For the first time on record, cigarette smoking among US adults fell below 10 percent in 2024. This is a public health milestone decades in the making, but it hasn’t been shared equally across communities.
As smoking declines nationally, the relative gap in smoking rates between higher-income and lower-income Americans has grown. In 2021, about 21.5 percent of low-income adults enrolled in Medicaid smoked—more than double the 8.6 percent rate among privately insured adults. As a result, Medicaid covers a large share of those who need help quitting.
Yet new Urban Institute research and a state-level data tool show that Medicaid-funded cessation treatment reaches only a small fraction of those who may benefit. And low treatment rates could be worsened by upcoming and proposed cuts to Medicaid and other smoking-cessation supports.
With funding from Global Action to End Smoking, we analyzed Medicaid State Drug Utilization Data on prescription fills for tobacco and nicotine cessation medications—including nicotine replacement therapies (NRTs), varenicline, and bupropion used for cessation—among adult Medicaid enrollees from 2019 through 2025. This analysis can help federal and state-level policymakers understand and address the current treatment gap and potential effects of federal policy changes.
The number of Medicaid-covered prescription fills for smoking cessation medications rose modestly from 2019 to 2025, but the mix shifted sharply
Overall Medicaid-covered cessation medication fills rose from about 2.8 million in 2019 to 3.1 million in 2025, or 9.1 percent. That modest increase did not outpace Medicaid enrollment growth during the COVID-19 pandemic, and it masked a major shift in which types of cessation medications enrollees received.
Fills of varenicline, which systematic reviews show to be a highly effective first-line cessation treatment, fell 35 percent over the period. Supply shocks contributed to the decline. The manufacturer of brand-name varenicline recalled the product and paused its distribution in 2021 because of a nitrosamine impurity in manufacturing, and generic varenicline supply was slow to fill the gap.
At the same time, NRT fills increased by 28.8 percent over the period. NRT medications, already a majority of cessation fills in 2019, grew from 54.0 percent to 63.7 percent of all fills, driven by large increases in fills for nicotine gum (up 101 percent) and lozenges (up 177 percent). Estimated bupropion fills for cessation rose modestly (7.7 percent).
Sources: Centers for Medicare & Medicaid Services (CMS) Medicaid State Drug Utilization Data (SDUD), 2019–25, and CMS Transformed Medicaid Statistical Information System Analytic Files, 2022.
Notes: Annual prescription fills represent the number of Medicaid-covered outpatient prescriptions and over-the-counter medications for tobacco or nicotine cessation, as recorded in the SDUD. Data are reported by National Drug Code and aggregated at the state-year level. Varenicline data include both brand and authorized generic versions. For information about our methodology, read our technical appendix.
Estimated cessation treatment rates are low for Medicaid enrollees with daily tobacco or nicotine use
Only about one in nine adult Medicaid enrollees who use tobacco or nicotine daily received any cessation medication in 2025. The estimated treatment rate was also essentially flat between 2019 and 2025. There was a midperiod dip during the COVID-19 pandemic, likely reflecting a temporary increase in enrollment, but enrollees who newly gained coverage were less engaged in health care than other Medicaid enrollees.
Every state Medicaid program provided cessation medications, but where an enrollee lives affects their access to treatment. In 2025, cessation medication fill rates ranged from a high of 909 per 1,000 enrollees with daily tobacco or nicotine use in Utah to a low of 38 in Alabama. (The median number of fills was 369.)
States that expanded Medicaid earliest generally reached the most enrollees. In states that expanded before 2019, the estimated treatment rate was 13.2 percent in 2025, compared with 11.0 percent in states that expanded later (2019 to 2023). In states that had not expanded Medicaid by 2024—many of which have the highest smoking rates—the estimated treatment rate was just 5.6 percent.
