Volume 2: No.
4, October 2005
Use of a New Comprehensive Insurance Benefit for Smoking-Cessation Treatment
Marguerite E. Burns, MA, Marjorie A. Rosenberg, PhD, Michael C. Fiore,
Suggested citation for this article: Burns ME, Rosenberg MA, Fiore
MC. Use of a new comprehensive insurance benefit for smoking-cessation treatment. Prev Chronic Dis [serial online] 2005 Oct [date cited]. Available from:
Uncertainty about levels of employee use
of an insurance benefit for smoking-cessation treatment has presented a
barrier to employers considering the adoption of such coverage.
This study examined self-reported awareness and use of a new
insurance benefit for smoking-cessation treatment among a sample of Wisconsin
state employees, retirees, and adult dependents.
We evaluated the self-reported use of insurance coverage for
smoking-cessation treatment during the first 2 years of its availability to
the Wisconsin state employee, retiree, and adult dependent population. We conducted analyses
of responses to smoking-related questions in 2001 and 2002 cross-sectional surveys of
insured state employees, retirees, and adult dependents, weighted to represent this population.
In 2002, benefit use among smokers aware of the benefit was 39.6%, and
benefit use among smokers unaware of the benefit was 3.5%. Only 27.4%
of smokers were aware of the benefit in 2002; use among all smokers was 13.6%.
Of all smokers, 30.4% used smoking-cessation treatment medication
(over-the-counter or covered) in 2002. Smoking prevalence was 15.6% in 2001
and 13.2% in 2002.
In an educated employee population, self-reported smoking-cessation
treatment benefit use was modest among all smokers during its first 2 years of
availability. Benefit awareness was low in this educated population, which may help
explain low use rates, particularly given the 30% of all smokers who attempted
to quit smoking with the help of smoking-cessation treatment medication. These
data provide use-rate estimates for states contemplating adoption of an
evidence-based smoking-cessation treatment benefit.
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As part of a comprehensive tobacco-control strategy, public health experts
recommend insurance coverage for evidence-based smoking-cessation treatments (SCTs) such as
smoking-cessation medications approved by the Food and Drug Administration
(FDA) (1-3). These medications can double or triple the likelihood of quitting
smoking compared with quitting without such treatment (3). Moreover, insurance
coverage for evidence-based SCTs has been shown to reduce smoking rates in
insured populations (4,5). Although some health plans have adopted these public health
recommendations, a sizeable gap remains between the recommended availability
and the actual availability of such coverage. For example, a sample of U.S. health plans reported
that 41% of their best-selling commercial health maintenance organization
(HMO) products provide coverage for at least one FDA-indicated
smoking-cessation medication (6). Coverage among employers varies despite
research showing that workplace productivity increases and absenteeism
decreases among former smokers compared with smokers (7). Nationally, 23%
to 64% of employers provide some form of insurance coverage for SCTs (8,9).
Health insurers and employers have offered various explanations for the
limited provision of health insurance coverage for SCTs; among these is their
uncertainty about the levels of use of such coverage.
In a series of focus groups, employers cited low benefit-use rates as one
of the primary reasons for not covering preventive health services, including
SCTs, and questioned the need to provide coverage for services that their
employees rarely used (10). Health care purchasers, insurance brokers, and
benefits consultants have named a lack of beneficiary demand as one
explanation for their limited efforts to negotiate health-behavior change
benefits and programs, including SCTs (11). Insurers have also expressed
skepticism about member use of SCT coverage and thus the need to cover it.
Insurers have asserted that many people quit smoking on their own (12), and
that smoking-cessation medication is available over-the-counter (OTC); thus,
SCT coverage is redundant (13).
