ACA's Tobacco-cessation Benefits Must Be Standardized, Clarified

Academy Joins Other Groups in Urging HHS to Act

March 31, 2014 02:31 pm News Staff
[A single cigarette]

Recently, the AAFP joined more than 30 other health care organizations in sending a letter to HHS Secretary Kathleen Sebelius(4 page PDF) asking her to provide clear guidance to insurers on the tobacco-cessation benefits that must be offered in accordance with the Patient Protection and Affordable Care Act.

The letter, which was spearheaded by the Campaign for Tobacco-Free Kids, referenced the recent U.S. surgeon general's report The Health Consequences of Smoking -- 50 Years of Progress(, which marked the 50th anniversary of the groundbreaking report from Surgeon General Luther Terry, M.D., that first laid out the evidence linking cigarette smoking to lung cancer and other respiratory diseases.

The groups' letter described the 2014 report as "historic" and noted that it called for a number of specific actions, including "fulfilling the opportunity of the Affordable Care Act (ACA) to provide access to barrier-free proven tobacco-use cessation treatment, including counseling and medication, to all smokers." Although the ACA requires insurance companies to provide tobacco-cessation services to their beneficiaries, said the stakeholders, "We are concerned that tobacco users who are ready to quit do not have access to free cessation services under the ACA."

Story highlights
  • The AAFP joined more than 30 other health care organizations in sending a letter to HHS Secretary Kathleen Sebelius asking her to provide clear guidance to insurers on the tobacco-cessation benefits that must be offered under the Patient Protection and Affordable Care Act.
  • A 2012 PLOS ONE study found that Massachusetts saved more than $3 for every $1 it spent on services to help beneficiaries in the state's Medicaid program to quit smoking.
  • Meanwhile, use of electronic cigarettes, which deliver nicotine in a vapor form, is increasing among both youth and adults.

Letter Reflects AAFP Tobacco Policy

Robert Bennett, AAFP's federal regulatory manager, said the letter is consistent with the "Treatment of and Payment for Tobacco Use" subsection from the AAFP's Tobacco and Smoking policy, which reads, in part: "The AAFP supports health plan coverage and appropriate payment for evidence-based physician services for treatment of tobacco use. The AAFP recommends that all tobacco users in the United States be aware of the existence of and have barrier-free access to all evidenced-based FDA-approved therapies and counseling as described in the U.S. Public Health Service's 2008 update of the Clinical Practice Guideline: Treating Tobacco Use and Dependence."(

According to the letter, the current surgeon general's report noted that implementation of tobacco-cessation treatment coverage mandated by the ACA varies significantly across private health insurance contracts. "In fact," the letter noted, "evidence indicates that many health care plans are not covering services that have been proven to help tobacco users quit."

For example, a 2012 study( by Georgetown University's Health Policy Institute found that only four of the 39 private health plans analyzed clearly covered a full range of evidence-based tobacco-cessation services. Those services included individual, group and phone counseling, as well as both prescription and OTC tobacco-cessation medications. Moreover, contract language in the plans reviewed often contained vague or conflicting terminology that made it impossible to determine which -- or even whether -- tobacco-cessation services were covered, the study reported.

Another point of concern raised in the Georgetown study was that some of the plans imposed a cost-sharing requirement for tobacco-cessation treatments. Tobacco-cessation treatments have received an 'A' rating by the U.S. Preventive Services Task Force, which, according to the letter, means that "there is a high certainty that tobacco users will benefit substantially receiving these services."

"As an 'A' rated service, non-grandfathered group plans and insurance issuers must cover these evidence-based tobacco-cessation services with no cost-sharing," said the letter.

The letter also discussed the cost-effectiveness of providing comprehensive tobacco-cessation benefits, citing a 2012 PLOS ONE study( that found Massachusetts saved more than $3 for every $1 it spent on services to help beneficiaries in the state's Medicaid program quit smoking. "These savings are conservative, as they do not include long-term savings, savings that might occur outside the Medicaid program, or savings beyond cardiovascular-related hospital admissions," the letter stated.

Growing Scrutiny Surrounds E-cigarettes

Even as tobacco-cessation efforts expand nationwide, stakeholders have set their sights on a related product -- one, in fact, that proponents tout as a tool for those trying to quit smoking.

In a letter sent last fall to President Obama(3 page PDF), the AAFP joined 15 other health care organizations in calling for the FDA to move forward with rulemaking that would grant the agency authority to regulate e-cigarettes and other tobacco-related products, such as little cigars, that currently do not fall under the agency's regulatory oversight.

Require Tobacco Makers to Reduce Harms, AAFP Tells FDA

On March 28, the Academy joined nearly three dozen other medical professional organizations and consumer advocacy groups in urging the FDA to compel tobacco manufacturers to take steps to reduce their products' toxicity and addictiveness.

"For the first time in history, the Family Smoking Prevention and Tobacco Control Act gives the FDA the authority to require changes in the content and design of cigarettes 'appropriate for the protection of public health,'" says a letter to Mitchell Zeller, director of the FDA Center for Tobacco Products. "Moreover, the recently released surgeon general's report, The Health Consequences of Smoking – 50 Years of Progress, makes it clear that FDA needs to act and act quickly to use this broad authority to require the tobacco companies to reverse the changes that have actually made their products even more dangerous."

In no other industry can manufacturers modify their products in ways that actually increase the fatal risks those products pose, the groups point out. "In light of the surgeon general's unequivocal finding that today's cigarettes do just that, we write to urge FDA to respond decisively by requiring whatever changes are needed in the design and composition of cigarettes to eliminate the increased risk of disease and death identified by the surgeon general."

According to the letter, use of e-cigarettes, which deliver nicotine in vapor form, is increasing among youth and adults. The CDC released data( last fall showing that from 2011-12, the number of students in grades 6-12 who reported ever having used an e-cigarette doubled from 3.3 percent to 6.8 percent. This trend is particularly concerning given that the 2014 surgeon general's report on smoking indicates that evidence suggests nicotine exposure during adolescence has lasting adverse consequences on brain development.

Complicating the picture further is the fact that e-cigarettes are big business. In an Aug. 26 Bloomberg Businessweek article(, Bloomberg Industries estimated e-cigarette sales would outpace those of traditional cigarettes by 2047 if their sales continue at current rates.

Acknowledging the rising use of e-cigarettes and the need to educate members about these devices, the AAFP approved an e-cigarettes policy in January. In the policy, the Academy calls for "rigorous research in the form of randomized controlled trials of e-cigarettes to assess their safety, quality and efficacy as a potential cessation device. The AAFP also recommends that the marketing and advertising of e-cigarettes, especially to children and youth, should cease immediately until e-cigarettes' safety, toxicity and efficacy are established."