III. Cessation Interventions 

Justifcation 

Rationale 

Promoting cessation is a core component of a 

comprehensive state tobacco control program’s 

efforts to reduce tobacco use.1,2 Encouraging 

and helping tobacco users to quit is the quickest approach to reducing tobacco-related disease, 

death, and health care costs.3 Quitting smoking has immediate and long-term health benefts.4 

Although quitting smoking at any age is benefcial, smokers who quit by the time they are 

35 to 44 years of age avoid most of the risk 

of dying from a smoking-related disease.5 

Population-wide interventions that change 

societal environments and norms related to 

tobacco use—including increases in the unit 

price of tobacco products, comprehensive 

smokefree policies, and hard-hitting media 

campaigns—increase tobacco cessation by 

motivating tobacco users to quit and making it 

easier for them to do so.1-3,6,7 Offering cessation 

assistance to smokers who attempt to quit in 

response to these interventions maximizes the 

impact of these interventions on cessation, while 

countering the perception that they are punitive.1-3,6-8 

Guiding Principles 

Population-wide cessation efforts—specifcally, 

policy, systems, or environmental changes—are 

most effcient and effective at reaching many 

people.1,2,6,8 Systems changes within health care 

organizations complement interventions in state 

and community settings by institutionalizing sustainable approaches that support individual 

behavior change.1,6,8 As in other areas of tobacco 

control, policy and/or systems approaches support 

healthy behaviors at both the individual and the 

societal or institutional levels.1,6,8 

Although it is appropriate and necessary for 

comprehensive state tobacco control programs 

to fund and provide certain cessation treatment 

services (i.e., to directly deliver cessation 

counseling and medications through populationbased approaches such as state quitlines) to 

certain populations, particularly groups that would 

otherwise not have access to these services (e.g. 

the uninsured), the programs’ focus should remain 

on population-level, strategic efforts to reconfgure 

policies and systems in ways that normalize 

quitting and that institutionalize tobacco use 

screening and intervention within medical care.1,6,8 

State tobacco control programs can educate 

private and public health care systems, health 

insurers, and employers on the importance of 

assuming responsibility for, and covering the costs 

of, providing cessation services to their members 

and employees.1 States can also monitor and 

leverage provisions in the Affordable Care Act that 

require new private health plans and state Medicaid 

programs to expand coverage of evidence-based 

tobacco use cessation treatments.9 The Affordable 

Care Act and the Health Information Technology 

for Economic and Clinical Health Act, which gave 

rise to the Meaningful Use of Electronic Health 

Records Incentive Program, provide states with a 

unique opportunity to focus cessation efforts on 

promoting and supporting the implementation 

of policies and systems within health care 

organizations and health insurers that support 

cessation, and also offer eligible providers and 

hospitals federal funding to adopt electronic health 

records and use them in ways that can support 

improvements in the delivery of clinical preventive 

services, including tobacco dependence treatment. 

Such policies and systems have the potential 

to dramatically increase the delivery of evidencebased cessation interventions, thus making them 

more widely available and accessible. Cessation 

services directly provided or funded by a 

comprehensive state tobacco control program are 

best focused on populations that lack access to 

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Section A: Cessation Interventions 

these services through other channels, such as 

the uninsured and the underinsured.10 In addition, 

state programs may perform some functions that 

are most effciently handled at a centralized level, 

such as tagging mass-media advertisements with a 

phone number or Web site where individuals can 

obtain or be referred to basic cessation services. 

Population quit rates are determined by two 

factors: (1) the number of quit attempts, which 

includes the number of smokers who try to quit, 

and the number of times they make a quit attempt; 

and (2) the odds that smokers who try to quit will 

succeed in doing so.11 It is important that state 

efforts to increase population quit rates strive to 

increase both quit attempts and quit success, and 

attempt to strike a balance between the reach and 

intensity of interventions.1,11 State tobacco control 

programs play an important role in implementing 

interventions such as hard-hitting media campaigns 

that motivate smokers to quit, as well as ensuring 

that smokers who want help quitting, but who lack 

adequate cessation coverage, have access to effective 

cessation assistance and know how to obtain it. 

