Tobacco Treatment Program Models in US Hospitals and Outpatient Centers on Behalf of the SRNT Treatment Network

Abstract

Because tobacco use remains one of the leading causes of disease, disability, and mortality, tobacco treatment programs should be integrated into medical systems such as hospitals and outpatient centers. Medical providers have a unique, high-impact opportunity to initiate smoking cessation treatment with patients. However, there are several barriers that may hinder the development and implementation of these programs. The purpose of this review was to address such barriers by illustrating several examples of successful tobacco treatment programs in US health-care systems that were contributed by the authors. This includes describing treatment models, billing procedures, and implementation considerations. Using an illustrative review of vignettes from existing programs, various models are outlined, emphasizing commonalities and unique features, strengths and limitations, resources necessary, and other relevant considerations. In addition, clinical research and dissemination trials from each program are described to provide evidence of feasibility and efficacy from these programs. This overview of example treatment models designed for hospitals and outpatient centers provides guidelines for any emerging tobacco cessation services within these contexts. For existing treatment programs, this review provides additional insight and ideas about improving these programs within their respective medical systems.

Despite decades of policy changes and effective treatments that have resulted in declining tobacco use rates in the United States, smoking continues to be a leading cause of preventable death and disability.¹ Furthermore, smoking reduction remains a significant challenge across all populations.² Freely available tobacco services (eg, national quitlines) are often underutilized,³ showing the need for continued development and use of tobacco interventions. Integrating tobacco treatment into clinical care is a critical component of tobacco control.

Hospitals and medical centers are well suited for tobacco treatment interventions. Indeed, smoking is associated with numerous comorbidities⁴ and adversely affects treatment.⁵ Diagnosis and treatment of medical conditions can serve as “teachable moments” for encouraging tobacco cessation.⁶ It is strongly recommended, and for some conditions mandated, that patients receive tobacco cessation assistance from medical providers.⁷

Many hospital systems have integrated tobacco interventions as a standard practice within treatment protocols,^8,9 resulting in improved outcomes such as decreased readmissions and reduced costs.^{10, 11, 12, 13, 14} Tobacco treatment protocols align with efforts to enact smoke-free hospitals as well as the promotion of health behaviors consistent with hospital missions. These programs also promote a collaborative and interdisciplinary environment.¹⁵

The current review provides overviews of several extant tobacco treatment programs in the United States contributed by members of the Society for Research on Nicotine and Tobacco’s Treatment Network. Summaries are organized by scope, ranging from broad programs with multiple components to narrower programs capitalizing on fewer resources. These overviews are designed to: (1) encourage development and integration of established tobacco treatment programs; (2) characterize aspects of programs that may be useful for improving existing programs; and (3) provide support for gaining additional resources from administrators and key stakeholders to establish, expand, and/or improve tobacco treatment services. Table 1 summarizes reviewed programs and published outcomes.^{10,11,15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39}

Table 1.

