Reduced smoking rates, not much violent crime and low reports of sexually transmitted diseases make Vermont the healthiest state in the country, according to rankings released this week.

Vermont is the healthiest state in the country thanks to decreased rates of smoking and mental distress, along with low incidences of violent crime and certain sexually transmitted diseases, according to rankings released Thursday by the United Health Foundation.

The 30th annual America’s Health Rankings is “a composite index of over 30 metrics” that provides a snapshot of each state’s population compared to others, according to the foundation, a private nonprofit owned by UnitedHealth Group. Those metrics include behaviors (smoking, excessive drinking), community and the environment (public health funding, mental health providers) and outcomes (infant mortality, cardiovascular deaths).

“Over the past 30 years, the understanding and science of public health has changed dramatically,” Dr. Rhonda Randall, chief medical officer of UnitedHealthcare and advisor to the report, said in a statement. “Many health issues that were concerning in 1990 remain so today, and additional issues have arisen that require action now.”

Vermont moved up three spots to claim the no. 1 ranking, which the report said was largely due to improvement in the category of disparities in health status, driven by a “large increase in the percentage of adults with less than a high school education who reported high health status (24.3 percent to 36.7 percent).”

Massachusetts, Hawaii, Connecticut and Utah round out the top five. Three of those are in the Northeast, the report notes, while all of the bottom five states—Mississippi, Louisiana, Arkansas, Alabama and Oklahoma—are in southern regions of the country.

Mississippi ranked as the least healthy state, falling one spot from 49th in 2018. That rank is “driven by drops in the policy and the behavior categories” and high rates of obesity (39.5 percent of the population is considered obese, compared to a national average of 30.9 percent) and cardiovascular deaths (363.2 deaths per 100,000, compared to 260.4 nationally).

Nationally, certain trends have improved in recent years, including a 13 percent increase in the number of mental health providers since 2017 and a 20 percent decline in the number of children in poverty since 2013. Ongoing challenges include rising rates of suicide (up 4 percent from 2018) and chlamydia (up 5 percent from 2018), as well as drug deaths (up 104 percent since 2007).

That steady rise in deaths related to drugs is largely due to the continuing opioid crisis, reflected in disparities among ethnic groups, genders and geographic locations. For example, the drug death rate is 6.6 times higher among whites than among Asian/Pacific Islanders, 1.9 times higher among males than females, and 6.7 times higher in West Virginia than in Nebraska, according to the report.