Tobacco in the Great Land - Alaska Department of Health and Social

203 Pages·2012·3 MB·English

Tobacco
in
Great Land
the
A Portrait of Alaska’s Leading Cause of Death
2012 Update
Sean Parnell, Governor, State of Alaska
William J. Streur, Commissioner, Department of Health and Social Services
Ward B. Hurlburt, MD, MPH, Chief Medical Officer and Director, Division of Public Health
Produced by the Section of Chronic Disease Prevention and Health Promotion, Tobacco Prevention and
Control Program through a contract with Program Design and Evaluation Services, Multnomah County
Health Department and Oregon Public Health Division.
Major contributors include:
Erin Peterson, MPH, Tobacco Prevention and Control Program
Kathy Pickle, MPH, Program Design and Evaluation Services
Myde Boles, PhD, Program Design and Evaluation Services
Matthew Bobo, MPH, Tobacco Prevention and Control Program
.
Acknowledgements Table of Contents
We would like to thank the following for their contribution to this report - Executive Summary .................................................................................................... i
Part I - Burden of Tobacco Use in Alaska ......................................................................... 1
Alaska Department of Health and Social Services
Part II - Alaska Tobacco Prevention and Control Program ...................................................... 5
Division of Public Health
Part III - Applying Science to Program Design ................................................................ 13
Section of Chronic Disease Prevention and Health Promotion
Andrea Fenaughty, PhD, Deputy Section Chief Part IV - Adult Tobacco Use
Charles Utermohle, PhD, Programmer/Analyst Chapter 1 - Cigarette Smoking and Quitting Smoking ................................................ 33
Rebecca Topol, SM, Alaska BRFSS Coordinator Chapter 2 - Smokeless Tobacco ............................................................................... 71
Wendy Hamilton, YRBS/School Health Program Manager Chapter 3 - Other Smoked Tobacco Types and Multiple Product Use .................................... 87
Section of Women’s, Children’s, and Family Health Part V - Youth Tobacco Use
Kathy Perham-Hester, MS, MPH, Alaska PRAMS Coordinator Chapter 4 - Smoking ............................................................................................... 95
Chapter 5 - Smokeless Tobacco Use ....................................................................... 109
Bureau of Vital Statistics
Chapter 6 - Use of Multiple Tobacco Products ......................................................... 119
Phillip Mitchell, MS, Section Chief
Chapter 7 - Selected Policies Related To Youth Tobacco Use ..................................... 131
Andrew Jessen, MIB, MA, Research Analyst
Division of Behavioral Health Part VI - Pregnant Women and Tobacco
Joe Darnell, Chief Investigator, Tobacco Enforcement and Youth Education Chapter 8 - Tobacco Use During Pregnancy ............................................................ 139
Part VII - Secondhand Smoke
Chapter 9 - Secondhand Smoke Exposure and Policies ............................................ 149
Alaska Department of Revenue
Chapter 10 - Support for Clean Indoor Air Policies ......................................................... 183
Tax Division
Chapter 11 - Health Risks of Secondhand Smoke Exposure ........................................ 205
Johanna Bales, CPA, Deputy Director
Part VIII - Conclusion and Next Steps ......................................................................... 215
Part IX - Appendices
Appendix A - Trend Tables ..................................................................................... 219
Appendix B - Descriptive Tables ........................................................................... 267
Appendix C - Data Sources and Technical Notes ....................................................... 329
List of Illustrations
Suggested Citation - Alaska Department of Health and Social Services, Division of Public Health, Section of Chronic Figures ............................................................................................................... 339
Disease Prevention and Health Promotion. Tobacco in the Great Land, A Portrait of Alaska’s Leading Cause of Death,
Tables ................................................................................................................. 343
2012 Update. Anchorage, AK: Alaska Department of Health and Social Services; 2012.
Copyright Information - All material in this document is in the public domain and may be reproduced or copied without
permission; however, citation as to source is appreciated.
Table of Contents
. .
Executive Summary
Since publication of the first Tobacco in the Great Land report in 2004, statewide partners in tobacco prevention
and control have worked aggressively to reduce the burden of tobacco use on Alaska’s people. The Behavioral
Risk Factor Surveillance System (BRFSS) has been expanded to include more respondents and to routinely
collect in-depth information on adult attitudes, knowledge, and behaviors around tobacco use. The enhanced
data collection system has allowed for the publication of numerous specialized reports, including summaries
of tobacco use within high-prevalence populations and compilations of data related to smoking cessation,
smokeless tobacco use, and exposure to secondhand smoke. Data from the Youth Risk Behavior Survey
(YRBS) have also been carefully examined, yielding valuable information about the trends and patterns of
tobacco use among Alaska youth.
