California’s Program on Medicaid Incentives to Quit Smoking (MIQS)

Results from a California program aimed at reducing smoking rates among Medicaid (Medi-Cal in California) patients have just been released in a special publication of the American Journal of Preventive Medicine. The program, known as MIQS (Medi-Cal Incentives to Quit Smoking) and funded under the 2010 Affordable Care Act, was conducted from 2011 to 2015 in a state that already had a distinguished record in tobacco control.

Today, California has the second lowest adult smoking prevalence in the country (10.5%), although it only recently raised its tobacco tax from $0.87 to $2.87 in 2006. Elements of CA’s strong history of tobacco control include: the first statewide comprehensive control and infrastructure (1989); the first toll-free state quitline (1993); the first statewide clean indoor air ban (1994); the creation of 58 jurisdictional bans on smoking in multi-unit housing (2007-present); banning of tobacco sales in San Francisco pharmacies (2008); tobacco free bans in higher education institutions (2014, 2017, and 2018); limiting age of tobacco purchase to those older 21 (second state after Hawaii, 2016); and San Francisco’s ban of all flavored tobacco products, including menthol (2018).

Despite its low prevalence of smoking, California’s huge population translates into 3.2 million adult smokers, the largest number of any state. Over time, smoking has become increasingly concentrated among vulnerable populations who are disproportionately represented in the state’s Medicaid program. The MIQS project appropriately targeted the almost 1.5 million Medi-Cal smokers, who account for 41.5% of all adult smokers in the state.

The special issue features 11 papers describing various MIQS components. MIQS featured several interventions: mailings that included inserts, selective marketing, modest financial incentives, and free provision of nicotine patches—as ways to stimulate quit attempts. A major focus was to drive smokers to the state quitline. Outcome measurements included quit attempts and self-reported abstinence at various time points. What were the results? Impressive increases in the desired process measures and modest but significant increases in both quit attempts and successful quits. For example, there was a 70% increase in quitline calls by Medi-Cal smokers, achieving a reach of 4.5%, which far exceeds the national quitline reach of 1% of smokers. Engagement of various ethnic groups was achieved, as was a modest increase in reaching pregnant smokers.

What lessons can other states learn from MIQS? First, the target population—those covered by Medicaid—should be a major focus of state tobacco control efforts, since smokers are increasingly concentrated among low-income persons. Second, there is no magic bullet to reduce smoking levels. Thus, it is important to apply both policy and clinical interventions. Third, although the results of individual policy and clinical interventions may be relatively modest, each contributes to driving down smoking rates and thus saving lives.

California is fortunate to have a culture and governance seriously devoted to tobacco control. We at the Smoking Cessation Leadership Center are engaged with one such effort, the California Behavioral Health and Wellness Initiative that is aimed at helping mental health and substance use disorder treatment centers go tobacco-free and encourage smoking cessation. Other states, especially those that have yet to accept the expansion of Medicaid enrollment, will have limited opportunity to launch programs such as MIQS. Nevertheless, our experience has demonstrated that even “Tobacco Nation” states such as Kentucky, North Carolina, Arkansas, Oklahoma, Mississippi, and South Carolina are home to devoted tobacco control advocates. Their efforts need to be encouraged in order to reduce the damaging toll from smoking. Despite being at a modern low, smoking still accounts for the premature deaths of 500,000 people annually in the US alone, plus an additional 16 million who are disabled from their tobacco use.