Advertisement

Quitline Promotion to Medicaid Members Who Smoke: Effects of COVID-19–Specific Messaging and a Free Patch Offer

Open AccessPublished:October 29, 2022DOI:https://doi.org/10.1016/j.amepre.2022.09.009

      Introduction

      People who smoke are at increased risk of serious COVID-19-related disease but have had reduced access to cessation treatment during the pandemic. This study tested 2 approaches to promoting quitline services to Medicaid members who smoke at high rates: using COVID-19-specific messaging and offering free nicotine patches. The hypotheses were that both would increase enrollment.

      Methods

      A California Medicaid mailing from October 2020 to January 2021 (N=7,489,093) included 4 versions of a flyer following a 2 × 2 design comparing generic with COVID-19-specific messaging and a no-patch with free-patch offer. The main outcome measure was quitline enrollments. Quit outcomes (attempted quitting, quit ≥7 days, quit ≥30 days) were assessed at 2 months. A subsequent free-patch offer was sent to all members (N=7,577,198) from April 2021 to June 2021. Data were collected in 2020–2021 and analyzed in 2022.

      Results

      The first mailing generated 1,753 enrollments. Response rates were 0.023% and 0.024% for generic and COVID-19-specific messaging, respectively (p=0.538), and 0.006% and 0.041% for no-patch and free-patch offers, respectively, the latter being 6.7 times more effective than the former (p<0.0001). Quit outcomes were comparable across conditions. The subsequent free-patch offer generated 3,546 enrollments at $40.28 per enrollee.

      Conclusions

      In a Medicaid mailing during COVID-19, offering free patches generated more than 6 times as many quitline enrollments as offering generic help. COVID-19-specific messaging was no more effective than generic messaging. Offering free patches was highly cost-effective. Medicaid programs partnering with quitlines should consider using similar strategies, especially during a pandemic when regular health care is disrupted.

      INTRODUCTION

      In March 2020, California became the first state in the U.S. to shelter in place owing to the coronavirus disease 2019 (COVID-19) pandemic.
      • Newsom G.
      Executive order N-33-20.
      Health care was disrupted because health systems prioritized the pandemic response and because patients delayed or canceled care.
      Legislative Analyst's Office
      Impact of COVID-19 on health care access.
      Recognizing that people who smoke were at increased risk of severe COVID-19-related disease,
      CDC COVID-19 Response Team
      Preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019–United States, February 12 – March 28, 2020.
      the state tobacco control program and its partners sought ways to promote tobacco cessation during the pandemic. The state planned an intensive, multicomponent, Quit for COVID campaign to encourage quitting and promote the state quitline. Quitlines provide free, telephone-based cessation counseling—a safe telehealth service—and the California quitline has been shown to double the odds of quitting successfully.
      • Zhu SH
      • Stretch V
      • Balabanis M
      • Rosbrook B
      • Sadler G
      • Pierce JP.
      Telephone counseling for smoking cessation: effects of single-session and multiple-session interventions.
      ,
      • Zhu SH
      • Anderson CM
      • Tedeschi GJ
      • et al.
      Evidence of real-world effectiveness of a telephone quitline for smokers.
      A key component of the Quit for COVID campaign focused on reaching the state's most vulnerable populations through ongoing quarterly mailings to Medicaid members. With a smoking prevalence rate twice that of privately insured individuals,
      • Zhu SH
      • Anderson CM
      • Wong S
      • Kohatsu ND.
      The growing proportion of smokers in Medicaid and implications for public policy.
      Medicaid members were identified as a high-priority target for cessation messaging. Previous research showed that inserting a flyer into Medicaid mailings is a cost-effective way to reach low-income tobacco users,
      • Anderson CM
      • Kirby CA
      • Tong EK
      • Kohatsu ND
      • Zhu SH.
      Effects of offering nicotine patches, incentives, or both on quitline demand.
      and the California Tobacco Control Program has used this strategy for several years to promote the state quitline. The earlier study also showed that offering an incentive of free nicotine patches quadrupled the likelihood of Medicaid smokers enrolling in the quitline compared with an offer of more generic help.
      • Anderson CM
      • Kirby CA
      • Tong EK
      • Kohatsu ND
      • Zhu SH.
      Effects of offering nicotine patches, incentives, or both on quitline demand.
      This study employed a 2 × 2 design to analyze and compare the impacts of using COVID-19-specific messaging and offering free patches in flyers inserted into these Medicaid mailings on quitline enrollment. One hypothesis was that COVID-19-specific messaging would increase enrollment relative to generic messaging because it would seem timelier and more relevant to people who smoke during the pandemic. The other hypothesis was that offering free patches would increase enrollment relative to a no-patch offer, in line with previous findings.
      • Anderson CM
      • Kirby CA
      • Tong EK
      • Kohatsu ND
      • Zhu SH.
      Effects of offering nicotine patches, incentives, or both on quitline demand.
      Findings from the first mailing in this study informed a second mailing. Both are included in cost analyses of these strategies for increasing quitline enrollment.

