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Jennifer K. Ibrahim, PhD, Helen Halpin Schauffler, PhD, Dianne C. Barker, MHS and C. Tracy Orleans, PhD

Jennifer K. Ibrahim and Helen Halpin Schauffler are with the Center for Health and Public Policy Studies, University of California, Berkeley. Dianne C. Barker is with Barker Bi-Coastal Health Consultants, Calabasas, Calif. C. Tracy Orleans is with the Robert Wood Johnson Foundation, Princeton, NJ.

Correspondence: Requests for reprints should be sent to Jennifer K. Ibrahim, PhD, University of California, San Francisco, Center for Tobacco Control Research and Education, 530 Parnassus Ave, Suite 366, San Francisco, CA 94143-1390 (e-mail: ibrahim{at}itsa.ucsf.edu).

	INTRODUCTION

TOP INTRODUCTION METHODS RESULTS DISCUSSION References

 
In 2000, 36% of the 32 million Medicaid recipients and 25% of pregnant Medicaid recipients were smokers.^1,2 Rates of tobacco use in the general population were considerably lower: 23% of the general population in 2000² and 12% of pregnant women in 1999.³ Helping pregnant women to quit smoking would have enormous health benefits, including reducing tobacco-related spontaneous abortions, rates of low-birthweight infants, admissions to neonatal intensive care units, infant deaths from perinatal disorders, and sudden infant death syndrome.^4,5

In addition, 9.2% of youths in grades 6 through 8 and 28.5% of youths in grades 9 through 12 reported being current smokers in 2000.⁶ Reduction in tobacco use by youths and their parents would also have important health benefits. Not only are children and adolescents harmed by exposure to secondhand smoke, but they also underestimate the addictiveness of nicotine and its future health consequences; 73% of teen daily smokers who think they won’t be smoking in 5 years are still smoking 5 to 6 years later.⁷ Nearly 90% of adult smokers had their first cigarette before they were 18 years old.⁷

The 2000 Public Health Service (PHS) clinical practice guideline Treating Tobacco Use and Dependence recommends health insurance payment for services demonstrated to be effective in helping smokers to quit, thereby reducing the barrier of cost.⁸ Nonmedication counseling interventions, including individual face-to-face, group, and telephone counseling, are recommended as the first line of treatment for pregnant smokers at the initial prenatal visit and throughout pregnancy, given the uncertain risks and benefits of pharmacotherapy for maternal and fetal health outcomes.⁸

For adolescents, the PHS guideline recommends assessing tobacco use and offering cessation counseling⁸ that increases quit rates above naturally occurring levels.⁹ The guideline also recommends that pediatricians "offer smoking cessation advice and interventions to parents to limit children’s exposure to secondhand smoke."⁸ Medicaid requires states to cover specific preventive services, including prenatal care and Early and Periodic Screening, Detection, and Treatment (EPSDT) services for youths younger than 21 years.¹⁰ Coverage for additional preventive services, such as treatments for tobacco use and dependence, is optional and decided by each state.

The purpose of this research was to determine the extent to which guidline-based tobacco dependence treatments are covered by state Medicaid programs for pregnant women, and under EPSDT for children and their parents who smoke.

	METHODS

TOP INTRODUCTION METHODS RESULTS DISCUSSION References

 
In the fall of 2000, we faxed a 10-page survey to the directors of all states plus the District of Columbia Medicaid programs (n = 51) to obtain information on Medicaid coverage of tobacco dependence treatments.¹¹ One-third of the directors responded within 2 weeks of the initial fax; we followed up by telephone, e-mail, and fax for a 100% response rate. Survey questions addressed coverage for pharmacotherapy, counseling services, and screening practices under EPSDT, as well as special cessation programs, home visits, and counseling for pregnant women.

	RESULTS

TOP INTRODUCTION METHODS RESULTS DISCUSSION References

 
Coverage for Pregnant Women
Ten state Medicaid programs offer benefits specifically for the treatment of tobacco dependence in pregnant women, with all but 1 of these including some form of counseling (Table 1). Additionally, of the 21 states that reported covering home visit programs for pregnant women, 13 include coverage of counseling for tobacco dependence. In all, 16 state programs cover some form of counseling for pregnant smokers.