Program Descriptions, Components, and Related Publications

Program/Publication	Components of Program/Description of Publication						Publication Components
	Funding	Counseling	Pharmacotherapy	QL	LCS	Referral	Feasibility / Acceptability	Describe Patient Sample	Engagement	Abstinence: > 6 mo	Abstinence: < 6 mo	Pharmacotherapy Use	Other health/Performance Effects	Funding, Costs, Cost-Savings
University of Kansas Medical Center; established 2006	H	B	NRT	X	X	E, O
Faseru et al,16 2009	Patients treated on surgical, obstetric, and psychiatric services are less likely to be referred for tobacco treatment than those treated on medical services						X	X
Stoltzfus et al,17 2011	Offering quitline referral regardless of patients’ self-professed readiness to quit expands the reach of quitline counseling												X
Faseru et al,18 2011	Many smokers make unassisted quit attempts postdischarge because use of cessation medications and quitline counseling is low						X	X	X		X	X
Rigotti et al,19 2015	E-cigarette use increased substantially from 2010 to 2013 among a large sample of hospitalized adult cigarette smokers							X					X
Fitzgerald et al,20 2016	Although one-half of inpatients with HIV smoke, few are referred for tobacco treatment. One in five who received treatment reported they quit							X	X		X
Richter et al,21 2016	Enrolling patients in quitline via a “warm handoff” doubles enrollment compared with fax referral. Hospital-borne costs are significantly lower in warm handoff than in fax referrals								X		X	X		X
Carrillo et al,22 2017	When resources are committed to compliance, the CMS Inpatient Psychiatric Facilities Quality Reporting Program results in a 10-fold increase in the number of smokers with mental disorders who receive inpatient treatment							X	X			X
Mussulman et al,23 2018	Pilot study findings suggest that a warm handoff is a promising intervention for hospitalized people living with HIV and AIDS								X		X		X
Patel et al, 24 2019	Among smoking inpatients with no contraindications, only 41% who requested a quit smoking script on discharge actually received one							X				X
	Funding	Counseling	Pharmacotherapy	QL	LCS	Referral	Feasibility/Acceptability	Describe Patient Sample	Engagement	Abstinence: Short Term, < 6 mo	Abstinence: Long Term, > 6 mo	Pharmaco-therapy Use	Other Health/Performance Effects	Funding, Costs, Cost-Savings
Scheuermann et al,25 2019	Referring hospitalized patients to quitline via warm handoff increases adherence to quitline services								X			X
Liebmann et al,26 2019	Getting inpatient NRT predicts receipt of a postdischarge script for NRT								X			X
Liebmann et al,27 2019	Engaging in both postdischarge quitline services and pharmacotherapy independently facilitates long-term quitting; both are important								X		X	X
Mussulman et al,28 2019	Among patients who were interested in quitting and participated in a clinical trial, 37% relapsed to smoking within 1 h of leaving the hospital							X		X			X
Medical University of South Carolina; established 2014	H, C3I	B, OP	NRT, Bu, V	X	X	E, O
Nahhas et al,29 2016	Most patients choose to opt-in to a smoking cessation intervention and follow-up. Those who do not are more likely to be male, younger in age, and not visited by a counselor during admission						X	X
Nahhas et al,30 2017	An opt-out smoking cessation service for hospitalized inpatients is feasible to implement, well accepted by patients, and increased short-term abstinence, medication use, and quitline use						X	X	X	X		X
Buchanan et al,31 2017	An opt-out smoking cessation program is feasible and accepted by patients admitted to the perinatal unit of the hospital, and increased abstinence rates following discharge.						X			X			X
Cartmell et al,11 2018	Smokers who engage in a visit with the tobacco treatment service while admitted have lower rates of readmission at 30, 90, and 180 days following discharge													X
Cartmell et al,10 2018	Health-care charges 1 year following discharge were reduced among smokers who received counseling from the tobacco treatment service while an inpatient. Tobacco treatment costs were low													X
Boston Medical Center; established 2016	H	B, OP	NRT Bu, V	X	X	E, O
Kathuria et al,32 2019	Hospital inpatients with a substance use disorder were significantly more likely to smoke, but cigarette use was de-prioritized during addiction treatment							X	X
Seth et al,33 2020	Implementing a large-scale tobacco treatment program is feasible and acceptable by patients; however, barriers related to clinician adaptation affect uptake						X	X	X			X
Herbst et al,34 2020	An opt-out service at a large safety-net hospital was effective at improving hospital-level tobacco performance metrics, increasing NRT use during and following admission, as well as increasing abstinence rates following discharge										X	X	X
Smilow Cancer Hospital at Yale New Haven Hospital; established 2011	H, C3I	QL, OP, TXT	NRT, Bu, V	X		E, O
Johns Hopkins Medical Center; established 2018	H	B, OP	NRT, Bu, V		X	E, O
Galiatsatos et al,35 2020	A case study of a patient who was identified as having hypersensitivity pneumonitis following secondhand exposure to electronic cigarettes.							X
Washington University in St. Louis/BJC Healthcare System; established 2018	H, R, C3I	QL, TXT	NRT, Bu, V	X	X	E, O
Ramsey et al,36 2019	A point-of-care, low-burden model of tobacco treatment service integrated in the electronic health record increased identification and treatment referrals for patients with cancer						X	X	X			X	X
Ramsey et al,15 2019	Participatory mixed methods study revealed that hospital-based smoking cessation treatment program should address key leverage points: workflow disruptions from patient smoking, misalignment between patient and provider perceptions, and coordination across the medical team to use standardized approaches (eg, nurse-driven protocol) to treat nicotine withdrawal and promote cessation						X	X	X			X		X
Ramsey et al,37 2020	Low-barrier, easily accessible tobacco treatment programs increase the use of services, especially among clinics that otherwise may not have access to such a resource						X	X	X			X	X
State University of New York at Buffalo Hospital; established 2015	R	R				R
Wen et al,38 2019	A pilot intervention of contingency management smoking cessation intervention for pregnant women was shown to be efficacious and acceptable among participants						X	X	X	X
Wen et al,39 2019	Following a smoking cessation intervention for pregnant smokers, the infants of those who successfully quit early in pregnancy had lower rates of rapid weight gain, which is a risk factor for child obesity									X			X

