Resources and Partnerships: State Examples of Tobacco Cessation Programs that Advance Health Equity

July 27, 2017|3:41 a.m.| Claire Rudolph, MPH, MCHES Director, Health Equity and Joshua Berry, MPH, Analyst, Health Promotion and Disease Prevention

Public health officials and the medical community agree that tobacco use leads to a variety of poor health outcomes including cancer, heart disease, and death. In the United States, certain populations are significantly more likely to use tobacco, and suffer from associated poor health outcomes, than others. Individuals with lower levels of education and higher levels of poverty are more likely to smoke cigarettes and use tobacco compared to the general population. Comprehensive tobacco control programs have the potential to reduce smoking rates and tobacco-related death and disease. ASTHO highlights state efforts to implement comprehensive tobacco control programs to reduce tobacco use and improve the health of residents through a series of success stories. While each state initiative has different priorities and objectives, two major themes exist: the importance of resources and funding for tobacco control programs, and the need for establishing creative partnerships in sustaining tobacco control efforts. These stories and examples illustrate how state and local health agencies can advance health equity through focused tobacco control programs.

Resources and Funding

Due to federal budget cuts, resources for public health efforts have been dwindling in recent years, but the need for public health programs, including tobacco control programs, remains crucial. While most states continue to receive annual funds from the 1998 Tobacco Master Settlement Agreement – a financial agreement between states and tobacco companies relating to the marketing and promotion of tobacco products – states often spend the majority of these funds on areas outside of tobacco control because of budget shortfalls. As a result, most states are only able to allocate less than half of the CDC recommended amount on tobacco prevention programs.

Georgia, West Virginia, U.S. Associated Pacific Islands, Tennessee, and Texas recently cited the importance of utilizing existing resources, or obtaining new resources and funding, to address the needs of specific populations. For example, in Tennessee, county health departments used state tobacco settlement funds to implement the Baby and Me Tobacco Free (BMTF) program in April 2014 for pregnant women in the state. BMTF is a national program that trains health departments and other care providers to deliver the BMTF evidence-based curriculum to pregnant women who smoke. The smoking rate for pregnant women was almost twice the national average in 2014, leading to poor birth outcomes for Tennessee infants, including high levels of premature birth and high levels of racial and ethnic disparities in preterm birth.

Since its implementation, nearly 4,000 pregnant women in Tennessee have participated in the BMTF program, and women who have completed the program are 60 percent less likely of having a low birth weight baby. The funding to develop the BMTF program was essential, and the decision to utilize an existing program and curriculum was also an important financial factor in being able to offer the program. When limited resources are in high demand, partnerships can help fill the gap, and utilizing existing resources can also help to form new relationships. The example of BMTF in Tennessee also illustrates that investing tobacco settlement funds into tobacco control programs can help reduce a state’s health and financial burdens from tobacco use.


Strategic partnerships can help leverage resources and broaden understanding of public health issues, including tobacco control and health equity. Georgia, West Virginia, the Pacific Partners for Tobacco-Free Islands, the National Council for Behavioral Health, New Orleans, Texas, and Vermont all cited the importance of partnerships to the success of their initiatives.

Medicaid is an example of a critical partner to public health and provides healthcare services for more vulnerable citizens including pregnant women, children, and those living in or near poverty. In Vermont, the state’s Medicaid agency operates distinctly from the department of health. When the Vermont Department of Health (VDH) realized that their tobacco cessation efforts were not reaching lower income groups, they partnered with Medicaid to focus on the issue. In Vermont, 29 percent of adults who live at or below 250 percent of the federal poverty level smoke cigarettes, compared with just 18 percent of the state’s general population. VDH teamed up with the state Medicaid agency to send targeted mailings, adjust the content of the state’s tobacco cessation website, and make the website accessible for mobile phones to reach the lower income population of the state.

“Us being at the table together with our state Medicaid office has been invaluable,” says Rhonda Williams, chronic disease program chief at the Vermont Department of Health. “By sharing data and recognizing the opportunities to expand and promote the tobacco benefit, we became true partners in the work. We started meeting together quarterly more than four years ago, and it’s become a provider-beneficiary health promotion initiative that we all enjoy.”

As a result of this partnership, Vermont’s quitline saw a 112 percent increase in quitline registrations from the state’s Medicaid population, including a 57 percent increase in telephone engagement and a 238 percent increase in visits to Vermont’s Quit Online web activity. State tobacco quitlines, which are a free resource that offer smokers an array of evidence-based smoking cessation services, have been found to improve smokers’ likelihood of successfully quitting. Thus Vermont’s increased quitline engagement represents strong evidence that Vermont’s efforts will lead to improved health outcomes in the state’s lower income population. Their example also represents how successful a partnership between a state health department and a state Medicaid agency can be in terms of improving health outcomes for this population, a relationship that that VDH plans to replicate for other chronic diseases as well.

Looking Ahead

Funding will likely continue to be a challenge in the years ahead for all public health programs, so using existing resources and creatively seeking new funds will remain important. This only increases the value of strategic partnerships in tobacco control that allow for greater involvement of community groups, state government agencies, and private health programs that can help state health departments implement successful tobacco control programs. As long as disparities in tobacco use and tobacco-related disease exist, tobacco control will remain a critical opportunity for states to work towards health equity. Improving the health of all people can be daunting, but through focused comprehensive tobacco control programs state and local health agencies have made progress towards advancing optimal health for all people.

All of ASTHO’s stories on comprehensive tobacco control programs and health equity can be found on ASTHO’s main success stories webpage. Tobacco control stories and resources can also be found at the Tobacco Control Network’s resources page.

About this Series

This article is part of a series on advancing health equity being published in 2016-2017 on ASTHO's blog,