Two-thirds to three-quarters of smokers who 

try to quit do not use any evidence-based cessation 

counseling or medications.12,13 Smokers improve 

their odds of successfully quitting when they use 

these treatments.14 It is important for state cessation 

initiatives to make smokers aware of this fact and 

to ensure that cessation treatments are readily 

available through health care systems and providers, 

state telephone quitlines, and other communitybased cessation resources.1 This message can be 

communicated without implying that smokers 

cannot quit successfully without using cessation 

treatments, so as not to lessen the impact of tobacco 

education campaigns on increasing quit attempts.15,16 

An Altered Landscape 

The cessation landscape has changed considerably 

since Best Practices —2007 as a result of the following developments: 

 Publication of an updated version of the Public 

Health Services Clinical Practice Guideline, 

Treating Tobacco Use and Dependence, in 2008 

 Enactment of the Patient Protection 

and Affordable Care Act 

 Implementation of the Meaningful Use initiative 

 Widespread adoption of electronic 

health records 

 Creation of the Centers for Medicare 

and Medicaid Innovation 

 Introduction of new voluntary Joint Commission 

hospital cessation performance measures 

 Increasing shift to managed care 

plans in state Medicaid programs 

 Changes in the organization of private 

health care 

 Increased emphasis on establishing 

linkages between public health 

interventions and clinical interventions 

 Introduction of the national tobacco 

education media campaign, Tips From 

Former Smokers, conducted by CDC 

These changes have presented signifcant 

new opportunities to expand cessation coverage, 

institutionalize tobacco use screening and 

interventions within health care systems, 

and increase the availability and use of 

evidence-based cessation treatments. 

Three Major Goals 

Comprehensive state tobacco control program cessation activities should focus on three broad goals: 

 Promoting health systems change 

 Expanding insurance coverage and 

utilization of proven cessation treatments 

 Supporting state quitline capacity 

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Section A: Cessation Interventions 

Promoting Health Systems Change 

The health care system provides multiple opportunities institutionalizing cessation interventions in health care 

for motivating and helping smokers to quit.6,8,14,17 More systems and integrating these interventions into routine 

than 80% of smokers see a physician every year,18 and clinical care.6,8,14,17 This increases the likelihood that 

most smokers want and expect their physicians to talk to health care providers will consistently screen patients 

them about quitting smoking and are receptive to their for tobacco use and intervene with patients who use 

physicians’ advice.14 Tobacco dependence treatment tobacco, thus increasing cessation and making evidenceis both clinically e!ective and highly cost-e!ective, based tobacco dependence treatment the standard of 

and results in reduced health care costs, increased care.14,17,19 When a health system seeks to intervene with 

productivity, and reduced absenteeism.14 every tobacco user at every visit,14 it can substantially and 

E!ective tobacco cessation interventions advance rapidly increase cessation.14,17,19 

the goals of national and state health care reform e!orts 

to improve health care, to improve health, and to reduce 

health care costs. Health systems change involves 

State efforts to promote health systems change 

involve working with health care systems and 

organizations to fully integrate tobacco dependence treatment into the clinical workfow.6,8, 

14,17,19 The goal is to ensure that every patient is 

screened for tobacco use, their tobacco use status 

is documented, and patients who use tobacco are 

advised to quit.6,8,14,17,19 This is followed by offering 

the patient cessation medication (unless contraindicated), counseling, and assistance, as well 

as arranging follow-up contact either on-site or 

through referrals to the state quitline or other community resources.6,8,14,17,19,20 This approach has been 

summarized as the “5 A’s”: (1) ask about tobacco 

use; (2) advise to quit; (3) assess willingness to 

make a quit attempt; (4) assist in the quit attempt; 

and (5) arrange follow-up.14 

One way to increase the use of this approach 

is through provider reminder systems, which 

prompt health care providers to screen and 

intervene with patients around tobacco use and 

increase provider delivery of cessation advice.6,14 

Consistent screening and delivery of cessation 

interventions are also facilitated by assigning 

multiple members of the health care team (e.g., 

medical assistants, physician assistants, nurses, and 

physicians) clearly identifed roles in this area.14 

State tobacco control programs can promote 

health systems change in multiple ways. For 

example, state governments provide health care 

coverage to Medicaid enrollees and state employees. 

States also regulate or otherwise interact with 

the health insurance market. These roles provide 

opportunities to improve health systems approaches 

to tobacco use prevention and cessation. In addition, 

state tobacco control programs can educate health 

care decision makers about the health and economic 

burden imposed by tobacco use and the evidence 

base for clinical cessation interventions, including 

the cost-effectiveness and return on investment 

of these interventions.1,21,22 State tobacco control 

programs can also offer technical assistance to help 

health care organizations and providers measure 

the implementation of health systems changes and 

the impact of these changes on outcomes in their 

patient populations using data from electronic 

health records, insurance claims, and other sources. 