      METHODS

      Study Sample

      The study sample included all California Medicaid members who, as of October 2020, were on the state's list to receive JvR mailings. JvR stands for Jackson versus Rank, a court case in the 1980s that resulted in the quarterly mailing of benefits information to all Medicaid members in California.
      California Department of Health Services
      Jackson versus Rank court case settlement: all County Welfare Director's Letter–ACWDL 86-08.
      The list is maintained by the California Department of Health Care Services, which oversees the state's Medicaid program. The mailings are conducted by the Office of State Publishing (OSP).
      The first mailing in this study, conducted from October 2020 to January 2021, was sent to 7,489,093 Medicaid members on the mailing list at that time. A second mailing, conducted from April 2021 to June 2021, was sent to 7,577,198 members then on the list.
      Participants were counted as responding to the mailings if they contacted the quitline and had Medicaid, were aged 18 years, smoked cigarettes or called on behalf of someone who did, and had a valid promotional code. For practical reasons, participants had 6 months from the end of the mailing to be counted.
      For the first mailing in this study, OSP printed and distributed 4 similar versions of a flyer, shown in Figure 1. All 4 flyers featured a young woman with a pained expression holding a cigarette in one hand and a picture of blackened lungs in the other. All 4 provided the quitline's contact information, but they varied with respect to messaging and the services offered. Following a 2 × 2 design, the flyers included either the generic message, “Stop smoking. Live your life,” or a COVID-19-specific message, “Quit for COVID. Smokefree lungs fight harder,” and they included either a usual care offer, “Free quit service—Can increase your chances of quitting for good,” or an offer of free nicotine replacement therapy (NRT), “Free patches—Call the Helpline for home delivery.” Because patches were only available for a limited time through research funding, the free-patch offer also included the following in smaller print: “While supplies last. Must be 18.” For tracking purposes, each version of the flyer had a different promotional code. The flyers were printed in English on one side and Spanish on the other.
      Figure 1
      Figure 1The 4 flyers distributed in the first JvR mailing.
      Note: Clockwise from upper left: (1) generic messaging with a free-patch offer, (2) generic messaging with a no-patch offer, (3) COVID-19-specific messaging with a no-patch offer, (4) COVID-19-specific messaging with a free-patch offer.
      OSP took steps to distribute the flyers as randomly as possible. The 4 versions were printed on a single large sheet before being cut and boxed, ensuring that they were printed in equal quantities. During fulfillment, OSP staff used the boxes of flyers in a nonpreferential manner to maintain roughly equal proportions throughout the mailing. It would have been optimal to use a randomized series to mix the 4 flyers, but that was not feasible because of operational constraints.
      The second mailing included only 1 flyer featuring a free-patch offer to ensure that all Medicaid members were informed of this opportunity. This flyer also had a unique promotional code.
      During the study, all participants were eligible for free telephone counseling, considered usual care. All Medicaid members who smoked were also eligible for free patches, unless contraindicated, regardless of which flyer they received. Patches were not considered usual care because they were available only through the research grant funding this study. Eligible participants received a 2-week starter kit of over-the-counter patches sent by express mail. Alternatively, Medicaid members could receive NRT by obtaining a prescription from their doctor and taking it to a pharmacy. However, previous research showed that Medicaid members are much more likely to use NRT when it is sent to them directly.
      • Anderson CM
      • Cummins SE
      • Kohatsu ND
      • Gamst AC
      • Zhu SH.
      Incentives and patches for Medicaid smokers: an RCT.
      All services were provided by the quitline.
      Only participants who agreed to follow-up were contacted for evaluation. The study was approved by the Human Research Protections Program of the University of California, San Diego (number 171562).

      Measures

      A standardized intake protocol was used to enroll participants in the quitline. Data collected during intake included standard demographic measures (gender, age, race/ethnicity, language, education), insurance status, chronic health conditions (hypertension, diabetes, previous heart attack, previous stroke), behavioral health conditions (depression, anxiety, bipolar disorder, schizophrenia, alcohol or other drug disorder), smoking status, and cigarettes per day. Medicaid members who smoked were asked whether they received a flyer and, if so, were asked for the promotional code on the flyer they received.
      The primary outcome measure was the number of quitline enrollments (the number of Medicaid members completing intake who provided a promotional code corresponding to a flyer in the study). Other outcome measures included response rates (the number of enrollments divided by the number of members receiving flyers of a given condition), relative responsiveness (the response rate for a given condition divided by the response rate for the generic flyer in that condition), and promotional cost per enrollee (the total cost of flyers in a given condition divided by the number of enrollments in that condition).
      Staff not involved in delivering counseling conducted follow-up calls 2 months after enrollment. Secondary outcome measures assessed in these calls included the quit attempt rate and 7-day and 30-day point prevalence abstinence rates (self-reported, with no biochemical verification). Evaluators assessed current smoking status first, then asked when the most recent quit attempt was and how long it lasted. Abstinence focused on smoking only. Quit attempts were defined as intentional attempts lasting at least 1 day.
      Of enrolled participants, 92.6% consented to evaluation. However, 14.1% of these were not sampled for follow-up because their primary language was not English, they had called on behalf of someone else, or they were recruited into other studies. Of those sampled for follow-up, evaluators reached 61.1%. The analysis of quit attempt and abstinence rates was based on these participants.

