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Tobacco Cessation Intervention on the State Level


The advancement in the field of health care in the USA is particularly concerned with the improvement of health outcomes for the population in the areas that are most indicative of having issues. High morbidity and mortality rates of particular diseases and states trigger a response from the decision-makers and policy-makers to address the problematic areas through federal and state action. One of the significant preventable factors leading to cardiovascular disease and death is smoking. The prevalence of tobacco use in the American population reaches “14.1% of US adults – more than 30 million people – smoked in 2017” (Barua et al., 2018). Despite the decline within the past decades, these numbers remain high, which requires enacting specially designed policies to promote smoking cessation.

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Therefore, federal and state involvement in the addressing of the health issue is required. In this regard, the inclusion of tobacco cessation interventions in the Affordable Care Act (ACA) health plans is a beneficial decision that requires Medicaid and private insurers to bear coverage for state cessation interventions (DiGiulio et al., 2020). Given the context of the issue at hand, this case study is aimed at examining the implementation of tobacco cessation state quitlines’ shared coverage under ACA. It discovers the changes in stakeholders, their collaboration particularities, the impact of the policy on operational decision-making, and the dependence of quitline success on the communication capabilities of health plan informants. All these features are analyzed in the report to validate that the engagement of multiple stakeholders in the implementation of state tobacco cessation interventions is essential for the improvement of the coverage, procedure conducting, tobacco users’ enrollment, and the overall health outcomes of the general population of the USA.

Changes in Stakeholders in Tobacco Cessation since ACA Passage and Their Implications

The method of case study allows for proper investigation of the health issues and program implementation success within a particular perspective, such as the effectiveness of stakeholder collaboration. The case study analyzed in the report is the research conducted by Lemaire et al. (2015) on the outcomes of meeting the coverage requirements under the ACA provisions. The study was aimed at exploring how different stakeholders perceived cost-sharing related to state tobacco cessation quitlines (Lemaire et al., 2015). The researchers conducted a qualitative inquiry with the representatives of “state health departments, quitline service providers, health plans, and insurance brokers in 4 US states” (Lemaire et al., 2015, p. 699). It found that the perception of the state tobacco cessation interventions varied from stakeholder to stakeholder throughout the states.

Overall, the initiation of the tobacco cessation interventions under shared coverage has become ACA’s requirement in 2014. Since that time, the law has placed “the financial responsibility for providing tobacco cessation treatment on the insurer or health plan, at no cost to the patient” (Lemaire et al., 2015, p. 699). With the introduction of a new requirement, the treatment interventions for smoking cessation have become an essential element in the health plans, which increased the attention of stakeholders to the issue. Overall, the stakeholders involved in the collaboration under the new provisions of the ACA include state departments of health care, private insurance companies, public health plan providers, and the services that specialize in providing telephone-based quitline interventions. The range of the involved parties has significantly increased since the passage of ACA requirements, placing more responsibilities for health plan providers and integrating both public and private entities in one collaborative framework.

Under the provisions of the law, all insured individuals suffering from tobacco use and seeking cessation support should have free access to the services specifically designed by state authorities for tobacco use treatment. In this context, the term ‘free’ implies no financial liabilities on patients’ side, while a quitline and a health plan provider share financial responsibilities for the provided services (Lemaire et al., 2015). As stated earlier in the report, the intervention is a set of state-based telephone programs that function as quitlines providing services. They include “telephone counseling, medications, information, and other support to help tobacco users quit and to comply with standards set by the US Public Health Services clinical guideline” (Lemaire et al., 2015, p. 699). To ensure that all patients obtain proper services, the number of stakeholders involved in the programs increased to include national organizations, service providers, and departments of health in each state. Thus, the ACA passage has influenced the increase in the number of stakeholders engaged in the provision of smoking cessation services, as well as modified their responsibilities.

In particular, the most important responsibility that is entailed by the initiated quitline programs is cost-sharing. According to the provision of law, private insurers are expected to cover fully or partially the costs spent on the delivery of tobacco cessation services to their clients through state programs. However, the study conducted by Lemaire et al. (2015) has demonstrated that there exists a misperception of the financial responsibilities associated with quitlines. The results of the interviews conducted with the stakeholders representing four different states have shown that the majority of health plans and insurance brokers perceived quitlines as free services (Lemaire et al., 2015). Moreover, private insurers in three out of four states disregarded cost-sharing, which is indicative of the drawbacks in the implementation of the programs to meet the requirements of the law.

In this regard, a pivotal element in the integration of quitlines in the insurance plans and the launching of cost-sharing initiatives is leadership at the state level. Indeed, in many states, the decision-making on the sharing of costs with quitlines is obstructed due to the lack of leadership’s orders or instructions (Lemaire et al., 2015). Nonetheless, thanks to the ACA’s requirement, both private and public insurance and service providing entities are more aware of the programs for tobacco cessation, learn about the risks of non-addressing the smoking issue, and are willing to share costs with quitlines to cover for medications and interventions. Stakeholders’ unwillingness to share costs and mere lack of knowledge about ACA requirements have been found as negative characteristics of stakeholder roles. However, the involvement of state authorities for thorough funding of quitlines has been improved after the passage of ACA, which indicates a significant improvement.