State programs can further support health 

systems change by carrying out academic 

detailing initiatives.21,22 This involves providing 

technical assistance to health care organizations 

and providers in implementing health systems 

changes that institutionalize tobacco use screening 

and intervention, including referrals to the state 

quitline.20-24 The technical assistance is typically 

provided in-person in the health care setting by 

trained personnel.21,22 Studies of academic detailing 

initiatives have found that they have the potential to 

increase: use of the “5 As”;25,26 frequency of tobacco 

cessation counseling;27 appropriate use of cessation 

medications;27 and fax referrals to quitlines.20–24 

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Section A: Cessation Interventions 

Under the Meaningful Use initiative, the Centers 

for Medicare and Medicaid Services is making 

substantial fnancial incentives available to eligible 

providers and hospitals to migrate from paper 

to electronic health records in order to improve 

health care and health care outcomes.28 When 

electronic health records are implemented in a way 

that explicitly incorporates tobacco dependence 

treatment as part of a broader process of health 

systems change, they can serve as a powerful 

provider reminder system, prompting providers 

to screen their patients for, and intervene on, 

tobacco use by embedding prompts, language, 

and documentation within the records themselves, 

and helping to seamlessly integrate these steps 

into the clinical workfow.29-33 The implementation 

of electronic health records with a cessation 

component can have an even greater impact if it 

is coupled with training and technical assistance 

to all members of the health care team.32,33 

Electronic health records can also make it easier 

for providers to refer patients to state quitlines, 

counseling within the health organization, and 

community-based cessation programs, especially 

when these referrals can be made electronically.20,30-32 

Several provisions of the initial stages of Meaningful 

Use require electronic health records to capture 

identifcation of and intervention with patients who 

use tobacco and require providers to report on these 

measures in order to receive fnancial rewards.8,20 

Health care organizations that have 

implemented electronic health records in 

combination with other health systems changes 

are able to achieve levels of 80% or higher for 

both screening and intervention, with additional 

improvement possible.19 State tobacco control 

programs can seek opportunities to leverage 

the implementation of electronic health records 

by working with large health care systems to 

integrate tobacco dependence treatment into their 

workfows.33 Electronic health records can also be 

used to monitor provider performance for purposes 

of feedback, recognition, and rewards at the 

organization and/or provider levels, as well as to 

conduct surveillance of tobacco-related measures.19,30 

Finally, new hospital performance measures 

implemented by the Joint Commission in January 

2012 expand and strengthen previous Joint 

Commission measures by calling on hospitals 

to provide cessation interventions to all tobacco 

users, not just those with specifc diagnoses, and 

by expanding the scope of these interventions.34-36 

State tobacco control programs can work with 

the health care sector to encourage hospitals to 

adopt these voluntary cessation measures and can 

provide technical assistance with implementation.36 

Sample State Activities: Promoting Health Systems Change 





Build and maintain relationships with large health 

care systems and key stakeholders in the health care 

sector, and educate them about the feasibility and 

health and economic benefts of integrating tobacco 

dependence treatment into their clinical workfows. 

Conduct academic detailing initiatives to provide 

technical assistance to health care organizations and 

providers in implementing health systems changes 

that institutionalize tobacco use screening and 





Collaborate with health care systems, regional 

extension centers, and other stakeholders to integrate 

tobacco dependence treatment into electronic health 

records and workfows. 

Leverage data from electronic health records, 

insurance claims, and other sources for surveillance/ 

evaluation of the implementation and outcomes of 

health systems change cessation interventions. 

intervention, including promoting referrals to the 

state quitline. 

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Section A: Cessation Interventions 

Expanding Insurance Coverage and 

Utilization of Proven Cessation Treatments 

Expanding cessation insurance coverage increases the Expanding cessation insurance coverage also has 

number of smokers who attempt to quit, use evidence- the potential to reduce tobacco-related population 

based cessation treatments, and successfully quit by disparities.6,14,17,37 Comprehensive cessation coverage can 

removing cost and administrative barriers that prevent also support providers in their e!orts to o!er patients 

smokers from accessing cessation counseling and e!ective cessation treatments.14,17 Finally, health systems 

medications. 6,14,17,37 cessation interventions can increase patients’ use of 

available coverage.14,17 

One important function of state tobacco control 

programs is to educate key stakeholders—including private and public health care systems, health 

insurers, the state Medicaid program, and employers—on the meaning of comprehensive cessation 

coverage and the importance and benefts of 

implementing such coverage. Educating employers on these topics is important because employers 

can play a key role in expanding cessation coverage by demanding such coverage and because 

self-insured employers are in a position to directly 

provide such coverage.14,17 

For cessation insurance coverage to be 

effective in increasing cessation, it is important for 

it to be comprehensive in scope. Comprehensive 

coverage includes all evidence-based cessation 

treatments—including individual, group, and 

telephone counseling—and all seven Food and 

Drug Administration (FDA) approved cessation 

medications (bupropion, varenicline, and fve forms 

of nicotine replacement therapy (NRT), including 

the patch, gum, lozenge, inhaler, and nasal spray). 

