Revisiting the Case for Tobacco Cessation Services in the Wake of the Opioid Crisis

This is an exclusive BHB+ story

Tobacco cessation services often rank low on the list of offerings for substance use disorder providers. Still, there could be a business opportunity to expand offerings in this space.

Tobacco use is still the leading cause of preventable death in the U.S., responsible for just under half a million deaths annually – about 1,300 deaths daily. Yet, addiction treatment services are not as concentrated on the treatment of tobacco or nicotine as they used to be.

A primary focus in the zeitgeist of addiction treatment continues to highlight opioid use disorder (OUD), which killed nearly 82,000 in 2022. While the opioid crisis continues across the U.S., it has a fraction of the impact that tobacco addiction has on mortality.

The ongoing prominence of the opioid epidemic may be driving a disproportionate treatment of tobacco use disorders, even among providers who offer these treatments, experts told Behavioral Health Business.

“It is so under-treated. Tobacco is kind of the ‘homeless’ substance use disorder. Many addiction specialists don’t necessarily house tobacco services because it may not appear to be significant enough since it’s not having the same immediate impacts on an individual,” Dr. Smita Das, an addiction psychiatrist and clinical associate professor at Stanford School of Medicine, said. “Nicotine and tobacco end up being the substance use disorder that everybody else thinks that someone else is treating, when in reality, it is much more effective to integrate nicotine and tobacco treatment into mental health treatment, for example.”

A large part of treatment conversations are also driven by what is being given oxygen in society. Opioid use disorder (OUD) has risen in prominence as an urgency, while tobacco addiction has essentially taken the couch.

“There is less public media around smoking and tobacco — vaping is getting some media. Opioids are getting all the media. Alcohol use is starting to have a rise in the conversation,” Dr. Nzinga Harrison, chief medical officer of Eleanor Health, told BHB. “But that does affect who seeks treatment, because what you see in that cultural environment affects who comes in asking for help once they get to help.”

Eleanor Health is an addiction treatment provider headquartered in Waltham, Massachusetts that operates virtual and in-person services across nine states.

Treating treatment differently

Tobacco and nicotine use often co-occur with other substance use disorders (SUDs). Still, many practices focus on treating the most urgent or deadly substance use behavior first instead of treating the addictions simultaneously.

Concurrent treatment offers better long-term outcomes, according to new research, which also translates to a more favorable business outlook for providers.

Despite the emerging research, the push for concurrent treatment remains an uphill climb.

“There is an incorrect lore that still persists in substance use disorder treatment that you can’t ask people to stop everything at once,” Harrison said. “The literature actually says the opposite. A person who continues to smoke has a higher relapse risk of other substance use disorders at one year than a person who gets treated for both concurrently.”

The lack of an immediate deadly impact from tobacco addiction compared to other substances like opioids, while important distinctions, also influence provider decision-making around how and what to treat and when.

“I think the intuitive response to that has been: ‘That’s not the biggest problem right now. The tobacco use is not causing you to fall down drunk, drive drunk, overdose or anything like that. Let’s deal with that later. Let’s just get the alcohol or opioid use under control now,’” Dr. Suzette Glasner, chief scientific officer at Pelago, told BHB. “I think that this response has mostly been due to a fear-based set of decisions around if doing so is going to mess up recovery from the other thing.”

New York City-based Pelago is a virtual clinic for substance use management for tobacco, alcohol, opioid and cannabis use.

Reimbursement and ROI

Treating a patient for an OUD or other substance use issue first and adding on tobacco cessation also doesn’t guarantee reimbursement for that additional care, Dr. Chad Elkin, president of the Tennessee Society of Addiction Medicine and CEO of National Addiction Specialists, explained.

“We’ll start treating all these other substance use disorders like tobacco or nicotine as an add-on, but we may or may not get reimbursed for those things,” Elkin told BHB. “We’re just doing that for the patients. Sometimes there are add-on codes for these things and some insurance companies don’t have them. These services are kind of hit-and-miss, whether or not we get reimbursed for them.”

Reimbursement rates also tend to be higher for other addiction treatment services outside of tobacco or nicotine cessation. Putting reimbursement rates for any substance use disorder at the same level across the board would help shift provider focus to treating tobacco use alongside other SUDs more proactively, Elkin said.

“I think all substance use disorders need to be on par with the same should be the same level of reimbursement that an opioid use disorder visits are reimbursed at,” Elkin said. “I think that would help.”

Despite the potential for lower reimbursement, there is still a strong business case for offering this treatment as a provider, Glasner at Pelago argued. Pelago’s own research shows a 4.5 to 1 return on investment (ROI) across their substance use disorder programs, with tobacco cessation specifically yielding more than $6,000 in savings per member in the first year of treatment, she said.

“By treating a tobacco use disorder effectively, a program like ours may be addressing the alcohol use and other chronic, co-occurring conditions that both tobacco and alcohol contribute to,” Glasner said. “The greatest sources of cost savings are on the medical side rather than on the behavioral health side. When people become able to manage those conditions more effectively, then they’re utilizing inpatient and emergency care with about a third less of the frequency because they’re not having the related health complications that are bringing them into the hospital or the ER.”

The rise of vaping nicotine has also added confusion to the field and sparked more conversations about what reimbursement should look like.

Das, with the Stanford School of Medicine, has done work on the federal level to help influence reimbursement rates for tobacco counseling and improve coverage for medication-assisted therapies like nicotine replacement.

“While it’s still not optimal in the last decade or so that I’ve done this work, we have seen some gains from several of us trying to advocate for these changes,” Das said. “For an employer or a health plan, the business case is absolutely there. We know that continued tobacco use is very costly from a public health point of view. This ranges from the lives impacted, but also there’s more than $300 billion per year in direct medical care and lost productivity costs. This is very significant to groups that are thinking about the business case.”

The two areas of reimbursement that have had the most progress related to tobacco cessation are the inclusion of a Current Procedural Terminology (CPT) code for tobacco counseling and convincing more commercial insurers to cover medications for tobacco use disorder, she explained, but there’s still work to be done.

“Medications for tobacco use disorder are very effective and yet heavily underutilized. I think we’ve made some really great progress in making those medications be covered more, and we continue to push,” Das said. “But Medicare does not do this because nicotine replacement therapy is over the counter, which is so unfortunate because if I’m thinking about my community practice, my patients who rely on Medicare, they would really benefit from that, from that coverage.”

Shifting reimbursement models and mindsets

With the rise of vaping and an uptick in the use of nicotine pouches, demand for tobacco and nicotine cessation services is likely to grow in the coming years. Currently, it is unclear exactly how this will impact service line offerings or business margins for providers.

Better integration of mental and physical health care when it comes to substance use and shifting from a fee-for-service environment to one that is value-based could help reignite the uptake of tobacco use disorder treatment more broadly.

“Smoking and vaping have mental health consequences, physical health consequences, that drive up the total cost of care and drive down clinical outcomes,” Harrison said. “In the value-based environment, there’s an even bigger reason why value-based behavioral health providers should be centering smoking cessation support in their model. In the fee-for-service environment, the business case is harder – you wouldn’t just have a smoking cessation appointment, which is a tragedy.”

Since the current treatment landscape primarily treats tobacco cessation services as an “add-on,” to make progress in building back the business case to treat it as a substance use disorder will also require an industrywide shift in mindset.

“If we made a shift to say that tobacco is a primary need – that it is something we need to focus our energy on as providers, and it has the same impact, if not an even heavier impact, on public health compared to the other substance use disorders,” Das said. “If we can do that, then hopefully, we’ll see a shift in how often it’s treated.”