This update to Tobacco in the Great Land is designed to link program information and tobacco-related data.
It contains a summary of the applied research and evaluation activities undertaken since 2005, key trends in
tobacco use through 2008, and current tobacco use statistics among population subgroups. It summarizes
program efforts to prevent tobacco use and eliminate exposure to secondhand smoke and indicates both
areas of success and areas where challenges remain. The document can be used both as a reference and
as a guide to program efforts to further reduce death and disease caused by tobacco use.
The Burden of Tobacco Use in Alaska
Tobacco use remains Alaska’s leading preventable cause of disease and death. More Alaskans die as a
result of tobacco use than from infectious diseases, alcohol, car accidents, illegal drugs, murders and
suicides combined. Tobacco use exacts an enormous burden on the State of Alaska and its residents,
causing premature death and millions of dollars of avoidable medical care expenditures. The single best
thing that Alaskans who use tobacco can do to improve their health and the health of those around them
is to quit using any tobacco products.
Tobacco costs Alaska:
• More than 500 deaths per year as a direct result of tobacco-related diseases, including cancers,
heart disease, respiratory disease and harm to unborn children.
• Approximately $325 million per year in health-related costs, including hospitalization, clinical care,
medications and nursing home care.
• Approximately $221 million per year in lost productivity, including the value of lost work time for
people suffering from illnesses, families who support them, and lost wages due to premature death.
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Executive Summary
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Alaska Tobacco Prevention and Control • In general, more Alaskans are protecting families from secondhand smoke by making their homes
smoke-free. Alaska Native homes, and homes with children age 5 and under, were more likely to be
The Alaska Tobacco Prevention and Control (TPC) Program, housed within the state Department of Health
smoke-free.
& Social Services, Division of Public Health, receives funding to implement evidence-based programs in
tobacco prevention and control. Funding is available primarily as a result of a national legal settlement • Men, people younger than 45, people with less formal education and people living in non-urban
areas are all more likely to use smokeless tobacco. Alaska Native people are more likely to use
between states’ Attorneys General and several tobacco companies. The program has four primary goals:
smokeless tobacco than non-Native people statewide, in large part due to use of Iq’mik – a unique
• Preventing young people from starting to use tobacco smokeless tobacco product – in the Y-K Delta region.
• Helping tobacco users quit The most current prevalence summaries of tobacco use and related factors are provided through Tobacco
Facts, an annual report available at the Alaska TPCP website:
• Reducing exposure to secondhand smoke
http://www.hss.state.ak.us/dph/chronic/tobacco/
• Reducing tobacco-related disparities
The TPCP’s main activities include state and community programs (such as grants to communities and Adult Tobacco Use
schools), health communications interventions (such as a hard-hitting statewide media campaign), cessation
Information about adult tobacco use is available through the statewide Behavioral Risk Factor Surveillance
interventions (including the statewide toll-free Quit Line that provides free medication and counseling to
System (BRFSS), an anonymous, random telephone survey of non-institutionalized adults. The BRFSS is a
anyone in the state), and ongoing data collection and evaluation to improve effectiveness.
national survey sponsored by the Centers for Disease Control and Prevention, and is conducted in every
Additionally, since 1992, leadership has been provided by the diverse statewide partners in the Alaska state. It has been implemented in Alaska since the mid-1990s by the Alaska Division of Public Health.
Tobacco Control Alliance (ATCA). This statewide tobacco prevention and control coalition is made up of
Cigarette smoking is the most common form of tobacco use nationally and in Alaska. Current smokers
tribal and community-based organizations, health care organizations, schools, and other health advocates.
are defined as those who have smoked at least 100 cigarettes in their lifetime and report that they now
ATCA has led successful campaigns to increase the price of tobacco, reduce youth access, and secure
smoke every day or some days.
funding for ongoing work of the TPCP.
• Cigarette smoking and sales statewide have decreased significantly since 1996.