Comprehensive cessation coverage also eliminates 

or minimizes cost sharing and other barriers to 

accessing this coverage.38 Finally, comprehensive 

cessation coverage includes proactively promoting 

the coverage to ensure that smokers and their health 

care providers are aware of it, thus increasing the 

chances that they will use it, and documenting 

and reporting utilization of the coverage.14,38–41 

In January 2011, the Offce of Personnel 

Management (OPM) implemented a cessation beneft 

for federal employees through the Federal Employees 

Health Benefts Program.42 Highlights of that beneft, 

which is a model of comprehensive, evidencebased coverage, are listed in the following box. 

Components of the Cessation Beneft Available to Federal Employees 

through the Federal Employees Health Benefts Program42 

 Individual, group, and telephone counseling.  Coverage for two quit attempts per year, with 

four counseling sessions per attempt.  All seven FDA-approved cessation 

medications, including both prescription  No copays, coinsurance, or deductibles. 

and over-the-counter medications.  No annual or lifetime limits. 

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Section A: Cessation Interventions 

Once comprehensive cessation coverage has been 

achieved, state tobacco control programs may 

want to consider working with private and public health care systems, health insurers, employers, 

and other partners to publicize this coverage to 

smokers and their health care providers and to 

monitor its utilization.39–41 High utilization is essential for a cessation beneft to be effective, because 

even the most comprehensive cessation coverage 

will have little impact if smokers and providers 

are not aware of it or don’t use it.39–41 In assessing 

the quality of cessation coverage, it is important to 

take into account barriers to access and utilization, 

as well as the cessation treatments covered. 

In addition to working with the state 

Medicaid program to expand Medicaid cessation 

coverage, state programs can also seek to 

expand cessation coverage for state employees.37 

These employees typically make up a signifcant 

proportion of the state workforce, and the 

cessation coverage offered to this group can 

serve as a model for private employers and 

health plans.37 Another approach taken by several 

states is to mandate private health insurers to 

provide some level of cessation coverage.37 

Results of Massachusetts’ Medicaid Cessation Beneft Implemented in 200! 

 The beneft was utilized by about 37% of Medicaid enrollees who used the beneft fell by 46% 

recipients who smoked, or more than 70,000 and 49%, respectively.44 

individuals in its frst 21⁄2 years.43 

 The beneft was found to generate a return on 

 The smoking rate among Medicaid enrollees fell from investment of $3.12 in cost savings from averted 

38.3% to 28.3%.43 hospitalizations for acute cardiovascular events for 

every dollar spent on it.45 

 Annual hospital admissions for heart attacks and 

other acute heart disease diagnoses among Medicaid 

Several provisions in the Affordable Care Act 

expand private and Medicaid cessation coverage.9,37,46 The legislation requires non-grandfathered 

private plans to cover, with no cost-sharing, preventive services that receive an ‘A’ or ‘B’ rating 

from the U.S. Preventive Services Task Force, 

which includes tobacco cessation treatments.9,37,46 

This requirement also applies to the insurance 

plans available to the individual and small group 

health insurance markets through each state’s 

Health Insurance Marketplace.9,37 Neither the Task 

Force recommendations nor the U.S. Department 

of Health and Human Services rules implementing the relevant provisions of the Act clearly 

defne the specifcs of the required tobacco cessation coverage; thus, these specifcs remain 

somewhat open to interpretation.37,47,48 To the 

extent possible, it is important for state tobacco 

control programs to work with large health insurers to ensure that they realize the full potential 

of these provisions by implementing comprehensive, evidence-based cessation coverage. 

As of October 2010, the Affordable Care Act 

requires state Medicaid programs to cover cessation 

counseling for pregnant women.9,37,46 Effective 

January 2014, the legislation bars these programs 

from excluding FDA-approved cessation medications 

from their coverage for all Medicaid enrollees.9,37,46 

In addition, states that choose to expand Medicaid 

eligibility must provide tobacco cessation coverage 

to newly eligible adults through a benchmark 

beneft package.9,37 State Medicaid programs are also 

eligible for an increased federal medical assistance 

percentage if they provide recommended clinical 

preventive services, including tobacco cessation 

treatment, to traditional Medicaid recipients without 

cost sharing.9,46 State tobacco control programs 

can work with state Medicaid programs to ensure 

that the potential of these provisions is fully 

realized. Medicaid enrollees smoke at higher rates 

than the general population, and smoking-related 

diseases in this population are a major driver of 

increasing state and federal Medicaid costs.37,49 

Another provision of the Affordable Care Act 

allows health insurers in the individual and small 

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Section A: Cessation Interventions 

group markets to charge tobacco users higher 

premiums than nontobacco users, up to a ratio 

of 1.5 to 1.0.9,37,46 States retain the ability to reduce 

the ratio or to prohibit this practice entirely,9,37 and 

several states have reportedly done so.37 Although 

imposing higher premiums on tobacco users could 

motivate them to quit, it could also lead them to 

misrepresent their tobacco use status, avoid seeking 

cessation assistance, or forego health insurance, 

and could impose a prohibitive cost burden on lowincome tobacco users.37,50 The rule implementing 

this provision seeks to avert such outcomes by 

requiring health insurers in the small group market 

to allow tobacco users the opportunity to avoid 

paying the full amount of the tobacco rating 

factor by participating in a wellness program.51,52 

It is important for state tobacco control programs 

to monitor the implementation of this provision, 

and states may choose to restrict or prohibit 

the practice of charging tobacco users higher 

premiums if negative effects become apparent. 

