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 authorization, or annual limits on quit attempts (CG-Tobacco use). As of 2016, the US Food and Drug Administration (FDA) has approved nine therapies for tobacco cessation: individual counseling, group counseling, nicotine patches, nicotine gum, nicotine lozenges, nicotine nasal sprays, nicotine inhalers, Bupropion, and Varenicline (CDC-MMWR-DiGiulio 2016).
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.
Expected Beneficial Outcomes (Rated)
Increased quit rates
Increased access to cessation treatment
Increased use of cessation treatment
Evidence of 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 rates (CG-Tobacco use, Hoffman 2015, Cochrane-Reda 2012*).
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 success in quitting (CG-Tobacco use, Hoffman 2015, Cochrane-Reda 2012*). A Massachusetts-based study suggests that efforts that include coverage expansion for medications and counseling may also increase quit rates (Land 2010).
States with expanded Medicaid coverage for tobacco cessation therapies have higher levels of cessation treatment (Ku 2016*) and higher quit rates (Greene 2014*) than states with lower levels of coverage. Expanded Medicaid coverage for tobacco cessation therapies may also reduce smoking among women before they become pregnant (Adams 2013a).
Cessation therapies may be underutilized even when Medicaid covers cessation treatment (Ku 2016*). Common barriers to cessation treatment for Medicaid patients include prior authorization requirements, limits on length of treatment, annual limits on quit attempts, and co-payment requirements (CDC-MMWR-Singleterry 2015). 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 rates (Ku 2016*).
Pharmacotherapies, behavioral therapies (Ruger 2012, Richard 2012a), and multi-component efforts (Richard 2012a) 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 expenditures (Athar 2016*). Former smokers have lower health care costs than current smokers over the long-term (Hockenberry 2012*).
Impact on Disparities
As of July 2016, 32 states and Washington DC expanded Medicaid coverage, including tobacco cessation benefits, under the Affordable Care Act (ACA). Nine states (Colorado, Connecticut, Indiana, Massachusetts, Minnesota, North Dakota, Ohio, Pennsylvania, and Vermont) have comprehensive coverage for all nine approved tobacco cessation therapies (CDC-MMWR-DiGiulio 2016).
CDC-Cessation coverage - Centers for Disease Control and Prevention (CDC). 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.
Citations - Evidence
* Journal subscription may be required for access.
CG-Tobacco use - The Guide to Community Preventive Services (The Community Guide). Tobacco.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Citations - Implementation Examples
* Journal subscription may be required for access.
CDC-MMWR-DiGiulio 2016 - DiGiulio A, Haddix M, Jump Z, et al. State Medicaid expansion tobacco cessation coverage and number of adult smokers enrolled in expansion coverage - United States, 2016. Morbidity and Mortality Weekly Report (MMWR). 2016;65(48):1364-1369.
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