Applying Science to Program Design
• About half of Alaska’s adults have tried smoking. More than one of every five adults (22%) still
Multiple data collection systems have been implemented in the state to provide better understanding smoke cigarettes in the state.
about cigarette smoking, smokeless tobacco use, and secondhand smoke exposure. Several intensive
• Declines have been significant among adults age 30 and older, but not among younger adults.
evaluation studies or focused data reports have been completed to help with continuously improving tobacco
control efforts in the state. Major findings have included: • Declines have been significant for residents of Anchorage/Mat-Su, Gulf Coast, Southeast and Fairbanks
North Star regions, but not significant for other areas of the state. Smoking rates are highest in the
• Alaskans are smoking less. Smoking prevalence for both adults and youth has declined during
North/Northwest/Interior and Southwest regions.
recent years, as the Alaska TPCP has accelerated population-based tobacco control activities. Declines
are due to both decreases in initiation and increases in quitting. Different regions of the state have • Alaska Native adults are still more than twice as likely as non-Native adults to smoke. Among
shown different levels of success. non-Native adults, those of lower socio-economic status (SES) are twice as likely as those of higher
SES to smoke. Smoking has not declined significantly in these populations.
• Alaska Native people and people of low socioeconomic status (low SES – typically, low income
and/or education) are disproportionately affected by tobacco use and subsequent health consequences. • About three out of four smokers smoke every day. Among daily smokers, Alaska Native people,
Young adults are also a population of concern. Specialized focus of tobacco control activities to reach women and young adults smoke fewer cigarettes per day.
these groups is warranted.
• Quitting has increased in recent years. About two-thirds of current smokers want to quit, and
• The Alaska Tobacco Quit Line has been an effective tool for many people to quit using tobacco. nearly the same percent tried to quit in the past year. Alaska Native adults have consistently tried to
Nearly 40% of all tobacco users (both cigarette smokers and smokeless users) who called the Quit quit at a similar or higher rate than non-Native adults. About one in four current smokers has a plan
Line for help in quitting were tobacco-free three months later. Quit rates were somewhat lower for to quit in the next month.
Alaska Native people, women and older smokers. More than 90% of callers were satisfied with their
service overall and with specific components of the service. • About two-thirds of adult smokers who saw a doctor in the past year were advised to quit, but
fewer smokers than non-smokers have health care coverage and had health care visits in the past
• Among youth, a variety of risk factors were correlated with increased tobacco use, including alcohol, year.
marijuana, and sexual activity. Connectedness with parents, teachers and other caring adults appeared
to have a protective effect against tobacco use. • About one in twenty adult tobacco users in Alaska have ever called the state Quit Line, which is
similar to rates seen in other states.
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Executive Summary Executive Summary
. .
Smokeless tobacco (SLT) includes commercial smokeless products (chew, spit, snuff), as well as the Youth Tobacco Use
Alaska Native smokeless variant known as Iq’mik or Blackbull. Rates of SLT use among adults have been
Information about youth tobacco use is available through the Youth Risk Behavior Survey (YRBS). The
stable during recent years. Current adult SLT users are defined as those who report that they now use
YRBS is an anonymous written survey about health behaviors that is given to a sample of the state’s
one or more forms of SLT every day or some days.
high school youth during the spring of odd-numbered years. This survey is sponsored by the Centers for
• Most (two out of three) SLT users are daily users, and most use only one type of SLT. Disease Control and Prevention and implemented by the Alaska Department of Health and Social Services,
Department of Education and Early Development.
• Nearly half of Alaska Native SLT users use Iq’mik, but this use is primarily confined to the Southwest
region of the state. In this region, about one in six Alaska Native adults uses Iq’mik, and prevalence A high school student is defined as a “current smoker” if he or she has smoked on any of the past 30
does not differ between men and women.
days. This is the nationally accepted definition for youth smoking.
• Alaska Native people have SLT use rates about three times higher than non-Native people. Males
• Current youth cigarette smoking has decreased significantly since 1995, including across high
are nine times more likely than females to use smokeless tobacco in the general population. While
school age groups, for both boys and girls, and for both Alaska Native and non-Native youth.
Alaska Native women are less likely to use SLT than men overall, their rates are much higher than
non-Native women and more similar to non-Native men. • About one of every six Alaska high school youth (16%) currently smoke cigarettes.
• SLT tobacco use has increased slightly, but significantly, among current smokers during recent • About half of high school youth have ever tried smoking cigarettes. About one in ten of all high
years. This could be associated with increasing restrictions on smoking in public places. school youth first tried a cigarette before age 13.