Separate from the Affordable Care Act, the 

Centers for Medicare and Medicaid Services has 

in recent years taken several steps to expand 

cessation coverage for Medicare enrollees, 

who comprise another potentially vulnerable 

population.37 This coverage now includes individual 

counseling and prescription cessation medications, 

but not comprehensive cessation coverage.37 

There are opportunities to promote Medicare 

cessation benefts to increase their utilization.37 

Sample State Activities: Expanding Insurance Coverage of 

Proven Cessation Treatments 

 Build and maintain a relationship with private health 

insurers, the state Medicaid program, the state 

employee health plan, and large employers and 

educate them about the defnition of comprehensive 

cessation coverage and about the health and 

economic benefts of providing such coverage. 

 Work with the state Medicaid program to ensure that 

both fee-for-service and managed-care Medicaid 

plans provide comprehensive cessation coverage. 

 Promote and monitor utilization of the 

state Medicaid cessation beneft. 

 Work with state government to ensure that state 

employees have comprehensive cessation coverage. 

 Implement a state mandate requiring 

private health insurers to provide 

comprehensive cessation coverage. 

 Monitor implementation and e!ects of the 

provisions of the A!ordable Care Act that have 

the potential to expand cessation coverage, as 

well as the provision that allows health insurers 

to charge tobacco users higher premiums. 

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Section A: Cessation Interventions 

Supporting State Quitline Capacity 

Quitlines are telephone-based services that help can also serve as clearinghouses and referral/triage 

tobacco users quit by providing callers with counseling, centers, educating callers about the cessation coverage 

practical information on how to quit, referral to other available from their health insurer and referring callers to 

cessation resources, and, in some states and for certain community cessation services1,16 

populations, FDA-approved cessation medications.16 State quitlines can play an important role 

Quitlines potentially have broad reach, are e!ective with in supporting and increasing provider cessation 

diverse populations, and increase quit rates.14 interventions by o!ering a resource for additional, more 

State quitlines are one of the most accessible intensive cessation counseling.20,60,61 Having the option 

cessation resources and can eÿciently reach large of referring patients to state quitlines for follow-up 

numbers of smokers.14,16 In addition, quitlines are e!ective assistance increases the likelihood that providers will 

in reaching certain racial/ethnic populations, including intervene with patients who smoke.20,60,61 Most state 

African Americans; persons who predominantly speak quitlines have established fax referral programs,20 and 

Asian languages; and low-income smokers.53-56 many state quitlines are developing the capacity to 

Quitlines are highly cost-e!ective relative to other accept e-referrals directly from patients’ electronic health 

commonly used disease prevention interventions.14,57–59 records and to electronically send patient reports to the 

State quitlines are also typically the most visible referring provider/health care organization. 

component of state cessation e!orts and frequently serve 

as a hub or centerpiece of these e!orts.16 State quitlines 

Notwithstanding their many advantages and potentially broad reach, state quitlines on average reach 

only about 1% of smokers annually.62,63 This situation is largely a function of modest state funding 

for providing and promoting state quitline services.62,63 Some states, employers, and health 

plans have attained quitline reach levels of 6% or 

more.64,65 State quitlines should seek to reach 8% of 

their state’s tobacco users annually, with a target of 

90% of these callers accepting counseling services. 

These guidelines take into account the experiences 

of state quitlines that have achieved higher levels 

of reach for limited periods.1,64,65 These guidelines 

are also based on expectations that more health 

care providers will refer patients to quitlines as a 

result of Meaningful Use and the adoption of electronic health records, that more health plans will 

refer their members to quitlines in response to 

the Affordable Care Act, and that CDC’s National 

tobacco education campaigns will continue to 

drive more callers to 1-800-QUIT-NOW. 

In developing funding and service models, 

it is crucial to balance reach and intensity. It is 

important for state quitlines to seek to ensure that 

all callers have access to a basic level of service 

while providing higher levels of service to certain 

populations that would otherwise lack access 

to such services. Ensuring that a basic level of 

quitline service is in place is important to support 

interventions that are likely to increase interest 

in quitting and calls to quitlines, such as national 

or state media campaigns and implementation 

of smokefree laws or tobacco price increases. 