Federal rules that limit coverage of cessation medications and impose work requirements will make treatment harder for Medicaid enrollees to access
Federal rules set a floor for Medicaid coverage of cessation medications. But they do not generally bar utilization-management barriers, such as prior authorization, duration limits, and annual limits on a patient’s number of quit attempts, which can reduce treatment access. In 2022, 39 states put duration limits on cessation medications, 35 capped the number of quit attempts, and 30 required prior authorization. Only three states—Kentucky, Missouri, and Wisconsin—didn’t impose access barriers. (These barriers apply only to standard Medicaid enrollees, not enrollees who gained coverage under expansion through the Affordable Care Act, who are federally guaranteed barrier-free coverage of cessation medications.)
Upcoming changes to the federal policy landscape could also worsen the low estimated treatment rates revealed in this analysis. The most consequential will begin January 1, 2027, when the One Big Beautiful Bill Act will impose Medicaid work-reporting requirements and more-frequent eligibility redeterminations. The Urban Institute estimates these changes to the program could reduce enrollment by 4.9 million to 10.1 million people in 2028. As of September 17, 2026, we identified no publicly available state proposal that expressly treats tobacco use disorder as a standalone exemption in the substance use disorder category of the medical frailty exemption from the work-reporting requirement.
Medicaid coverage losses could also be disproportionately high for enrollees who smoke. That’s because people who use tobacco and nicotine are disproportionately represented among those who may find both the exemption paperwork and the work-reporting requirements challenging to complete because of disability, serious psychological distress, and unstable work.
At the same time, the federal government has weakened tobacco-control infrastructure. The Office on Smoking and Health at the Centers for Disease Control and Prevention, which runs national tobacco surveillance, the Tips From Former Smokers campaign, and quitlines in some states, was largely dismantled in 2025. This year, the American Lung Association’s federal scorecard again issued a D for cessation coverage and an F for tobacco taxes.
In addition, the US Food and Drug Administration withdrew the proposed menthol cigarette ban in January 2025. It has not moved forward on a proposed rule to reduce the level of nicotine in cigarettes to minimally addictive levels, which it had projected would prevent 1.8 million tobacco-related deaths by 2060. In May 2026 guidance, the agency deprioritized enforcement against many unauthorized e-cigarette and nicotine-pouch products, some of which contain highly toxic heavy metals such as lead and nickel.
These policy choices also defy harm-reduction principles by blurring real differences in risk across tobacco and nicotine products. Combustible tobacco is generally the most harmful, followed by vaping products (especially unauthorized vapes), then nicotine pouches. But this risk gradient remains understudied and deserves to be a focus of federal research. Better evidence would support policymakers in setting and enforcing health-focused standards matched to each product’s risk and would provide the critical information needed for public health messaging.
Congress and state policymakers could help more Medicaid enrollees quit using tobacco and nicotine
Cessation treatment works, and two-thirds of smokers want to quit. Treatment is also inexpensive relative to what smoking costs Medicaid. In 2024, Medicaid programs spent a net $137.6 million on cessation medications—less than 1 percent of the tens of billions Medicaid has historically spent each year on smoking-related care. As Medicaid budgets tighten, underfunding such a low-cost treatment is counterproductive. But our findings of low treatment rates and the shifts in federal policy pose barriers to helping more Medicaid enrollees access treatment.
Congress has proposed policy options that could help address Medicaid’s treatment gap. The Helping Tobacco Users Quit Act (S. 2064) would require Medicaid to cover a wider range of cessation services without cost sharing and with an enhanced 90 percent federal match. But the bill has not advanced beyond committee.
The bipartisan Increasing Access to Lung Cancer Screening Act (S. 4566 / H.R. 6178) would extend free coverage without prior authorization for smoking and vaping cessation to all Medicaid enrollees, though duration limits and quit-attempt caps would be allowed.
But state legislators and Medicaid programs don’t have to wait for Congress to act. They can
- remove utilization-management barriers,
- standardize barrier-free coverage across managed care plans where they are prevalent,
- and use Medicaid administrative matching funds to sustain the popular “quitlines” for Medicaid enrollees as federal support recedes.
Tobacco use remains the leading cause of preventable death in the US, and cessation treatment is a low-cost intervention that can generate Medicaid savings within a short budget cycle. Whether cessation help reaches the Medicaid enrollees who need it depends on the choices federal and state policymakers make over the next year.