      Statistical Analysis

      Data on printing costs and the numbers of flyers distributed were obtained from OSP. Intake and outcome measures were provided by the quitline. Data were collected from October 2020, when the first mailing began, through December 2021, 6 months after the second mailing ended.
      Response rates were compared using the GENMOD procedure in SAS for generalized linear models. Marginal means for the 2 × 2 design were compared to ascertain the effect of each condition. Demographics of participants from the first mailing were analyzed and compared by whether they responded to the free-patch or no-patch offer. Quit outcomes for the first mailing were analyzed by condition. Follow-up rates did not significantly differ by condition, so a complete case analysis was used. Analyses were conducted in 2022 using SAS, Version 9.4.

      RESULTS

      A total of 1,753 Medicaid members enrolled in the quitline in response to the first mailing. As shown in Table 1, flyers with generic messaging and COVID-19-specific messaging generated 873 and 880 enrollments, respectively. The 2 approaches had similar response rates: 0.023% and 0.024%, respectively. Relative responsiveness to COVID-19-specific messaging compared with that of generic messaging was 1.01. Promotional costs per enrollee were also similar for the 2 approaches: $84.85 and $84.17, respectively (all p=0.996).
      Table 1Impacts of Type of Messaging and Type of Offer on Quitline Enrollment
      ConditionsQuitline enrollmentsResponse rate,
      Based on a mailing of 7,489,093 flyers divided into equal halves.
      %
      Relative responsiveness
      Setting the first group in each condition at 1.00.
      Promotional cost per participant,
      Based on an overall cost of $148,140 for the mailing. Promotional costs per participant include printing and mailing costs but not the costs of providing counseling and nicotine patches, considered treatment costs. Having called the quitline, all Medicaid members were eligible for counseling and patches regardless of which flyer they received.
      U.S.$
      Type of messaging
       Generic8730.0231.0084.85
       COVID-19-specific8800.0241.0184.17
      Type of offer
       No patch2270.0061.00326.30
       Free patch1,5260.0416.7248.54
      a Based on a mailing of 7,489,093 flyers divided into equal halves.
      b Setting the first group in each condition at 1.00.
      c Based on an overall cost of $148,140 for the mailing. Promotional costs per participant include printing and mailing costs but not the costs of providing counseling and nicotine patches, considered treatment costs. Having called the quitline, all Medicaid members were eligible for counseling and patches regardless of which flyer they received.
      In contrast, the nature of the offer had a large impact on enrollment. The generic, no-patch offer generated 227 enrollments, whereas the free-patch offer generated 1,526 enrollments. Response rates for these 2 approaches were 0.006% and 0.041%, respectively. Relative responsiveness to the free-patch offer compared with that of the no-patch offer was 6.72. Promotional costs per enrollee were $326.30 for the no-patch offer vs $48.54 for the free-patch offer (all p<0.0001).
      Table 2 shows the characteristics of enrollees overall and by type of offer. Among enrollees overall, 52.9% were female, 73.8% were aged ≥45 years, 51.4% were non-White, 8.8% were Spanish speakers, 49.9% had a high school education or less, 52.1% had a chronic health condition, 49.4% had a behavioral health condition, 34.2% smoked a pack of cigarettes or more daily, 28.8% co-used marijuana, and 17.4% co-used another tobacco product besides cigarettes. There were no significant differences either by type of offer or by whether COVID-19-specific messaging was used (the latter not shown).
      Table 2Demographics of Medicaid Members Responding to the First Mailing, Overall and by Type of Offer
      VariablesOverall (N=1,753), %No-patch offer (n=227), %Free-patch offer (n=1,526), %p-value
      Gender0.178
       Female52.947.553.7
       Male46.651.645.9
       Other0.50.90.5
      Age, years0.465
       18–242.11.82.2
       25–4424.026.923.6
       45–6453.254.253.1
       ≥6520.617.221.1
      Race/ethnicity0.093
       White48.652.548.0
       Black13.611.114.0
       Hispanic22.519.422.9
       Asian/Pacific Islander4.46.04.2
       American Indian1.00.91.0
       Multiracial7.25.17.5
       Other2.85.12.4
      Language0.215
       English91.293.490.9
       Spanish8.86.69.1
      Education0.388
       <High school22.425.322.0
       High school, GED27.527.127.5
       Some college37.933.538.6
       BA/BS+12.114.011.9
      Physical health condition0.067
       Hypertension46.239.847.2
       Diabetes14.210.214.8
       Heart attack5.56.05.4
       Stroke5.64.65.7
       Any of the above52.146.353.0
      Behavioral health condition0.291
       Anxiety34.535.734.3
       Depression36.440.735.7
       Bipolar13.411.013.8
       Schizophrenia6.77.56.6
       Drug or alcohol9.312.98.7
       Any of the above49.452.848.9
      Cigarettes per day0.528
       ≤1048.945.449.4
       11–1916.918.516.7
       ≥2034.236.133.9
      Marijuana co-use28.830.428.60.571
      Other tobacco product co-use17.417.617.40.925
      Note: All racial groups are non-Hispanic. Percentages may not add up to 100.0% because of independent rounding. Physical and behavioral health conditions are self-reported.
      BA/BS+, bachelor's degree or higher.
      Table 3 shows quit outcomes by condition. Overall, 75.5% attempted quitting, 37.7% quit for at least 7 days, and 28.6% quit for at least 30 days (data not shown). There were no significant differences in outcomes by condition. Participants responding to the no-patch offer appeared more likely to attempt quitting than those responding to the free-patch offer, 82.6% vs 74.4%, but the difference was not significant (p=0.056).
      Table 3Quit Outcomes of Enrollees at 2-Month Follow-Up, by Condition (Complete Case)
      Type of messagingType of offer
      OutcomesGeneric messaging (n=422),COVID-19-specific messaging (n=430),p-valueNo patch (n=115),Free patch (n=737),p-value
      % (95% CI)% (95% CI)% (95% CI)% (95% CI)
      Made quit attempt77.3 (73.2, 81.3)73.7 (69.6, 77.9)0.23182.6 (75.7, 89.6)74.4 (71.2, 77.5)0.056
      Quit ≥7 days39.6 (34.9, 44.2)35.8 (31.3, 40.4)0.25834.8 (26.1, 43.5)38.1 (34.6, 41.6)0.491
      Quit ≥30 days29.1 (24.8, 33.5)28.1 (23.9, 32.4)0.74525.2 (17.3, 33.2)29.2 (25.9, 32.5)0.383
      The second mailing in this study, which included a flyer with a free-patch offer, generated 3,546 enrollments. The response rate, 0.047%, was similar to that of the free-patch offer in the first mailing, but the promotional cost, $40.28, was 17.0% lower (data not shown).