Fifteen state Medicaid programs require EPSDT providers to screen youths younger than 18 years for tobacco use. Six of these states also require EPSDT providers to screen parents. Seventeen states require Medicaid providers to conduct health education with youths during routine visits; 6 of those states require providers to conduct health education with the children’s parents.

Validation
Because data were collected by selfreport, we asked each state Medicaid director to submit a written copy of his or her state’s tobacco dependence treatment policies for validation; 20 provided written documentation validating what they had reported, 11 reported having no specific benefit language for tobacco dependence treatments (indicating that pharmacotherapy was covered under their standard drug benefit), and 3 did not respond to our request for documentation. We observed no contradictions when we compared the survey responses with the documentation.

	DISCUSSION

TOP INTRODUCTION METHODS RESULTS DISCUSSION References

 
The PHS guideline for treating tobacco dependence—as it pertains to pregnant women, children, and adolescents—is not being followed by the majority of state Medicaid and EPSDT programs, despite strong evidence that health insurance coverage for tobacco dependence treatments increases both the use of these services and quit rates.^12,13 Adding coverage for effective tobacco dependence treatments to the federally mandated Medicaid benefits package for pregnant women and for children and parents under EPSDT would eliminate the disparities in coverage across the states and make a significant difference in the health of low-income pregnant women and their children, 2 of our most vulnerable populations.

	Acknowledgments

 
This research was conducted by the Center for Health and Public Policy Studies at the University of California, Berkeley, and funded by grant 022246 from the Robert Wood Johnson Foundation.

Human Participant Protection
No protocol approval was needed for this study.

	Footnotes

 
J. K. Ibrahim is the primary author and was responsible for analyzing the survey data from the 50 state Medicaid programs, conducting background research, and writing the brief. H. Halpin Schauffler is the second author and was responsible for obtaining funding for the state Medicaid surveys, creating the framework, reviewing and revising the analysis of the survey data, and writing the brief. Both D. C. Barker and C. T. Orleans participated in creating the framework for the brief, as well as reviewing and revising drafts.

Peer Reviewed

Accepted for publication April 23, 2002.

	References

TOP INTRODUCTION METHODS RESULTS DISCUSSION References

 
1. Kaiser Family Foundation. Medicaid Enrollment: Kaiser Commission on Medicaid and the Uninsured. Washington, DC: Kaiser Family Foundation; 2000.

2. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 2000 survey data. Available at: http://www.cdc.gov/brfss/ti-surveydata2000.htm. Accessed September 9, 2002.

3. Mathews TJ. Smoking during pregnancy in the 1990s. National Vital Statistics Report.2001:49(7):1–16.

4. Melvin CL. Pregnant women, infants, and the cost savings of smoking cessation. Tob Control. 1997;6(suppl 1):S89–S91.

5. Women and Smoking: A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2001.

6. Centers for Disease Control and Prevention. Investment in Tobacco Control: State Highlights, 2001. Atlanta, Ga: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2001.

7. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994.

8. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, Md: US Dept of Health and Human Services, Public Health Service; 2000.

9. Sussman S, Lichtman K, Ritt A, Pallonen UE. Effects of thirty-four adolescent tobacco use cessation and prevention trials on regular users of tobacco products. Subst Use Misuse. 1999;34:1469–1503.[Medline]

10. Centers for Medicare and Medicaid Services. Medicaid: A Brief Summary. Available at: http://cms.hhs.gov/publications/overview-medicare-medicaid/default4.asp. Accessed September 9, 2002.

11. Schauffler HH, Mordavsky J, Barker D, Orleans CT. State Medicaid coverage for tobacco dependence treatments—United States, 1998 and 2000. MMWR Morb Mortal Wkly Rep. 2001;50:979–982.[Medline]

12. Schauffler HH, McMenamin S, Olsen K, Boyce-Smith G, Rideout JA, Kamil J. Variations in treatment benefits influence smoking cessation: results of a randomised controlled trial. Tob Control. 2001;10:175–180.[Abstract/Free Full Text]

13. Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. N Engl J Med. 1998;339:673–679.[Abstract/Free Full Text]

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