• SLT use (both commercial and Iq’mik) is higher in Alaska Native homes where children are present • About one in twenty Alaska high school youth smokes frequently (20 or more days in the past
vs. when children are not present; for non-Native homes there is no difference in SLT use by presence month). This is less than one-third of current youth smokers.
of children.
• Current smoking rates among Alaska Native youth are about double those among non-Native
• Among non-Natives SLT use is slightly higher in the Gulf Coast region than in other regions of the youth.
state. Among Alaska Native people, SLT use is highest in Southwest Alaska (fifteen times higher
• Current smoking rates are similar among boys and girls overall. Alaska Native girls are more likely
than in Anchorage/Mat-su), and also high in the North/Northwest/Interior region (three times higher
than Alaska Native boys to smoke. Alaska Native girls are more likely than any other group of boys
than in Anchorage/Mat-su).
or girls to be frequent smokers.
• Nearly two-thirds of SLT users want to quit.
• Generally, smoking rates increase with age of the youth.
Other types of tobacco that people smoke include cigars, pipes, bidis and clove cigarettes. Current adult
• Alaska Native youth are about twice as likely as non-Native youth to have tried smoking before
users of these types of tobacco are defined as those who report that they smoked cigars pipes, bidis or
age 13.
clove cigarettes in the past month.
• More than half of all youth smokers tried to quit in the past year. Quitting attempts were similar
• Less than one in ten adults in Alaska currently uses some type of other smoked tobacco product. for boys and girls, but slightly higher for Alaska Native youth smokers than non-Native youth.
• Use of any other smoked tobacco product is highest among men and young adults (18-29). • Current cigar smoking has increased somewhat among youth during recent years. More than half
of youth who smoke cigars also smoke cigarettes.
• Of these different tobacco types, cigars are the most popular.
A high school student is defined as a “current smokeless tobacco (SLT) user” if he or she has used SLT
• More than half of adults who use some other type of smoked tobacco product also smoke conventional
cigarettes. on any of the past 30 days. This is the nationally accepted definition for youth SLT use.
• Overall, current SLT use among youth has not changed significantly in recent years.
• Boys are about twice as likely as girls to use SLT.
• Overall, Alaska Native high school youth are about twice as likely as non-Native youth to use SLT
overall, and Alaska Native girls use SLT at rates similar to non-Native boys.
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Executive Summary Executive Summary
. .
About one in four youth uses some type of tobacco. Pregnant Women and Tobacco Use
• About one-third of tobacco-using youth only smoke cigarettes. Information about prenatal care, maternal health risk behaviors and infant health is collected using the
Pregnancy Risk Assessment Monitoring System (PRAMS). This ongoing, anonymous written survey is
• About one in five tobacco-using youth only use SLT.
given to a sample of mothers with newborn infants about six weeks after delivery. PRAMS is sponsored
• One in ten tobacco-using youth smoke cigars only. by the Centers for Disease Control and Prevention, and administered in every state. Alaska’s PRAMS is
implemented by the Division of Public Health.
• About one-third of tobacco-using youth use more than one tobacco product.
Since 1996, there has been an overall decline in the percentage of women who report smoking during the
• Among tobacco-using girls, about half use only cigarettes. Among tobacco-using boys, one in five
third month of their pregnancy.
use only cigarettes.
• About one in six mothers overall smoke during the last three months of pregnancy.
A number of effective interventions exist to prevent youth tobacco use, and most adults support these interventions.
• Two-thirds of mothers who smoked during their last three months of pregnancy smoked five or
• Tobacco prevention policies that include comprehensive tobacco-free rules in schools are an important
fewer cigarettes per day.
complement to education and intervention programs. About nine out of ten adults agree that tobacco
use by adults should not be allowed on school grounds or at any school events – including more • Smoking during the last three months of pregnancy was about three times higher among Alaska
than eight out of ten current adult smokers. About one in ten youth report recently using tobacco Native mothers than non-Native mothers, and five times higher among women with less than a high
on school property; rates of use on school property are twice as high among Alaska Native youth as school education vs. those with more than a high school education. Younger mothers are more likely
non-Native youth. to smoke during pregnancy than older mothers.
