The Massachusetts experience suggests that a good benefit design, combined with broad promotion, can result in a significant reduction in smoking prevalence. In the past 20 years, dramatic reductions occurred in smoking prevalence among the college educated in Massachusetts. These results suggest that when offered easy access to low-cost medications, the Medicaid population can also show significant reductions in smoking prevalence. Furthermore, there was a significant increase in quit success without any corresponding increase in the proportion of smokers making quit attempts. Further research is required to determine the role of promotion in the decrease in smoking prevalence in this population. Data was not available in the Massachusetts BRFSS to determine whether there was any increase in evidence-based quit attempts in the post-benefit period.
Several limitations should be noted. Smoking prevalence might be increasingly underestimated by BRFSS traditional survey method because adults lacking landlines are more likely than the general population to smoke 
. However, systematic bias introduced by declining response rates or the ongoing trend away from landlines would have been gradual. In contrast, the joinpoint analysis and logistic regression suggest a sharp change in smoking prevalence trend. Estimates of smoking prevalence were based on self-report, but self-reported smoking status has been shown to have high validity 
Also, enrollment in MassHealth increased following health reform. While much of this increase may have come from the rolls of the previously uninsured, most uninsured found insurance through other programs 
. Responses to the BRFSS did not include questions about the length of time one was insured through any particular insurer, therefore it cannot be precisely determined how much the increased enrollment affected prevalence estimates. To partially account for these demographic changes resulting from enrollment increases, prevalence estimates were computed using a weighting scheme that forced the demographic characteristics of the post-benefit period to match those in the pre-benefit period.
Finally, smoking cessation was promoted broadly to the full Massachusetts population in several ways during the study time period. For example, MTCP ran a general media campaign November 2007 – January 2008; pharmaceutical companies advertised products for cessation; and on July 1, 2008, the state excise tax increased by $1 per pack and the state quitline began offering free nicotine patches to callers. The proportion of MassHealth subscribers among quitline callers did not change between 2005 and 2008. Thus, it seems unlikely that broad-based actions such as advertising, as opposed to the tobacco cessation treatment itself, are the primary explanations for MassHealth subscribers' higher quit rate over the last 2 years.
Information comparable to that reported here for Massachusetts has not been published for other states or the U.S. as a whole. The crucial health implications of preliminary findings from Massachusetts strongly suggest that similar analyses be undertaken in other states. Variations across states in level of benefits, ease of access to services, extent of advertising and other promotion of benefits, and baseline smoking prevalence provide opportunities for comparative analyses that could help identify variables that foster the largest possible impacts of benefits. Subsequent research might focus on linking drops in smoking prevalence to improved health outcomes, reduction in claims, and specific cost-containment strategies.
The Public Health Service's Clinical Practice Guideline for treating tobacco use and dependence recommends that both medication and counseling be offered to patients 
. Similarly, offering cessation services is an integral part of the World Health Organization's MPOWER policy package for reversing the tobacco epidemic 
. The Massachusetts tobacco cessation benefit claims utilization data are, by inspection, suggestive that pharmacotherapy treatments might be particularly promising in terms of probability of being utilized. One possible reason why cessation counseling was little used by MassHealth subscribers is that relatively few primary care settings had the staff resources needed to make 30- or 60-minute tobacco treatment sessions readily available. Although speculative, it seems likely that many office encounters leading to prescriptions for tobacco cessation medications also included caregiver discussion and advice on quitting, even if counseling was not the primary purpose of the visit.
The Massachusetts findings suggest that a broadly-promoted, accessible, comprehensive smoking cessation benefit can reduce smoking prevalence in the Medicaid population. In 2004, U.S. Medicaid expenditures for smoking-related conditions totaled $22 billion 
. Tobacco cessation treatment is cost-effective and should be made available to all smokers 
via health insurance benefits. Fully implementing known tobacco control strategies has strong promise to end the U.S. tobacco epidemic