The survey found that in 2000, 33 states and the District of Columbia provided at least some Medicaid coverage of smoking cessation services, up from 24 states and the nation's Capitol in 1998.

"The states that don't cover tobacco dependence treatments are really letting Medicaid enrollees down," said Helen H. Schauffler, professor of health policy at UC Berkeley's School of Public Health and lead author of the report.

The survey was funded by the Robert Wood Johnson Foundation and published by the U.S. Centers for Disease Control and Prevention (CDC) in the Nov. 9 Morbidity and Mortality Weekly Report.

Providing insurance coverage of tobacco dependence treatments is particularly important for Medicaid enrollees because they have a disproportionately high rate of smoking, the researchers said. Medicaid currently provides health insurance for 32 million low-income Americans. More than 11.5 million enrollees smoke, a rate 50 percent higher than the general population.

"Low-income Americans have the highest smoking rates and the least access to tobacco dependence treatments," said C. Tracy Orleans, senior scientist at the Robert Wood Johnson Foundation and co-author of the report. "Medicaid coverage reduces out-of-pocket treatment costs for people who need it most."

Schauffler noted that a typical 12-week course of drug therapy runs $200 to $400, putting the treatments out of reach for most low-income smokers. According to the CDC, the relatively high cost and the lack of health insurance coverage for effective smoking cessation treatments present some of the biggest barriers low-income smokers face in attempting to quit.

"Many Medicaid recipients simply can't afford the help they need to quit smoking," said Rosemarie Henson, director of CDC's Office on Smoking and Health.

The researchers argue that helping smokers quit not only provides health benefits, it can reduce costs associated with tobacco-related diseases. "Smoking cessation treatments are the gold standard for cost-effectiveness in medical care," said Schauffler, who also heads the Center for Health and Public Policy Studies at the campus. "States that provide smoking cessation coverage would not only improve the health of Medicaid enrollees, they may get a return on their investment in health care costs."

The economic benefits of tobacco dependence treatments are especially dramatic in the case of pregnant women. "For every dollar spent on smoking cessation programs for pregnant women, three dollars are saved in health care costs of treating low-birth-weight babies and other tobacco-related complications," said Dianne Barker, head of the Barker Bi-Coastal Health consulting firm in Los Angeles and another study co-author.

Providing insurance coverage for effective tobacco dependence treatments in all 50 states and the District of Columbia is one of the goals established by the U.S. Surgeon General in the Healthy People 2010 initiative. Studies have shown that increasing smokers' access to treatment options increases the number of their attempts to quit, and guidelines set by the U.S. Public Health Service and the CDC recommend insurance coverage of tobacco dependence treatments to reduce out-of-pocket costs for patients and encourage efforts to stop smoking.

Treatments shown to be effective include over-the-counter drugs such as the nicotine patch, gum and nasal spray, as well as buproprion, sold by prescription under the brand names Zyban or Wellbutrin. The Public Health Service also recommends counseling services available individually with a health care provider, in a group or by phone, said Schauffler.

"We recommend coverage for all these services," said Schauffler. "Drug treatments and counseling together are more effective than either one alone." Prescription drugs are covered in 31 states, while over-the-counter treatments are covered in 23 states. Only 13 states provide Medicaid coverage for counseling services.

California provides Medicaid coverage for all drug therapies, but dropped coverage for tobacco counseling services in 2000. Coverage of counseling services is only available for pregnant smokers in New Mexico. Oregon stands out as the only state that currently provides Medicaid enrollees coverage for all the smoking cessation services recommended by the Public Health Service.

Barker said it is particularly important for pregnant smokers to have access to counseling services since no tobacco drug treatments are currently approved for use during pregnancy. "For a pregnant woman who smokes, tobacco dependence counseling is the most likely intervention a physician would recommend," she said.

Although Medicaid is jointly funded by state and federal governments, its administration is largely left up to individual states. "We found large disparities among states in their Medicaid coverage for smoking cessation programs," said Schauffler, part of UC Berkeley's Health Sciences Initiative, a bold effort to solve today's major health problems. "That supports the argument for providing the coverage on the federal level as part of the core benefit package under Medicaid."

U.S. Senate Bill 854, introduced in May by Sens. Richard Durbin (D-Ill.), Sam Brownback (R-Kan.), Bob Graham (D-Fla.) and Jeff Bingaman (D-NM), would provide such coverage.

This is the fourth consecutive year the Robert Wood Johnson Foundation funded the nationwide survey of Medicaid coverage of tobacco dependence treatments.