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Analysis of States’ Stakeholder Collaboration Efficacy for Tobacco Cessation

One of the significant determinants of the success of implementing a health policy is the establishment of properly distributed roles between the involved parties and their close collaboration. Cooperative methods of problem-solving deem pertinent in large-scale and prevalent issue management like smoking cessation. Moreover, stakeholder engagement proves to be a pivotal element in achieving long-term positive results in the implementation of smoking treatment programs (Flocke et al., 2019). In particular, the intertwined interaction between the national organizations, service providers, and state health departments is the basis for the overall functioning of the telephone-based cessation support provision (Lemaire et al., 2015). In each state, the quality of cooperative skills exhibited by the involved parties directly influences the success of program implementation.

The case study unveiled that the state’s authorities and stakeholders had a different level of awareness about the ACA’s requirements and, ultimately, a different level of involvement. Indeed, according to the study, the level of engagement of states represented in the research in cost-sharing activities ranged from high in one state, medium-high in one state, and low in the other two states (Lemaire et al., 2015). It is important to note that the Medicaid coverage for tobacco cessation in the states with medium-high and high engagement in cost-sharing activities was estimated as adequate and good. However, the coverage in the states with low engagement was insufficient (Lemaire et al., 2015). Moreover, the prevalence of smoking across the states was disproportionately distributed and ranged from very low to very high. These indicators show that higher engagement in cost-sharing depends on multiple factors, including smoking rates and Medicaid coverage.

The review of the collaboration styles employed by different states allows for assuming a hierarchal type of interaction, in which the actions of service providers were regulated by state health departments. In particular, in State 1, the ACA provisions enactment was delayed due to the lack of support from the state authorities. Although the transition to ACA and the engagement in cost-sharing was eventually initiated, “the service provider for the quitline was asked not to initiate any direct contracts with health plans in the state” (Lemaire et al., 2015, p. 701). Thus, it implies a correlation of efforts and responsibilities within the system of stakeholders, which might serve as both a regulating factor and a restricting determinant.

On the other hand, in State 2, the state department of health was less collaborative and less knowledgeable about the ACA requirements, which ultimately influenced the provision of the service to patients. Indeed, the health department was not initiating any relationships with the private sector entities in an expectation that “the quitline service provider would develop those relationships” (Lemaire et al., 2015, p. 702). Such a drawback in a collaboration led to a negative engagement in cost-sharing and an insufficient enrolment of patients in the telephone-based program. It is imperative to eliminate uncertainties in the distribution of roles between the stakeholders to ensure proper and efficient program implementation.

Furthermore, in State 3, the collaboration between the health department and private entities was dependent on the bureaucratic distribution of power and the influence of the political interest. According to the case study, the “state had only CDC funding for the quitline and no state funds were provided, which might partially explain the lack of initiative regarding the quitline and ACA” (Lemaire et al., 2015, p. 702). On the contrary, State 4 used a proactive leadership approach to improve the engagement of the state health department in the following of ACA requirements. The state’s stakeholders used ACA “as an opportunity to improve systems, improve access, and incentivize cost-sharing to lead to a more sustainable funding strategy of the state quitline in the future” (Lemaire et al., 2015, p. 703). Thus, the analysis of collaborative action in the states and their its impact on the efficacy of program implementation demonstrated that States 1 and 4 had a proactive leadership approach to the cost-sharing initiating, while States 2 and 3 applied for a passive leadership position with little knowledge about ACA requirements and low level of engagement.

The Impact of Case Study Findings on Operational Decision-Making of Health Plan Informants

Operational decision-making of the stakeholders involved in tobacco cessation implies efforts aimed at solving particular short-term problems to mitigate long-term risks and difficulties. In the case of smoking rate reduction, the operational decision-making of health plan informants involves direct interaction with the clients for their enrollment in the program by sharing costs with the states for the expenses. The long-term goals that such an approach would help achieve are the reduction of the number of smokers in the United States and better health outcomes of the population on average. According to Thrul et al. (2021), the effectiveness of smoking cessation policies, including taxation and treatment promotion, remains insufficient. That is why it is essential to promote better stakeholder involvement of stakeholders in general, and health plan informants in particular, to increase enrollment and achieve program goals following the law requirements.

The ability to make decisions is informed by the responsibilities and access to proper means enabling a stakeholder to promote the solutions necessary for the served community. A recently conducted study among insurance coverage recipients in several states showed that smokers who are eligible for Medicaid and enrolled in the smoking cessation programs had successful quitting results and better health outcomes (Yip et al., 2020). Such a positive result in the implementation of tobacco use treatment measures validates the necessity of stakeholders’ improvement of operational decision-making by health plan providers and service providers. Indeed, the finding of Lemaire et al. (2015) indicates that the states’ informants considered the need for proactive measures as a driving force of the success of quitline programs. Thus, predicting possible risks and addressing them beforehand is an effective decision-making tactic that should be used by health plan informants.