State tobacco control programs can use several 

approaches to increase quitline reach, including 

paid media campaigns, promotion of cessation 

medicine giveaways, and outreach efforts to 

generate fax or electronic referrals from health 

care organizations and providers.1,6,23,24,66,67 

It is also important for state tobacco control 

programs to consider the level of funding for 

quitline operations and promotion that can 

realistically be sustained over time and to explore 

long-term funding sources. For example, programs 

can establish public-private partnerships, in which 

health plans or employers reimburse the state 

quitline for services provided to their members/ 

employees, or contract directly with a quitline 

vendor to provide these services.67,68 The Colorado 

and Minnesota tobacco control programs worked 

with their states’ major private health plans to 

implement the frst and second models, respectively; 

both these partnerships have been successful and 

have remained in place for a number of years.67,68 

State tobacco control programs can also work with 

their state Medicaid programs to secure the 50% 

federal match for quitline counseling provided to 

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Section A: Cessation Interventions 

Medicaid enrollees, who typically account for a 

substantial proportion of state quitline callers.69 

State quitlines should consider providing 

some form of cessation assistance to all callers, 

including ensuring that all callers who want to talk 

to a quitline coach receive at least one ten-minute 

reactive call (i.e., a call initiated by the caller in 

which brief counseling is offered). Beyond this 

initial call, state quitlines can offer an additional 

three proactive counseling calls (i.e., calls initiated 

by the quitline in which counseling is offered) to 

the uninsured and underinsured, persons enrolled 

in a plan through the state Health Insurance 

Marketplace, Medicaid enrollees, and members 

of health plans and employees of companies that 

have contracted with the state to receive quitline 

services. Callers with private health insurance 

that provides adequate cessation coverage can be 

directed to their insurer or employer for cessation 

services after receiving an initial counseling call, 

or alternatively, the cost of additional calls can 

be reimbursed by their insurer or employer.67,68 

State quitlines can also provide a free 2-week 

starter supply of NRT patches or gum to: uninsured 

and underinsured callers, persons in state insurance 

marketplace plans, and Medicaid enrollees.1 This can 

increase calls to the quitline from these populations 

and these callers’ success rates.6,66,70–72 Another 

priority activity is to conduct targeted outreach to 

increase the state quitline’s reach to underserved 

populations with high smoking rates. Longer-term 

efforts include: developing the capacity to accept 

e-referrals from patient electronic health records; 

integrating telephone cessation services with text 

messaging interventions and cessation services 

provided through other technologies, such as the 

Web and social media; and re-engaging previous 

quitline callers who agree to be re-contacted in quit 

attempts.6,73 Text messaging, Web, and social media 

interventions could potentially extend the reach 

and impact of quitlines, particularly among younger 

individuals.14 

State quitlines may also consider revisiting their 

eligibility protocols and service offerings in light 

of changes in health insurance coverage resulting 

from the implementation of the Affordable Care 

Act, including changes in the proportion of adults 

covered by different types of health insurance and 

in the cessation coverage provided. For example, 

several studies have documented the benefcial 

impact of providing brief introductory courses of 

NRT through quitlines.6,66,70–72 However, most of 

these studies were conducted at a time when overthe-counter NRT was not generally available as a 

covered medication through health insurance plans. 

Accordingly, it is important for state tobacco control 

programs to monitor the situation in their states as 

it evolves and to consider limiting state quitlines’ 

provision of longer (e.g., 8 week) courses of NRT 

to the uninsured, as appropriate. State quitlines 

can also revise the information they provide on 

NRT on the basis of recent FDA changes to the 

warnings on labeling of over-the-counter NRT 

products regarding long-term use and combined 

use with other NRT products or cigarettes.74 

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Section A: Cessation Interventions 

Sample State Activities: Supporting State Quitline Capacity 

 Ensure that all callers receive some form of cessation 

assistance and that all callers who want to talk to a 

quitline coach receive at least one 10-minute reactive call. 

 Ensure that all uninsured and underinsured callers 

and callers enrolled in state insurance marketplaces 

and Medicaid are o!ered three proactive counseling 

calls in addition to the reactive call and a free 2-week 

starter supply of NRT patches or gum. 

 Ensure that all members of health plans and 

employees of companies that have contracted with 

the state quitline to receive quitline services are 

o!ered three proactive counseling calls in addition to 

the reactive call and a free 2-week starter supply of 

NRT patches or gum. 

 Establish public-private partnerships under 

which health plans and employers either 

reimburse the state quitline for services provided 

to their members/employees or provide their 

own quitline services to these groups. 

 Secure the federal Medicaid quitline match. 

 Conduct targeted outreach to increase the state 

quitline’s reach to underserved populations with 

high smoking rates, including promoting the national 

Spanish-language quitline portal 1-855-DÉJELO-YA 

(1-855-335-3569) and the national Asian-language 

quitline. 

 Develop the capacity to accept e-referrals from 

patient electronic health records. 

 Integrate quitline services with text messaging by 

referring callers to NCI’s text messaging program. 

