Smoking is a leading cause of preventable death in the United States, resulting in an estimated 450,000 annual premature deaths, or nearly one of every five deaths. It is responsible for roughly 30% of all cancer deaths, for nearly 80% of deaths from chronic obstructive pulmonary disease, and for early cardiovascular disease deaths 
. More than one-third of the smoking-attributable years of potential life lost are related to cardiovascular disease 
. The annual economic burden of smoking in the U.S. has been estimated at nearly $193 billion in direct medical costs and productivity losses 
. While the life-time prevalence rate for adult smokers in the U.S. population is about 20% of this rate is about twice as high among adults insured by Medicaid 
. Smoking-related medical costs are responsible for 11% of Medicaid expenditures, representing an estimated $22 billion in 2004 
Federal policy has sought to reduce smoking by Medicaid beneficiaries as an important public health goal. For instance, one of the key objectives of Healthy People 2020 is to “increase comprehensive Medicaid insurance coverage of evidence-based treatment for nicotine dependency in States and the District of Columbia 
.” Considerable efforts have been made at the state level to reduce smoking. In 2009, Medicaid programs in 47 states and the District of Columbia offered at least some form of coverage for tobacco-dependence treatments, although most had a limited range of benefits 
. The Patient Protection and Affordable Care Act will increase this coverage; it requires all states to offer comprehensive tobacco cessation services for pregnant women as of 2010 (Section 4107 of the Act) and to cover anti-smoking medications under Medicaid by 2014 (Section 2502).
The state of Massachusetts initiated early efforts to provide comprehensive tobacco cessation medications and services to low-income Medicaid enrollees under its Tobacco Cessation & Prevention Program, starting in 2006. Under the program, with a physician's prescription, Medicaid beneficiaries could obtain FDA-approved smoking cessation medications with a copayment ranging from $1 to $3 per month. No preauthorization was required for a nicotine patch, gum or lozenge, bupropion (e.g., Zyban) or varenicline (Chantix) 
. Massachusetts also offered up to five sessions of free telephone counseling for the state's quit line (although this was not required to get medications).
Research by Thomas Land, et al. found that this program reached a substantial share of smokers in Medicaid, achieving about a 37% use rate, and was successful in contributing to a 10% reduction in the rate of smoking by Medicaid beneficiaries 
. Further analyses by Land, et al. examined the inpatient hospital utilization of Medicaid enrollees who used the smoking cessation benefit. The study used generalized estimating equations to examine changes in hospitalization trends among 21,656 Medicaid beneficiaries before and after the use of the tobacco cessation benefit, adjusting for demographics, comorbidities, seasonality, and other factors. On average, study participants were followed over four years, with 70 weeks in the post-benefit period. The study found that participation in the program was associated with statistically significant reductions of 46% in hospital inpatient admissions for acute myocardial infarction (AMI) (p<.05), 49% for coronary atherosclerosis and other heart disease (p<.05), and 32% for non-specific chest pain (p<.1), relative to the rate without the benefit 
. There were no significant differences in hospitalizations for respiratory conditions or other seven other diagnostic groups evaluated.
In this study, we estimated the economic value of Massachusetts' tobacco cessation program's reduction on cardiovascular hospitalizations relative to program costs. We use the estimate of reductions in cardiovascular hospitalizations reported in Land's inpatient study 
. Previous research has examined the efficacy of smoking cessation methods and found that pharmacotherapy can be a cost-effective treatment modality 
. A recent study by Ladapo simulated the lifetime cost-effectiveness of a smoking counseling program for smokers hospitalized with AMI and concluded that counseling would reduce hospitalization costs but might increase lifetime healthcare costs by extending longevity 
. In contrast, our study focuses on prevention of cardiovascular problems among smokers prior to hospitalization, primarily using pharmacotherapy, and focuses on short-term costs and savings, as opposed to lifetime cost-effectiveness. This study does not seek to measure all potential long-term savings due to the implementation of the tobacco cessation program, but represents a conservative estimate of short-term savings solely related to the avoidance of inpatient hospital admissions and treatment of cardiovascular diseases among Massachusetts Medicaid beneficiaries and smokers.