Uncertainty about levels of SCT use poses a second challenge to adopting such
coverage: employers and insurers find it difficult to anticipate the cost of
SCT coverage. At a minimum, employers require short-term cost estimates for an SCT benefit to make a coverage decision (14). Employers have further indicated
that to increase coverage for preventive services such as SCTs, information on
coverage costs and potential returns on such an investment is also needed
In recent years, several studies have addressed the extent to which
insured individuals use SCT benefits when they are available. In evaluating
four SCT-benefit designs on benefit use and smoking outcomes, Curry et al
estimated SCT benefit-use rates of 2.4% to 10% among smokers; rates depended
upon the benefit design (4). To use the medication component of these
benefits, the health plan required smokers to participate in a
smoking-cessation counseling program. This requirement may have reduced use of
the benefit. If so, the study findings may underestimate population use rates
for a pharmacotherapeutic benefit that does not require participation in a
In another study, Schauffler et al examined the relationship between SCT
coverage, SCT use, and smoking outcomes; they reported that 25% of smokers
with SCT coverage used the covered medication (5). The sample included only
smokers who were willing to participate in a randomized controlled trial. To
the extent that the smokers in the sample were more interested in quitting
than a population-based sample of smokers (they volunteered for the study),
the results may overestimate SCT benefit-use rates.
In other aspects of the studies discussed above, Schauffler et al and Curry
et al showed that providing insurance coverage for SCTs increases treatment use
(5) and reduces smoking prevalence within defined populations (4). In
contrast, Boyle et al found similar SCT-use rates for smokers with and without
SCT insurance coverage; approximately 24% of smokers used bupropion, and 27%
used nicotine replacement therapy to make an attempt to quit (15). In the Boyle
sample, almost half of smokers reported an interest in quitting within the
next 30 days. Because of the interest in quitting among smokers in the sample, the treatment-use rates
observed in this population may overestimate rates that an employer or insurer
could expect from their total population. For example, in a population-based
study, Wewers et al found that approximately 8% of daily smokers planned to
make an attempt to quit during the next 30 days. However, this same group of
smokers also reported that they had stopped smoking for a day or more during
the past 12 months (16). One cannot conclude that the results of these
three studies on SCT benefit use will apply to population-based studies.
The purpose of the present population-based study is to evaluate the
self-reported use of insurance coverage for SCTs during the first 2 years of
its availability to the Wisconsin state employee, retiree, and adult dependent population.
The study findings are intended to reduce the uncertainty surrounding what
employers, particularly large public employers, can expect when they provide a
new SCT benefit.
In January 2001, the Wisconsin Department of Employee Trust Funds
(DETF) introduced a health insurance benefit for SCTs for its approximately
183,000 insured employees and their dependents. The DETF required that state
employee health insurance plans provide counseling and prescription medication
for smoking cessation. (One health plan was exempt from this requirement. Its
members, approximately 10% of the total insured population, were excluded from
this study.) The benefit included one 3-month course of prescription
pharmacotherapy and one office visit for counseling per calendar year.
Counseling was not required to obtain pharmacotherapy, and OTC medication was
not covered by the benefit. There was no lifetime limit.
Table 1 provides a
summary of the benefit.
Before January 2001, the availability and scope of coverage for SCTs for
Wisconsin state employees, retirees, and adult dependents varied widely. A 1998 survey
found that 7 of the 25 Wisconsin state employer-sponsored health plans covered
some form of SCT. Significant up-front patient cost sharing was often
required, with reimbursement contingent upon the completion of counseling,
maintaining abstinence from smoking, or both (13). Thus, the benefit
introduced in 2001 expanded the availability of SCTs for the insured state
employee, retiree, and adult dependent population.
The DETF notified its employee and retiree populations in October 2000 of the new SCT
benefit in the open enrollment materials provided to employees, retirees, and
adult dependents. A summary of the SCT benefit was included among other health
plan or benefit changes listed in the first two pages of the group health
insurance plans and provisions booklet (17).