 Re-engage previous quitline callers who agree to be 

re-contacted in quit attempts. 

Achieving Equity to Eliminate 

Tobacco-Related Disparities 

Signifcant population disparities exist with regard 

to tobacco cessation.12,14 For example, recent data 

suggest that African American adults are more 

likely to express interest in quitting and more 

likely to have tried to quit in the past year than 

white adults, but are less likely to use proven 

treatments and are less likely to succeed in quitting.12 Similarly, adults of lower socio-economic 

status express signifcant interest in quitting, but 

are more likely to be uninsured or on Medicaid 

and are less likely to receive cessation assistance.14 

Medicaid enrollees smoke at higher rates than the 

general population37,49 and also express similar 

interest in quitting smoking as smokers with private insurance but are less likely to succeed.12 One 

likely reason for this population’s lower quit rates 

is that few state Medicaid programs provide comprehensive coverage of cessation treatments.37 

Adults with mental illness have a much higher 

smoking prevalence than adults without mental 

illness, smoke more cigarettes per month, and are 

less likely to quit smoking.14,75 Potential reasons 

that smokers with mental illness are less likely to 

quit include higher levels of nicotine addiction 

among this population and less access to cessation 

treatment, which may result from a lack of fnancial 

resources, a lack of health insurance, or a general 

reluctance of mental health care providers and 

facilities to address tobacco use in their patients.14,75 

Lower quit rates in certain populations may 

result in part from environments and social norms 

that are less supportive of cessation and more 

supportive of tobacco use.1,6,76,77 For example, blue 

collar and service workers have traditionally been 

less likely to be protected by smokefree workplace 

policies than white collar workers, and African 

Americans are less likely to live under smokefree 

home rules and are more likely to be exposed to 

secondhand smoke at work.7,78,79 Similarly, until 

recently, many mental illness and substance abuse 

treatment facilities have not implemented tobaccofree or smokefree policies.75 Comprehensive 

smokefree policies have been shown to effectively 

reduce population-level smoking, irrespective of 

socioeconomic status or race/ethnicity.80 Because 

environments that are smokefree and norms that 

reduce the social acceptability of smoking motivate 

smokers to quit and make it easier for them to do 

so,7,76,77 the lack of such environments and norms 

poses a barrier to cessation. State tobacco control 

programs can also increase cessation among 

population subgroups that make fewer quit attempts 

or are less likely to quit successfully by ensuring 

that settings where they spend time are smokefree. 

For example, state programs can seek to ensure 

49 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section A: Cessation Interventions 

that comprehensive state and local smokefree 

policies are fully implemented in all workplaces, 

and can work with primary and behavioral health 

care organizations serving these populations 

to implement tobacco-free campus policies. 

In jurisdictions where comprehensive smokefree 

policies have already been implemented, other 

efforts can be made to encourage cessation, 

including the establishment of smokefree private 

settings, such as homes (including multiunit 

housing) and vehicles; and tobacco price 

increases, which motivate smokers to quit, and 

which low-income populations are especially 

responsive to. Increasing tax rates on tobacco 

products and dedicating a portion of the resulting 

revenue to fund cessation services for lowincome populations can be an effective way to 

increase cessation in these populations.6,81 

As illustrated in some of the examples cited 

above, lower quit rates in certain populations are 

often driven in part by reduced access to and use 

of evidence-based cessation treatments, which 

in turn results in less success in quitting.12,14 One 

important way to improve cessation outcomes in 

populations with lower quit rates is to provide 

these populations with comprehensive cessation 

coverage.6,14,37 Reducing barriers to accessing 

proven cessation treatments, including language 

and cost barriers, would be expected to increase 

quit attempts, use of effective cessation treatments, 

and success in quitting in these populations.6,14,37 

Providing comprehensive state Medicaid coverage 

would have a substantial impact, and is one 

of the most important steps a state can take to 

increase cessation and reduce tobacco use.37,43–45 

Another effective approach is to conduct 

outreach and education to ensure that health care 

organizations serving these vulnerable populations 

with high smoking rates, such as federally qualifed 

health centers, mental health care facilities, and 

substance abuse treatment facilities, integrate 

tobacco dependence treatment into routine health 

care delivery. Additionally, state tobacco control 

programs can address population disparities by 

conducting targeted outreach to increase the state 

quitline’s reach to underserved populations with 

high smoking rates. This can include promoting 

national quitline resources developed to assist these 

populations, such as the national Spanish-language 

quitline portal 1-855-DÉJELO-YA (1-855-335-

3569) and the national Asian-language quitline. 

