Lendle

Significant declines in prenatal smoking over the last decade have brought the U.S. closer to its Healthy People 2020 goal of reducing the prevalence of cigarette smoking among pregnant women to 1% (U. S. Department of Health and Human Services, 2013), yet smoking during pregnancy remains unacceptably high at 10–12% (Tong, Jones, Dietz, D’Angelo, & Bombard, 2009). Smoking among pregnant women covered by Medicaid is even higher, with 21% of these women smoking during the last 3 months of pregnancy compared to only 6% among those privately insured (PRAMS, 2008). Smoking during pregnancy increases the risk of fetal growth restriction and preterm delivery, and the higher rate of smoking among women insured through Medicaid has implications for both health and medical costs (U.S. Department of Health and Human Services, 2010, 2006, 2004). Indeed, prenatal smoking is associated with 5%–8% of preterm deliveries and 13%–19% of term, low birth weight deliveries in the U.S. (Dietz, et al., 2010). Medicaid insured over 40 percent of all births in the majority of states in 2009 (Kaiser Family Foundation [KFF], 2009), and more than two-thirds of total infants’ costs at delivery attributable to maternal smoking were paid by the Medicaid program (Adams, Melvin, Raskind-Hood, Joski, Galactionova. (2011). Thus, reducing smoking among women covered by Medicaid could save tax payers money and improve the health of women and infants.

Findings from clinic-based trials and population-based policy evaluations indicate that reduced out-of-pocket costs for both cessation counseling and medications have been effective in increasing the number of tobacco users who quit (CDC, 2012). Several studies have evaluated cessation coverage for Medicaid populations of both men and women. Earlier studies using the Current Population Survey found Medicaid coverage associated with increased odds of intention to quit and quit attempts among Medicaid insured enrollees (Liu, 2010, 2009). This association was no longer statistically significant when cigarette taxes were accounted for in one study (Liu, 2010); the other did not control for taxes (Liu, 2009). One study examined the effect of mandated coverage of tobacco cessation for the Massachusetts Medicaid population in 2006 and found that the smoking prevalence significantly decreased from 38.3% in the pre-benefit period compared to 28.3% in the post-benefit period, representing a decline of 26 percent (Land et al., 2010). Two previous studies have focused solely on women before, during, or after pregnancy. An earlier study (Petersen, Garrett, Melvin, & Hartmann, 2006) linked 1998 coverage cessation data to 1998–2000 PRAMS data and found that quit rates were significantly higher in states with Medicaid coverage of pharmacotherapies or counseling than in states without cessation service coverage. However, this analysis was limited to only one year of coverage data, and only a few states changed policies during their short study period. The second study linked PRAMS data to state data on cigarette taxes/prices and smoke-free indoor air laws for all women with recent births 2000–2005; findings indicated that both types of policies increased quits by the 3rd trimester; this study did not analyze Medicaid coverage (Adams, Markowitz, Kannan, Dietz, Tong, & Malarcher, 2012). The present study adds to this literature by examining the effects of Medicaid coverage of cessation services for women on Medicaid before or during pregnancy in a current, twelve year time period while also controlling for state variation in cigarette prices and smoke free indoor air laws.