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After years of decline, Vermont’s adult smoking rate appears to have stalled and now “lags behind the nation,” advocates say.
At the same time, state investment in tobacco-related programming is shrinking. A tobacco trust fund that once held $31 million now has no money, and only a small portion of the state’s yearly settlement payments from the cigarette industry go toward Vermont’s Tobacco Control Program.
Officials say those problems don’t cancel out the progress Vermont has made on the health and regulatory fronts. And the state is continuing to target trouble spots, including high smoking rates among Medicaid recipients and pregnant women.
But some argue that it’s time for the state to recommit itself to the battle against smoking, even though budgets are perennially tight and the opioid epidemic has taken precedence.
“If you want to address health care costs, there has to be a long-term commitment to reducing tobacco use,” said Rebecca Ryan, a senior director of health education and public policy with the American Lung Association in Vermont.
Vermont’s most recent five-year tobacco plan says the state, “along with the rest of the nation, has achieved significant success in reducing tobacco use and its associated burden over the past 15 years.”
The state’s adult smoking rate declined from 21 percent in 2000 to 18 percent currently. Also, youth smoking rates have decreased from 24 percent in 2011 to 11 percent as of a 2015 survey.
Vermont officials also have pushed back against secondhand smoke by enacting laws like Act 135 of 2014, which banned smoking on school grounds; at licensed child care facilities; at hotels and motels; outside state buildings; and in cars occupied by children in a car seat or booster seat.
Additionally, the state has beefed up smoking-cessation programs under the banner of 802Quits, which residents can access online, via phone and in person. The state’s tobacco plan puts Vermont adults’ quit-attempt rate at 59 percent, comparable to a national average of 60 percent.
In spite of those measures, Ryan says Vermont’s smoking rates are “kind of stuck.” The state’s 18 percent adult-smoking rate is higher than the 15.5 percent national average, and it ticked up a percentage point between 2015 and 2016.
“That was discouraging,” said Rhonda Williams, chronic disease prevention chief with the state Health Department.
Vermont’s youth smoking rate – covering grades 9 through 12 – stands at 11 percent, which is roughly equivalent to the national average. But the same survey showed that 25 percent of youths used some form of tobacco product, which included e-cigarettes.
A state report on “electronic vapor products” such as e-cigarettes says three out of 10 Vermont high school students had tried products as of 2015, and “the proportion of students who have tried or currently use electronic vapor products increases with grade.”
Though the U.S. surgeon general has warned about the potential health effects of e-cigarettes, Ryan said she believes that “kids are using electronic cigarettes because they think they’re safe.”
The state’s five-year plan places special emphasis on preventing tobacco use among young people, saying it is “critical to ending the tobacco epidemic.”
“Despite significant declines in tobacco use among youth in Vermont, if smoking in Vermont continues at the current rate, (the federal government) estimates more than 10,000 of Vermonters currently younger than 18 years of age will die from smoking,” the plan says.
About 1,000 Vermonters die each year from smoking-related causes, according to the state Health Department. Tobacco use is classified as the No. 1 preventable cause of death.
But state spending on tobacco use prevention appears to be on the decline. Williams said funding for Vermont’s Tobacco Control Program, which includes a variety of prevention, cessation and enforcement work, has decreased by 26 percent since 2009.
Vermont gets payments each year from the tobacco industry via what’s called the “master settlement agreement.” But an analysis in the Vermont Tobacco Evaluation and Review Board’s most recent report showed that just 8 percent of the $24.6 million in settlement money the state received for fiscal year 2018 was allocated to the Tobacco Control Program.
The review board itself, which is supposed to evaluate tobacco programs, now goes unfunded.
And there’s also no money in the state’s tobacco trust fund, which initially was endowed by the Legislature with $19.2 million in 1999 and at its peak held more than $31 million. Only $500,000 from that trust fund ever went toward the Tobacco Control Program, according to the lung association.
“That was created for future sustainability for the program,” Ryan said. “If things had happened the way they were supposed to happen, we’d be living off that fund.”
Instead, the money has been used “to pay for other programs and fill budget gaps,” the state’s tobacco plan says.
Williams said state health officials understand that “legislators in our state and in others are grappling with many issues.” But she also said tobacco programming should be a high priority.
“The evidence of tobacco control and prevention as researched by many over the years … is that a well-funded, comprehensive program for tobacco pays off and is shown to reduce prevalence,” Williams said.
State officials say they’re doing what they can with what funding they have. “What we are and have been doing is prioritizing our resources,” Williams said.
Smoking prevalence varies based on factors like education and income. For instance, the smoking rate among Vermont adults insured by Medicaid is 32 percent, significantly higher than the state’s overall rate.
So the state has prioritized the Medicaid population, in part by expanding benefits to include cessation counseling and promoting that benefit to providers.
“We’re starting to see the smoking rate for the Medicaid insured come down,” Williams said. “We’re going to continue that work and amplify it this fall.”
Vermont also has one of the highest smoking rates in the nation for pregnant women, at 17 percent. Officials have directed more training and promotion to that problem, with a particular focus on the Rutland area, where rates are higher than the state average.
“We are dedicated to bringing that down,” Williams said.
Still, there’s only so much the state can do with dwindling funding. And some say it’s time for a cash infusion into Vermont’s tobacco programs.
The review board and the lung association advocate for boosting the Tobacco Control Program’s budget to $5.65 million in fiscal year 2019, which would be an increase of about $2 million.
Some or all of that increase, advocates suggest, could come from the state’s recent $28 million windfall in additional settlement money from the tobacco industry. That one-time funding source also “seems like an opportunity to start rebuilding the trust fund,” Ryan said.
The House’s version of the fiscal 2019 budget allocates significant portions of the tobacco windfall money toward substance abuse programs. It does not specifically spend that money on tobacco programs.
But the budget has not been finalized. Sen. Ginny Lyons, D-Chittenden and vice chair of the Senate Health and Welfare Committee, said allocation of the $28 million is “a continuing dialog between the administration, the House and the Senate.”
“As we think about the use of that money, it will be very important to think about how to improve the system of prevention and how to improve the system of recovery,” Lyons said.
That was a theme echoed by others – the idea that tobacco programs should not be thought of as separate from the state’s other substance-abuse work, but instead should be integrated.
For example, Lyons said it might be time to “redefine” the tobacco review board – of which she is a member – in order to broaden its mission and more broadly apply its proven prevention methods.
That might also make the board more apt to receive funding.
“I would like to see the conversation move toward, how can we utilize that board and their skills to expand to other substances?” Lyons said. “It’s not a conversation that has happened.”
All funding issues aside, Lyons also is a strong proponent of making it harder for young people to access tobacco products by raising the age for purchase and use of tobacco and related electronic devices to 21. She believes that alone could cut the state’s smoking rates.
“For me, I think that what may be causing us to lag behind where we would like to be is the culture of access,” Lyons said. “If you have an 18-year-old who can buy cigarettes, that is probably easily distributed to kids who are 17 and 16 and 15. So they’re going to try them.”
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