Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence

Abstract

Background: Approximately 50% of smokers die prematurely from tobacco-related diseases. In July 2006, the Massachusetts health care reform law mandated tobacco cessation coverage for the Massachusetts Medicaid population. The new benefit included behavioral counseling and all medications approved for tobacco cessation treatment by the U.S. Food and Drug Administration (FDA). Between July 1, 2006 and December 31, 2008, a total of 70,140 unique Massachusetts Medicaid subscribers used the newly available benefit, which is approximately 37% of all Massachusetts Medicaid smokers. Given the high utilization rate, the objective of this study is to determine if smoking prevalence decreased significantly after the initiation of tobacco cessation coverage.

Methods and findings: Smoking prevalence was evaluated pre- to post-benefit using 1999 through 2008 data from the Massachusetts Behavioral Risk Factor Survey (BRFSS). The crude smoking rate decreased from 38.3% (95% C.I. 33.6%-42.9%) in the pre-benefit period compared to 28.3% (95% C.I.: 24.0%-32.7%) in the post-benefit period, representing a decline of 26 percent. A demographically adjusted smoking rate showed a similar decrease in the post-benefit period. Trend analyses reflected prevalence decreases that accrued over time. Specifically, a joinpoint analysis of smoking prevalence among Massachusetts Medicaid benefit-eligible members (age 18-64) from 1999 through 2008 found a decreasing trend that was coincident with the implementation of the benefit. Finally, a logistic regression that controlled for demographic factors also showed that the trend in smoking decreased significantly from July 1, 2006 to December 31, 2008.

Conclusion: These findings suggest that a tobacco cessation benefit that includes coverage for medications and behavioral treatments, has few barriers to access, and involves broad promotion can significantly reduce smoking prevalence.

Figure 1. Demographic-Adjusted Smoking Prevalence of MassHealth Members, Age 18–64, 1999 to 2008 (Joinpoint Trend).

(1) The diamonds on the chart represent the 6-month smoking prevalence estimates based on responses to the BRFSS. Initial weighting of prevalence estimates used a standard BRFSS weighting scheme in which data are directly weighted for the probability of selection of a telephone number, the number of adults in a household, and the number of telephones in a household. A final post-stratification adjustment is made for non-response and non-coverage of households without telephones. Data were also weighted in such a way to force prevalence estimates to match demographic characteristics for the period from 1/1/2003 through 6/30/2006. (2) The lines on the chart represent the smoking prevalence trends for the MassHealth population as estimated by the joinpoint analysis. The period between 1/1/1999 and 6/30/2006 showed no significant change (p = 0.93). Beginning 7/1/2006, there was a significant downward trend (p<0.05).