Smoking is one of the leading causes of disease, disability, and death in the United States. Psychologists have been at the forefront of smoking cessation treatment for decades, and thanks to recent advocacy by APA, they can now be reimbursed for providing screenings and brief interventions for tobacco use, both of which have contributed to a decrease in smoking rates nationwide.
According to research from the U.S. Centers for Disease Control and Prevention, smoking among all adults declined from 20.9% in 2005 to 12.5% in 2020. Experts attribute this drop in tobacco use to several efforts in which psychologists have been involved: developing new treatments for addiction, better health insurance coverage for these treatments, adopting smoke-free policies in public settings, anti-smoking educational campaigns, and new evidence-based interventions to help people avoid or quit using cigarettes.
Now that APA has secured reimbursement for psychologists to intervene with patients who smoke, the next step is to better integrate smoking cessation therapies into existing behavioral health treatments to help smokers who have comorbid mental health conditions, such as depression.
“It is crucial that health care providers treat all the health issues that a patient experiences, not just their depression or drug use disorder at a given point in time,” said Wilson Compton, MD, deputy director of the National Institute on Drug Abuse (NIDA). “The result will be longer and healthier lives for all people.”
Stepping up to stop the puff
Over the past year, APA has taken steps toward addressing commercial tobacco use from a population health approach by advocating that health care payers reimburse psychologists and other mental health providers for tobacco cessation screenings and brief intervention services.
Medicare reimbursement codes for tobacco cessation screenings and brief interventions have been around for many years; however, an edit within the National Correct Coding Initiative (NCCI) had long prevented mental health providers from billing these codes in conjunction with psychotherapy services.
“It never made any sense, as psychologists are the ones who developed these brief motivational interviewing-based interventions and are often the ones to train physicians on how to use them with patients,” said Stephen Gillaspy, PhD, senior director of APA’s Office of Health Care Financing.
Toward the end of 2021, APA submitted paperwork to NCCI to get this edit modified, allowing psychologists and other mental health providers to use the following Current Procedural Terminology (CPT®) billing codes:
- 99406 to bill for a smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes;
- 99407 to bill for a smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes, while also conducting psychotherapy services for other mental health conditions.
“We made the case that psychologists are going to have more ongoing involvement with these patients than a primary-care provider, providing an ideal opportunity to intervene,” Gillaspy said. A patient’s primary-care provider, for example, likely sees a patient only once or twice a year, whereas a psychologist providing ongoing therapy would likely treat a patient more frequently, allowing for more regular follow-up with them with regard to their smoking cessation work.
APA’s efforts were successful, and now these codes can be used by psychologists to receive reimbursement for brief interventions, such as screening for tobacco use, using motivational interviewing techniques, and referring to a smoking cessation expert or state tobacco quit line for help, or for conducting brief behavioral health interventions themselves in conjunction with the other mental health services the psychologist is providing.
“Psychologists can contribute to population health simply by intervening when appropriate,” Gillaspy said. “To me, it helps the field move out of just being mental health providers and instead being part of the larger health care system.”
Confronting smoking in therapy
In addition to a decline in overall smoking rates among adults, new research suggests that smoking rates have also been decreasing among smokers with comorbid mental health conditions—a population that in recent years has not seen substantial reductions in tobacco use.
Analyzing data from more than 558,000 people 18 years and older, NIDA researchers found that while people with major depression, substance use disorder, or both were more likely to smoke cigarettes than people without these disorders, improvements in smoking cessation were seen among individuals with these psychiatric disorders between 2006 and 2019. Results of the study, published in April in JAMA (Vol. 327, No. 16, 2022), showed that past-month smoking rates declined by 13.1% during this 14-year period among adults with a past-year depressive episode and by 10.9% among adults with past-year substance use disorder.
These findings—while showcasing a step in the right direction—still highlight ongoing disparities in commercial tobacco use and the role mental health providers can play in continuing to combat smoking, said Compton, senior author of the study.
“These declines tell a public health success story,” Compton said. “However, there’s still a lot of work to be done to ensure tobacco use in patients with substance use disorder, depression, and other psychiatric conditions continues to decrease.”
One of the first steps in curbing commercial tobacco use is ensuring psychologists are asking their patients about it, said Jon Hart, PhD, a health psychologist and director of Oklahoma’s Tobacco Helpline.
