Tobacco Cessation Change Package
Tobacco dependence is a chronic, relapsing condition that often requires repeated intervention and long-term support.1
Future smoking-related illnesses, deaths, and costs can be prevented by helping individuals who use tobacco to quit.1 Evidence-based treatments, including counseling and Food and Drug Administration (FDA)-approved medications, are available1–5 but are underutilized.6–11
Clinicians play a critical role in delivering cessation support; at least 70% of persons who smoke see a physician each year.1
Patients expect physicians to address tobacco use, and consistent interventions from clinicians improve patient outcomes.1
Even brief advice to quit from a clinician increases quit rates, and more intensive clinical interventions have progressively greater impact.1
What Is the Tobacco Cessation Change Package?
The Tobacco Cessation Change Package (TCCP) is a quality improvement tool created by the Centers for Disease Control and Prevention (CDC) that:
- Is intended for health care professionals in outpatient, inpatient, and behavioral health settings, and public health professionals who partner with these groups.
- Presents a list of process improvements that clinicians can implement as they seek to deliver optimal treatment to patients who use tobacco.
- Gives clinical teams a practical resource to increase the reach and effectiveness of tobacco cessation interventions and to incorporate these interventions into the clinical workflow.
How Should We Use the Tobacco Cessation Change Package?
Start by bringing together a multidisciplinary team of stakeholders (e.g., physicians, pharmacists, nurses, medical assistants, social workers, care managers, quality improvement coordinators, health informaticians, and administrators).
The team can look at the elements in Figure 1 and conduct an assessment to determine the aspects of tobacco dependence treatment that are most in need of improvement in your health system. You may also benefit from talking directly with others who have undertaken similar efforts to learn from their experience.
Once your team has identified and prioritized the needs, interventions can be selected from the TCCP to create a supportive treatment environment to address those needs.
You can then choose strategies from the TCCP that have been shown to result in improvement. Each strategy you choose should first be tested on a small scale (i.e., conduct a “small test of change”) to assess feasibility and allow the team to evaluate and adjust before instituting the change on a broader, more permanent scale.
Health care practices should not attempt to implement all the interventions described in the TCCP at once, nor is it likely that all of these interventions will be applicable to every clinical setting.
The TCCP is composed of change concepts, change ideas, and tools and resources:
- Change concepts are general notions that are useful for developing more specific strategies for changing a process.
- Change ideas are actionable, specific ideas or strategies that can be rapidly tested on a small scale to determine whether they result in improvements in the local environment.
- Each change idea is linked to evidence- or practice-based tools and resources that can be adopted or adapted to implement each change idea.
Figure 1. Tobacco Cessation Change Package Focus Areas
Note: The TCCP is not a comprehensive clinical guide on treating tobacco dependence; rather, it is designed to complement other Million Hearts® tools:
- Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, U.S. Public Health Service; 2008.
- Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev. 2016; 3:CD008286.
- Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2012;11:CD000146.
- Stead LF, Koilpillai P, Lancaster T. Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation. Cochrane Database Syst Rev. 2015(10):CD009670.
- Matkin W, Ordóñez-Mena JM, Hartmann-Boyce J. Telephone counselling for smoking cessation. Cochrane Database Syst Rev. 2019(5):CD002850.
- Quinn VP, Hollis JF, Smith KS, et al. Effectiveness of the 5-As tobacco cessation treatments in nine HMOs. J Gen Intern Med. 2009;24(2):149–154.
- Schauer GL, Malarcher AM, Zhang L, Engstrom MC, Zhu SH. Prevalence and correlates of quitline awareness and utilization in the United States: an update from the 2009–2010 National Adult Tobacco Survey. Nicotine Tob Res. 2014;16(5):544–553.
- Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting smoking among adults — United States, 2000–2015. MMWR Morb Mortal Wkly Rep. 2017;65(52):1457–1464.
- Marynak K, VanFrank B, Tetlow S, et al. Tobacco cessation interventions and smoke-free policies in mental health and substance abuse treatment facilities — United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(18):519–523.
- King BA, Dube SR, Babb SD, McAfee TA. Patient-reported recall of smoking cessation interventions from a health professional. Prev Med. 2013;57(5):715–717.
- Bernstein SL, Yu S, Post LA, Dziura J, Rigotti NA. Undertreatment of tobacco use relative to other chronic conditions. Am J Public Health. 2013;103(8):e59–e65.
