August 2023

Tobacco use is the number one preventable cause of death. In Vermont, smoking costs approximately $404 million in annual healthcare costs and results in about 1,000 smoking-related deaths each year. The 2021 Behavioral Risk Factor Surveillance Survey (BRFSS) Report found that 16% of adults in Vermont smoke every day or some days of the past 30 days. Quitting smoking reduces the risk of chronic disease and premature death. 

The tobacco burden is not evenly distributed across Vermont’s population. The 2021 BRFSS data shows 23% of Vermonters who report having been diagnosed with depression report smoking every or some days. This is down from 28% when first surveyed in 2012 and from a peak in 2016 at 29%.  The program is partnering with the Division of Substance Use, the Department of Mental Health, Clara Martin and the National Mental Health Council among others to integrate tobacco into treatment; ask/advise and connect; use motivational interviewing with patients and clients to help prioritize wellness and recovery through tobacco treatment, and provide resources Through utilizing multiple strategies with partners, the target goal is 20% by close of 2023.

People with depression who smoke can benefit from extended support including counseling, peer engagement, and nicotine replacement therapy to successfully quit tobacco use.

The CDC reports over one-third of adults with any mental illness (32%)reported current use of tobacco in 2016 compared to 23% of adults with no mental illness. Smoking causes premature death; people who smoke die on average 10 years earlier than people who don't smoke. According to the Surgeon General 2020 Report, smoking is associated with one third of all cancers and causes chronic diseases including diabetes and heart disease.

Those with depression, especially those with mental health diagnosis, can die even earlier because of higher tobacco use and therefore greater toxin exposure. Addressing higher tobacco use and burden among those with depression is an important priority for the Tobacco Program.

This indicator is part of the State Health Improvement Plan for 2019-2023. The Plan documents the health status of Vermonters, the disparities between different populations, and goals that will guide public health work through 2023. The State Health Improvement Plan has an emphasis on populations that experience health disparities.

Blueprint for Health- The Blueprint for Health designs community-led strategies for improving health and well-being. This work includes designing and improving health care delivery. The Blueprint for Health collaborates with the Tobacco Program offering the Vermont Quit Partner program an in-person branch of 802Quits.

Department Mental Health-The Department of Health works to promote and improve the health of Vermonters through direct service, community oversight, investment in peer support services, and practice improvement.

National Alliance on Mental Illness Vermont - NAMI Vermont supports, educates and advocates so that all communities, families, and individuals affected by mental illness or mental health challenges can build better lives.

National Behavior Health Network – Funded by the CDC as a resource for state tobacco programs, the organization serves as a resource hub to help combat the disparities seen among those with mental health illness.

National Jewish Health (NJH)- The Tobacco Program's contractor provides the phone, web, and text messaging support for those trying to quit tobacco known as 802Quits. The services on the phone are offered in over 200 languages. Services on the web are offered in English and Spanish. In 2021, the Tobacco Program added both a specialized Behavioral Health Protocol, as well as a financial incentive, to the suite of quitline services. This protocol is designed specifically for individuals living with behavioral health conditions, and establishes more community-level support for tobacco cessation. Through adding a financial incentive to this protocol, the Tobacco Program aims to increase engagement and utilization of this protocol by Vermonter’s living with a behavioral health condition.

Vermont Care Partners– Helps to collect and share tobacco screening and treatment data with the tobacco program that over time can be used to provide feedback and acknowledgement of wellness work underway at designated agencies.

Healthcare providers: Encourage and support patients to quit smoking.

As identified by the CDC and its national networks, the Tobacco Control Program (TCP) deploys a number of best-practices for alleviating health disparities. 

• Assure that questions regarding mental illness are included in programmatic surveys in order to monitor the disparity and reach of programs into these communities and share the results.
• Protect against secondhand smoke exposure through encouraging smoke-free events and creating smoke-free multiunit housing throughout the state.
• Offer quit support that is inclusive and accessible for people with mental illness such as Vermont’s 802Quits program. The program offers phone, web, or in-person support.
• Ensure media campaigns reach and impact populations with mental illness and ensure messaging is inclusive and effective.
• Raise tobacco taxes to fund programs for people with mental illness.
• Evaluate the impact and efficacy of current programs used by people with mental illness.
• Diversify the tobacco control movement through engaging community members with mental illness to gain knowledge and information on how to better serve the population.

The TCP uses CDC identified policies and multiple strategies to lower the prevalence of smoking among people experiencing depression including:

• The TCP includes mental illness questions on the cessation support phone intake and monitors the percentage of callers reporting mental illness. The major youth and adult surveys also include questions about mental health.
• The TCP has worked with the Department of Mental Health (DMH) on wellness initiatives in order to encourage smoke-free grounds, inclusion of cessation into treatment, and feedback on what the program can do to better serve their clients. The TCP completed a successful grant with Clara Martin facility on building sustainability around screening and treating tobacco onsite; the tobacco program is looking for resources to grant another designated agency once workforce issues are no longer as pressing.
• The TCP collaborates with their cessation phone support vendor on how to best serve this population, including supporting a specialized protocol for callers reporting depression. The protocol included providing phone support coaches with enhanced training.
• The program is seeking to restart meeting annually with the Vermont Chapter of the National Alliance on Mental Illness (NAMI) to serve this population and to disseminate information on our services.
• The TCP has started to digitally promote cessation benefits available through the state which do not include co-pays or prior authorization for varenicline and bupropion.
• The TCP is working with the National Behavioral Health Network, one of eight CDC National Networks, which serves as a resource hub for organizations, health care providers, and public health professionals seeking to address these disparities among individuals with mental illnesses and addictions.

Current smoking is defined as having smoked at least 100 cigarettes in a lifetime and now smokes every day or some days. Depression is defined as those who have ever been diagnosed with a depressive disorder, including depression, major depression, dysthymia, or minor depression.

Data on smoking and depression are collected every year using a telephone survey of adults called the Behavioral Risk Factor Surveillance Survey (BRFSS) (http://www.healthvermont.gov/health-statistics-vital-records/population-health-surveys-data/brfss). Two years of data are combined for this measure (most recent year is noted in graph associated with this story behind the curve) and results are weighted to represent the Vermont adult population (18 or older). Due to BRFSS weighting methodology changes beginning in 2011, comparisons between data collected in 2011 and later and that from 2010 and earlier should be made with caution. Differences between data from 2011 forward and earlier years may be due to methodological changes, rather than changes in opinion or behavior.

In order to remain consistent with the methods of comparison at a national level, this measure is age-adjusted. In other words, the estimates were adjusted based on the proportional age breakdowns of the U.S. population in 2000. For more detailed information on age adjustment visit http://www.cdc.gov/nchs/data/statnt/statnt20.pdf.