B = bedside counseling inpatient; BJC = Barnes Jewish Center; Bu = bupropion; CMS = Centers for Medicare & Medicaid Services; C3I = affiliated cancer center received Cancer Center Cessation Initiative support; E = electronic medical record identification; H = hospital funded; LCS = association with lung cancer screening program; N = national funding; NRT = nicotine replacement therapy; O = opt-out service; OP = outpatient counseling; QL = state quitline referral/treatment; R = research-related funding, intervention, and recruitment; TXT = referral to text message intervention; V = varenicline; X = affirmative of characteristic.

US Health-Care System

US health care is based off a health insurance system wherein individuals purchase insurance through private companies. Service coverage is negotiated for select hospitals, which may be privately or publicly owned. Uninsured patients may use a safety net hospital, which provides treatment regardless of insurance status. Integration of tobacco treatment programs is facilitated by use of electronic health record (EHR) systems. Patient registries and algorithms allow health systems to sort patients based on smoking status. Closed-loop functionality refers patients to counseling entities for cessation interventions and provides feedback to clinicians.

National Cancer Institute Cancer Center Cessation Initiative

Oncology patients who smoke experience higher rates of mortality and second tobacco-related cancers, relative to never smokers.⁴ The Cancer Center Cessation Initiative (C3I) promotes the establishment of programs that are fully integrated into oncology clinic workflows to document the tobacco use status of every patient and to offer evidence-based cessation treatment. The C3I, funded by the Cancer Moonshot⁴⁰ and launched in 2017, awarded 42 National Cancer Institute (NCI)-designated cancer centers 2 years of funding in two cohorts.⁴¹ Following 2 years of initial funding, the two cohorts were then expected to sustain these initiatives through institutional support. In 2020, the NCI provided additional 1-year supplements for 11 funded centers and 10 previously unfunded centers. Three C3I-awarded centers are among institutions highlighted in this article (Table 1).

Cancer centers face many challenges in providing cessation support: time constraints, costs, complexity of clinical care, fear of medications among both providers and patients, lack of tobacco treatment training, reluctance by patients to quit, and limitations of insurance coverage. C3I awardees have developed diverse strategies with respect to the personnel involved (eg, pharmacists or patient navigators), intensity of cessation counseling, types of medications provided, and other program characteristics.⁴¹ Perhaps the most important and yet difficult strategies capitalize on EHR functionalities⁴²; examples include creating EHR smart phrases for prescriptions, automating data upload to a tobacco user registry, and providing e-referrals to text-messaging programs.

Between the prefunding and first funding period, the number of C3I Centers offering in-person cessation counseling increased from 10 to 15 (45.5% to 68.2%). Four centers (18.2%) offered text and Web-based cessation programs in the first funding year compared with only one center (4.5%) in the prefunding period. EHR referrals increased from 31.8% to 68.2% of centers.⁴³ Successfully introducing new system procedures requires commitment from clinical leadership and cancer center directors, as well as the recognition by cancer center staff that cessation interventions are not only consistent with the cancer center mission but also are clinically imperative.⁴²

University of Kansas Medical Center

The University of Kansas Hospital partnered with the Department of Population Health to establish the UKanQuit Tobacco Treatment Service when the campus became tobacco free in 2006. UKanQuit delivers inpatient consults, arranges inpatient and outpatient medications, and refers patients to postdischarge support to provide the level of intervention found to be effective by Cochrane meta-analyses.⁹ UKanQuit serves three hospitals, including an inpatient psychiatric campus, with > 27,000 inpatient admissions per year. The hospital supports UKanQuit with general funds through an annual contract to the Department of Population Health.