This document was conceptualized and authored by Brenna VanFrank, MD, MSPH*; Kaitlin Graff, MSW, MPH*; Gillian Schauer, PhD, MPH (McKing Consulting)*†; Rob Adsit, MEd‡; Lauren Owens, MPH (IHRC, Inc.)*; Stephen Babb, MPH*; Danielle McCarthy, PhD‡; Anna Schecter, MPH*; and Hilary K. Wall, MPH*.
*Centers for Disease Control and Prevention
†University of Washington, School of Public Health, Department of Health Services
‡University of Wisconsin, Center for Tobacco Research and Intervention
The following individuals provided review and feedback on this document: Steven L. Bernstein, MD (Yale Schools of Medicine and Public Health); Carol Essenmacher, DNP, NCTTP (Battle Creek VA Medical Center); Tim McAfee, MD, MPH (University of Washington, School of Public Health, Department of Health Services; SEED Consulting [Plowshare Group]); Kait Perry, MPH (American Academy of Family Physicians); Sarah Price, MSN-Ed, RN (National Association of Community Health Centers); Nancy Rigotti, MD (Tobacco Research and Treatment Center, Massachusetts General Hospital and Harvard Medical School); and Catherine Saucedo (University of California, San Francisco, Smoking Cessation Leadership Center).
Graphic Design and Editorial Assistance
Graphic and HTML design support was provided by Shelby Barnes, MPH, CHES*; Booker Daniels, MPH*; Susan Davis (Northrop Grumman Corporation)*; and Jessica Spraggins, MPH*.
*Centers for Disease Control and Prevention
Website Hosting Assistance
Website hosting support of tools and resources was provided by the National Association of Chronic Disease Directors.
We would like to extend special thanks to the following organizations for their willingness to share tools and resources to improve smoking cessation, as further denoted within the Tobacco Cessation Change Package:
- American Academy of Family Physicians (AAFP)
- American College of Cardiology (ACC)
- American Lung Association
- Arizona Smokers’ Helpline (ASHLine)
- California Quits
- California Smokers’ Helpline
- Cayuga Medical Center
- Center of Excellence for Health Systems Improvement for a Tobacco-Free New York
- Essentia Health
- Group Health Cooperative of South Central Wisconsin
- HealthyHearts NYC
- Heart Health Now!
- Hospitals Helping Patients Quit
- Institute for Clinical Systems Improvement (ICSI)
- Institute for Healthcare Improvement (IHI)
- Kansas Health Foundation
- Legacy (now Truth Initiative®)
- MultiCare Health System
- National Alliance on Mental Illness Kansas (NAMI KS)
- National Behavioral Health Network for Tobacco & Cancer Control
- National Cancer Institute (NCI)
- National Quality Forum (NQF)
- Navy and Marine Corps Public Health Center
- New York City Department of Health and Mental Hygiene (NYC DOHMH)
- New York City Health + Hospitals (NYC Health + Hospitals)
- New York State Department of Health
- New York State Smokers’ Quitline
- North American Quitline Consortium (NAQC)
- Northern Lakes Community Mental Health Authority
- Oklahoma Health Care Authority
- Oklahoma State Department of Health, Center for Chronic Disease Prevention and Health Promotion
- Oklahoma Tobacco Settlement Trust (OK TSET)
- Oregon Health Authority
- Partnership for Prevention
- Plymouth Family Physicians
- Substance Abuse and Mental Health Services Administration (SAMHSA)
- University of California Quits (UC Quits)
- University of California, San Francisco, Schools of Pharmacy and Medicine (UCSF Schools of Pharmacy & Medicine)
- University of California, San Francisco, Smoking Cessation Leadership Center (UCSF SCLC)
- University of Colorado, Anschutz Medical Campus (CU Anschutz Medical Campus)
- University of Maryland School of Medicine (UM Medicine)
- University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI)
- University of Wisconsin Health (UW Health)
- University of Wisconsin–Madison, School of Medicine and Public Health (UW-Madison SMPH)
- U.S. Department of Veterans Affairs (VA)
- Wisconsin Hospital Association (WHA)
- Wisconsin Nicotine Treatment Integration Project (WiNTiP)
Centers for Disease Control and Prevention. Tobacco Cessation Change Package. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2019.