August 2023

Tobacco use remains the leading cause of preventable disease, disability, and death in the nation (CDC, 2017). In Vermont there are approximately 1,000 smoking-related deaths each year. Tobacco burden is significantly greater among those insured by Medicaid, with a smoking prevalence approximately twice as high as the national average (28% vs. 16%). While the state’s smoking rate in 2022 is 16%, among Medicaid-insured the rate is 28%. Over the past decade, smoking prevalence among those insured by Medicaid has remained relatively unchanged while overall smoking prevalence in the United States and among other insurance groups decreased. Starting in 2012 at the Health Department’s Division of Health Promotion and Disease Prevention we prioritized addressing the health and needs of lower income, among those Medicaid-insured. The Tobacco Program started meeting regularly with colleagues at the Department of Vermont Health Access (DVHA). Some progress has been made. The prevalence among Medicaid-insured was 43% (2014) and has declined to 28% (2021).  In partnership with DVHA, tobacco treatment specialists, community grantees, clinicians and leadership, our goal is to reduce the smoking rate among Medicaid-insured adults to less than 25% by 2023.

While we have made progress in Vermont to reduce the prevalence among Medicaid-insured, we still have a disparity that indicates the need to continue to prioritize tobacco prevention and control strategies to the Medicaid-insured population (Zhu et al., 2017). The Tobacco Program continues efforts to expand the tobacco benefit offered to Medicaid members by providers, the Quitline, Quit Online, and Self Management Programs, and to promote that benefit to both providers and members. The Tobacco Program also added in 2021 a financial incentive to the quitline phone counseling services for Medicaid members, as a way to increase engagement and utilization of the state quitline. The Tobacco Program and DVHA meet regularly to plan promotions, assess obstacles to accessing the benefit by members, and challenges for providers in offering the benefit (counseling and nicotine replacement therapy and quit medications). We created a Medicaid Tobacco Initiative Overview with annual data monitoring and published a paper, A Framework for Effective Promotion of a Medicaid Tobacco Cessation Benefit in the Journal of Health Promotion and Disease Prevention. To be released in late summer 2023 is an infographic on the return of investment for Vermont’s Medicaid budget by lowering smoking prevalence. If interested in any of these publications, email tobacccovt@vermont.gov.

Current and Future Partners include:

• Department of Vermont Health Access (DVHA): DVHA is responsible for the management of Vermont's publicly funded health insurance programs and determines the tobacco benefit for counseling and nicotine replacement therapy that when used together more than doubles the likelihood of quit success.

• Professional Data Analysts (PDA): a national company that provides technical and evaluation services including to the Health Department’s Health Promotion and Disease Prevention (HPDP) Division. The Vermont Tobacco Program contracts with PDA to provide evaluation, planning, and technical assistance. PDA involves staff and stakeholders in evaluation to ensure relevant data that inform program improvement and demonstrate program impacts.

• Organizations representing low-income residents: Vermont 211, Vermont Affordable Housing Coalition, Vermont Community Action Partnership, United Way and Vermont Public Interest Research Group among others represent the vulnerabilities and needs of low-income in our state. The Tobacco Program communicates periodically with Vermont 211 but hasn’t built relationships with other organizations.

• Department of Mental Health: The Department of Mental Health has the mission to promote and improve the health of Vermonters. Many Vermonters with mental health disorders are Medicaid-insured. We collaborate to support smoke-free facilities, provide training and other supports for tobacco treatment. 

• American Lung Association: A national leader in providing technical assistance and case studies for addressing tobacco use among Medicaid-insured including policy changes needed to promote identifying and treating tobacco use.

• Community Grantees: Tobacco-funded grantees create yearly work plans aimed at reducing the toll of tobacco use and the impact of tobacco advertising and marketing on Vermont’s most vulnerable.

• Residents with Lived Experience: The participation of informed and concerned residents can help deepen understanding and support for protective policies that are inclusive. Policy advancement is aided when there is support and demand from residents for changes that benefit all Vermonters regardless of insurance status, income, class, race, geography or gender.

• Department of Housing and Urban Development: Vermont HUD property directors are working with the Tobacco Program to find ways to partner and provide cessation services to individuals living in HUD facilities, without penalizing individuals. Referrals to 802Quits and its resources for counseling, free nicotine replacement therapy and text support are preferred over pursuing eviction for smoking in housing units.

The program will continue to implement prevention and treatment practices to prevent tobacco impacting the health and well-being of low-income Vermonters using  evidence-based practices including:

• reducing number of tobacco outlets especially located near schools and places of learning
• reducing discounting and establising a minimum price floor for tobacco
• restricting price discount promotions in low-income neighborhoods and communities
• countering tobacco industry influence through requiring content neutral advertising
• promoting quitline and other cessation services, with financial incentives
• promoting smoke-free and clean indoor air laws to protect everyone from secondhand smoke, and
• providing higher level of supports for effective cessation outcomes for Medicaid-insured.

No data was collected in 2016, baseline is from 2014.

Use of tobacco products is defined as smoking cigarettes or using another tobacco product every day or some days. This data is provided by the Department of Vermont Health Access and collected every year in the Consumer Assessment of Healthcare Providers & Systems (CAHPS), a patient experience survey of Medicaid members. About 1,650 member households are surveyed by mail or telephone between mid-October through mid-December of the measurement year using a standard questionnaire. The survey draws as potential respondents the adult members of Vermont Medicaid who were continuously enrolled in the plan for at least 6 months as of September 1, with no more than one enrollment gap of 45 days or less.