Does HHS and CMS understand the impact of smoking on health and health care costs for seniors?

The most recent Surgeon Generals’ Report estimates that over 480,000 people die of tobacco related diseases each year. Most of those people are seniors who on average die ten years sooner than non-smokers. Tobacco-related diseases profoundly affect the quality of life for over 16 million people and are estimated to contribute 8.6 percent of the total medical expense in the USA. The data summarized below suggests that clinicians who care for seniors are performing poorly on tobacco cessation services and that seniors are not getting the message about the availability of resources to help them stop. In spite of much excellent work, HHS and CMS need to do more.

A recent report on the prevalence of tobacco use shows that notwithstanding overall declines in the reported use of cigarette smoking from 2011 to 2022,  among adults 65 years and older, smoking prevalence increased slightly from 8.7% in 2011 to 9.4% in 2022. Trends in US Adult Smoking Prevalence, 2011 to 2022 | Health Policy | JAMA Health Forum | JAMA Network. Most smokers want to quit, yet more than two-thirds of adult cigarette smokers who tried to quit during the past year did not use evidence-based treatment such as counselling or medication. Smoking Cessation: A Report of the Surgeon General (Executive Summary) (hhs.gov), page 4.

 Kleykamp and Kulak observing the same data raised this concern in the American Journal of Public Health over a year ago, but there has been little response. Cigarette Use Among Older Adults: A Forgotten Population - ProQuest. They argue that the intense focus on youth adoption of tobacco in all its forms may have drawn away from appropriate attention to current smokers.

 Other evidence suggesting that CMS may be disregarding the available evidence on poor performance includes:

The recently released HHS Framework to Support and Accelerate smoking cessation does not reference seniors as one of the groups with a disparate impact, when in fact most of the effects of disparities become manifest among seniors. HHS Framework to Support and Accelerate Smoking Cessation 2024. While there is extensive presentation of the many tobacco control initiatives since 1980, there is no analysis of their limitations. The new framework presented is laudable but is likely to underperform if clinicians do not provide the basic services of tobacco cessation.

 The CMS Universal Foundation for Aligning Quality Measures released in 2023 does not include smoking cessation. Aligning Quality Measures across CMS — The Universal Foundation | New England Journal of Medicine (nejm.org)

 The highly detailed assessment of the Million Hearts Program does not include measures of tobacco cessation medications or counseling, and scant reference to tobacco use status which would have the highest impact of all modifiable risk factors. Evaluation of the Million Hearts® Cardiovascular Disease Risk Reduction Model Final Evaluation Report (cms.gov)

 The annual report from the North American Quitline Association stated that 22% of the 255,372 unique calls to one of the states’ quitlines were covered by Medicare. With 65M Medicare enrollees and a 9% prevalence, this indicates that only 0.1 percent of eligible smokers called. Quitlines average a success rate of 32 percent and provide free nicotine patches and gum which are not available from Fee for Service Medicare or Medicare Advantage plans. FY23_Annual_Survey_Slides_FI.pdf (ymaws.com)

Unpublished claims data from my former employers shows that fewer than 1% of Medicare Advantage members received both smoking cessation counseling and medication. The average number of counselling sessions for seniors who receive this service is 1.1 per year, even though the benefit is up to eight per year. Data from commercial insurance plans has similar evidence of underutilization of both medical and pharmacy interventions. While commercial insurers have state of the art resources available for all members who request them, these resources are not aggressively promoted. Many smokers are thus graduated to Medicare.

Data from electronic medical records of a large health system in Pennsylvania and Maryland show that smoking cessation counseling is rarely billed, with only 4.7 percent receiving counselling over a 3 year period. eventpower-res.cloudinary.com.pptx (live.com). At a meeting with CMS, held on 11/9/2022, representatives of ATTUD presented 2019 data showing that “Medicare currently is only spending $11.3 million annually on reimbursing for the current smoking cessation codes”. If the average reimbursement for those codes is $14.00, then there were approximately 800,000 counseling sessions. With over 65 million Medicare enrollees at that time, and a prevalence of 9%, this suggests that fewer than 1/7 smokers received cessation services.

Although NCQA has recognized the inadequacies of its CAHPS-based measure on advice to quit smoking, there is no haste in replacing it with a more reliable HEDIS measure. NCQA HEDIS measures and Medicare Stars measures have had a profound impact on physician practice but there has never been a STARS measure linked to tobacco. NCQA is exploring the development of two new measures related to tobacco use and lung cancer screening. These measures would potentially become part of HEDIS no earlier than measurement year 2026. CMS is considering proposing these measures for the Star Ratings pending future rulemaking. Summary of Changes in the 2025 Advance Notice (healthmine.com). Let’s make sure they adopt NQF 0028 Quality ID #226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention – National Quality Strategy Domain: Community / Population Health - Claims (cms.gov)

The recently released HHS Framework to Support and Accelerate smoking cessation does not reference seniors as a group  with a disparate impact, when in fact most of the effects of these disparities become manifest among seniors. HHS Framework to Support and Accelerate Smoking Cessation 2024

The key arguments for greater action are outlined by Tim McAfee Ignoring our elders: tobacco control’s forgotten health equity issue | Tobacco Control (bmj.com)

There is much more that HHS, CMS, health insurers, Accountable Care Organizations, hospitals and clinicians can do to improve cessation services to seniors.

Edward Anselm, MD Assistant Clinical Professor of Medicine, Icahn School of Medicine at Mount Sinai