Current smoking and quit-attempts among US adults following Medicaid expansion

The objective of this study was to estimate the influence of the Affordable Care Act (ACA) Medicaid Expansion on current smoking and quit attempts in expanded and non-expanded states. We analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) between 2003 through 2015 to evaluate changes in current smoking and quit attempts using multivariable logistic regression and generalized estimating equations (GEE), adjusting for socioeconomic factors. Time periods evaluated were: 2003-2009 (pre-expansion) and 2011-2015 (post-expansion), and in supplemental analysis, also 2011-2017. Overall, smoking prevalence among adults in expanded and non-expanded states were 16% and 17% (p < 0.001), respectively, and quit attempt prevalence for expanded and non-expanded states were 56% and 57% (p = 0.05), respectively. In adjusted models comparing post- versus pre- expansion periods, current smoking declined by 6% in both expanded (RR: 0.94, 95% CI: 0.93-0.94) and non-expanded (RR: 0.94, 95% CI: 0.94-0.95) states. Quit attempts increased by 4% (RR: 1.04, 95% CI: 1.04-1.05) in expanded states, and by 3% (RR: 1.03, 95% CI: 1.02-1.03) in non-expanded states. States that imposed barriers to utilization of smoking cessation services e.g. prior authorization, saw only a 3% increase in quit attempts regardless of expansion status, while expanded states that did not impose barriers experienced a 6% (RR: 1.06, 95% CI: 1.05-1.06) increase in quit attempts. Reducing administrative barriers to smoking cessation programs may enhance further declines in smoking rates among US adults.