“It seems simplistic, but often we’re just not focused on that,” Hart said. “The client isn’t coming in to see us with smoking as the primary thing they need help with, and a lot of times, we see what they are coming in for as the bigger problem, so the thought is often, well, we’ll attend to the smoking later, after we’ve fixed the other problem.”
Hart recommended that psychologists ask about smoking habits, as well as advising those who smoke that it is something they should consider stopping and offering to help. If the patient shows a willingness to quit, practitioners shouldn’t just passively refer them to their state’s “quit smoking” telephone helpline, or quit line; instead, Hart suggests clinicians immediately help patients register with the quit line. Or, if the practitioner is comfortable doing so, provide some brief motivational interviewing interventions around smoking cessation.
Hart explained that all state quit lines provide, at minimum, cessation coaching from a certified tobacco treatment specialist, and most also provide nicotine replacement therapy, such as gum, patches, or lozenges, though the amount will vary by state based on funding. He also noted that some quit lines are beginning to branch out and provide counseling via text or web chat, while others have been integrating app-based approaches in conjunction with counseling.
Hart emphasized that it is also important for psychologists to circle back with patients throughout their smoking cessation transition to ask about progress and to check in periodically with smokers who have declined help with quitting.
“None of the [tobacco cessation] models say, ‘Ask once, and if the answer is no, never ask again,’” he said. As more of the patient’s acute issues, such as depression, anxiety, or a relationship concern, are addressed, he recommends touching base with the patient again and asking more about what role tobacco use plays in their lives and whether they recognize how destructive it can be. “If we’re treating someone with cognitive behavioral therapy or a positive psychology approach to help them with depression or anxiety or marital issues, but then they’re also actively engaging in the leading cause of preventable death, I’d think we’d want to highlight that, and ask how this might be holding them back from living the life they say they’re wanting help to live.”
Better interventions for women
Psychologists can also make headway on decreasing smoking rates by providing targeted interventions to populations who historically have dealt with more extensive medical risks due to smoking, particularly women.
“Female smokers experience more health consequences related to smoking but are less likely to quit and more sensitive to negative affect, stress, and depression, which all impact their efforts to quit smoking,” said MacKenzie Peltier, PhD, a clinical psychologist and assistant professor of psychiatry at the Yale School of Medicine who studies individual factors that affect quitting smoking, specifically among women.
One key factor underlying the difficulty in quitting for women is sex and gender differences in medication response, Peltier noted. Specifically, research has shown that commonly used nicotine replacement therapies for smoking cessation, including transdermal patches, gum, lozenges, inhalers, and nasal sprays, are 40% less effective among female smokers as compared with male smokers (Biology of Sex Differences, Vol. 13, No. 34, 2022).
Peltier noted, however, that a previously published study has determined that varenicline, a prescription medication used to treat smoking addiction often referred to by its brand name, Chantix, has led to relatively equal quit rates among men and women (Nicotine and Tobacco Research, Vol. 18, No. 5, 2016). She also pointed to several research studies suggesting that women generally smoke to regulate negative mood and stress, more so than men.
As a result, Peltier is working with psychologist Sherry McKee, PhD, also at Yale, to target what is called the “noradrenergic” system in the brain to understand if the area is key to developing medications to treat smokers.
McKee is running a clinical trial examining whether a combination of varenicline and a medication called guanfacine—originally developed as a blood pressure medication—can have a positive effect on stress-induced smoking behavior and help increase quit rates among women.
While obviously clinical psychologists in most of the country aren’t able to prescribe medication, understanding the context in which women are more likely to smoke can be of tremendous help in smoking cessation treatment, Peltier said.
“Helping a client recognize that stress is a trigger for smoking and working with them to develop alternative thoughts and coping strategies is something even clinicians who don’t specialize in tobacco cessation can do,” Peltier said. “Simply giving them more tools in their toolbox to help them cope, rather than being stressed and needing to go outside and smoke a cigarette.”
Hart agreed, noting that psychologists are in a great position to help patients who smoke through what is often an incredibly difficult, stressful transition.
“We know that, as psychologists, we’re equipped to assist clients with exploring and enhancing the motivation to break free from destructive patterns and habits,” he said. “When clients succeed in running away from something destructive, we also have the privilege of assisting them with reframing that loss by considering what they are now running toward and support them in reclaiming and rebuilding aspects of life that commercial tobacco was robbing from them. To me, this is the most exciting, rewarding work of tobacco cessation.”
