Smoking cessation is not innovative or trendy or even particularly exciting, but as a primary care doctor, in most cases helping a patient quit smoking is the best thing that I can do to help that patient over their lifetime. Without question. And for that reason, I always make it a priority to talk about it with smokers on every visit – even if I just mention it and am met with “I don’t wanna talk about it, doc!” every time.
Smokers die about 10 years earlier than non-smokers, and smoking leads to more than 480,000 deaths and costs $300 billion per year in the United States. Clinicians have a wide variety of evidence-based smoking cessation treatments to offer patients, ranging from nicotine replacement therapies such as patches or gum, to oral medications that reduce cravings for nicotine such as varenicline (Chantix) and bupropion (Zyban). Because of the profound health benefit, improvement in outcomes, and savings that smoking cessation can produce, it has become an important quality metric for all payers and regulatory bodies in healthcare. Access to and uptake of these therapies is of great interest in public health research and were examined in an important new manuscript.
Kelly C. Young-Wolff and colleagues address the intersection of smoking cessation efforts with the Affordable Care Act in their recent publication in Medical Care, Association of the Affordable Care Act with Smoking and Tobacco Treatment Utilization among Adults Newly Enrolled in Healthcare. The researchers analyzed new enrollees in Kaiser Permanente Northern California Medicaid, California exchange, or non-exchange insurance plans during the first six months of the ACA rollout in early 2014. They found that Medicaid enrollees had higher rates of smoking at 22%, as opposed to 13% of individuals on exchange plans or 12% of commercial enrollees. Crucially, however, when researchers controlled for key sociodemographic and clinical characteristics, smokers on Medicaid had significantly greater rates of tobacco cessation treatment than smokers who had commercial insurances (OR=1.49, 95% CI=1.29-1.73). Notably, researchers also found that men, especially younger men, and individuals of Latino and Asian descent were at risk for underuse of tobacco cessation treatment.
As Young-Wolff and colleagues point out, it has been known for some time that poor and underserved populations typically smoke at disproportionately high rates compared to privately insured populations. The important contribution of this paper is that it demonstrates a strong uptake of smoking cessation therapies when they are available. This could be due to pent-up demand and hunger for access to smoking cessation treatment, just as pent-up demand for other types of medical treatment has been seen in newly eligible Medicaid enrollees.
Young-Wolff’s paper illuminates another important policy implication of the ACA in the current political climate. The ACA mandates coverage of smoking cessation treatments without cost-sharing. This is defined as four counseling sessions and 90 days of evidence based medications without copays or additional fees passed on to the patient. While the majority of Medicaid patients were able to access these services without any copay, 80% of patients with coverage through commercial plans in 2014 still had cost-sharing for smoking cessation medications. Given the profound public health benefit that smoking cessation brings to our whole society, this article illuminates yet another benefit that the ACA has brought to all consumers of healthcare and will be at risk should the ACA be repealed.
While most coverage of a possible ACA repeal by the Trump administration has focused on the very dramatic cases of individuals with cancer or other grave pre-existing conditions, there are clear public health benefits, such as increased access to smoking cessation treatment, that the ACA has brought to all Americans that should also be considered as the debate goes forward in Congress and at the White House.
Audrey Provenzano