Comment to the Centers for Medicare & Medicaid Services Opposing the Proposed Removal of Two Tobacco Measures at Inpatient Psychiatric Facilities



Centers for Medicare & Medicaid Services: C5-05-27

7500 Security Blvd.

Baltimore, MD 21244

Re: Comments in Docket No. CMS-2018-0053, FY 2019 Inpatient Psychiatric Facilities Prospective Payment System – Rate Update CMS-1690-P

Despite recent and impressive decreases in smoking prevalence, smoking remains the number one health problem in the United States.[i] Increasingly, the burden of smoking has fallen on persons with mental illness and substance use disorders, who smoke at rates two to three times higher than the general population.[ii] Tragically, for many years, the mental health treatment culture ignored and even encouraged cigarette smoking, even though smoking was, and continues to be, the most important contributor to death and disability in this population.[iii] Research has demonstrated that smokers with behavioral health conditions are motivated to quit, have the capacity to do so, and benefit greatly from evidence based cessation treatment.[iv] More recently, a shift has occurred, and clinicians and institutions are beginning to address smoking cessation.

An important component of that evolution was The Centers for Medicare & Medicaid Services’ (CMS) landmark decision to promote the use of tobacco measures as quality indicators within psychiatric facilities, namely TOB-1, 2, and 3. These measures have the effect of reminding clinicians of the importance of addressing tobacco use and encouraging them to take action. Thus, it is dismaying to learn that CMS is considering removing TOB-1, TOB-3, and TOB-3a. The stated reason for removing TOB-1 is that the performance is so high. However, maintaining high performance is precisely the intent. We are very concerned about reversing valuable gains that have been made should the measure be removed. While it is clear that increased numbers of clinic staff are addressing cessation with clients, there is still significant room for improvement. According to a recent report, only 48.9 percent of mental health treatment facilities reported screening patients for tobacco use and only 64 percent of substance abuse treatment facilities reported screening patients for tobacco use.[v]

The rationale for removing TOB-2 and TOB-3 is to ease regulatory burdens. Given the magnitude of the smoking epidemic, and the relatively minor burden of addressing it, we believe the proposal is an example of being “penny wise and pound foolish,” and we strongly recommend retaining all three measures.

Respectfully Submitted,

Smoking Cessation Leadership Center

Truth Initiative

American Cancer Society, Inc.

American Cancer Society Cancer Action Network

American Psychological Association

National Association of State Mental Health Program Directors

National Council for Behavioral Health

Tobacco Control Legal Consortium


[i] Carter BD, Abnet CC, Feskanich D, et al. Smoking and Mortality – Beyond Established Causes. N Engl J Med 2015; 372: 631-40. DOI: 10.1056/NEJMsa1407211

[ii] Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The NSDUH Report: Adults with Mental Illness or Substance Use Disorder Account for 40 Percent of All Cigarettes Smoked. March 20, 2013. Rockville, MD. Accessed 2018 June 15.

[iii] Schroeder SA, Clark B, Cheng C, Saucedo CB. Helping Smokers Quit: The Smoking Cessation Leadership Center Engages Behavioral Health by Challenging Old Myths and Traditions. J Psychoactive Drugs 2017; Dec 26:1-8.

[iv] Prochaska JJ, Das S, Young-Wolff KC. Smoking, Mental Illness, and Public Health. Annu Rev Public Health 2017; 38:165-85. DOI: 10.1146/annurev-publhealth-031816-044618

[v] 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; 67:519-23. DOI: