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State of Tobacco Control 2019

Access to Cessation Services Methodology

The Access to Cessation Services grading system sets targets for states and awards points in three areas:

  1. Medicaid coverage of tobacco cessation treatments,
  2. State Employee Health Plan coverage of tobacco cessation treatments and
  3. 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 are available in two other target areas, Standards for Private Insurance and Tobacco Surcharges.

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 (generic) or Zyban (brand name) 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 2014 Best Practices for Comprehensive Tobacco Control Programs document, discussed previously in the Tobacco Prevention and Control Spending section above, the CDC establishes benchmarks for quitlines that are funded at the recommended levels. Grading in this section is based on the amount of funding provided to the state quitline for services divided by the number of smokers in the state.

In 2015, the Lung Association incorporated information on what tobacco cessation treatments are provided to the Medicaid expansion population into this grade. Points awarded in the Medicaid Coverage section below incorporate this information. Points available in the Medicaid coverage section were 40 to represent new Medicaid expansion enrollees. If a state has not opted to expand Medicaid up to the levels established in the Affordable Care Act (ACA), the state receives an automatic deduction of 8 points to represent the substantial number of tobacco users that do not have access to cessation treatments because of this decision.

The Lung Association will deduct up to 2 points for any state that implements a policy to charge Medicaid enrollees a tobacco surcharge or that has policies that charge Medicaid enrollees that smoke more for coverage than non-tobacco user Medicaid enrollees. The Lung Association also added 2 bonus points available to states who prohibit or limit tobacco surcharges, or health insurance policies that charge tobacco users more in premiums than non-tobacco users. States can limit or remove these surcharges.

All data in the Cessation section of "State of Tobacco Control" 2019 was collected and analyzed by the American Lung Association.

The cessation grades are based on the maximum number of total points, a score of 70, assigned according to the categories described in detail below. Over half of the points (40 points total) under the Access to Cessation Services section are awarded for coverage under a state's Medicaid program. This weighting is due to the 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. Twenty points total are awarded for the investment per smoker in the state's quitline and 10 points total are awarded for State Employee Health Plan coverage.

The score of 70 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:


Points Earned


63 to 70


56 to 62


49 to 55


42 to 48


41 and under

Key to Cessation Coverage Ratings by Category:

Medicaid Coverage (40 points):1

Target is barrier-free coverage of all Guideline-recommended medications and counseling for the state's entire Medicaid population (including the Medicaid expansion population).

  1. States receive up to 14 points for coverage of medications: 1 point for coverage of each of the 7 medications, and an additional point per medication if ALL Medicaid enrollees have coverage of that medication;
  2. States receive up to 13 points for coverage of counseling: 1 point for covering any counseling for all members, and 2 points for each type of counseling covered (individual, group and phone). Two additional points per type of counseling were given if ALL Medicaid enrollees have coverage of that type of counseling;
  3. States receive up to 13 points for providing coverage without barriers: 1 to 3 points are deducted for each barrier to coverage that exists in a state.  Deductions vary based on type of barrier and severity.
  4. If a state has not expanded Medicaid coverage up to the levels established in the Affordable Care Act (138 percent of the federal poverty level for all eligibility categories), 8 points are automatically deducted from the Medicaid coverage score.
  5. State that impose a tobacco surcharge or charge tobacco users' higher premiums than non-tobacco users for Medicaid coverage will have two points deducted from the Medicaid coverage score.

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;
  3. 0 to 2 points are given if coverage is free of barriers.

Quitlines (20 points)

States are graded based on a curve set by the median investment per smoker, which in 2019 was $2.21 per smoker. Points are awarded based on the scale below:

$$ Per Smoker


> $4.41


$3.32 – $4.41


$2.21 – $3.31


$1.11 – $2.20


< $1.11


Standards for Private Insurance Coverage (up to 5 bonus points)

Target is a legislative or regulatory standard requiring coverage of all PHS-recommended medications and counseling in private insurance plans within the state.

  1. 1 point given for the presence of a legislative or regulatory private insurance standard or if a state insurance commissioner issues a bulletin on the enforcement of the tobacco cessation FAQ issued by the federal government2;
  2. 0 to 2 points given for required coverage of medications;
  3. 0 to 2 points given for required coverage of counseling.

Tobacco Surcharges (up to 2 bonus points)

Target is a state policy prohibiting small group and individual health insurance plans from charging tobacco users' higher premiums than non-tobacco users. States can prohibit this practice or limit these surcharges to amounts smaller than federal law allows, which is 50 percent.

  1. 2 points given if state prohibits tobacco surcharges; OR
  2. 1 point given if state limits tobacco surcharges to less than 50 percent of the premium charged to non-tobacco users.
  • Sources
    1. As of January 1, 2014, the Affordable Care Act (ACA) required that state Medicaid programs no longer exclude coverage of tobacco cessation medications. In State of Tobacco Control 2019 a state was only given credit for covering tobacco cessation medications if there is documentable evidence that the Medicaid program is covering that medication, regardless of the federal requirement.
    2. On May 2, 2014, the U.S. Departments of Labor, Health and Human Services and Treasury issued an FAQ that clarified what health insurance plans under the Affordable Care Act should cover in terms of tobacco cessation medications and counseling, (see question 5).

    Did You Know?

    1. More than 27 percent of high school students in the U.S. use at least one tobacco product, including e-cigarettes, according to the 2018 National Youth Tobacco Survey.
    2. 7.2 percent of middle school students use at least one tobacco product, including e-cigarettes, according to the 2018 National Youth Tobacco Survey.
    3. From 2017 to 2018, high school e-cigarette use increased by 78 percent and middle school e-cigarette use increased by close to 50 percent in the 2018 National Youth Tobacco Survey.
    4. Smoking is the number one preventable cause of death in the U.S., killing over 480,000 people per year.
    5. Secondhand smoke kills more than 41,000 people in the U.S. each year.
    6. 28 states and Washington D.C. have passed laws making virtually all public places and workplaces, including restaurants and bars smokefree.
    7. The District of Columbia has the highest cigarette tax in the country at $4.50 per pack.
    8. Missouri has the lowest cigarette tax in the country at 17 cents per pack.
    9. The average of all states plus the District of Columbia's cigarette taxes are $1.78 per pack.
    10. Three states – Connecticut, Tennessee and West Virginia – spend no state dollars at all tobacco prevention programs.
    11. No state is funding its tobacco control programs at or above the CDC-recommended level (in Fiscal Year 2019).
    12. Kentucky, Oklahoma and the District of Columbia increased their cigarette taxes in 2018.
    13. No state approved a comprehensive smokefree workplace law in 2018.
    14. 12 states – California, Colorado, Connecticut, Indiana, Kansas, Kentucky, Maine, Massachusetts, Missouri, Ohio, Oregon and South Carolina– offer a comprehensive cessation benefit to tobacco users on Medicaid.
    15. Each of the 50 states and the District of Columbia provide tobacco quitlines, a phone number for quit smoking phone counseling. The median amount states invest in quitlines is $2.21 per smoker in the state.
    16. Massachusetts passed legislation increasing its minimum sales age for tobacco products to 21 in 2018.
    17. Six states, the District of Columbia and over 350 communities have passed Tobacco 21 laws.
    18. Nationwide, the Medicaid program spends more than $39.6 billion in healthcare costs for smoking-related diseases each year – more than 15.2 percent of total Medicaid spending.
    19. In 2009, the American Lung Association played a key role in the passage of the Family Smoking Prevention and Tobacco Control Act, which gives the U.S. Food and Drug Administration authority over tobacco products.
    20. The American Lung Association played a key role in airplanes becoming smokefree in the 1990s.
    21. 43 states and the District of Columbia spend less than half of what the CDC recommends on their state tobacco prevention programs.
    22. States spend less than three cents of every dollar of the $27.3 billion they get from tobacco settlement payments and tobacco taxes to fight tobacco use.
    23. Each day, more than 2,000 kids under 18 try their first cigarette and more than 300 kids become new, regular smokers.
    24. Each day, more than 1,900 kids try their first cigar. On average, more than 80 kids try their first cigar every hour in the United States – equaling about 712,000 every year.
    25. Smoking costs the U.S. economy over $332 billion in direct health care costs and lost productivity every year.
    26. The five largest cigarette companies spent over $23 million dollars per day marketing their products in 2016.
    27. Secondhand smoke causes $5.6 billion in lost productivity in the U.S. each year.
    28. Smoking rates are over twice as high for Medicaid recipients compared to those with private insurance.
    29. A 2013 study of California's tobacco prevention program shows that the state saved $55 in healthcare costs for every $1 invested from 1989 to 2008.
    30. A 2017 study found that states which expanded Medicaid had a 36 percent increase in the number of tobacco cessation medication prescriptions relative to the states that did not expand Medicaid. This means more quit attempts with proven cessation treatments are being made. 
    31. In 2018, three states, Idaho, Nebraska and Utah, voted to expand their Medicaid coverage, providing more smokers with access to tobacco cessation treatments.
    32. Uninsured Americans smoke at a rate more than two times higher than people with private insurance.
    33. An estimated one-third of Americans living in public housing smoke.
    34. Persons with mental illness consume close to 40 percent of all cigarettes in the U.S.
    35. Native Americans and Alaska Natives have the highest smoking rates among any racial/ethnic group.
    Get more facts »

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