Budget 

Promoting Health Systems 

Change/Expanding Cessation 

Insurance Coverage 

The tobacco control goal of health systems 

change is to increase health care providers’ identifcation of and intervention with patients who 

smoke. Because more than 80% of smokers see 

a physician each year, the clinical setting is an 

important channel for motivating smokers to 

quit and for delivering evidence-based cessation treatments. In addition, as noted previously, 

by removing barriers to accessing effective cessation treatments, expanding cessation insurance 

coverage increases the number of smokers who 

attempt to quit, who use effective treatments, and 

who successfully quit. As a result, it is important for state tobacco control programs to work 

with health systems as part of a comprehensive 

approach to encourage and help smokers to quit. 

The budget recommendation for the state 

program for this component includes $150,000 

per state, in addition to $17,850,000 allocated 

across states in proportion to total population, for 

grants to selected health care organizations, health 

insurers, and employers to evaluate cessation 

interventions, document the results, including 

cost-effectiveness and return on investment, and 

develop and disseminate reports on the fndings. 

Efforts to promote health systems change and 

expand cessation insurance coverage are demanding 

and time-intensive, requiring a sophisticated 

understanding of tobacco cessation and health care 

systems and sustained relationship-building with 

health care organizations, health insurers, and the 

state Medicaid program. Therefore, it is important 

to ensure that the tobacco control program’s 

staff includes a dedicated, full-time cessation 

coordinator to oversee its cessation efforts, as well 

as additional staff and/or contractual personnel 

to conduct academic detailing and outreach to 

health care systems and insurers and to conduct 

data collection and analysis around cessation 

interventions and outcomes, including examining 

data from electronic health records and claims data. 

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Section A: Cessation Interventions 

Supporting State Quitline Capacity 

The goal of state quitlines is to provide a convenient, readily accessible, evidence-based 

cessation service for smokers who want help 

quitting, a referral option for health care organizations and providers, and a clearinghouse for 

other cessation resources. Budget recommendations for this component are based on the percent 

of a state’s smokers calling the state quitline (or 

other quitlines that health plans or employers 

have contracted with) for assistance each year, 

with a lower bound of 8% (minimum level) and 

an upper bound of 13% (recommended level). 

These parameters are based on the level of reach 

recommended in Best Practices —2007, combined with the updated assumption that 90% 

of callers will accept counseling and NRT. 

These budget recommendations are based 

on offering all callers a single 10-minute reactive 

call and offering callers who are uninsured, 

underinsured, or enrolled in state insurance 

marketplaces or Medicaid three additional proactive 

counseling calls. The recommendations assume 

that callers who accept counseling will be provided 

with a total of four calls at a cost of $45.60 per 

call and that callers who accept medication will 

be provided with 2 weeks of NRT patches or gum 

at a cost of $38.00 per caller, with these estimates 

being based on state experience. In order to 

support population-based interventions such as 

smokefree policies and mass-media campaigns, state 

tobacco control programs may want to consider 

covering the cost of providing the initial reactive 

call during periods when such interventions are 

being implemented. During periods when such 

interventions are not being implemented, state 

quitlines can shift the cost of the initial call to other 

payers, except for uninsured and underinsured 

callers and callers enrolled in insurance through 

the state marketplaces and Medicaid. 

It is assumed that the state program will cover 

100% of the cost of providing the three proactive 

counseling calls to uninsured callers, underinsured 

callers, and callers who are enrolled in state 

insurance marketplaces and 50% of the cost of 

providing counseling to Medicaid callers, on the 

basis of the state quitline securing the 50% federal 

match for quitline counseling provided to Medicaid 

enrollees. In addition, it is assumed that the state 

tobacco control program will cover 100% of the 

cost of providing 2 weeks of NRT (patches or gum) 

to callers who are uninsured, underinsured, or 

enrolled in insurance through state marketplaces 

or Medicaid. Finally, it is assumed that other callers 

will have the costs of the three proactive quitline 

counseling calls and the 2 weeks of NRT borne 

by their payers. The payer will vary depending on 

the callers’ insurance coverage, the quitline they 

call, and whether the state quitline has developed 

public-private partnerships with health plans and/ 

or employers and secured the federal match for 

quitline counseling provided to Medicaid enrollees. 

Providing Cessation Services Via 

Other Technologies 

Emerging technologies, such as text messaging, 

Web, and social media interventions, could potentially extend the reach and increase the impact of 

quitlines by complementing telephone cessation 

assistance with quitting motivation and support 

delivered through other modalities.14 These interventions are in some ways more convenient and 

readily accessible than quitlines and might engage 

young adult smokers, who may be especially 

likely to use these technologies and may prefer 

receiving cessation support through these familiar channels.6,14 Budget recommendations for this 

component of the report are based on a fxed cost 

of $135,000 per state. Because these communication channels may continue to evolve and expand 

over time, it is important for state tobacco control programs to annually assess whether it may be 

cost-effective to increase this funding level to meet 

their goals. 

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Section A: Cessation Interventions 

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