      DISCUSSION

      This study during the COVID-19 pandemic found that outreach materials offering free nicotine patches generated >6 times as much quitline enrollment among low-income individuals who smoke as a generic quitline offer did. It also found that COVID-19-specific messaging was no more effective than generic messaging. The strength of this study was its 2 × 2 design embedded in an ongoing mailing to nearly 7.5 million Medicaid members, allowing a direct comparison of the impacts of these 2 variables on quitline enrollment. To ensure that all members were informed of the NRT availability, a subsequent mailing offered free patches to all, achieving a response rate comparable with that of the first patch offer. Through these 2 mailings, more than 5,000 Medicaid members enrolled in counseling and received free patches. This population health strategy increased access to tobacco treatment during a time when health systems were prioritizing the broader COVID-19 response and clinical preventive care services were disrupted.
      The finding that offering free patches increased quitline enrollment is consistent with that of previous research. Numerous pre‒post studies have shown that quitline utilization significantly increases when free medication is offered.
      • Miller N
      • Frieden TR
      • Liu SY
      • et al.
      Effectiveness of a large-scale distribution programme of free nicotine patches: a prospective evaluation.
      • An LC
      • Schillo BA
      • Kavanaugh AM
      • et al.
      Increased reach and effectiveness of a statewide tobacco quitline after the addition of access to free nicotine replacement therapy.
      • Bauer JE
      • Carlin-Menter SM
      • Celestino PB
      • Hyland A
      • Cummings KM.
      Giving away free nicotine medications and a cigarette substitute (Better Quit) to promote calls to a quitline.
      • Cummings KM
      • Fix B
      • Celestino P
      • Carlin-Menter S
      • O'Connor R
      • Hyland A
      Reach, efficacy, and cost-effectiveness of free nicotine medication giveaway programs.
      • Fellows JL
      • Bush T
      • McAfee T
      • Dickerson J.
      Cost effectiveness of the Oregon quitline “free patch initiative.
      • Tinkelman D
      • Wilson SM
      • Willett J
      • Sweeney CT.
      Offering free NRT through a tobacco quitline: impact on utilisation and quit rates.
      • O'Connor RJ
      • Carlin-Menter SM
      • Celestino PB
      • et al.
      Using direct mail to prompt smokers to call a quitline.
      • Keller PA
      • Christiansen B
      • Kim SY
      • et al.
      Increasing consumer demand among Medicaid enrollees for tobacco dependence treatment: the Wisconsin “Medicaid Covers It” campaign.
      • Davis KA
      • Coady MH
      • Mbamalu IG
      • Sacks R
      • Kilgore EA.
      Lessons learned from the implementation of a time-limited, large-scale nicotine replacement therapy giveaway program in New York City.
      • Hood-Medland EA
      • Dove MS
      • Stewart SL
      • et al.
      Direct-to-member household or targeted mailings: incentivizing Medicaid calls for quitline services.
      • Kerr AN
      • Schillo BA
      • Keller PA
      • Lachter RB
      • Lien RK
      • Zook HG.
      Impact and Effectiveness of a stand-alone NRT starter kit in a statewide tobacco cessation program.
      • Keller PA
      • Lien RK
      • Beebe LA
      • et al.
      Replicating state Quitline innovations to increase reach: findings from three states.
      Effect sizes in these studies ranged from 1.4 to 25 times.
      • Bauer JE
      • Carlin-Menter SM
      • Celestino PB
      • Hyland A
      • Cummings KM.
      Giving away free nicotine medications and a cigarette substitute (Better Quit) to promote calls to a quitline.
      ,
      • Tinkelman D
      • Wilson SM
      • Willett J
      • Sweeney CT.
      Offering free NRT through a tobacco quitline: impact on utilisation and quit rates.
      Quasi-randomized studies have had similar findings. One that targeted disadvantaged Australians who smoke found that offering free patches attracted 2.7 times as many people as offering counseling alone.
      • Miller N
      • Frieden TR
      • Liu SY
      • et al.
      Effectiveness of a large-scale distribution programme of free nicotine patches: a prospective evaluation.
      The other, by the current research team targeting California Medicaid members who smoke, found that offering free patches increased quitline enrollment fourfold.
      • Anderson CM
      • Kirby CA
      • Tong EK
      • Kohatsu ND
      • Zhu SH.
      Effects of offering nicotine patches, incentives, or both on quitline demand.
      This study, conducted 7.5 years later during COVID-19, found a greater-than-sixfold increase in enrollment from flyers offering free patches. This study also occurred during a time when many people who smoke use E-cigarettes to quit instead of approved medications,
      • Caraballo RS
      • Shafer PR
      • Patel D
      • Davis KC
      • McAfee TA.
      Quit methods used by U.S. adult cigarette smokers, 2014–2016.
      ,
      • Patel M
      • Cuccia AF
      • Zhou Y
      • Kierstead EC
      • Briggs J
      • Schillo BA.
      Smoking cessation among U.S. adults: use of E-cigarettes, including JUUL, and NRT use.
      yet it showed that patches still appeal to many who want to quit. These consistent findings suggest that among low-income people who smoke, offering free quitting aids is a much stronger inducement to enroll in quitlines than more generic offers of help.
      The study found no significant differences in baseline characteristics by condition. However, among participants overall, 51.4% were non-White, similar to the 46.6% in an earlier Medicaid mailing study.
      • Anderson CM
      • Kirby CA
      • Tong EK
      • Kohatsu ND
      • Zhu SH.
      Effects of offering nicotine patches, incentives, or both on quitline demand.