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From approximately March through June in both 2001 and 2002, the DETF
conducted a computer-assisted telephone-interviewing (CATI) survey of covered
state employees, retirees, and adult dependents to assess their experiences and satisfaction with
their health insurance plan and health care. The DETF used the adult
commercial Consumer Assessment of Health Plans Survey (CAHPS) (18), adding questions on smoking to the CAHPS core instrument for survey years 2001 and 2002.
Added questions covered current smoking status, awareness of the SCT insurance
benefit, use of the SCT benefit, and in 2002, use of over-the-counter SCTs. We collected
sociodemographic data on age, education, and sex.
CATI interviewers progressed through a four-step training process,
including 1) learning about the data-collection instrument, 2) mock
interviewing, 3) monitoring veteran interviewers, and 4) ongoing performance
feedback through the data-collection period. A minimum of 10% of all
interviews was monitored by telephone laboratory supervisors.
The sampling frame included all state employee and retiree contracts for
individual or family employer-sponsored health insurance in which employees had
been in their selected health plan for 12 or more months. In 2001, the
sampling frame included 82,984 contracts; in 2002, the sampling frame included
69,600 contracts. The sampling frame
was stratified by health insurance plan or carrier (henceforth called plan),
with 19 plans in 2001 and 22 plans in 2002. The sample size in each stratum
was based on two considerations: 1) the estimated number of state employees,
retirees, and dependents in each plan and 2) the state’s interest in
reaching a precision level of ±5% of each plan’s population mean for the
response to each survey question with 95% confidence. After the sample size by stratum was
determined, a random sample of employee and retiree health insurance contracts
was selected within each stratum with a goal of achieving a 70% response rate
for each stratum.
Each contract in each stratum had a known, nonzero probability of selection.
Table 2 presents the number of contracts, the estimated number of state
employees, retirees, and adult dependents and the number of respondents for each stratum.
The survey respondent was the person in the household most knowledgeable
about the health care received by all family members covered by the
employer-sponsored health plan. These respondents constituted our sample. The
interviewer used the following screening question to identify this respondent:
“For this study, we are interested in speaking to the person who knows the
most about the health care received by all of the people in your family
covered by your health care plan. Would that be you?” If the respondent
indicated that he or she was that person, the interview continued. If not, the
interviewer asked the respondent to identify the appropriate person. If
necessary, the interviewer arranged a call back to contact this person. The
interviewer then began the interview with the above screening question.
The survey contact rates (the number of households
contacted divided by the total sample) were 64% for 2001 and 70%
for 2002. The survey refusal rates (the number of households that refused to
participate divided by the total sample) were 14% for 2001 and
12% for 2002. The survey response rate in both years was 64%. We calculated
the response rate using the Council of American Survey Research Organizations method
employed for the Behavioral Risk Factor Surveillance System (19).
According to this method, the numerator is the number of completed interviews,
and the denominator includes all valid households in the sampling frame (i.e.,
living employees, retirees, and adult dependents, working telephone number, valid health
plan membership). This method allocates households with unknown validity (e.g.,
busy phone line, no answer) to valid or invalid status according to the
proportion of valid and invalid households among those with known validity.
The final sample included 5609 individuals in 2001 and 6518 individuals in
2002 who subscribed to health plans that were required to provide coverage for SCT.
Assessing smoking status
There were some differences in the smoking-related questions in the
2001 survey compared with the survey questions in 2002 because the 2001 survey was
conducted within a few months of the introduction of the new SCT benefit. In
2001, we included a question to assess smoking status just before the
introduction of the benefit. Respondents were asked if they had smoked every
day, some days, or not at all during the month of December 2000. This
question was used only to estimate the number of individuals who might use
insurance coverage for SCT in 2001.
In 2001 and 2002, we asked respondents if they had smoked every day,
some days, or not at all during the past 12 months. Individuals were
considered smokers if they reported smoking every day or some days. Responses
to this question were used to estimate the smoking prevalence rate for the
state employee population, to compare estimates between the 2 years, and to
estimate the population eligible to use the SCT benefit in 2002.
