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Changing the default for a behavioral change smoking cessation program from opt in to opt out resulted in large gains for referrals to treatment in new research. However, gains in referrals didn’t lead to gains in quitting smoking.

Scott Sherman, MD, MPH, with VA New York Harbor Healthcare System in New York City presented his team’s poster at Society of General Internal Medicine (SGIM) 2025 Annual Meeting in Hollywood, Florida.

“This change, which did not require additional staff, had a profound effect on care,” the authors wrote. But Sherman told Medscape Medical News he was disappointed when they found out with surveys at 2 years and electronic health record information that increased referrals and engagement didn’t lead to the ultimate goal of quitting.

Behavioral Treatments Underused

Behavioral treatments for helping patients quit smoking are effective but underused, and most use an opt-in approach so patients have to enroll, the authors wrote. This opt-out approach refers everyone to treatment unless they choose not to participate.

The researchers conducted a cluster randomized trial at the VA New York Harbor Healthcare System and randomized all nursing assistants and registered nurses (NAs/RNs) either to an opt-in or opt-out approach.

In the opt-in approach group (n = 1975), providers got clinical reminders annually to refer patients who smoke either to the New York State Quitline program or to a text messaging service. Interested patients completed a referral form. In the opt-out group (n = 749), the reminder instructed the NAs/RNs to tell people who smoke that they would be automatically referred to the Quitline or to text messaging unless they opted out by completing a form.

Referrals Spike With Opt-Out

They found people seen by NAs/RNs in the opt-out group (n = 749) were much more likely to be referred to text messaging (46% vs 6%; odds ratio [OR], 21.0; 95% CI, 8.9-49.8) or the Quitline (45% vs 5%; OR, 29.2; 95% CI, 11.5-74.2) than those seen in the opt-in approach.

Those in the opt-out group were also much more likely to participate in text messaging (43% vs 5%; OR, 23.5; 95% CI, 9.7-56.9) and more likely to engage in counseling through the Quitline (5% vs 0.7%; OR, 8.9; 95% CI, 4.1-19.5) than patients in the opt-in group.

Patients were just as likely in either group to report they were strongly encouraged to receive a referral (OR, 1.48; 95% CI, 0.87-2.51) and that the overall quality of discussion was very good or better (OR, 1.23; 95% CI, 0.79-1.98). However, the researchers noted, those in the opt-out group were twice as likely to report they felt forced to receive a referral (OR, 2.04; 95% CI, 1.14-3.68).

No Added Staffing, But Unknown Costs

Jennifer Hauler, DO, a family and emergency medicine physician and chief medical officer at Premier Health in Dayton, Ohio, noted that behavioral counseling programs have proven effective in helping people to quit smoking. She told Medscape Medical News that strategies that increase referrals to these programs are of high interest especially when they don’t require additional staffing.

However, she said, “While the study highlights that no additional staff resources were required, it does not quantify the potential increased costs incurred by the Quitline or cessation programs.”

Hauler added that combination with pharmacotherapy may boost results.

“The addition of pharmacotherapy to behavioral interventions has been shown to enhance cessation outcomes,” she said.

Sherman said he hopes to tweak the protocol in future research to see if changes could bring better results in quitting.

“We got them to treatment, so why didn’t it work?” he said he asks himself.

He said there are still messages in the work for physicians. One is that “simple changes to the way we deliver care can have profound effects,” Sherman said. “The only thing we did was change the default.” 

More physician encouragement for patients trying to quit may also help those who have gotten as far as treatment, he said. “Patients often say that the doctor’s advice really matters to them.”

Sherman said he was surprised to see that twice as many patients in the opt-out group felt forced to receive a referral.

“As a primary care doctor, I certainly don’t want to force my patients to do anything, but at the same time I don’t mind pushing them to do something that’s really good for their health.” Finding the right balance is key, he said.

Sherman and Hauler reported no relevant financial relationships.