      More than half had a chronic health condition, and nearly half had a behavioral health condition. Nearly 3 in 10 co-used marijuana, and 17.4% co-used E-cigarettes or other tobacco products. These findings suggest that promoting cessation in Medicaid communications can reach a diverse and high-need population.
      Notably, there was no difference in response rates on the basis of COVID-19-specific messaging. The value of linking quitline promotion to COVID-19 was previously unknown. It was hypothesized that the Quit for COVID theme would increase the perceived relevance and timeliness of flyers and make recipients more inclined to contact the quitline. That did not appear to be true, perhaps owing to pandemic fatigue, because the flyers were distributed nearly a year after COVID-19 was first reported in the news. It is possible that different COVID-19 messages would have had more impact, but it seems unlikely that even optimal messaging could have improved the response rates as much as the free-patch offer did.
      Quit outcomes in this study were high overall and showed no significant differences by condition. The similarity in outcomes by patch condition was unsurprising, given that participants self-selected into the study, and all were offered free patches at intake. Providing both medication and behavioral support, either in person or by telephone, has been shown to increase quit rates compared with medication alone.
      • Hartmann-Boyce J
      • Hong B
      • Livingstone-Banks J
      • Wheat H
      • Fanshawe TR.
      Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation.
      The study was designed not to find differences in quit outcomes but to assess whether participants quit at expected rates, which they did. In fact, participants responding to the free-patch offer in this study had outcomes comparable with those of participants receiving free patches (n=1,093) in a previous RCT with California Medicaid members.
      • Anderson CM
      • Cummins SE
      • Kohatsu ND
      • Gamst AC
      • Zhu SH.
      Incentives and patches for Medicaid smokers: an RCT.
      Quit attempt rates were 74.4% and 77.5% in the current and previous studies, respectively (p=0.1221); 7-day abstinence rates were 38.1% and 33.1%, respectively (p=0.0278); and 30-day abstinence rates were 29.2% and 25.7%, respectively (p=0.1022). The consistent outcomes suggest that offering free NRT, even a 2-week starter kit, remains a viable strategy both for promoting quitline enrollment and for helping Medicaid members who smoke to quit.
      The 4 flyers cost the same amount to produce, so differences in response rates translated directly to differences in promotional costs. With or without COVID-19 messaging, the flyers cost just under $85 per enrollee. Without the free-patch offer, the flyers cost $326 per enrollee, comparable with the reported $260 per caller in the first national TIPS media campaign a decade earlier.
      Centers for Disease Control and Prevention (CDC)
      Increases in quitline calls and smoking cessation website visitors during a national tobacco education campaign–March 19–June 10, 2012.
      With a free-patch offer, the promotional cost was only $49 per enrollee. In the subsequent mailing offering free patches to all Medicaid members, the promotional cost was even lower, about $40 per enrollee. Adjusting for inflation, this was close to the $32 promotional cost for the comparable flyer in our Medicaid study 7.5 years earlier.
      • Anderson CM
      • Kirby CA
      • Tong EK
      • Kohatsu ND
      • Zhu SH.
      Effects of offering nicotine patches, incentives, or both on quitline demand.
      The promotional savings from this approach were more than enough to cover the cost of the NRT itself.
      These findings have real-world implications. First, free cessation medications, unless contraindicated, should be offered to all quitline users and should be the main selling point in messages promoting quitlines. Second, effective cessation messaging should not be dropped or postponed during a crisis such as COVID-19, especially when cessation can help protect people from that crisis. Third, Medicaid programs should use mass communication strategies to motivate their members to take advantage of covered medications, whether through quitlines or through local providers. Fourth, to scale this intervention for population impact, Medicaid programs should cover the cost of medications provided to their members by quitlines. This is especially important in states where the public health agency funding the quitline is legally prohibited from paying for pharmacotherapy. Medicaid programs can and should fully fund and promote the widespread use of approved quitting aids because treating tobacco use is ultimately less costly than treating tobacco-related diseases.
      • Curry SJ
      • Grothaus LC
      • McAfee T
      • Pabiniak C.
      Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization.
      ,
      • Fiore MC
      • Jaén CR
      • Baker TB
      • et al.
      Adopting these strategies would help to move Medicaid programs beyond basic treatment coverage
      • Fiore MC
      • Jaén CR
      • Baker TB
      • et al.
      • Greene J
      • Sacks RM
      • McMenamin SB.
      The impact of tobacco dependence treatment coverage and copayments in Medicaid.
      • Singleterry J
      • Jump Z
      • DiGiulio A
      • et al.
      State Medicaid coverage for tobacco cessation treatments and barriers to coverage–United States, 2014–2015.
      toward the more active promotion of tobacco cessation.
      • Zhu SH
      • Anderson CM
      • Wong S
      • Kohatsu ND.
      The growing proportion of smokers in Medicaid and implications for public policy.
      ,
      • Zhu SH
      • Anderson CM
      • Zhuang YL
      • Gamst AC
      • Kohatsu ND.
      Smoking prevalence in Medicaid has been declining at a negligible rate.
      ,
      • Brantley EJ
      • Greene J
      • Bruen BK
      • Steinmetz EP
      • Ku LC.
      Policies affecting Medicaid beneficiaries’ smoking cessation behaviors.

