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The cessation grading system sets targets for states and awards points in three areas – Medicaid coverage of tobacco cessation treatments, State Employee Health Plan coverage of tobacco cessation treatments and 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 were available in a fourth target area, Standards for 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. Targets established in the Medicaid, State Employee Health Plan and Standards for Private Insurance categories were based on these Public Health Service Guideline recommendations for cessation treatments.

In the 2007 Best Practices for Comprehensive Tobacco Control Programs document, discussed previously under the Tobacco Prevention and Control Spending section above, the CDC establishes benchmarks for quitlines that are funded at the recommended levels. The CDC, in conjunction with the North American Quitline Consortium, determined that to meet these benchmarks, a quitline must spend $10.53 per smoker in the state.¹ Grading criteria for quitlines in this section is based on this funding level.

The American Lung Association collected and analyzed the data about cessation treatments in Medicaid, state employee health plans and private insurance in the report. Data on quitlines, unless otherwise noted, were provided by the North American Quitline Consortium, through its Annual Survey of Quitlines.

This grading category replaced youth access laws as a grading category in the State of Tobacco Control 2008 report.

The cessation grades are based on the maximum number of total points, a score of 60, assigned according to the categories described in detail below. Half of the points (30 points total) under the cessation coverage section are awarded for coverage under a state’s Medicaid program. This weighting is due to the much higher smoking rates among the Medicaid population than among the general population, as well as the need to cover treatments to help low-income smokers quit. One-third of the points (20 points total) are awarded for the state quitline’s investment per smoker and one-sixth of the points (10 points total) are awarded for State Employee Health Plan coverage.

The score of 60 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 (30 points): Target is barrier-free coverage of all Guideline-recommended medications and counseling for the state’s entire Medicaid population.

1. States receive up to 10 points for coverage of medications: 1 point for coverage of each of the 7 medications, and 0 to 3 points based on whether coverage is available to all Medicaid members (or just members of certain managed care organizations);
2. States receive up to 10 points for coverage of counseling: 5 points for each type of counseling (individual and group). Deductions were made if coverage is only available to certain Medicaid members (pregnant women or members of certain managed care organizations, for example);
3. States receive up to 10 points for providing coverage without barriers: 1 to 2 points are deducted for each barrier to coverage that exists in a state. Deductions vary based on type of barrier and severity.

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; a bonus point (+1) is available in this section if phone and/or online counseling is covered;
3. 0 to 2 points are given if coverage is free of barriers.

Quitlines (20 points): Target is an investment in quitlines per smoker of $10.53 or more.

• $$/smoker ≥ 9.5 = 20 points
• $$/smoker 8.5 – 9.4 = 18 points
• $$/smoker 7.5 – 8.4 = 16 points
• $$/smoker 6.5 – 7.4 = 14 points
• $$/smoker 5.5 – 6.4 = 12 points
• $$/smoker 4.5 – 5.4 = 10 points
• $$/smoker 3.5 – 4.4 = 8 points
• $$/smoker 2.5 – 3.4 = 6 points
• $$/smoker 1.5 – 2.4 = 4 points
• $$/smoker .5 – 1.4 = 2 points
• $$/smoker < .5 = 0 points

Standards for Private Insurance Coverage (5 bonus points): Target is a legislative or regulatory standard requiring coverage of all PHS-recommended medications and counseling in all private insurance plans within the state.

1. 1 point given for the presence of a standard;
2. 0 to 2 points given for required coverage of medications;
3. 0 to 2 points given for required coverage of counseling.

Upcoming Cessation Scoring Change for 2013 State of Tobacco Control Report

In June 2011, the Centers for Medicare and Medicaid Services (CMS) changed its policy regarding Medicaid reimbursement for quitlines. Previously, Medicaid programs were not allowed to spend Medicaid dollars on state quitlines. As of June 2011, this policy is reversed, and Medicaid programs are able to use funds to pay for Medicaid enrollees who use state quitlines. With this change, Medicaid programs are now able to cover all three types of recommended counseling: individual, group and phone. The American Lung Association recognizes that this policy change happened after most states had finished their fiscal year 2012 budgets and/or adjourned their legislative sessions, and that states need time to respond. Therefore, the methodology for this section will be changed in the State of Tobacco Control 2013 report to include Medicaid coverage of quitlines.