Smoking is such a familiar health hazard that some experts say it doesn’t get the attention it deserves; the focus is often on other lifestyle-related conditions, especially obesity. But smoking is still the No. 1 cause of preventable death in this country. Nearly half a million people die prematurely because of smoking-related illnesses, including lung cancer, heart disease and chronic obstructive pulmonary disease, according to the Centers for Disease Control and Prevention.

Most smokers need some sort of assistance to quit, whether it’s counseling, support groups or medication to help reduce nicotine cravings. But getting that help can be difficult.

Scrambling to address budget problems, states this year will spend less than 2 percent of their tobacco-tax and tobacco-settlement billions on programs to help people quit smoking or prevent them from starting , according to a recent report by a coalition of public-health organizations. In the past four years, state spending on tobacco prevention and cessation has declined by 36 percent, to $457 million.

Tobacco-related health-care spending is nearly $100 billion annually, according to the CDC.

“It’s a travesty,” says Danny McGoldrick, vice president for research at the Campaign for Tobacco-Free Kids. “These programs more than pay for themselves.”

Carrots And Sticks

While public funding falters, a growing number of companies offer smoking-cessation programs to their workers. Last year, two-thirds of companies with 200 or more workers offered such programs, while 31 percent of smaller companies did so, according to the Kaiser Family Foundation’s annual survey of employer-sponsored health benefits. (Kaiser Health News is an editorially independent program of the foundation.)

At the same time that they offer a helping hand to quit, more companies are also penalizing employees who don’t kick the habit by hitting them with higher health insurance premiums.

At firms with more than 20,000 employees, 24 percent vary premiums based on whether someone smokes, as do 12 percent of companies with 500 or more workers, according to the 2011 survey of employer-sponsored health plans by human resources consultant Mercer.

Public-health advocates generally agree that this punitive approach isn’t ideal. “The issue isn’t smokers, it’s smoking,” says McGoldrick. Charging people higher premiums may just make smokers drop their coverage, he says.

But employers argue that charging smokers more is only fair. “The cost of medical care for smokers is considerably higher,” says Helen Darling, chief executive of the National Business Group on Health, an employer group. “Employers are increasingly saying that if someone costs the pool more, they should pay more.”

Darling points out that companies that go this route typically offer free smoking-cessation services and give employees plenty of notice before implementing the change.

A Quitter’s Story

For Tommy Piver, 59, the combination of pricier cigarettes and looming health insurance penalties finally motivated the two-pack-a-day smoker to give up the habit he’d started at age 13. Increased taxes had caused the price of a pack of cigarettes at the gas station near his home in Naples, Fla., to double within a year, to $5. Then he got a notice that his insurance carrier was going to triple the health insurance premium and reduce the amount it covered for all sorts of care from 90 percent to 70 percent for smokers.

“Kicking and screaming,” Piver quit on Jan. 1, 2010. About a week later, he saw a television ad for an online stop-smoking program developed by Legacy, a nonprofit created under the settlement between the states and the tobacco industry. Piver joined the free EX program and hasn’t had a cigarette in two years.

The EX campaign is an “excellent, science-based tool” for smokers who want to quit, says Thomas Glynn, director of cancer science and trends for the American Cancer Society. Another option is a national toll-free line, 1-800-QUIT-NOW, which routes callers to free support services, including free medication in the handful of states that provide it, says Glynn.

The 2010 federal health law expanded coverage for smoking cessation, though not to the degree that advocates wanted. Under the law, states must provide tobacco-cessation coverage for all pregnant women in their Medicaid programs at no cost. But anti-smoking activists would like broader Medicaid coverage requirements: Although’ percent of adults smoke overall, 31 percent of adults living below the poverty line are smokers.

The health law also requires that new health plans – those that have either just begun or have changed their benefits sufficiently to lose grandfathered status under the law – screen adults for tobacco use and provide free stop-smoking interventions.

Exactly how much intervention is required isn’t spelled out in the law; that will be up to federal rulemakers to decide. Smokers typically make several attempts to quit before they succeed. Advocates hope that federal guidelines will provide coverage for more than a single four-session counseling module, for example, or a standard 12-week round of medication. “Data is accumulating that 12 weeks is not enough,” says Glynn.