      Limitations

      This study had limitations. First, because of operational constraints, it was not feasible to achieve full randomization in the mailings, although the 4 flyers were printed in equal quantities and distributed as randomly as possible. Second, the strong response to the free-patch offer may have been due partly to the fact that the quitline is not normally funded to provide NRT. The offer even included the phrase “while supplies last,” an appeal to scarcity that may have increased the response rate.
      • Cialdini RB.
      The science of persuasion.
      The offer may also have appealed to people who smoke by boosting their self-efficacy (i.e., by making it easier to take action).
      • Witte K.
      Putting the fear back into fear appeals: the extended parallel process model.
      It is not possible to determine how much of the response was owing to the appeal of patches themselves versus how the offer was presented. Finally, the extent to which the repeated use of the Medicaid mailing strategy over the previous 7.5 years influenced response rates in this study is unknown, as is the impact of contemporaneous promotions.

      CONCLUSIONS

      In a 2 × 2 study embedded in a statewide Medicaid mailing during the COVID-19 pandemic, offering free nicotine patches generated more than 6 times as much quitline enrollment as offering generic help, whereas COVID-19-specific messaging was no more effective than generic messaging. The response rate for the free-patch offer was replicated in a subsequent mailing in which all Medicaid members were offered free patches. This population health strategy connected many diverse Medicaid members with physical and behavioral health conditions to evidence-based tobacco treatment and was more cost effective than traditional media campaigns promoting state quitlines. Medicaid programs should consider these findings when partnering with quitlines on mass communication approaches to drive quit attempts and improve access to treatment, especially during a pandemic when regular health care is disrupted.

      ACKNOWLEDGMENTS

      The authors would like to thank the staff of Duncan Channon, who developed the creative content described in this study; California Tobacco Control Program staff: April Roeseler, Valerie Quinn, Vikki Ueda, Sandra Soria, and Beth Olagues; Office of State Publishing staff: Tim Staffler; UC San Diego personnel: Sandra Hernández, Yue-Lin Zhuang, and Anthony Gamst; and Tobacco-Related Disease Research Program officer: Norval Hickman.
      The contents of this study are solely the responsibility of the authors and do not necessarily represent the official views of the study sponsors. The sponsors had no role in study design; collection, analysis, or interpretation of data; writing of the report; or the decision to submit the report for publication.
      The promotional campaign described in this paper was funded by the California Department of Public Health, California Tobacco Control Program, Media Campaign Unit. Quitline intake and counseling services were funded by the California Department of Public Health, California Tobacco Control Program, under contract Number CDPH 19-10009, with additional support from First 5 California and the Centers for Disease Control and Prevention. Nicotine replacement therapy provision, the study itself, and the drafting of this paper were supported by a grant from the Tobacco-Related Disease Research Program (award Number 28CP-0039HS). The study was approved by the Human Research Protections Program of the University of California, San Diego (Number 171562).
      No financial disclosures were reported by the authors of this paper.