UKanQuit is fully integrated into hospital workflows. The EHR provides a real-time list of all smokers in the hospital, and upon admission, all patients are offered a visit from a counselor. Those who accept are referred for treatment via nurse-initiated requests, and providers initiate orders for tobacco treatment. Counselors are tobacco treatment specialists certified by the Association for the Treatment of Tobacco Use and Dependence. At bedside, they assess withdrawal, and if needed, contact nurses or residents regarding nicotine replacement therapy (NRT). Counselors assess motivation to quit, provide an intervention, and develop treatment plans for all patients. Counselors also screen for eligibility for low-dose CT (LDCT) lung cancer screening.

Following encounters, counselors text resident physicians and unit pharmacists to request postdischarge prescriptions, refer eligible patients for LDCT screening, and document the encounter in the EHR. Patients who consent to postdischarge support are enrolled via e-referral and Web site portal into quitline, text message, and/or in-person group support. Because hospital stays are short, when necessary, counselors call patients’ homes and administer interventions to those discharged before UKanQuit could provide bedside care.

UKanQuit is a well-accepted partner in the research, teaching, and service missions of the hospital. UKanQuit provides an annual award to the physician, nurse, and cancer care provider who exemplify “Tobacco Champions.” It conducts quality improvement initiatives and is a platform for National Institutes of Health-funded research. It has treated 21,145 patients since 2006 and enrolled 1,915 patients in clinical trials. Over the past service year, UKanQuit treated 15% of all inpatient smokers with a self-reported quit rate of 37% at 1-month postdischarge. Quality measures incentivize the hospital to continue funding, but lack of inpatient reimbursement for tobacco treatment specialists limits treatment reach and sustainability.

The Medical University of South Carolina Hospital System

The Tobacco Treatment Program (TTP) is part of the Division of Population Health and the Hollings Cancer Center within the Medical University of South Carolina (MUSC) Medical University Hospital Authority. The TTP serves four inpatient hospitals and outpatient clinics in the Charleston area, with plans to expand to two newly acquired hospitals in South Carolina.

The TTP was initially created by using academic startup funds from faculty members in 2014, which funded a full-time inpatient tobacco treatment specialist and a half-time clinical pharmacist. Both clinical positions were eventually paid for by hospital funds. In 2015, the program came under the leadership of a clinical psychologist and hired a full-time scheduler, postdoctoral fellow, and a part-time predoctoral psychology intern. As of 2020, the TTP is staffed by a director, an associate director, a full-time administrative assistant, a full-time inpatient tobacco treatment specialist, a half-time clinical pharmacist, two psychology predoctoral interns, three part-time telehealth counselors, and research staff.

The clinical psychologist and interns take cases requiring a higher degree of behavioral health counseling. The clinical pharmacist prescribes medications, which are reviewed and co-signed by a physician. The psychologist and pharmacist bill for care. All other providers and staff are underwritten by the Medical University Hospital Authority. Patients are given written materials that include the quitline phone number. All patients are enrolled in a telephonic interactive voice recognition (IVR) program that tracks patients over time and allows for a warm transfer to the quitline. The TTP is an important resource for the Lung Cancer Screening program, as well as all MUSC-affiliated health centers.

When comparing 1-month quit rates for IVR plus bedside counseling vs IVR alone, quit rates were 24% vs 9%.^29,30 The adjusted mean health-care charges 12 months following discharge for patients who were treated by the TTP were $7,299 lower (P < .05) than those not exposed to TTP services, at a cost of $34.21 per patient.¹⁰ Those engaged in TTP services during hospitalization also had lower re-admission rates 30, 90, and 180 days’ postdischarge,¹¹ a benefit consistent with the goals outlined by the US Hospital Readmission Reduction Program.⁴⁴ The MUSC TTP demonstrates clinical efficacy and cost effectiveness.