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In order to mitigate the unwillingness of employers to engage in cost-sharing and enrollment of employees in the telephone-based tobacco cessation programs, specific decisions should be made. In particular, it was stated that “data capacities of the quitlines need to be maintained and built into cost-sharing agreements as an incentive to sustain engagement of the health plans” (Lemaire et al., 2015, p. 703). In such a manner, the obligations of the private entities will be clarified and bound to their coverage responsibilities, thus contributing to the efficacy of the program implementation. For that matter, when making decisions at a state level, stakeholders should be aware of the long-term goals pursued by the program and prioritize solutions that contribute to the accessibility and availability of the services despite costs. Overall, the findings of the case study might help the stakeholders see the problematic issues in the sphere of tobacco cessation support services distribution and the positive examples demonstrated by successful states. States that show high levels of cost-sharing engagement yield positive results in a smoking rates reduction. Thus, decision-makers should facilitate cost-sharing initiatives to gain better outcomes through operational decision-making.

Each Health Plan Informants’ Communication Capabilities’ Impact on the Overall Efficacy and Sustainability of the State’s Quitline

Communication is essential for a successful implementation of the programs related to health care, especially when the dissemination of the information of their availability directly impacts immediate health outcomes. The case of tobacco use demonstrates that the quit rates significantly depend on the availability of information and awareness about the programs provided by states within the quitline services (Nair et al., 2019). In particular, without being properly and fully informed about the program’s existence, smokers, both seeking cessation support and those not willing to quit, will not have an opportunity to succeed at eliminating this harmful factor from their lifestyle. It is essential for people to know not only about the existence of such a program but also its affordability for the insured due to the cost responsibilities being placed on the insurers and quitlines. As stated by Gordon et al. (2019), quitlines “are efficient, highly scalable, and available throughout the United States, yet they are underutilized by smokers” (p. 1). Indeed, the reason why individuals do not access telephone-based programs for smoking cessation is due to the drawbacks in communication.

It is pivotal to ensure that people are aware of the program so that it yields the outcomes relevant to the goals of reducing smoking rates in the USA. According to Nair et al. (2019), enrollment rates directly influence quit outcomes for patients, which is why it is important for the stakeholders to expand their communication strategies to enroll more people into the program. In particular, the findings of the research study conducted by Nair et al. (2019) vividly prove “the need for tailored messaging around enrolling and availing of cessation services at the provider level” (p. 6). It is implied that service providers should be acknowledged of ACA’s requirement of including quitline programs in the health plans; moreover, they should improve their communication tactics to actively disseminate messages for better patient enrollment. Therefore, the quality, frequency, and clarity of communication between the stakeholders and prospective program participants predetermine long-term outcomes of the whole population of the country. Thus, the contribution of each of the stakeholders in the process of program implementation is indicative of the overall success, efficacy, and sustainability of its results.

Overall, private insurers on a general level in the USA are willing to share costs for smoking cessation. The findings of Maclean et al.’s (2019) study demonstrate that the Medicaid-financed cessation medication prescriptions increased by 34%, which indicates a “shift in payment from private insurers and self-paying patients to Medicaid” (p. 1798). For that matter, it is essential to ensure clarity of communication between all the engaged stakeholders to identify gaps in funding and generate effective solutions. In terms of health departments and service providers, the quality of communication between them is primarily based on the discussion of the initiative of cost-sharing, which yields positive sustainability outcomes (Lemaire et al., 2015). In particular, through the engagement “with a much broader community, including health plans, broker groups, and associations,” health departments and service providers will be able to facilitate cost-efficiency and long-term functioning of the initiatives (Lemaire et al., 2015, p. 703). Since health departments are in a key leadership position when it comes to the initiation of cooperation with private entities, their communication strategies should be evidence-based and sustainability-bound.

As for the health plans, their communicational role particularly unfolds in the setting of interacting with clients. According to Lemaire et al. (2015), their primary concern is educating clients and care providers about possible opportunities available under ACA. Furthermore, insurance brokers’ communication primarily involves interactions with employers when determining coverage plans. For that matter, their communication strategies directly influence the outcomes of availability of quitlines to their employees. From a long-term perspective, the manner in which the information about smoking cessation coverage is distributed among the stakeholders and clients predetermines the sustainability of the programs. Therefore, it is essential to apply the findings of the case study to educate the stakeholders and facilitate their engagement to ensure proper, efficient, and sustainable health outcomes.


In summation, the presented case study analysis has unveiled the particularities of the implemented tobacco cessation intervention on the state level within the framework of ACA essential requirements. The law requires that insurers and health plans bear the responsibility of costs spent on the implementation of quitlines, which are telephone-based tobacco cessation treatment programs. After the passage of the law, the number of stakeholders involved in quitlines increased, and their roles expanded, which has complicated the clarity of responsibilities. Health departments of the states and service providers are often confused with the responsibility of cost-sharing, as well as lack proper information about the program implementation. The results of the case study might be used by health plan informants to improve their operational decision-making toward more evidence-based collaborations and clarity of cost-sharing responsibilities. Enhanced communication and collaboration between the stakeholders should be based on the best practices of proactive leadership used by successful states to ensure sustainability and efficacy of quitline programs implementation.


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