National Working Group for ACTTION

January 26, 2010

The most extensive tobacco control programs in the United States, including cessation services, are provided or regulated by the states. Several recent reports offer a snapshot view of the progress that states are making in directly providing cessation services, paying for them, or assuring that other payers cover them.   The results fall far short of what is needed to reach the goal set by the Call to ACTTION—expand access to comprehensive tobacco cessation treatment to 50% of smokers by 2015, and 100% by 2020. 

The 2009 report, “ A Broken Promise to Our Children: The 1998 State Tobacco Settlement 11 Years Later,” reviewed annual spending by states to reduce tobacco use, ranking  state efforts according to the funding levels recommended by the U.S. Centers for Disease Control and Prevention (CDC).  By that measure, only one state (North Dakota) is funding tobacco-use prevention at the recommended level and only nine others at even half the recommended level. According to the report, in 2009 the total state and federal spending for all tobacco control programs was $629.5 million, or about 17 percent of the CDC recommendation. (http://www.tobaccofreekids.org/reports/settlements/)

The report, released by the Campaign for Tobacco-Free Kids, American Heart Association, American Cancer Society Cancer Action Network, American Lung Association and Robert Wood Johnson Foundation, did not examine funding levels for the specific program components of the CDC recommendations, such as cessation. However, it is instructive to review what the recommended cessation services would include if adequately funded.

The CDC Best Practices for Comprehensive Tobacco Control Programs discusses the elements and funding that should be included in state tobacco use prevention programs.  Slightly over $1 billion is recommended for cessation intervention, out of $3.7 billion total annual spending recommended for all state programs,   

Using the Public Health Service Clinical Practice Guideline on Cessation as a starting point, the CDC describes the interventions that states should provide.  The recommended budget includes funding for screening of tobacco users and brief advice for quitting, as well as telephone-based quitline services and limited provision of no-cost or low-cost over-the-counter nicotine replacement therapy. 

In addition to the cessation services envisioned in the state tobacco control budget, the CDC expects that states will work with Medicaid and private insurers to increase comprehensive insurance coverage.  The American Lung Association (ALA) looked at how states were doing in providing these services in its report “Helping Smokers Quit: State Cessation Coverage 2009.” (http://www.lungusa.org/assets/documents/publications/other-reports/smoking-cessation-report-2009.pdf) 

Medicaid coverage for cessation services varies widely across the states.  According to the ALA, only six states provide comprehensive coverage for Medicaid recipients, while another 15 provide almost comprehensive coverage.  Half the states provide inadequate cessation coverage and five none at all.  The overview of state employee health plans is just as varied and just as unimpressive as that for Medicaid.  Only five states provide their own employees comprehensive coverage through their insurance plans, another five offer almost comprehensive coverage, and the remaining 40 have inadequate coverage, with eight of those offering none. The November 6, 2009 MMWR article “State Medicaid Coverage for Tobacco-Dependence Treatments—- United States, 2007” had similar findings. (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5843a1.htm)

Massachusetts has had amazing success providing virtually free access to tobacco cessation services for its Medicaid recipients.  This program was featured in the Partnership webinar on November 19. (https://www120.livemeeting.com/cc/intercall1/view?cn=&id=111909&pw=view)

and in the New York Times (http://www.nytimes.com/2009/12/17/us/17smoke.html?scp=2&sq=cessation&st=cse). Senators Richard J. Durbin of Illinois and Bernard Sanders of Vermont introduced an amendment to the health reform bill that would provide similar new Medicaid coverage for tobacco addiction nationwide.  Partnership and 10 other ACTTION partners sent a strong letter of support for this provision before the final Senate vote in December

As the ALA report notes, private insurance coverage for cessation varies widely state-by-state, employer-by-employer, and plan-by-plan. In a few states, laws or insurance regulations do require cessation coverage in some or all private insurance plans in the state. There is no uniformity in these requirements. Some have requirements for a “tobacco ces­sation program” or “interventions” to be covered, but do not specify which treatments are included. Other states are more specific, ensuring that certain medications or types of counseling are available for all applicable smokers.

States also aid cessation through tobacco cessation telephone quitlines. Every state has its own cessation quitline as a result of the 2004 National Net­work of Tobacco Cessation Quitlines Initiative by the U.S. Department of Health and Human Services. These quitline phone num­bers are available to anyone, regardless of insurance status. However, services available from the quitline can vary depending on the insurance status of the caller and other eligibility requirements. The North American Quitline Consortium found in its 2008 survey that quitlines were reaching about 1% of the U.S. smoking population. (http://www.naquitline.org/resource/resmgr/ql_about_facts/2008_quitline_facts_qa_final.pdf)

At the CDC recommended funding level, states could serve 8% of their adult tobacco users through the quitline.