      CRediT AUTHOR STATEMENT

      Elisa K. Tong: Conceptualization, Funding acquisition, Writing–review and editing. Sharon E. Cummins: Investigation, Supervision, Writing–review and editing. Christopher M. Anderson: Writing–original draft, Writing–review and editing. Carrie A. Kirby: Project administration, Writing–review and editing. Shiushing Wong: Data curation, Formal analysis, Validation, Writing–review and editing. Shu-Hong Zhu: Conceptualization, Investigation, Methodology, Writing–review and editing.

      REFERENCES

        • Newsom G.
        Executive order N-33-20.
        Executive Department State of California, Sacramento, CA2020 (Published March 3Accessed May 10, 2022)
        • Legislative Analyst's Office
        Impact of COVID-19 on health care access.
        Legislative Analyst's Office, Sacramento, CA2021 (Published May 7Accessed May 10, 2022)
        • CDC COVID-19 Response Team
        Preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019–United States, February 12 – March 28, 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 382-386https://doi.org/10.15585/mmwr.mm6913e2
        • Zhu SH
        • Stretch V
        • Balabanis M
        • Rosbrook B
        • Sadler G
        • Pierce JP.
        Telephone counseling for smoking cessation: effects of single-session and multiple-session interventions.
        J Consult Clin Psychol. 1996; 64: 202-211https://doi.org/10.1037//0022-006x.64.1.202
        • Zhu SH
        • Anderson CM
        • Tedeschi GJ
        • et al.
        Evidence of real-world effectiveness of a telephone quitline for smokers.
        N Engl J Med. 2002; 347: 1087-1093https://doi.org/10.1056/NEJMsa020660
        • Zhu SH
        • Anderson CM
        • Wong S
        • Kohatsu ND.
        The growing proportion of smokers in Medicaid and implications for public policy.
        Am J Prev Med. 2018; 55 (suppl 2): S130-S137https://doi.org/10.1016/j.amepre.2018.07.017
        • Anderson CM
        • Kirby CA
        • Tong EK
        • Kohatsu ND
        • Zhu SH.
        Effects of offering nicotine patches, incentives, or both on quitline demand.
        Am J Prev Med. 2018; 55 (suppl 2): S170-S177https://doi.org/10.1016/j.amepre.2018.07.007
        • California Department of Health Services
        Jackson versus Rank court case settlement: all County Welfare Director's Letter–ACWDL 86-08.
        California Department of Health Services, Sacramento, CA1986 (Published March 6Accessed March 27, 2018)
        • Anderson CM
        • Cummins SE
        • Kohatsu ND
        • Gamst AC
        • Zhu SH.
        Incentives and patches for Medicaid smokers: an RCT.
        Am J Prev Med. 2018; 55 (suppl 2): S138-S147https://doi.org/10.1016/j.amepre.2018.07.015
        • Miller N
        • Frieden TR
        • Liu SY
        • et al.
        Effectiveness of a large-scale distribution programme of free nicotine patches: a prospective evaluation.
        Lancet. 2005; 365: 1849-1854https://doi.org/10.1016/S0140-6736(05)66615-9
        • An LC
        • Schillo BA
        • Kavanaugh AM
        • et al.
        Increased reach and effectiveness of a statewide tobacco quitline after the addition of access to free nicotine replacement therapy.
        Tob Control. 2006; 15: 286-293https://doi.org/10.1136/tc.2005.014555
        • Bauer JE
        • Carlin-Menter SM
        • Celestino PB
        • Hyland A
        • Cummings KM.
        Giving away free nicotine medications and a cigarette substitute (Better Quit) to promote calls to a quitline.
        J Public Health Manag Pract. 2006; 12: 60-67https://doi.org/10.1097/00124784-200601000-00012
        • Cummings KM
        • Fix B
        • Celestino P
        • Carlin-Menter S
        • O'Connor R
        • Hyland A
        Reach, efficacy, and cost-effectiveness of free nicotine medication giveaway programs.
        J Public Health Manag Pract. 2006; 12: 37-43https://doi.org/10.1097/00124784-200601000-00009
        • Fellows JL
        • Bush T
        • McAfee T
        • Dickerson J.
        Cost effectiveness of the Oregon quitline “free patch initiative.
        Tob Control. 2007; 16: i47-i52https://doi.org/10.1136/tc.2007.019943
        • Tinkelman D
        • Wilson SM
        • Willett J
        • Sweeney CT.
        Offering free NRT through a tobacco quitline: impact on utilisation and quit rates.
        Tob Control. 2007; 16: i42-i46https://doi.org/10.1136/tc.2007.019919
        • O'Connor RJ
        • Carlin-Menter SM
