Thomas Land and colleagues show that among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was followed by a substantial decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease.
Insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence in a population. However, uncertainty about the impact of this coverage on health care utilization and costs is a barrier to the broader adoption of this policy, especially by publicly funded state Medicaid insurance programs. Whether a publicly funded tobacco cessation benefit leads to decreased medical claims for tobacco-related diseases has not been studied. We examined the experience of Massachusetts, whose Medicaid program adopted comprehensive coverage of tobacco cessation medications in July 2006. Over 75,000 Medicaid subscribers used the benefit in the first 2.5 years. On the basis of earlier secondary survey work, it was estimated that smoking prevalence declined among subscribers by 10% during this period.
Methods and Findings
Using claims data, we compared the probability of hospitalization prior to use of the tobacco cessation pharmacotherapy benefit with the probability of hospitalization after benefit use among Massachusetts Medicaid beneficiaries, adjusting for demographics, comorbidities, seasonality, influenza cases, and the implementation of the statewide smoke-free air law using generalized estimating equations. Statistically significant annualized declines of 46% (95% confidence interval 2%–70%) and 49% (95% confidence interval 6%–72%) were observed in hospital admissions for acute myocardial infarction and other acute coronary heart disease diagnoses, respectively. There were no significant decreases in hospitalizations rates for respiratory diagnoses or seven other diagnostic groups evaluated.
Among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was associated with a significant decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease, but no significant change in hospital claims for other diagnoses. For low-income smokers, removing the barriers to the use of smoking cessation pharmacotherapy has the potential to decrease short-term utilization of hospital services.
Please see later in the article for the Editors' Summary
Smoking is the leading preventable cause of death in the world. Globally, it is responsible for one in ten deaths among adults. In developed countries, the death toll is even higher—in the USA and the UK, for example, one in five deaths are caused by cigarette smoking. In the USA alone, where a fifth of adults smoke, smoking accounts for more than 400,000 deaths every year; globally, smoking causes 5 million deaths per year. On average, smokers die 14 years earlier than nonsmokers, and half of all long-term smokers will die prematurely because of a smoking-related disease. These diseases include lung cancer, other types of cancer, heart disease, stroke, and lung diseases such as chronic airway obstruction, bronchitis, and emphysema. And, for every smoker who dies from one of these smoking-related diseases, another 20 will develop at least one serious disease because of their addiction to tobacco.
Why Was This Study Done?
About half of US smokers try to quit each year but most of these attempts fail. Many experts believe that counseling and/or treatment with tobacco cessation medications such as nicotine replacement products help smokers to quit. In the USA, where health care is paid for through private or state health insurance, there is some evidence that insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence. However, smoking cessation treatment is poorly covered by US health insurance programs, largely because of uncertainty about the impact of such coverage on health care costs. It is unknown, for example, whether the introduction of publicly funded tobacco cessation benefits decreases claims for treatment for tobacco-related diseases. In this longitudinal study (a study that follows a group of individuals over a period of time), the researchers ask whether the adoption of comprehensive coverage of tobacco cessation medications by the Massachusetts Medicaid program (MassHealth) in July 2006 has affected claims for treatment for tobacco-related diseases. During its first two and half years, more than 75,000 MassHealth subscribers used the tobacco cessation medication benefit and smoking prevalence among subscribers declined by approximately 10% (38.3% to 28.8%).
What Did the Researchers Do and Find?
The researchers used MassHealth claims data and a statistical method called generalized estimating equations to compare the probability of hospitalization prior to the use of tobacco cessation medication benefit with the probability of hospitalization after benefit use among MassHealth subscribers. After adjusting for other factors that might have affected hospitalization such as influenza outbreaks and the implementation of the Massachusetts Smoke-Free Workplace Law in July 2004, there was a statistically significant annualized decline in hospital admissions for heart attack of 46% after use of the tobacco cessation medication benefit. That is, the calculated annual rate of admissions for heart attacks was 46% lower after use of the benefit than before among MassHealth beneficiaries. There was also a 49% annualized decline in admissions for coronary atherosclerosis, another smoking-related heart disease. There were no significant changes in hospitalization rates for lung diseases (including asthma, pneumonia, and chronic airway obstruction) or for seven other diagnostic groups.
What Do These Findings Mean?
These findings show that, among MassHealth subscribers, the use of a tobacco cessation medication benefit was followed by a significant decrease in claims for hospitalization for heart attack and for coronary atherosclerosis but not for other diseases. It does not, however, show that the reduced claims for hospitalization were associated with a reduction in smoking because smoking cessation was not recorded by MassHealth. Furthermore, it is possible that the people who used the tobacco cessation medication benefit shared other characteristics that reduced their chances of hospitalization for heart disease. For example, people using tobacco cessation medication might have been more likely to adhere to prescription schedules for medications such as statins that would also reduce their risk of heart disease. Finally, these findings might be unique to Massachusetts, so similar studies need to be undertaken in other states. Nevertheless, the results of this study suggest that, for low-income smokers, removing financial barriers to the use of smoking cessation medications has the potential to produce short-term decreases in the use of hospital services that will, hopefully, outweigh the costs of comprehensive tobacco cessation medication benefits.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000375.
The US Centers for Disease Control and Prevention Office on Smoking and Health has information on all aspects of smoking and health, including advice on how to quit
The UK National Health Service Choices Web site provides advice about quitting smoking; more advice on quitting is provided by Smokefree
The American Heart Association provides information on heart disease, including advice on how to quit smoking (in several languages)
Information about MassHealth is available, including information on smoking and tobacco use prevention