State Employee Health Insurance Coverage for Tobacco Dependence

By Ronald L. Scott

Representative McClendon has introduced a bill in the recently-convened Texas Legislature to mandate that state employee health insurance plans provide coverage of pharmaceutical prescriptions to assist in stopping smoking.  See HB 88 filed Nov. 12, 2002.  The bill amends section 1551.205 of the Texas Insurance Code to provide that the state may not contract for or provide a coverage plan that “does not provide for coverage of pharmaceutical prescriptions to assist in stopping smoking.” The act takes effect September 1, 2003.

Until recently, the addictive nature of tobacco was debated, at least by tobacco companies.  Now, even the tobacco companies concede that their products are addictive.   In fact, “[m]ost smokers are addicted and meet diagnostic criteria for the medical disorder known as dependence in the Diagnostic and Statistical Manual of the American Psychiatric Association.” See Tobacco dependence treatment; scientific challenges; public health opportunities, Tobacco Control (Spring 2000).  However, treatment for tobacco dependence is less likely to be covered by insurance than treatment for other addictions.

One objective in Healthy People 2010 is to “[i]ncrease insurance coverage of evidence-based treatment for nicotine dependency to 100 percent.”  See Treating Tobacco Use and Dependence, Clinical Practice Guideline (PHS Guideline) available at  Tobacco dependence is often not treated adequately in the health care setting, largely because insurers and other health care plans do not routinely reimburse providers for tobacco cessation therapy.

Until recently, health care plans may have erroneously believed that tobacco cessation therapies are not effective—or at least not cost-effective.  However, the release of the 2000 PHS Guideline now provides compelling evidence of the efficacy (medically and economically) of both pharmacotherapies and behavioral interventions.  In Texas and some other states, Medicaid provides better coverage for tobacco cessation pharmacotherapies than most private health care plans.  See State Medicaid Coverage for Tobacco-Dependence Treatments (2001) available at The Texas Cancer Plan concluded that pharmacotherapies should be covered by health plans for smokers who are trying to quit.  See Texas Cancer Plan (3d ed.1998) available at  The Koop-Kessler report and the PHS Guideline both recommend that states require health plans to provide better coverage for tobacco cessation treatment.  See Report of the Koop-Kessler Advisory Committee on Tobacco Policy and Public Health available at

The PHS Guideline identified five “first line” drugs that “reliably increase long-term smoking abstinence rates.”  The five drugs of choice are bupropion SR, nicotine gum, nicotine inhalers, nicotine nasal spray and nicotine patch.  The only non-nicotine drug in the first line list is bupropion SR.  It is the first FDA approved non-nicotine medication for smoking cessation.  Bupropion SR is a prescription medication marketed under two names: Zyban and Wellbutrin.  Zyban is available for smoking cessation, and Wellbutrin is sold as a treatment for depression.  The PHS Guideline concluded that “the use of bupropion SR approximately doubles long-term abstinence rates when compared to a placebo.”

Nicotine gum improves long-term abstinence rates by 30 to 80 percent compared with placebo.  While nicotine gum is available over-the-counter, the nicotine inhaler is available only by prescription.  Studies show that the nicotine inhaler is also an effective aid to cessation.  It is more than twice as effective as a placebo inhaler in improving long-term abstinence rates.  Nicotine nasal spray, also available only by prescription, is similarly effective at improving long-term abstinence.  The nicotine patch is available over-the-counter as well as by prescription.  Use also doubles long-term abstinence rates. See PHS Guideline.

Based on peer-reviewed clinical evidence, the PHS Guideline found that “tobacco dependence treatments are both clinically effective and cost-effective relative to other medical and disease prevention interventions.”  Therefore, the PHS Guideline recommends that all health insurance plans should “include as a reimbursed benefit the counseling and pharmacotherapeutic treatments identified as effective…”

Research studies support the efficacy of smoking cessation treatments, but efficacy is not the only factor that might be considered.  Given the budget shortfall, legislators will be looking closely at the fiscal note attached to the bill (which is not yet available).  There may also be philosophical objections to imposing another type of insurance mandate, even one limited to state employee health plans.  These factors will all be weighed over the next few months.