State Access to Cessation Services Methodology

The Access to Cessation Services grading system sets targets for states and awards points in three areas:

1. State Medicaid coverage of tobacco cessation treatments,
2. State Employee Health Plan coverage of tobacco cessation treatments and
3. The Investment per Smoker each state makes in its quitline, a service available in all states that provides tobacco cessation counseling over the phone.

Bonus points are available in two other target areas, Standards for Private Insurance and limiting or prohibiting Tobacco Surcharges in private insurance.

In 2008, the U.S. Department of Health and Human Services' Public Health Service published an update to its Clinical Practice Guideline on Treating Tobacco Use and Dependence. This Guideline, based on a thorough review of scientific evidence on tobacco cessation, recommends several treatment options that have proven effective in helping people quit smoking. These options include the use of five nicotine-replacement therapies (gum, patch, lozenge, nasal spray, inhaler), bupropion and varenicline (non-nicotine medications), and three types of counseling (individual, group and phone). It also recommends that all public and private health insurance plans cover the cessation treatments recommended in the Guideline ¹.  In 2020, the U.S. Surgeon General reiterated the need for this comprehensive cessation benefit without barriers in the “Smoking Cessation: A Report of the Surgeon General ².” Targets established in the Medicaid, State Employee Health Plan and Standards for Private Insurance categories were based on these Public Health Service Guideline and U.S. Surgeon General recommendations for cessation treatments.

In the 2014 Best Practices for Comprehensive Tobacco Control Programs document, supporting state quitlines is one of the major goals under Cessation Interventions for state tobacco control programs ³. Funding to the state quitline is included in the Access to Cessation Services section to show a full picture of what the state is offering for cessation services. Grading in this section is based on the amount of funding provided to the state quitline for services divided by the number of individuals who smoke in the state.

In 2015, the Lung Association incorporated information on what tobacco cessation treatments are provided to the Medicaid expansion population into this grade. Points awarded in the Medicaid Coverage section below incorporate this information. Points available in the Medicaid coverage section were 40 to represent new Medicaid expansion enrollees. If a state has not opted to expand Medicaid up to the levels established in the Affordable Care Act (ACA), the state receives an automatic deduction of 8 points to represent the substantial number of individuals who use tobacco that do not have access to cessation treatments because of this decision.

The Lung Association will deduct up to 2 points for any state that implements a policy to charge Medicaid enrollees a tobacco surcharge or that has policies that charge Medicaid enrollees that smoke more for coverage than Medicaid enrollees that do not use tobacco. The Lung Association also added 2 bonus points available to states that prohibit or limit tobacco surcharges, or health insurance policies that charge individuals who use tobacco more in premiums than individuals who do not use tobacco. States can limit or remove these surcharges.

All data in the Access to Cessation Services section of "State of Tobacco Control" 2024 was collected and analyzed by the American Lung Association.

The cessation grades are based on the maximum number of total points, a score of 70, assigned according to the categories described in detail below. Over half of the points (40 points total) under the Access to Cessation Services section are awarded for coverage under a state's Medicaid program. This weighting is due to the higher smoking rates among the Medicaid population than among the general population, as well as the need to cover treatments to help people of lower income who smoke quit. Twenty points total are awarded for the investment per smoker in the state's quitline and 10 points total are awarded for State Employee Health Plan coverage.

The score of 70 serves as the denominator, and the state's total points serves as the numerator to calculate a percentage score. Grades were given following a standard grade-school system using that percentage score.

The grades break down as follows:

Key to Cessation Coverage Ratings by Category:

Medicaid Coverage (40 points):⁴

Target is barrier-free coverage of all Guideline-recommended medications and counseling for the state's entire Medicaid population (including the Medicaid expansion population).

1. States receive up to 14 points for coverage of medications: 2 points for coverage for all enrollees of each of the 7 medications. If coverage of a medication varies by plan or pregnancy status, 1 point is awarded for each medication covered in this way;
2. States receive up to 12 points for coverage of counseling: 4 points for each type of counseling covered (individual, group and phone). If a counseling coverage varies by plan or pregnancy status, 2 points is awarded for each type of counseling coverage;
3. States receive up to 14 points for providing coverage without barriers: 1 to 3 points are deducted for each barrier to coverage that exists in a state. Deductions vary based on type of barrier and severity.
4. There is an automatic letter grade deduction for the Access to Cessation Services grade, if a state has not expanded Medicaid coverage up to the levels established in the Affordable Care Act (138% of the federal poverty level for all eligibility categories).
5. States that impose a tobacco surcharge or charge individuals who use tobacco higher premiums than individuals who do not use tobacco for Medicaid coverage will have 2 points deducted from the Medicaid coverage score.

State Employee Health Plan Coverage (10 points):

Target is barrier-free coverage of all Guideline-recommended medications and counseling for all of a state's employees and dependents.

1. 0 to 4 points are given for coverage of medications; deductions were made if only some health plans/managed care organizations provide coverage;
2. 0 to 4 points are given for coverage of counseling; deductions were made if only some health plans/managed care organizations provide coverage;
3. 0 to 2 points are given if coverage is free of barriers.

Quitlines (20 points):

States are graded based on a curve set by the median investment per smoker, which in fiscal year 2023 was $1.93 per smoker. Points are awarded based on the scale below:

Standards for Private Insurance Coverage (up to 3 bonus points):

Target is a legislative or regulatory standard requiring coverage of all PHS-recommended medications and counseling in private insurance plans within the state.

1. 1 point given for legislation requiring the coverage of some tobacco cessation treatments or if a state insurance commissioner issues a bulletin on the enforcement of the tobacco cessation FAQ issued by the federal government ⁵;
2.  2 points given for legislation requiring coverage of all tobacco cessation treatments for some state regulated private insurance plans;
3. 3 points given for legislation requiring coverage of all tobacco cessation treatments for all state regulated private insurance plans.

Tobacco Surcharges (up to 2 bonus points):

Target is a state policy prohibiting small group and individual health insurance plans from charging individuals who use tobacco higher premiums than individuals who do not use tobacco. States can prohibit this practice or limit these surcharges to amounts smaller than federal law allows, which is 50%.

1. 2 points given if state prohibits tobacco surcharges; or
2. 1 point given if state limits tobacco surcharges to less than 50 percent of the premium charged to individuals who do not use tobacco.