Evidence Summary: Reduce Tobacco Use
Evidence-based Intervention: Payers
- Increase access to evidence-based tobacco cessation treatments, including individual, group, and telephone counseling and Food and Drug Administration (FDA)-approved cessation medications (in accordance with the 2008 Public Health Service Clinical Practice Guideline1 and the 2015 U.S. Preventive Services Task Force (USPSTF) tobacco cessation recommendation statement).2
- Remove barriers that impede access to covered cessation treatments, such as cost-sharing and prior authorization.
- Promote increased use of covered treatment benefits by tobacco users.
Smoking is the leading cause of preventable disease and death in the United States. It results in about 480,000 premature deaths and more than $300 billion in direct health care costs and lost productivity each year.12,13
The prevalence of cigarette smoking is especially high among certain groups of adults, particularly persons of lower socioeconomic status and persons with mental illness or substance use disorders.
As an important first step, payers can continue to utilize multiple avenues to accurately and thoroughly identify plan members who use tobacco products to help health systems and providers understand and monitor the scope of their members’ tobacco use.
Reducing tobacco users’ out-of-pocket costs can involve policy or program changes that make evidence-based treatments, including medication, counseling or both, more affordable and accessible. The CDC Community Preventive Services Task Force found that reducing tobacco users’ out-of-pocket costs for evidence-based cessation treatments has strong evidence of effectiveness in increasing the number of tobacco users who quit.3
Payers are continuing to maximize tobacco cessation by covering all evidence-based tobacco cessation treatments with no or minimal barriers and by promoting cessation coverage to ensure that tobacco users are aware of and use the covered treatments.
Payers are continuing to ensure that they are following cessation recommendations and current federal guidance4 by providing tobacco users access to individual, group, and telephone counseling and all FDA-approved cessation medications without cost sharing or prior authorization.
Payers have contributed an even greater impact on access and cessation by removing other coverage barriers such as limits on quit attempts.
Payers are increasing cessation by working with health care providers and practices to implement the clinical and health systems interventions recommended in the 2008 Public Health Service Clinical Practice Guidelines5, the 2015 USPSTF tobacco cessation recommendation statement,6 and the CDC Million Hearts tobacco cessation protocol.7 These interventions allow health systems to integrate tobacco dependence treatment into routine clinical practice in order to ensure that this treatment becomes a standard of care.
An important first step in implementing clinical cessation interventions is for providers to ask all patients about tobacco use at every visit. If patients are not identified as tobacco users, providers will not be able to intervene with them. In addition, health care systems will not have an accurate understanding of tobacco use prevalence in their patient population.
Once they have identified patients who use tobacco products and documented their tobacco use in electronic health records, providers should create a workflow or process where they:
- advise these patients to quit;
- assess their willingness to make a quit attempt;
- assist them in their quit attempts, either directly or by referring them to another cessation resource such as a telephone quitline; and
- arrange follow-up5,8
To increase efficiency and lessen the burden on physicians, these steps can be distributed among the health care team, including nurses, physician assistants, and medical assistants. Each member of the team should have a clear understanding of their roles during a patient visit for tobacco cessation.
Tobacco cessation services can be delivered by a multi-disciplinary health system team (e.g. identification of smokers at every office visit as part of the workflow, recording of readiness to quit into the electronic health record, team support for the quit attempt, prescribing medications and cessation counseling to support the quit attempt) can sustain cessation efforts and improve cessation rates.8
Having each member of a medical team contribute to the workflow or process of tobacco cessation visits can improve tobacco cessation rates of standard visit-based treatments.9 Proactively offering barrier-free treatments to known tobacco users, independent of their health care visits, has shown to be a feasible, cost-effective way to increase the reach of treatment (primarily Nicotine Replacement Therapy [NRT]) and to increase short-term quit rates.10
Payers can promote covered treatments to tobacco users and health care providers to increase awareness that these treatments are available, interest in quitting, and use of evidence-based treatments.11
- Covers individual cessation counseling, but not group or telephone cessation counseling.
- Asymptomatic persons are not subject to cost-sharing for counseling, but persons who have already developed a smoking-related disease may be subject to cost-sharing.
- Covers prescription medications, but not over-the-counter cessation medications.
- Varies by state.
- As of October 2010, traditional (i.e., non-expansion) state Medicaid coverage is required to provide a comprehensive cessation benefit, including cessation counseling and medications, to pregnant women on Medicaid without cost-sharing.14
- Under a Centers for Medicare & Medicaid Services policy announced in 2011, state tobacco control programs can work with their state Medicaid programs to secure a 50 percent administrative match rate for counseling provided to Medicaid enrollees by state quitlines.15
- As of January 2013, traditional state Medicaid programs can cover, but are not required to cover, cessation counseling for non-pregnant enrollees.16,17
- As of January 2014, traditional state Medicaid coverage can no longer exclude FDA-approved cessation medications from coverage.18 However, this coverage can still impose barriers such as copayments or prior authorization on these medications.19,20
- As of January 2014, expansion Medicaid coverage is required to cover evidence-based preventive services, including tobacco cessation, without cost-sharing.14,21
- As of January 2017, Medicaid programs in ten states covered individual and group counseling and all seven FDA-approved cessation medications, while Medicaid programs in 32 states covered all seven FDA-approved cessation medications.22
- As of January 2013, state Medicaid programs receive a 1% increase in the Federal Medical Assistance Percentage for certain preventive services, including tobacco cessation, if they cover all these services without cost-sharing.14
- Varies by plan.
