I recently attended the annual conference of the North American Quitline Consortium (NAQC) held on April 15, a gathering of clinicians dedicated to delivering high-quality tobacco cessation counseling by telephone. It is a remarkable model; quietly operating in the background of our healthcare system, staffed by professionals, whose sole focus is helping individuals stop using tobacco, at no cost to the callers.
I have long held deep respect for this community and their work. For many years, I ran smoking cessation programs myself and was often invited to teach at regional meetings of this group. Over time, however, I came to a humbling realization: they are better at this than I ever was. Their expertise is not theoretical. It is built on repetition, structure, and a singular focus on behavior change. As a result, I now say to people who want to stop their tobacco use “would you like to talk to an expert?”
Here is why their 2025 annual report was so unsettling. In the past year, Quitlines in the United States reported assisting just over 246,000 people who use tobacco. Set against the broader landscape, that number is strikingly small. According to the Centers for Disease Control and Prevention, approximately 19% of U.S. adults, 49 million people, use tobacco in one form or another. The contrast is difficult to ignore. We have, embedded within our system, a highly effective, accessible, and free treatment, and yet only a fraction of those who could benefit are ever connected to it.
It raises a basic but uncomfortable question: how did it come to pass that one of our best treatments is so rarely used?
Prior to the availability of medications, treatment of tobacco use was entirely based on counseling strategies which had produced significant and reliable outcomes. Participants in counseling learn to identify the triggers that precipitate tobacco use and develop strategies to cope with those episodes without using nicotine. Patients learn a sense of self-efficacy in controlling their use of tobacco products and are taught how to prevent relapses. The availability of medications to support tobacco treatment has been transformational, allowing any physician to help a patient initiate a quit attempt.
Virtually all published papers on the use of medications for the treatment of tobacco involved the addition of a medication to individual counseling. The control groups received counseling plus a placebo. Placebo alone (just counseling) produced pretty good results, but the addition of medications doubled or in the case of varenicline, even tripled the effectiveness of the placebo treatment. Framed the other way, counseling can double the effectiveness of any medication. The gap between clinical studies and the real world is rarely discussed. Patients enrolled in the studies received ten or more sessions of face-to-face counseling. Thus, one of the main drivers of successful treatment was frequent counselling sessions. In the real world, counseling is not readily available and not commonly used.
Counseling can be provided face to face by physicians or other clinicians in medical practices or telephonically, through Quitlines operated in each state. Numerous studies demonstrate that the ratio of physicians prescribing to physician counseling is between 4:1 and 5:1. Studies of medical claims show that when physicians provide counseling, the average number is 1.1; far from the ten sessions given in the published studies. Some physicians may mention that counseling is available at no charge by calling a toll- free number, but a direct connection is not made. The data from NAQC confirms this treatment gap.
Since 2008, clinical practice guidelines have recommended that people who use tobacco should be given advice to quit at every visit, and that they should be offered medications and counseling. Yet the data from the National Health Interview Survey shows that people who want to stop smoking use evidence-based treatment 38% of the time. Most people who want to stop do not receive any treatment at all. The failure to routinely provide treatment and provide effective treatment which includes counseling may help explain why people who are successful at quitting may make as many as twenty attempts and why many others just give up.
The barriers to guideline recommended treatment for tobacco use have been studied extensively: Physicians feel that there is insufficient time during the clinical encounter to address all the patients’ needs, tobacco treatment is not adequately reimbursed, and they do not feel that they are effective in providing treatment.
Looking at the workflow by which some clinicians refer their patients to the Quitline provides some simple and scalable solutions. The electronic medical record can be modified to make a referral to the Quitline with a single click. Quitlines will often make outbound calls to engage patients directly to make appointments for counseling. In recent years, there has been a shift from “opt in” programs to an “opt out” strategy. The previous approach asked patients if they were “ready to quit” and only referred those who stated they were ready to quit in the next month. New data shows even patients who say they are not ready to change can be successful after the application of motivational interviewing or a trial of quitting. Today, the EMR can be set to refer all tobacco users to the quit line regardless of their readiness to change. The trial of quitting is especially interesting as patients who have a low sense of self-efficacy are given a sample of a medication such as varenicline or nicotine and can discover their own behavior can change when nicotine-related cravings are reduced.
Although individual clinicians have a role in improving tobacco treatment, the failure to deliver evidence-based treatment on a routine basis is really a systems problem. There is a growing literature on systems change for tobacco treatment, but tobacco has remained a low priority for most medical groups and academic medical centers. As we move toward value-based care, the cost- effectiveness of treating tobacco will become increasingly important in driving change.
One of the barriers to effective tobacco treatment has been the lack of feedback and accountability. This will be remedied by a new HEDIS measure from the National Commission on Quality Assurance (NCQA). Previously NCQA measured treatment of tobacco through the CAHPS survey which only looked at a small sample of a health plans membership. The new approach will use electronic medical records and administrative data to measure screening for tobacco and its treatment. This level of granular data will allow health plans and clinical leaders to provide direct feedback to practicing clinicians and link performance to incentives.
What we are observing is not a failure of evidence but a failure of translation. The gap between 246,000 individuals served and forty-nine million who use tobacco is not driven by lack of motivation among patients. It reflects a system that has not operationalized one of its most effective treatments. Clinical leaders need to improve their workflows and upgrade their electronic medical records systems to support routine screening and treatment of tobacco.
The question, then, is not whether counseling works. It is whether we are willing to build systems that deliver it reliably. Quitlines represent a fully developed infrastructure for tobacco treatment. Their underuse is not a minor inefficiency; it is a missed opportunity at population scale.
If we are serious about reducing the burden of tobacco-related disease, we need to move beyond awareness and into system design. That means embedding counseling into routine care pathways, aligning incentives with outcomes, and ensuring that the connection between diagnosis and treatment is direct and dependable. Until that happens, one of our most effective treatments will remain one of our least used.
References:
Tobacco Product Use among U.S. Adults, 2023–2024 | NEJM Evidence
NAQC Annual Meeting - North American Quitline Consortium
Tobacco_Cessation_Change_Pkg.pdf
Tobacco Treatment as a Profit Center — Edward Anselm, MD
The Importance of Counseling in Treatment of Tobacco Use — Edward Anselm, MD