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Marguerite E. Burns, MA, Timothy W. Bosworth, PhD and Michael C. Fiore, MD, MPH

Marguerite E. Burns is with the Center for Tobacco Research and Intervention and the Department of Population Health Sciences, University of Wisconsin Medical School, Madison. Timothy W. Bosworth is with the Center for Tobacco Research and Intervention, University of Wisconsin Medical School, Madison. Michael C. Fiore is with the Center for Tobacco Research and Intervention and the Department of Medicine, University of Wisconsin Medical School, Madison.

Correspondence: Requests for reprints should be sent to Marguerite E. Burns, MA, Center for Tobacco Research and Intervention, University of Wisconsin Medical School, 1930 Monroe St, Suite 200, Madison, WI 53711 (e-mail: meburns{at}ctri.medicine.wisc.edu).

	ABSTRACT

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Public health experts recommend that health insurance include coverage for smoking cessation treatment as an evidence-based strategy to reduce smoking. As employers, states can implement this policy for more than 5 million individuals nationwide. This study identified the extent to which states require smoking cessation treatment insurance coverage for their employees; of 45 states, 29 required coverage for at least 1 US Public Health Service (PHS)–recommended treatment, and only 17 of 45 provided coverage that was fully consistent with PHS recommendations.

	INTRODUCTION

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Public health experts recommend that health insurance products include coverage for evidence-based smoking cessation treatment.^1–3 Among the entities with the authority to effect this health policy change, employers are especially promising agents of change. Employers have shown increasingly significant influence on the design and delivery of health care.^4,5 As employers, states purchase health insurance for more than 5 million employees and retirees nationwide.⁶ In many markets, states and other public employers serve as leaders and influence both what insurers offer employers and what employers offer employees.⁷ By including coverage for smoking cessation treatment in health insurance benefits, states can encourage smoking cessation among state employees while also serving as a model for other local and regional employers and insurers.

	METHODS

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We describe the extent to which states use their purchasing power to buy insurance coverage for smoking cessation treatment for their employees. For each state, we identified and surveyed the agency responsible for state employee health care purchasing between September 2002 and February 2003. The agency was identified through an Internet search, and telephone follow-up was used to identify its administrator. We asked the administrator to nominate an employee health benefits staff person to provide information on health insurance coverage for state employees. Forty-five state agency administrators nominated staff persons to participate. We asked each nominee to complete a faxed survey describing the current insurance coverage for smoking cessation treatment that the agency required for state employees. Staff persons in 45 states completed the survey.

Survey questions assessed the presence of insurance coverage for smoking cessation treatment recommended in the US Public Health Service (PHS) Treating Tobacco Use and Dependence: Clinical Practice Guideline,³ including the following: over-the-counter nicotine gum, over-the-counter nicotine patch, prescription nicotine patch, prescription nicotine nasal spray, prescription nicotine inhaler, Zyban (GlaxoSmithKline, Middlesex, UK), group counseling, face-to-face individual counseling, and telephone counseling. The survey also assessed whether insurance coverage for smoking cessation treatment applied to all or some state employees because states may negotiate different benefits from the various insurers serving state employees.⁸

	RESULTS

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For analytic purposes, we mapped each treatment to 1 of 3 categories: (1) counseling, (2) prescription medications, or (3) over-the-counter medications. Just 7 states required smoking cessation treatment coverage that was fully consistent with the US PHS guideline recommendations for all state employees (Table 1). That is, they required coverage for some form of group or individual counseling and 1 or more of the 5 Food and Drug Administration–approved medications for smoking cessation treatment. An additional 10 states required US PHS consistent coverage for at least some of their state employees. A total of 29 states required insurance coverage for 1 or more of the US PHS guideline–recommended treatments for at least some state employees. Smoking cessation treatment coverage was not required for any state employees in 16 states (Table 2).

	DISCUSSION

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In the study, we considered only the role of the state employer as health care purchaser in providing insurance coverage for smoking cessation treatment. That is, we addressed the extent to which the state agencies required insurance coverage for smoking cessation treatment for their employees. We did not catalog the general availability of smoking cessation treatment to state employees. Treatment may have been available to employees through other employee benefits (e.g., wellness programs) or through health insurers that provided this coverage in addition to the benefits package negotiated for state employees. For agencies that reported requiring insurance coverage of smoking cessation treatment for "some" employees, the study design did not allow us to ascertain the exact percentage of employees subject to this coverage. Finally, the survey did not capture the degree to which employees shared the cost of smoking cessation treatment when coverage was provided (e.g., copayments, deductibles).

