Enhancing Tobacco Treatment for Medicaid Recipients

Audrey Darville, PhD, APRN; Lovoria Williams, PhD, FNP-BC; Jean Edward, PhD, RN; Karen Butler, DNP, RN; Kathy Rademacher, BA; Brittney Gray, MS; Clair M. Tischner, MS; Hannah Keeler, MPH; Ellen J. Hahn, PhD, RN


South Med J. 2022;115(8):603-610. 

In This Article

Abstract and Introduction


Objective: Medicaid recipients are vulnerable to increased morbidity and mortality secondary to high tobacco use prevalence and barriers to accessing tobacco treatment. The purpose of the pilot study was to explore managed care administrators' perceptions of the facilitators and barriers to tobacco treatment for Medicaid recipients.

Methods: Focus groups with key informants (n = 14) from managed care organizations were conducted in fall 2018. Participants included case, integrated care, quality and field care managers, and individuals working in provider and network relations.

Results: Facilitators to tobacco treatment were universal quality reporting requirements, access to medications, and the role of case management in identifying and engaging tobacco users in treatment. Barriers included bias regarding smokers' ability to quit, communication challenges, and competing priorities.

Conclusions: The analysis provided data to support the development of a policy brief and recommendations to the Department for Medicaid Services for enhancing tobacco dependence treatment.


Tobacco use is the leading cause of preventable death in the United States. Tobacco-attributable illness accounted for 8.7% of US healthcare costs in 2010.[1] Notably, Medicare/Medicaid and other federal programs pay 60% of these costs. Smoking prevalence among Medicaid recipients is nearly twice that of those with private insurance,[2–4] costing nearly $76 billion from Medicaid alone.[5]

Despite high tobacco use rates among the 63 million Medicaid recipients in the United States,[2] there is a lack of universal coverage for cessation benefits. Only 10 state Medicaid programs provide coverage for all cessation treatments,[3] including barrier-free access to all cessation medications, with no copays, and all forms of counseling that are not a prerequisite for medication coverage. In Kentucky and other states, Medicaid managed care organizations (MCOs) often impose specific requirements, such as a prescription for over-the-counter nicotine replacement. These requirements are obstacles that also can lead to confusion for both recipients and healthcare providers.

For tobacco dependence treatment to be effective, it is essential that evidence-based strategies are supported and used to enhance cessation.[6] Medicaid recipients are receptive to tobacco cessation advice from physicians and other healthcare specialists, which promotes quitting.[7] Intensive tobacco treatment, combining counseling and medication use, is highly effective and cost-effective with Medicaid recipients.[8] Tobacco dependence is a chronic, relapsing condition; therefore, tobacco treatment must be offered at every visit. Clinicians, however, frequently rely on individuals to request, or opt-in to treatment, leading to low cessation counseling and medication utilization.[9]

Providing both advice to quit and additional treatment in medical settings can be effective in promoting quitting;[10,11] however, studies exploring provider advice to quit in vulnerable populations, such as those with serious mental illness, are sparse.[12] Furthermore, physicians self-report relatively low levels of using a 5 A's format (Ask, Advise, Assess, Assist, Arrange for follow-up) for cessation support as recommended by current clinical practice guidelines.[6] An average of 63% advise their patients to quit, but only 44% provide assistance, and only 22% arrange for follow-up.[13]

Specialists trained in delivering evidence-based tobacco treatments have improved outcomes, compared with untrained providers, including higher quit rates and reduced relapse.[14–16] Standardized and accredited tobacco treatment specialist (TTS) training is widely available. Pairing TTSs with physicians and other healthcare specialists is an effective model for delivering tobacco treatment services,[17] but Medicaid recipients often have limited access to TTS-trained providers despite clear associations of tobacco use with poor health outcomes and excess healthcare costs.[5] Treating tobacco use not only saves lives but also it is highly cost-effective for Medicaid programs.[18]

The objectives of our pilot study were to explore the facilitators and barriers to tobacco treatment delivery to Medicaid recipients from the perspective of managed care administrators in one state and develop policy recommendations to promote barrier-free access to tobacco treatment services for Medicaid recipients.