        • Celestino PB
        • et al.
        Using direct mail to prompt smokers to call a quitline.
        Health Promot Pract. 2008; 9: 262-270https://doi.org/10.1177/1524839906298497
        • Keller PA
        • Christiansen B
        • Kim SY
        • et al.
        Increasing consumer demand among Medicaid enrollees for tobacco dependence treatment: the Wisconsin “Medicaid Covers It” campaign.
        Am J Health Promot. 2011; 25: 392-395https://doi.org/10.4278/ajhp.090923-QUAN-311
        • Davis KA
        • Coady MH
        • Mbamalu IG
        • Sacks R
        • Kilgore EA.
        Lessons learned from the implementation of a time-limited, large-scale nicotine replacement therapy giveaway program in New York City.
        Health Promot Pract. 2013; 14: 767-776https://doi.org/10.1177/1524839912471816
        • Hood-Medland EA
        • Dove MS
        • Stewart SL
        • et al.
        Direct-to-member household or targeted mailings: incentivizing Medicaid calls for quitline services.
        Am J Prev Med. 2018; 55 (suppl 2): S178-S185https://doi.org/10.1016/j.amepre.2018.06.026
        • Kerr AN
        • Schillo BA
        • Keller PA
        • Lachter RB
        • Lien RK
        • Zook HG.
        Impact and Effectiveness of a stand-alone NRT starter kit in a statewide tobacco cessation program.
        Am J Health Promot. 2019; 33: 183-190https://doi.org/10.1177/0890117118772493
        • Keller PA
        • Lien RK
        • Beebe LA
        • et al.
        Replicating state Quitline innovations to increase reach: findings from three states.
        BMC Public Health. 2020; 20: 7https://doi.org/10.1186/s12889-019-8104-3
        • Caraballo RS
        • Shafer PR
        • Patel D
        • Davis KC
        • McAfee TA.
        Quit methods used by U.S. adult cigarette smokers, 2014–2016.
        Prev Chronic Dis. 2017; 14: E32https://doi.org/10.5888/pcd14.160600
        • Patel M
        • Cuccia AF
        • Zhou Y
        • Kierstead EC
        • Briggs J
        • Schillo BA.
        Smoking cessation among U.S. adults: use of E-cigarettes, including JUUL, and NRT use.
        Tob Control. 2021; 30: 693-695https://doi.org/10.1136/tobaccocontrol-2020-056013
        • Hartmann-Boyce J
        • Hong B
        • Livingstone-Banks J
        • Wheat H
        • Fanshawe TR.
        Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation.
        Cochrane Database Syst Rev. 2019; 6CD009670https://doi.org/10.1002/14651858.CD009670.pub4
        • Centers for Disease Control and Prevention (CDC)
        Increases in quitline calls and smoking cessation website visitors during a national tobacco education campaign–March 19–June 10, 2012.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 667-670
        • Curry SJ
        • Grothaus LC
        • McAfee T
        • Pabiniak C.
        Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization.
        N Engl J Med. 1998; 339: 673-679https://doi.org/10.1056/NEJM199809033391006
        • Fiore MC
        • Jaén CR
        • Baker TB
        • et al.
        Treating Tobacco Use and Dependence: 2008 Update. HHS, Rockville, MD2008
        • Greene J
        • Sacks RM
        • McMenamin SB.
        The impact of tobacco dependence treatment coverage and copayments in Medicaid.
        Am J Prev Med. 2014; 46: 331-336https://doi.org/10.1016/j.amepre.2013.11.019
        • Singleterry J
        • Jump Z
        • DiGiulio A
        • et al.
        State Medicaid coverage for tobacco cessation treatments and barriers to coverage–United States, 2014–2015.
        MMWR Morb Mortal Wkly Rep. 2015; 64: 1194-1199https://doi.org/10.15585/mmwr.mm6442a3
        • Zhu SH
        • Anderson CM
        • Zhuang YL
        • Gamst AC
        • Kohatsu ND.
        Smoking prevalence in Medicaid has been declining at a negligible rate.
        PLoS One. 2017; 12e0178279https://doi.org/10.1371/journal.pone.0178279
        • Brantley EJ
        • Greene J
        • Bruen BK
        • Steinmetz EP
        • Ku LC.
        Policies affecting Medicaid beneficiaries’ smoking cessation behaviors.
        Nicotine Tob Res. 2019; 21: 197-204https://doi.org/10.1093/ntr/nty040
        • Cialdini RB.
        The science of persuasion.
        Sci Am. 2001; 284: 76-81https://doi.org/10.1038/scientificamerican0201-76
        • Witte K.
        Putting the fear back into fear appeals: the extended parallel process model.
        Commun Monogr. 1992; 59: 329-349https://doi.org/10.1080/03637759209376276