Our results echo those of previous studies in other populations. The purchase and provision of insurance coverage for smoking cessation treatment remain uneven.^9–14 The content of that coverage, among states, is also highly variable despite the publication of evidence-based treatment recommendations in the US PHS Clinical Practice Guideline. Although research findings are not conclusive, insurance coverage for smoking cessation treatment holds promise as a means of reducing smoking rates in insured populations.^15–17 States have yet to use fully their health care purchasing power to realize that promise.

	Acknowledgments

 
This study was funded by the Robert Wood Johnson Foundation (grant 042084).

The authors thank the state agency personnel who contributed their time and expertise to make this study possible.

Human Participant Protection
This study was approved by the University of Wisconsin–Madison Health Sciences Human Subjects Committee (HSC protocol 2002-055). Written informed consent was obtained from the chief administrator of each agency for study participation. Verbal consent was then obtained from the survey respondents, if different from the chief administrators.

	Footnotes

 
Contributors
M. E. Burns, the coprincipal investigator, designed the study and survey, conducted the analyses, and wrote the brief. T. W. Bosworth, the study coordinator, conducted the survey. M. C. Fiore, the principal investigator, designed the study and oversaw study implementation and data analysis. All authors contributed to the writing and revision of several drafts.

Peer Reviewed

Accepted for publication October 4, 2003.

	References

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1. Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med. 2001;20(2S):10–15.[Medline]

2. Healthy People 2010: Understanding and Improving Health. Washington, DC: US Dept of Health and Human Services; 2001.

3. 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; June 2000.

4. Bodenheimer T, Sullivan K. How large employers are shaping the health care marketplace: first of two parts. N Engl J Med. 1998;338:1003–1007.[Free Full Text]

5. Bodenheimer T, Sullivan K. How large employers are shaping the health care marketplace: second of two parts. N Engl J Med. 1998;338:1084–1087.[Free Full Text]

6. 1999 Survey of State Employee Health Benefit Plans. Atlanta, Ga: The Segal Co; 2000.

7. Watts C, Christianson JB, Heineccius L, Trude S. The role of public employers in a changing health care market. Health Aff. 2003;22:173–180.

8. Maciejewski ML, Dowd BE, Feldman R. How do states buy health insurance for their own employees? Manag Care Q. 1997;5(3):11–19.[Medline]

9. Ibrahim JK, Schauffler HH, Barker DC, Orleans CT. Coverage of tobacco dependence treatments for pregnant women and for children and their parents. Am J Public Health. 2002;92:1940–1942.[Free Full Text]

10. 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]

11. Barbeau EM, Li Y, Sorensen G, Conlan KM, Youngstrom R, Emmons K. Coverage of smoking cessation treatment by union health and welfare funds. Am J Public Health. 2001;91:1412–1415.[Abstract/Free Full Text]

12. Why Invest in Prevention? Results From the Partnership for Prevention/William M. Mercer Survey of Employer-Sponsored Health Plans. Washington, DC: Partnership for Prevention; 1998.

13. McPhillips-Tangum C, Cahill A, Bocchino C, Cutler CM. Addressing tobacco in managed care: results of the 2000 survey. Prev Med Manag Care. 2002;3:85–94.

14. Pickette KE, Abrams B, Schauffler HH, et al. Coverage of tobacco dependence treatments for pregnant smokers in health maintenance organizations. Am J Public Health. 2001;91:1393–1397.[Free Full Text]

15. Boyle RG, Solberg LI, Magnan S, Davidson G, Alseci NL. Does insurance coverage for drug therapy affect smoking cessation? Health Aff. 2002;21:162–168.

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

17. 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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This Article Abstract Full Text (PDF) Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (10) Citing Articles via Google Scholar Google Scholar Articles by Burns, M. E. Articles by Fiore, M. C. Search for Related Content PubMed PubMed Citation Articles by Burns, M. E. Articles by Fiore, M. C. Related Collections Insurance Health Policy Smoking Cessation