- Non-grandfathered plans, whether fully insured or self-insured, are required to cover evidence-based preventive services, including tobacco cessation, without cost-sharing. These plans can ensure that they are in compliance with this requirement by following the current federal guidance on this topic.14,23
- Grandfathered plans are not subject to the requirement to cover evidence-based preventive services without cost-sharing.24 Little information is available on cessation coverage in these plans. While these plans still account for a substantial share of the market, this share is decreasing over time as plans make changes that result in the loss of their grandfathered status.
Fifteen studies of interventions to reduce out-of-pocket costs for cessation medications and counseling were assessed in a CDC Community Guide economic review. Cost-effective estimates were provided in four studies, with a median cost estimate of $2,349/ Quality-Adjusted Life Year saved (range of values: $1,290 to $24,647 in three studies) based on five estimates from two studies, a cost per life year saved estimate of $5,990 (one study), and a cost per disability-adjusted life year estimate (a measure of life lost to death and disability) averted of $7,695 to $16,559 (one study). Eight out of 10 studies found that benefits associated with these interventions exceeded costs.25 Thus, in all the studies that provided cost effectiveness estimates, the interventions were highly cost effective.
In 2006, Massachusetts implemented and widely promoted an evidence-based Medicaid tobacco cessation benefit. The benefit covered up to 16 individual or group cessation counseling sessions and two 90-day courses per year of FDA-approved cessation medications, including over-the-counter and prescription medications. More than one in three (37%) of smokers enrolled in the state Medicaid program used the benefit.26 The crude smoking rate decreased from 38.3% in the pre-benefit period to 28.3% in the post-benefit period—which overall is a 26% reduction from the pre-benefit to the post-benefit period. Annualized hospitalizations for heart attacks and other acute heart disease diagnoses fell by 46% and 49%, respectively27. These outcomes were achieved within a three-year timeframe. Finally, every $1 invested in the program was associated with $3.12 in savings in hospital costs for averted acute cardiovascular events alone, resulting in a return on investment of $2.12.28 These findings suggest that a tobacco cessation benefit that includes coverage for medications and behavioral treatments, has few barriers to access, and is heavily promoted to smokers and their health care providers can be widely used, substantially reduce smoking prevalence, lead to improved health outcomes, and achieve a favorable return on investment by reducing health care costs.
Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 UpdateExternal
Effective clinical treatments for tobacco dependence that have become available since the 2000 Guideline was published.
Treating Tobacco Use and Dependence: 2008 Update—OverviewExternal
Evidence tables and recommendations contained in the clinical practice guideline.
Coverage For Tobacco Use Cessation Treatments
This updated 2014 document provides an overview of the evidence base for tobacco cessation insurance coverage, best practices for designing cessation coverage, and the current status of cessation coverage.
Case Study: The Effect of Expanding Cessation Coverage—The Massachusetts Medicaid Cessation BenefitCdc-pdf
A case study of the implementation and outcomes of the 2006 Massachusetts Medicaid cessation coverage benefit.
Medicaid Tobacco Cessation Coverage in Oklahoma: A Case Study in Leveraging Systems and PartnershipsCdc-pdf
Summary of a consortium developed through a CDC-funded cooperative agreement to provide technical assistance to state tobacco control programs and national and state tobacco control organizations on tobacco cessation approaches.
Using Health Systems Change to Increase Tobacco Cessation: What Can State Tobacco Control Programs Do? Frequently Asked QuestionsCdc-pdf
This Frequently Asked Questions sheet is intended to provide state tobacco prevention and control managers with an overview about the basics of health systems change. This resource is meant to supplement information provided on this topic in the recent Best Practices Document.
Q&A with Harvard Vanguard Medical Associates and Atrius Health about Health Systems Change to Address SmokingCdc-pdf
Harvard Vanguard Medical Associates and Atrius Health respond to questions about an extensive health systems change effort they undertook in 2007 to improve tobacco dependence treatment in their health care system.
Louisiana State University Health System’s Tobacco Control Initiative Cdc-pdf
This question and answer style case study provides an overview of Louisiana State University’s Health System’s Tobacco Control Initiative, focused on developing and implementing a systematic approach to treating tobacco use in one of the largest safety-net health delivery systems in the country.
Help Your Patients Quit Tobacco Use: An Implementation Guide for Community Health CentersCdc-pdfExternal
A guide intended to help health centers integrate tobacco cessation into their clinical services.
Tobacco Cessation Protocol and Implementation GuidanceExternal
The customizable Million Hearts® Tobacco Cessation Protocol template is accompanied by implementation guidance on how to adopt and use a treatment protocol as well as examples for use in practices and health care systems.
