BACKGROUND: Despite good evidence that their smoking-cessation actions can be very effective, physicians have not consistently used the 5A actions (being asked, advised, assessed, assisted, and arranged) recommended in the U.S. Public Health Service tobacco guidelines. We tested the hypothesis that the introduction of coverage for smoking-cessation pharmacotherapy by the health plans covering most of the population in one region would increase physician use of 5A's. METHODS: A cohort of smoking members of two health plans was surveyed before and after the introduction of coverage for smoking cessation. A total of 1560 current smokers with a physician visit in the last year responded to both surveys. The key outcome measures were smoker reports of the guideline 5As for smoking-cessation support during the last physician visit. RESULTS: There were small significant absolute percentage increases only for reports of being assessed (+4.9%, p=0.01) and assisted (set quit date +6.5%, p=0.0004); encouraged to use medications (+8.8%, p=0.03); and given a prescription (+8.6%, p=0.0005). However, these increases were limited to smokers reporting awareness of the coverage, asking for quitting help, or both. CONCLUSION: Coverage for pharmacotherapy alone appears to have had no effect on physician behavior beyond that stimulated by smokers who were aware of the coverage, perhaps because they raised the issue. More research is needed on this suggestion that patients create physician behavior change.