Measuring awareness of SCT insurance benefits
We also asked respondents if prescription medications for smoking cessation
were covered by their health insurance plan. The question included
the list of medications that were actually covered by the DETF’s health
insurance benefits package. We considered respondents to be aware of coverage
if they answered yes to this question.
Defining users of SCT benefit
We asked self-reported smokers if their health plan had paid for
prescription medications to help them quit smoking. We posed a separate
question for each of the four prescription medications covered. In 2001, we
asked respondents to reply to these questions based on their experience since
January 1, 2001, the effective date of the SCT insurance coverage. In 2002, we
asked respondents to reply based on their experience during the past 12
Defining users of OTC medications
In 2002, we asked self-reported smokers if they had purchased OTC
medication, such as the nicotine patch or nicotine gum, to help them quit smoking. We defined OTC users as those who reported they had made
such a purchase. An individual could potentially report the prescription
benefit use, OTC use, or both.
Analyses consisted of descriptive statistics and tests of the relationships
between survey year and each outcome. We used Stata version 8.0 (Stata Corp,
College Station, Tex) (20) to perform all analyses, which were weighted for representativeness
in the population. To test for differences in demographic characteristics
between 2001 and 2002, we used a Pearson chi-square test for variables with
multiple response options (age and education) and a Student t test for
sex. For smoking prevalence, benefit awareness, benefit use, and OTC
medication use, we estimated population rates adjusted for the sampling
weights. For the outcomes assessed in both survey years using
comparable survey questions — smoking prevalence and benefit awareness —
we used a Student t test to test for a difference in population means
between 2001 and 2002.
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Table 3 presents the demographic characteristics of
the unweighted sample data; Table 4 presents the demographic characteristics
of the weighted sample data.
We discuss below the weighted sample demographics because our aim is to make
inferences to the state employee, retiree, and adult dependent population as a
whole. More than 80% of the sample had some college education, and more than
55% of the sample had a 4-year college degree or more. Approximately 44% of
the respondents in each year were male. Differences in age, education, and sex
for 2001 and 2002 were not statistically significant. We assume that the
demographic characteristics of the samples reflect the state employee,
retiree, and adult dependent population for each year.
The study outcomes assessed in 2001 and 2002 are presented in
Population smoking prevalence estimated from the sample declined from 15.6% in
2001 to 13.2% in 2002 (P = .01). Awareness of the benefit grew from an
initial 20.6% of smokers in 2001 to 27.4% in 2002 (P = .02). During the
first 3 to 6 months of the benefit’s availability in 2001, 7.1% of smokers
reported benefit use. In 2002, 13.6% reported benefit use. Benefit use among
smokers aware of the benefit was 23.6% in 2001 and 39.6% in 2002. Benefit use
among smokers who were unaware of the benefit was 2.9% in 2001 and 3.5% in
2002. (Unaware smokers who reported using the benefit would have paid a
typical copayment to receive SCT medications. We assume that they did not
interpret use of a copayment as insurance coverage for SCT
In 2002, we also collected information on OTC medication use. These
findings are presented in Table
6. We found that 9.3% of smokers reported use
of the benefit alone (i.e., no OTC medication use). Use of OTC medications alone
was reported by 16.9% of smokers (i.e., no benefit use). Few smokers (4.2%) used both OTC medications and the benefit. Of smokers unaware of the
benefit, 21.4% reported using OTC medications only to help them quit smoking;
5.2% of smokers aware of the benefit reported using OTC medications only. Among all smokers
in 2002, 30.4% reported use of some medication to help them quit smoking (i.e.,
OTC, benefit, or both).