Identifying and Treating Patients Who Use Tobacco: Action Steps for CliniciansCdc-pdfExternal
Provides evidence-based, tested tobacco use identification and intervention strategies for busy clinicians. These strategies consist of actions clinicians can take to improve care delivery and to increase the use of evidence-based brief interventions for patients who use tobacco. The guide includes links to resources and supporting references.
1 Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.
2 Siu AL; US Preventive Services Task Force. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163:622–34.
3 Rigotti NA, Bitton A, Kelly JK, Hoeppner BB, Levy DE, Mort E. Offering population-based tobacco treatment in a healthcare setting: a randomized controlled trial. Am J Prev Med. 2011; 41(5): 498-503.
4 United States Department of Labor. FAQs about Affordable Care Act Implementation (Part XIX). Available at United States Department of Labor. FAQs about Affordable Care Act Implementation (Part XIX)External. Accessed 22 September 2015.
5 Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.
6 Siu AL; US Preventive Services Task Force. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163:622–34.
7 Protocol for Identifying and Treating Patients Who Use Tobacco. Available at Protocol for Identifying and Treating Patients Who Use TobaccoCdc-pdfExternal. Accessed 21 November 2016.
8 Land TG, Rigotti NA, levy DE, Schilling T, Warner D, et al (2012). The Effect of Systematic Clinical Interventions with Cigarette Smokers on Quit Status and the Rates of Smoking-Related Primary Care Office Visits. PloS One. 7(7);e41649.doi:10.1271/journal.pone.0041649.
9 Rigotti, NA. Strategies to Help a Smoker Who Is Struggling to Quit. JAMA. 2012. 308(15);1573-1580.
10 Rigotti NA, Bitton A, Kelly JK, Hoeppner BB, Levy DE, Mort E. Offering population-based tobacco treatment in a healthcare setting: a randomized controlled trial. Am J Prev Med. 2011; 41(5): 498-503.
11 The Community Guide. Reducing tobacco use and secondhand smoke exposure: reducing out-of-pocket costs for evidence-based cessation treatments. Available at The Community Guide. Reducing tobacco use and secondhand smoke exposure: reducing out-of-pocket costs for evidence-based cessation treatmentsExternal. Accessed 28 August 2015.
12 US Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2014.
13 Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. Annual healthcare spending attributable to cigarette smoking: an update. Am J Prev Med. 2015;48:326–33.
14 The Patient Protection and Affordable Care Act, Public Law 111-148, 124 Stat. 855, § 4107, (March 2010).
15 Centers for Medicare and Medicaid Services. SDL # 11-007, ACA # 17, New Medicaid Tobacco Cessation Services. Available at Centers for Medicare and Medicaid Services. SDL # 11-007, ACA # 17, New Medicaid Tobacco Cessation ServicesCdc-pdfExternal. Accessed 20 October 2015.
16 McAfee T, Babb S, McNabb S, Fiore MC. Helping smokers quit – opportunities created by the Affordable Care Act. N Engl J Med. 2015;372:5-7.
17 Centers for Disease Control and Prevention. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage — United States, 2014–2015 Morbidity and Mortality Weekly Report. 2015:64(42);1194-9.
18 Public Law 111-148. Affordable Care Act 2010, Section 2502. Available at Public Law 111-148. Affordable Care Act 2010, Section 2502External. Accessed 28 September 2015.
19 McAfee T, Babb S, McNabb S, Fiore MC. Helping smokers quit – opportunities created by the Affordable Care Act. N Engl J Med. 2015;372:5-7.
20 Centers for Disease Control and Prevention. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage — United States, 2014–2015. Morbidity and Mortality Weekly Report. 2015:64(42);1194-9.
21 McAfee T, Babb S, McNabb S, Fiore MC. Helping smokers quit – opportunities created by the Affordable Care Act. N Engl J Med. 2015;372:5-7.
22 Personal communication from Anne DiGiulio, American Lung Association, January 9 and 12, 2017.
23 United States Department of Labor. FAQs about Affordable Care Act Implementation (Part XIX). Available at United States Department of Labor. FAQs about Affordable Care Act Implementation (Part XIX)External. Accessed 22 September 2015.
24 Preservation of Right to Maintain Existing Coverage. 45 C.F.R. 147.140 (October 1, 2011).
25 The Community Guide. Reducing tobacco use and secondhand smoke exposure: reducing out-of-pocket costs for evidence-based cessation treatments. Available at The Community Guide. Reducing tobacco use and secondhand smoke exposure: reducing out-of-pocket costs for evidence-based cessation treatmentsExternal. Accessed 28 August 2015.
26 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:e9770.
27 Land T, Rigotti NA, Levy DE, et al. A longitudinal study of Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease. PLoS Med. 2010;7:e1000375.
28 Richard P, West K, Ku L. The return on investment of a Medicaid tobacco cessation program in Massachusetts. PloS One. 2012;7(1)e29665. doi: 10.1371/journal.pone.0029665.