Tobacco Prevention and Cessation

By Karmen Hanson | Vol . 26, No. 41 / November 2018

LegisBrief logoDid You Know?

Smoking-related illness continues to be the leading preventable cause of death and disease, costing more than $300 billion each year in direct medical costs and lost productivity. And it’s the states that often bear much of these direct and associated costs.

Smoking cessation—the process of quitting smoking—has numerous health benefits. It lowers the risk of developing lung and other types of cancer, heart disease, respiratory complications and other negative health outcomes. Since 2002, there are more former smokers than current smokers, and state legislators and agencies continue to take steps to help people quit smoking and prevent people from using tobacco in the first place. 

State Action

California adopted a tobacco tax proposition in 1988 to fund a state tobacco control program. State-sponsored tobacco toll-free phone numbers, called quitlines, connect tobacco users to cessation resources, including free or reduced-cost nicotine replacement products (such as gum, lozenges and patches), prescription cessation medications and other counseling.

The Centers for Disease Control and Prevention (CDC) provides some funding for tobacco control programs and quitlines in all states, most territories and many tribal organizations. Grantees may use this funding for tobacco control programs and quitline capacity, among other efforts. Strong tobacco control programs have shown a high return on investment, up to $55 per $1 spent, by reducing health care costs for tobacco-related illnesses.

In order to see the greatest return on investment, the CDC recommends funding levels or each component of a comprehensive tobacco control program based on state population. The minimums range from 32 cents to $2.73 per component per person. For all components combined, the CDC recommends spending a minimum of $7.41 and a maximum of $10.53 per person. Possible funding streams for such programs include federal support, tobacco taxes and the Master Settlement Agreement, which requires the tobacco industry to pay states billions of dollars annually after state attorneys general sued cigarette manufacturers to recover the costs of treating sick smokers. However, as of fiscal year 2018, no state funds its tobacco prevention and cessation programs at the level recommended by the CDC.

According to the North American Quitline Consortium, nearly every state quitline provides free nicotine replacement patches, and more than half  provide free nicotine replacement gum or lozenges. Very few quitline programs provide free or discounted prescription cessation medications. Most states use Master Settlement Agreement funds to pay for quitlines and various cessation therapies.

Another common access point to tobacco cessation services is through Medicaid. Approximately 25 percent of Medicaid enrollees smoke cigarettes compared to 11.8 percent of privately insured Americans. Medicaid coverage of smoking cessation products approved by the U.S. Food and Drug Administration (FDA) increases access to cessation services and may improve a person’s chances of quitting, as determined by multiple studies in the Cochrane Database of Systematic Reviews.

According to research by the American Lung Association, from 2015 to 2017, all states provided access to multiple types of cessation treatments. Ten states covered all nine FDA-approved treatments. Unlike quitlines, nearly every state Medicaid program covers prescription cessation medications. However, copayments, prior authorization, stepped-care therapy (which requires people to use certain types of cessation tools before more expensive tools) or lifetime quit attempt limits may act as barriers and reduce the chances of quitting.

Because youth and adolescents are the most likely to be new tobacco users, some states are considering raising the tobacco sale age from 18 or 19 to 21. Since 2016, six states (California, Hawaii, Maine, Massachusetts, New Jersey and Oregon) and hundreds of localities have enacted “Tobacco 21” legislation to deter youth from purchasing tobacco for themselves or others who are underage.  

Research by the Institute of Medicine (now known as the National Academies of Sciences, Engineering and Medicine) determined that adolescents, including people ages 18 to 21, are particularly at risk of becoming addicted to nicotine and suffering from long-term cognitive effects and impaired brain development. Raising the tobacco sale age to 21 may delay young people’s initiation to tobacco, reducing the odds they will start and continue to use it into adulthood. 

Federal Action

The federal government is working to reduce the prevalence of tobacco use and increase cessation efforts. The FDA’s Center for Tobacco Products (CTP) oversees the Family Smoking Prevention and Tobacco Control Act. Some of the center’s priorities include establishing and reviewing tobacco product standards, regulating nicotine-containing products, monitoring and enforcing tobacco industry compliance, educating the public on the dangers of tobacco and protecting public health.

As part of its comprehensive plan on tobacco and nicotine regulation, the FDA is proposing to reduce the amount of nicotine in combustible cigarettes, which could lower the health risks associated with smoking and encourage smokers to choose alternative forms of nicotine, including e-cigarettes and other tobacco products. The FDA is also modernizing its approach to developing and regulating nicotine replacement therapies such as gum, patches and lozenges.