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In a highly educated, working-age population, use of a new SCT benefit was
modest among all smokers during its first 2 years of availability. In its
second year of availability, only 13.6% of all smokers used the benefit to
help quit smoking. However, among smokers who were aware of the benefit,
the benefit use rate was higher at 39.6%. These findings are relevant to
employers and purchasers in need of population-based benefit-use estimates to
introduce their own SCT benefit. For example, 25 state-government
employers do not provide an insurance benefit for SCTs to some or all of their
There are several potential explanations for the modest benefit-use rates
for all smokers identified in this study. Low benefit awareness is one
possibility. As described above, the state’s promotion of the new benefit
was limited. In our study, we found greater benefit use among smokers who were
aware of the benefit and greater use of only OTC medications among
smokers who were unaware of the benefit. In 2002, 39.6% of smokers aware of
the benefit and
3.5% of smokers unaware of the benefit reported using the benefit. In that same year, 21.4%
of smokers unaware of the benefit and 5.2% of smokers aware of the benefit reported using OTC medications
only to help them quit smoking. Boyle et al also found that smokers aware of
the benefit were
more likely to use Zyban, one of the covered medications in that study, to
make an attempt to quit than smokers who were unaware of the benefit (15). To our
knowledge, only one study has examined the effect of a benefit-promotion
intervention on smokers’ knowledge and use of a SCT benefit. In a randomized
controlled trial, Alesci et al found greater benefit knowledge among smokers
who received a promotional postcard than those who received notification of
the new SCT benefit within annual health plan enrollment materials (21).
There was no difference, however, in benefit-use rates between the two groups.
Additional research is needed to identify communication strategies that
increase benefit awareness and use to inform employers’ implementation and
promotion of SCT coverage.
Alternatively, perhaps low smoker interest in quitting explains the
relatively low rate of benefit use we observed. This explanation, however,
seems unlikely. Nationally, 70% of current smokers report that they want to
quit smoking (22), and approximately 41% of daily smokers reported making an
quit at least 1 day during the past 12 months (23). In our study,
the overall annual SCT use rate (benefit or OTC use) was roughly 30%. This
rate implies greater quitting activity than suggested by our annual
benefit-use rate of roughly 14%. Future research that examines benefit
features such as the products and services covered, their limitations, and how
a patient gains access to a benefit may further explain the factors that
influence benefit-use rates. Additionally, research that explores smokers’
reasons for not using an available SCT benefit would be useful in
understanding factors that may increase demand and inform benefit design.
As noted above, annual medication use for SCT in the Wisconsin state employee
population, obtained through the insurance benefit or OTC, was roughly 30% of all smokers in 2002. This rate of treatment use is high compared with
population-based rates found elsewhere. For example, in 1996, just 20% of
smokers who attempted to quit smoking used some form of assistance,
self-help, counseling, nicotine replacement therapy, or a combination of these
(24). Since that time, the variety and availability of FDA-approved
medications for smoking cessation has increased. Results from a 2000 survey
found that approximately 25% of privately insured smokers who attempted to
quit smoking used a cessation aid (25). The FDA-approved medications
assessed in our study can double or triple the likelihood of achieving
abstinence from smoking compared with quitting without a cessation aid (3).
Our population’s rate of SCT use may suggest that smokers
are increasingly using these efficacious cessation aides.
Based on our rate of OTC medication use, some may conclude that an SCT
benefit is unnecessary or redundant. However, if the objective is to maximize
smokers’ opportunities to quit, the presence of an SCT benefit may help do
just that. It may increase the number of smokers who make an attempt to quit. From
our data, we could not determine whether the use of this new benefit may have
supplanted the use of OTC medications. Future research should examine the
extent to which an SCT benefit increases the number of smokers who make an
attempt to quit beyond those who use OTC medications, the number of attempts
to quit made
beyond those made with the assistance of OTC medications, and the outcomes of
those attempts to quit.
Ultimately, the likely value of insurance coverage for SCTs to insurers,
employers, and purchasers is its effect on smoking prevalence. Studies have
demonstrated a promising link between SCT coverage and improved quit rates (5)
and reduced smoking prevalence (4). We observed a significant decline in
smoking prevalence in the study population during the first 2 years of the
benefit’s availability, from approximately 15% to 13%. Low smoking rates are
typical among highly educated populations nationally (23) and in Wisconsin
(26); thus, the level that we observed is not in itself surprising. However,
the decline in smoking prevalence during this short period suggests the need
for further research to identify its causes. Caution should be used in linking
this decline in prevalence solely to the new SCT benefit as other factors may
apply. Our study design did not allow us to isolate the effect of the new SCT
benefit on smoking prevalence in the population.
