Tobacco smoking is the leading cause of preventable disease and death in the United States, responsible for an estimated 450,000 deaths annually. Medicaid, which covered more than 42 million adults as of mid-2024, bears a disproportionate share of these health and financial costs, historically spending tens of billions of dollars on smoking-related care each year. Adults enrolled in Medicaid are more likely to use tobacco than other adults, yet few receive cessation medications. This Health Affairs DataWatch article examines Medicaid cessation medication treatment rates and spending from 2019 through 2024.
Why This Matters
Despite the availability of effective cessation medications, including nicotine replacement therapies, varenicline, and bupropion, treatment reach within Medicaid has remained stubbornly low. In 2024, net Medicaid spending on cessation medications totaled roughly $138 million, less than 1 percent of estimated annual Medicaid spending on smoking-related illness. Expanding cessation treatment is a low-cost intervention that could generate Medicaid cost savings relatively quickly while improving enrollees’ health. Understanding where and why treatment gaps persist is essential for policymakers seeking to reduce costs related to tobacco and nicotine use.
What We Found
Treatment rates were persistently low. Only about one in 10 adult Medicaid enrollees with daily tobacco or nicotine use filled a cessation medication prescription (10.4 percent in 2024), a rate that has changed little since 2019 and is broadly consistent with estimates from a decade earlier.
Prescription volume held steady, but the medication mix shifted. Adult Medicaid enrollees filled 2.6 to 2.9 million cessation prescriptions annually during 2019–24. Nicotine replacement therapies made up more than half of all fills each year, while varenicline use declined sharply after the brand-name drug (Chantix) was withdrawn in 2021.
State variation was substantial. In 2024, state-level treatment rates ranged from 1.3 percent (Alabama) to 26.6 percent (Utah). States that expanded Medicaid before 2019 generally had higher rates (11.9 percent on average) than nonexpansion states (5.3 percent). Higher-treatment states such as Kentucky, Massachusetts, and Vermont generally deployed a range of strategies, including comprehensive coverage without cost sharing, higher cigarette taxes, and sustained public health investments.
Federal retrenchment poses new risks. In 2025, CDC funding delays disrupted state Quitlines nationwide, causing service cuts and closures. Federal budget cuts reduced FDA tobacco enforcement, and Medicaid reductions in the One Big Beautiful Bill Act may further erode cessation infrastructure. States can partially offset these losses by leveraging Medicaid financing for Quitline services, but doing so may widen interstate inequities.
How We Did It
The authors analyzed Medicaid State Drug Utilization Data (2019–24) to measure prescription fills and spending for cessation medications, adjusting gross spending for federal statutory rebates. Daily tobacco and nicotine use denominators were constructed from National Survey on Drug Use and Health data (2021–22), adjusted using National Health Interview Survey trends (2019–23), and applied to Centers for Medicare and Medicaid Services enrollment counts. Bupropion cessation attribution rates and the average number of cessation prescriptions per treated enrollee were derived from the authors' analysis of Transformed Medicaid Statistical Information System claims from 12 states.
This work was funded by Global Action to End Smoking, formerly known as the Foundation for a Smoke-Free World. The funder had no role in the editorial direction or control of the content, analysis, or conclusions presented in this article.
