Tobacco cessation therapy affordability

Evidence Rating  
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Health Factors  
Decision Makers
Date last updated

Tobacco cessation therapies such as nicotine replacement therapy (NRT) and individual, group, and telephone counseling often include out-of-pocket costs for patients. Efforts to increase affordability of cessation therapies can include eliminating patients’ out-of-pocket expenses or reducing patients’ expenses by eliminating co-payments, limits on duration of treatment, prior authorizations, or annual limits on quit attempts1. Medicaid programs may choose to cover a combination of individual, group, and telephone counseling for tobacco cessation, and seven medications approved by the U.S. Food and Drug Administration (FDA): nicotine patches, nicotine gum, nicotine lozenges, nicotine nasal sprays, nicotine inhalers, Bupropion, and Varenicline2.

Note: The term “tobacco” in this strategy refers to commercial tobacco, not ceremonial or traditional tobacco. County Health Rankings & Roadmaps recognizes the important role that ceremonial and traditional tobacco play for many Tribal Nations, and our tobacco-related work focuses on eliminating the harms and inequities associated with commercial tobacco.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Increased quit rates

  • Increased access to cessation treatment

  • Increased use of cessation treatment

What does the research say about effectiveness?

There is strong evidence that reducing out-of-pocket costs for tobacco cessation therapy increases access to and use of cessation treatment and increases quit rates1, 3, 4.

Interventions that eliminate out-of-pocket costs for smokers in the process of quitting have been shown to increase quit attempt rates, use of smoking cessation treatments, and quitting success1, 3, 4. A Massachusetts-based study suggests that efforts that include coverage expansion for medications and counseling may also increase quit rates5.

States with expanded Medicaid coverage for tobacco cessation therapies may have higher levels of cessation treatment6 and quit rates7 than states with lower levels of coverage. Expanded coverage may also reduce smoking among women before they become pregnant8. However, evidence of the Affordable Care Act’s Medicaid expansion’s impact on cessation is somewhat mixed; while one study suggests smoking cessation increased9, another did not10, which may indicate there are other challenges and barriers to accessing cessation therapy10.

Cessation therapies may be underutilized even when Medicaid covers cessation treatment6. Common barriers to cessation treatment for Medicaid patients include the need for prior authorization(s), limits on length of treatment, annual limits on quit attempts, and co-payment costs11. Wisconsin and Massachusetts-based studies suggest that collaborative education campaigns by public health and Medicaid officials regarding the availability of smoking cessation therapy may improve cessation treatment usage rates6.

Pharmacotherapies, behavioral therapies12, 13, multi-component efforts13, and community-based interventions14 are cost-effective methods to reduce smoking. Economic modeling suggests that expanding Medicaid coverage to eliminate out-of-pocket costs for nicotine replacement therapy (NRT) may reduce overall Medicaid expenditures15. Former smokers have lower health care costs than current smokers over the long-term16.

How could this strategy impact health disparities? This strategy is rated likely to decrease disparities.
Implementation Examples

All state Medicaid programs cover some tobacco cessation treatments for all enrollees2. As of November 2021, 39 states and Washington, D.C. expanded Medicaid coverage, including tobacco cessation benefits, under the Affordable Care Act (ACA)17. As of September 2021, 20 states have comprehensive coverage for all nine approved tobacco cessation therapies2.

Implementation Resources

CDC-Cessation coverage - Centers for Disease Control and Prevention (CDC). Smoking & Tobacco Use: Coverage for tobacco use cessation treatments.

HealthPartners-CHA - HealthPartners Institute for Education and Research. Community health advisor (CHA): Resource for information on the benefits of evidence-based policies and programs: Helping communities understand, analyze, and model costs.


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1 CG-Tobacco - The Guide to Community Preventive Services (The Community Guide). Tobacco.

2 CDC-STATE Medicaid coverage fact sheet - Centers for Disease Control and Prevention (CDC). State tobacco activities tracking and evaluation (STATE) system. STATE system Medicaid coverage of tobacco cessation treatments fact sheet. 2021.

3 Hoffman 2015 - Hoffman SJ, Tan C. Overview of systematic reviews on the health-related effects of government tobacco control policies. BMC Public Health. 2015;15:744.

4 Cochrane-Reda 2012 - Reda AA, Kotz D, Evers SAA, van Schayck CP. Healthcare financing systems for increasing the use of tobacco dependence treatment. Cochrane Database of Systematic Reviews. 2012;(6):CD004305.

5 Land 2010 - Land T, Warner D, Paskowsky M, et al. Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence. PLOS ONE. 2010;5(3):e9770.

6 Ku 2016 - Ku L, Bruen BK, Steinmetz E, Bysshe T. Medicaid tobacco cessation: Big gaps remain in efforts to get smokers to quit. Health Affairs. 2016;35(1):62-70.

7 Greene 2014 - Greene J, Sacks RM, McMenamin SB. The impact of tobacco dependence treatment coverage and copayments in Medicaid. American Journal of Preventive Medicine. 2014;46(4):331-336.

8 Adams 2013a - Adams EK, Markowitz S, Dietz P, Tong VT. Expansion of Medicaid covered smoking cessation services: Maternal smoking and birth outcomes. Medicare & Medicaid Research Review. 2013;3(3):E1-E23.

9 Koma 2017 - Koma JW, Donohue JM, Barry CL, Huskamp HA, Jarlenski M. Medicaid coverage expansions and cigarette smoking cessation among low-income adults. Medical Care. 2017;55(12):1023-1029.

10 Donahoe 2019 - Donahoe JT, Norton EC, Elliott MR, et al. The Affordable Care Act Medicaid expansion and smoking cessation among low-income smokers. American Journal of Preventive Medicine. 2019;57(6):e203-e210.

11 CDC-MMWR-Singleterry 2015 - Singleterry J, Jump Z, DiGiulio A, et al. State Medicaid coverage for tobacco cessation treatments and barriers to coverage - United States, 2014-2015. Morbidity and Mortality Weekly Report (MMWR). 2015;64(42):1194-1199.

12 Ruger 2012 - Ruger JP, Lazar CM. Economic evaluation of pharmaco- and behavioral therapies for smoking cessation: A critical and systematic review of empirical research. Annual Review of Public Health. 2012;33(1):279-305.

13 Richard 2012a - Richard P, West K, Ku L. The return on investment of a Medicaid tobacco cessation program in Massachusetts. PLOS ONE. 2012;7(1):e29665.

14 Reisinger 2019 - Reisinger SA, Kamel S, Seiber E, et al. Cost-effectiveness of community-based tobacco dependence treatment interventions: Initial findings of a systematic review. Preventing Chronic Disease. 2019;16.

15 Athar 2016 - Athar H, Chen ZA, Contreary K, et al. Impact of increasing coverage for select smoking cessation therapies with no out-of-pocket cost among the Medicaid population in Alabama, Georgia, and Maine. Journal of Public Health Management & Practice. 2016;22(1):40-47.

16 Hockenberry 2012 - Hockenberry JM, Curry SJ, Fishman PA, et al. Healthcare costs around the time of smoking cessation. American Journal of Preventive Medicine. 2012;42(6):596-601.

17 KFF-State Medicaid expansion - KFF. Status of state Medicaid expansion decisions: Interactive map. 2023.