This study has a number of limitations. The sample design was a random
sample of employee and retiree contracts for health insurance stratified by
plan. The stratification did not extend to the level of sex, age, or education
within each plan. Some of these variables have been associated with smoking
status (23) and OTC use (27). To the extent that the sampling design did not
capture a representative sample of the population, our population outcome
estimates for prevalence of smoking and OTC use may be somewhat biased. We are
not aware of any published evidence demonstrating an association between sex,
age, and educational level with benefit use and benefit awareness.
We made two changes to the survey between 2001 and 2002. First, we altered
the reporting period for benefit use. In 2001, we asked respondents to report
on benefit use during the first 3 to 6 months of the benefit’s availability,
beginning with January 1, 2001. In 2002, we asked them to report on benefit
use during the previous 12 months. Thus, the 2001 survey reflected 3 to 6
months of SCT coverage, and the 2002 survey reflected 12 months
of SCT coverage. Because the benefit-use rates reflect different time periods,
they should not be directly compared. Second, we added a question to assess OTC
use in 2002.
The survey respondent was the person in the household most knowledgeable
about the health care received by all family members covered by the plan. To
the extent that such a knowledgeable person is more likely to be aware of and
use the SCT benefit, our estimated benefit awareness and use rates may
overstate what employers will observe in their insured populations. Future
research using claims data to assess benefit use would help to address this
Our study results can help employers overcome a common barrier to the
introduction of insurance coverage for SCTs: uncertainty about levels of
of a new SCT benefit. We found that approximately 14% of all smokers
used the benefit to help quit smoking during its second year of
availability. This benefit-use rate provides employers with essential
information to estimate the cost of a new SCT benefit. By providing this
decision-relevant information to employers, our results may hasten the
adoption of national recommendations for insurance coverage for SCTs (1-3). In
addition to serving employers’ informational needs, these findings may
inform public policy more generally as state and federal governments
consider implementing the National Action Plan for Tobacco Cessation’s
recommendation to provide universal coverage for evidence-based SCT
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Dr. Fiore has served as a consultant, given lectures sponsored by, or has
conducted research sponsored by GlaxoSmithKline, Pharmacia, Pfizer, and
Sanofi-Synthelabo. In 1998, the University of Wisconsin appointed Dr. Fiore
to a named chair, made possible by an unrestricted gift from GlaxoWellcome. This study was funded by grant number 042084 from The Robert Wood Johnson
Foundation. The authors thank the staff of the Wisconsin Department of
Employee Trust Funds, particularly Bill Kox and Sonya Sidky, for sharing their
time and expertise on employee benefits and for allowing us to participate in
an ongoing survey of state employees. We thank Darren Schauf for sharing his
expertise on Wisconsin’s implementation of the CAHPS survey. We appreciate
the comments and suggestions of three anonymous reviewers.
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Corresponding Author: Marguerite E. Burns, MA, Center for Tobacco Research
and Intervention and Department of Population Health Sciences, University of
Wisconsin Medical School, 610 Walnut St, Room 667, Madison, WI 53726.
Telephone: 608-265-3296. E-mail: email@example.com.
Author Affiliations: Marjorie A. Rosenberg, PhD, Department of
Actuarial Science, Risk Management and Insurance, University of Wisconsin
School of Business and Department of Biostatistics and Medical Informatics,
University of Wisconsin Medical School, Madison, Wisc; Michael C. Fiore, MD, MPH, Center for
Tobacco Research and Intervention and Department of Medicine, University of
Wisconsin Medical School, Madison, Wisc.
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