Boston Medical Center

Yearly, approximately 25% (6,598 of 25,246) of adult admissions to Boston Medical Center (BMC), a large safety-net hospital, are current smokers. In 2008, MassHealth (Massachusetts’ Medicaid program) implemented pay-for-performance and delivery system transformation initiatives programs, which incentivize improved patient outcomes rather than volume of services. In response, BMC designed and implemented an “opt-out” EHR-based inpatient Tobacco Treatment Consult (TTC) service in July 2016, staffed by certified tobacco treatment specialists.

The TTC service is funded by BMC and consists of a 0.5 full-time equivalent (FTE) respiratory therapist, 0.5 FTE nurse practitioner, and a 0.1 FTE supervising pulmonologist. Based on a series of rapid cycle evaluations, the BMC created an Inpatient Smoking Cessation best practice advisory + order set that automatically triggers consultation to the TTC service when any adult smoker is admitted.³³ Upon receipt of a consultation request, the TTC service provides: (1) brief bedside counseling; (2) recommendations for pharmacotherapy while hospitalized and at discharge; and (3) linkage to outpatient treatment (BMC Tobacco Treatment Center and/or the quitline). The BMC Tobacco Treatment Center, staffed by TTC members, is embedded within the pulmonary clinical space and offers both group and individual sessions. It serves as the internal resource for smokers participating in the Lung Cancer Screening and Pulmonary Nodule programs, as well as for all smokers affiliated with BMC and its community health centers.

The “opt-out”⁴⁵ EHR-based TTC service led to improved tobacco performance measures among MassHealth-insured patients. Compared with those who did not receive treatment, the TTC service also improved receipt of NRT both during hospitalization (51.5% vs 35.9%) and postdischarge (32.5% vs 12.4%), as well as self-reported 7-day smoking abstinence at 6 months (14.9% vs 10%).³⁴ This program adds to the growing body of evidence that “opt-out” approaches are effective at improving receipt of evidence-based tobacco treatment to all smokers,^{46, 47, 48} even among underserved smokers at a safety-net hospital. Rapid cycle evaluations facilitated implementation of an “opt-out” service and improved adherence to public reporting programs, which in turn convinced leadership to continue investing resources in the program, promoting sustainability.

Smilow Cancer Hospital at Yale New Haven Hospital

The Smilow Cancer Hospital Tobacco Treatment Service (STTS), part of the Yale New Haven Health (YNHH) system, provides outpatient care to patients at one hospital and 14 ambulatory oncology care centers across Connecticut. The entire hospital system is tobacco free, including the use of electronic nicotine delivery systems. The STTS was developed in efforts to align with the mission of the Yale Cancer Center.

The STTS comprises a clinical psychologist director, a physician medical advisor, an administrative assistant, two 0.6 FTE outpatient advanced practice nurses, and three clinical psychology predoctoral interns. Nurses and licensed psychology staff provide direct patient care and bill for services. All other providers and staff are underwritten by YNHH. The program’s funding is covered by a shared services agreement between Yale Cancer Center and the Department of Psychiatry of YNHH.

The STTS uses a referral-based, opt-in model. A best practice advisory is embedded within the EHR to facilitate connecting patients to tobacco treatment. The administrative assistant processes referrals and provides patients with a range of treatment options, including referrals to the quitline, NCI’s text-based tobacco cessation program (SmokefreeTXT), and individual treatment provided by STTS. Treatment includes up to eight contacts over 12 weeks and follow-up at 3, 6, and 12 months available at the main hospital and nine other locations serving the other ambulatory centers. All patients undergo an initial evaluation, are offered prescriptions for pharmacotherapies, and receive tobacco cessation counseling. Patients return for follow-up visits at a frequency that is tailored to their individual needs. Patients who are unable to quit smoking by the end of their initial treatment course may repeat another course of treatment (billed based on provider). Care is documented in the EHR.

