are not providing this service.

Tobacco Cessation Counseling as a Quality Measure

As part of its effort to build awareness and encourage cessation counseling, in 2006 ASCO began integrating smoking-related measures into the ASCO Quality Oncology Practice Initiative, a quality improvement program that enables oncology practices to assess their performance relative to their peers on a menu of quality measures. Participating practices are asked if cigarette smoking status was documented in patients receiving adjuvant therapy and if the charts documented that smoking cessation counseling was offered to active smokers. Data consistently show that while oncology practices are documenting smoking status the majority of the time (on average 87%), smoking cessation counseling is offered to only a small percentage of smokers (on average 25%).

Education and Training

ASCO recognizes the need for more education on how to integrate tobacco control into oncology practice. Recently the ASCO Annual Meeting has offered a limited number of sessions on this topic, and the Committee hopes the number and type of sessions on smoking cessation and related topics will be increased.

The ASCO Curriculum on Cancer Prevention devotes a comprehensive chapter to this topic, examining the biologic basis of nicotine addiction, addressing potential barriers to promoting cessation in patients with cancer, discussing adverse effects of continued smoking on cancer treatment outcomes, and recommending referral and consultation sources for patients requiring intensive clinical interventions. This curriculum is now available in a consumer version on Cancer.net.

Another major education initiative to assist oncologists in their tobacco control efforts is to significantly improve the visibility and accessibility of information related specifically to smoking cessation. ASCO's Web sites—asco.org and Cancer.net—are important information sources for oncologists and their patients, and logical repositories for such information. Recently, more resources and links to tobacco control and smoking cessation tools have been added to asco.org. Work is ongoing to add relevant material and practical resources that oncologists may use to better integrate smoking cessation and counseling services in their practices.

Current Legislative Activities.

Regulation of Tobacco Products.

The prospects for passage of tobacco control legislation improved in the 110^th Congress. S.625 (HR 1108 is the House bill) would grant FDA authority to regulate tobacco. Included in the bill are provisions that would: reinstate the 1996 FDA rule on youth access and marketing; grant FDA specific authority to restrict tobacco marketing; require detailed disclosure of ingredients, nicotine, and harmful smoke constituents; ban the use on labels or in advertising of terms such as “light,” “mild,” or “low”; require bigger, better health warnings; and protect states' ability to pass other tobacco control laws. This legislation is supported by the majority of the public health community, but is not without detractors among tobacco control advocates. It continues to move forward in Congress and at press time, the Senate bill had 59 cosponsors and the House bill had 233. The FDA has stressed that tobacco control “remains one of the most important—if not the most important—public health issue we face.” However, the Agency's position is that granting FDA the authority to regulate an inherently dangerous product would undermine its public health mission as well as be extremely difficult for FDA to implement.

Tobacco Taxes.

In October 2007, legislation to reauthorize and expand funding for the State Children's Health Insurance Program (SCHIP) included a 61-cent increase in cigarette taxes to help pay for the bill. Congress was twice unsuccessful in overcoming a presidential veto over objections to the overall cost and the tax increase. This issue will have to be revisited early in 2009 by the new Congress and Administration.

In addition to developing educational tools and resources for the oncology community on tobacco cessation, ASCO intends to work with the American Board of Internal Medicine to ensure that sufficient tobacco cessation content on the topic is included on exams as well as in MKSAP-ONC and the ASCO global curriculum.

Coding for Tobacco-Use Cessation Counseling.

In March 2005, CMS began providing coverage for smoking and tobacco-use cessation counseling. From 2005 through 2007, G codes were used to report these services; however in 2008, two new current procedural terminology codes were introduced and continue to be available for use in 2009.

99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

99407: Smoking and tobacco use cessation counseling visit, intensive, greater than 10 minutes

Smoking and tobacco-use cessation counseling services of 3 minutes or less are bundled into the evaluation and management (E&M) service.

If an E&M service is provided on the same day as smoking and tobacco cessation counseling, providers should choose the appropriate E&M code and use modifier −25 to indicate that the E&M service is a separately identifiable service from the smoking and tobacco cessation counseling service.

Medicare Part B covers two smoking cessation attempts each year. Each attempt may include a maximum of four intermediate or intensive sessions. A total of eight sessions are covered in a 12-month period.

Many private payers also provide coverage for these services. Check with your payers for their specific coverage policies.

Research

It is ASCO's view that more federal funding should be devoted to a broad array of tobacco control research, from epidemiological studies, better understanding the mechanisms of tobacco use and cancers, as well as behavioral and other treatment interventions. The 2006 to 2007 Annual Report of the President's Cancer Panel (PCP), “Promoting Healthy Lifestyles: Policy, Program and Personal Recommendations for Reducing Cancer Risk,”⁷ noted that the “Federal commitment to tobacco control research, has been out of balance with the burden of disease caused by tobacco.” Based on testimony from experts in the field, the PCP offers recommendations regarding tobacco use prevention and treatment. The report states that key federal research agencies/sponsors (National Cancer Institute, NHLBI, NIDA, Centers for Disease Control) should have an intramural research program that includes:

• Biochemical mechanisms of nicotine addiction to inform the development of more effective treatment strategies.

• Methods of assessing the type, amounts, and toxicity of constituents in cigarettes and other tobacco products, and measures to evaluate smoke chemistry, human toxicant exposure, harm, and addiction.

• Methods for quantifying individual smokers' risk of lung cancer based on combinations of genetic and environmental variables.

As physicians and other health care professionals who care for cancer patients, we are committed to decreasing death and suffering from cancer. And the scientific and medical evidence is indisputable that tobacco use poses a huge burden in cancer incidence and death in the United States and worldwide. It is our responsibility as health care professionals and cancer specialists to address the devastating consequences of tobacco use and to help cancer patients quit. ASCO is committed to providing the tools and resources to its members to meet this responsibility. In future issues of Journal of Oncology Practice, ASCO will continue to offer specific guidance about how to implement smoking cessation in your practice, current reimbursement strategies for such services, as well as other tools for you and your patients.