As of 2019, nearly one-quarter of patients who reported smoking were referred to the STTS, and roughly one-half attended at least one visit. Overall, 11% of cancer patients were treated. This level of engagement suggests program acceptability and interdisciplinary collaboration, and future analyses will elucidate the effects of these impacts on clinical outcomes.

Johns Hopkins Medical Center

In response to high rates of smoking in the greater Baltimore area, The Tobacco Treatment Clinic at Johns Hopkins School of Medicine (JHTTC) was formed in 2018. It is staffed by a physician, nurse, tobacco treatment specialist, and administrative personnel, and is located in the outpatient pulmonary-designated clinical section. Recently, the JHTTC has expanded to provide service to inpatients. The program is funded through the Division of Pulmonary and Critical Care, as well as cigarette restitution funding.

Referrals to the JHTTC are made by both inpatient and outpatient providers. During the initial clinic visit, clinicians assess each patient’s smoking patterns and nicotine dependence. A tailored individual plan is developed following a chronic care model.⁴⁹ First, each patient receives weekly check-ins to continue to discuss their smoking cessation attempt. These serve to communicate in an open dialogue with the patients, understanding their struggles and successes as well as whether they are having adverse reactions to medications. Second, the risks and benefits of medications for smoking cessation (NRT, bupropion, and varenicline) are discussed. Third, medications for smoking cessation that are to be used “as needed” (eg, NRT gum, lozenges, nasal spray, which deliver breakthrough nicotine) are reviewed and encouraged to be used during challenging cravings. Providers bill for time spent with patient. Patients are followed up for 2 years following treatment via telephone calls from staff.

An additional service available to patients at the Tobacco Treatment Clinic is the opportunity for a shared visit with the Department of Radiology for LDCT screening. Each patients’ screening status is reviewed at the clinic visit, and if they fulfill criteria, the patient may have the scan performed on the same day.

Washington University in St. Louis/Barnes Jewish Center Healthcare System

The Tobacco Treatment Program at Washington University started in 2017 with support from the National Cancer Institute Moonshot Initiative on smoking cessation. Specialist referral models of cessation care, while frequently used, have proven vulnerable to attrition from lack of referrals and no-show appointments. To address these multilevel implementation barriers and increase reach and effectiveness of evidence-based smoking cessation treatment, the Barnes Jewish Center Healthcare system implemented the EHR-enabled Evidence-based Smoking Cessation Treatment (ELEVATE) program,^36,37 a low-burden point-of-care model of smoking cessation treatment leveraging EHR tools and learning health system principles.

ELEVATE represents a decentralized approach that enables team-based tobacco treatment for all smokers at the point of care. Facilitated by EHR tools, a team of medical assistants, nurses, and physicians conduct tobacco use assessments, provide brief advice to quit smoking, order cessation medications for physicians to approve, and make “closed-loop” referrals to evidence-based telephone or text-based counseling. This EHR-based approach is compatible with clinic workflow and facilitates treatment via efficient prompts and scripts.

This team-based approach capitalizes on the: (1) frequently positive rapport between patients, nurses, and medical assistants; (2) high credibility of physicians and other clinicians; and (3) opportune delivery of needed care as part of patients’ clinic visits.

To enhance sustainability, we complement the point-of-care strategy with learning health system principles, engaging the full cycle of data-to-knowledge, knowledge-to-practice, and practice-to-data. For example, regular data-driven feedback is used to support and reward provider engagement and performance and to cultivate provider buy-in via increased knowledge of intervention value.^50,51 To enable the learning health system, an automatic reporting function is built into the EHR to generate data for provider feedback to the clinical team.

The program uses embedded clinical care teams, with no hiring of tobacco treatment specialists or other staff. Thus, the existing funding of the clinical teams allows for tobacco dependence treatments with minimal extra costs, which are estimated to be $3 per patient. Altogether, this approach maximizes cost per patient and sustainability, leading to the scale-up of ELEVATE from 21 clinics to > 700 clinics at Washington University and the Barnes Jewish Center Healthcare system.

In the inpatient setting, consequences of smoking produce substantial workflow burdens and detrimental hospitalization outcomes.¹⁵ To address these problems, we implemented a nurse-driven protocol for NRT in patients who smoke. This protocol aims to positively affect treatment delivery, patient smoking, and provider workflow outcomes.

State University of New York at Buffalo Hospital

For hospital systems that do not yet have tobacco treatment programs integrated into standard clinical operations, grant funding mechanisms may provide an opportunity and resources to establish a clinical practice.

Smoking prevalence is high among pregnant and postpartum women in the Greater Buffalo area, which contributes to poor maternal and infant health. To address this challenge, the State University of New York at Buffalo initiated the Pregnancy and Smoking Cessation Program in 2015. It is a multicomponent behavioral intervention program for maternal smoking cessation during pregnancy and up to 2 years’ postpartum. It has been funded by two National Institutes of Health Clinical and Translational Science Award pilot grants and one R21 grant; however, the team is actively seeking more sustainable funding sources, such as health insurance plans, private foundations, and donations. The smoking cessation clinic is located within the Department of Pediatrics at the State University of New York at Buffalo. To date, it has recruited 134 pregnant women who are daily smokers from local prenatal care clinics, communities, and social media (eg, Facebook) in the Greater Buffalo New York area. Most participants are socioeconomically disadvantaged, have low educational attainment, and have low family income. Visits are completed in the clinic, patients’ homes, and maternity hospitals.

Based on the Health Belief Model⁵² and Contingency Management,⁵³ the smoking cessation intervention consists of four components: education and counseling, smoking monitoring and feedback, contingent financial incentives, and teammate support. Interventionists include the Principal Investigator (a physician) and research staff (graduate, medical, and undergraduate students). Participants receive an 8-week smoking cessation intervention (10 sessions, two times per week for 2 weeks, once per week for 6 weeks), including behavioral counseling, progress review, praise for not smoking, craving analysis, and relapse prevention. Participants are encouraged not to use other nicotine or tobacco products, including NRT, due to safety concerns during pregnancy. At each appointment, if abstinence is confirmed by results of both breath carbon monoxide testing and a urine cotinine test, the participant receives a financial incentive. Participants are referred to the New York State quitline for further assistance if requested.

The Pregnancy and Smoking Cessation Program achieved an estimated smoking cessation rate of 70% at the second week of the intervention, and 63.3% at the conclusion of the 8-week intervention.³⁸ Most participants (85.7%) reported meeting/exceeding expectations, and 100% said they would recommend the program. Intervention-assisted smoking cessation during pregnancy was associated with large improvements in birth outcomes and normalization of infant growth,³⁹ providing further support for integration into obstetric practices.⁵⁴

Conclusions

Tobacco treatment programs integrated into clinical settings are critical for tobacco control. The current review provides illustrated examples of existing programs and key components. One of the most important factors is streamlined integration into the EHR system. Another feature necessary for efficacy of a program is flexible and adaptable counseling. Programs unable to support intensive in-person counseling have used other services such as quitlines and text messaging platforms. We encourage health-care providers to use Table 1 as a reference for program development.

Securing funding for comprehensive tobacco treatment programs may be the most significant issue faced by US hospital systems. It is imperative that existing programs continue to evaluate and disseminate data related to cost savings and revenue generated by tobacco dependence treatment. Indeed, key stakeholders and administrators within hospital systems are often inclined to emphasize the latter. Thus, systematic changes in the way preventive and whole health services are valued may be necessary. Future research should explore cost-effectiveness of tobacco treatment services and emphasize the significance of these metrics. For instance, generating revenue by reducing the length of stay is often monetized at a higher value than minimizing readmissions. Administrators have limited control in changing these valuations, despite national guidelines encouraging reduction of readmissions.⁴⁴

Several barriers hinder the development and continued maintenance of tobacco treatment programs.^55,56 Interventions should be developed and implemented by a trained, qualified workforce, aimed to reduce provider burden and increase effectiveness. Comprehensive, rigorous research using randomized controlled trials, or other quasi-experimental methods, will further inform the development and implementation of hospital treatment programs, including those mentioned in this review. These data will provide leverage for administrators to increase or maintain funding for tobacco treatment programs and can help to identify effective program features. Finally, future studies should compare tobacco treatment systems in the United States vs those that exist in countries with universal health care, or other similar systems.