• Age restrictions on the sale and distribution of tobacco products make tobacco more difficult for
Since 1996, there has been a significant decline in the percentage of women who use smokeless tobacco
youth to get tobacco and become addicted to it.. In Alaska, undercover “compliance checks” that
(SLT) during pregnancy.
measure whether stores will sell tobacco to minors have shown dramatic improvement, and there
has also been a dramatic decline in the number of youth smokers who say they usually get their
• Alaska Native women alone reported significant declines in use of any SLT during pregnancy since
cigarettes from a store. More than nine out of ten adults agree it is important to keep stores from
1996. Nearly one in five Alaska Native women currently uses tobacco during pregnancy.
selling tobacco to teenagers.
• Nearly one in five Alaska Native women uses Iq’mik during pregnancy, and there has been no significant
• Over two-thirds of youth who smoke indicate that they get their cigarettes with help from other
decline in Iq’mik use during pregnancy since this information was first included in PRAMS (2004).
people in their community. Additional efforts to foster smoke-free social norms can help keep youth
from starting to use tobacco. • At least half of Alaska Native women in Southwest Alaska reported using SLT or Iq’mik during
pregnancy; in other regions fewer than one in ten Alaska Native women reported using SLT.
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Executive Summary Executive Summary
. .
Secondhand Smoke Exposure Adults were also asked about their exposure to secondhand smoke in a variety of other settings.
Information about secondhand smoke exposure is available from BRFSS for adults and YRBS for high • About one in four adults had been exposed to secondhand smoke in a car during the past month.
school youth. Men, younger adults, low SES adults, and current smokers were more likely to be exposed.
Secondhand smoke exposure in the home occurs when someone smokes cigarettes, cigars or other tobacco • Nearly one-third of adults had been exposed to secondhand smoke at their indoor workplace during the
past month. Exposure was higher among men, young adults, low SES adults and current smokers. Adults
products inside the home.
in Southwest Alaska were less likely than in other regions to be exposed to secondhand smoke at work.
• Since 1998, rates of exposure to secondhand smoke at home have been reduced by more than
• Overall, since 1998, more adults report that their workplace bans smoking. However, there has not
two-thirds among all adults. Similarly, more homes have smoking bans. Less than one in ten adults
been an increase in the percent of Alaska Native adults who report that there are smoking bans at
has been exposed to secondhand smoke at home during the past month.
their indoor workplace.
• Declines in secondhand smoke exposure at home have occurred among both Alaska Native and
non-Native homes. Exposure to secondhand smoke at home is lower among Alaska Native adults Most adults support rules that protect against exposure to secondhand smoke.
than non-Native adults.
• More than eight out of ten adults agree that people should be protected from other people’s cigarette
• Declines in secondhand smoke exposure at home have been seen among both low SES and higher smoke. Even among smokers, three out of four agree people should be protected from secondhand
SES adults. About one in five low SES adults is exposed to secondhand smoke at home – more than smoke.
twice the exposure for high SES adults.
• Support for rules that protect against secondhand smoke has increased since 1998.
• Overall, about one in four current smokers is exposed to secondhand smoke at home. Fewer than
• Support for smoke-free indoor workplace rules is higher among adults who are employed indoors,
one in twenty non-smokers is exposed to secondhand smoke at home.
and higher among women than men.
• Among homes with children, secondhand smoke exposure at home has been decreased by more
• Support for smoke-free restaurants has increased since 1998, in all groups and regions of the
than half since 2004. Less than one in ten homes with children had smoking in the home during the
state. Nearly eight in ten adults agree that smoking should not be allowed anywhere in restaurants.
past month.
About three out of five current smokers support smoke-free restaurants.
• Alaska Native homes with children are about half as likely as non-Native homes to have smoking
• About nine out of ten adults say they would go the same or more often to bars if smoking was not
in the home during the past month. Less than one in twenty Alaska Native homes with children had
allowed. Nearly three out of four adult smokers say they would go to bars the same or more often
smoking in the home during the past month.
if smoking was not allowed.
• Low SES homes with children are more than twice as likely as higher-SES homes to have smoking
Most adults know that breathing secondhand smoke is very harmful.
in the home. About one in ten low SES homes with children had smoking in the home during the
past month.
• About three out of five adults think that breathing secondhand smoke is very harmful. Alaska Native
adults, women, young adults, and never- or non-smokers were more likely than other groups to
• Adult smokers living in homes with children were more likely to report having smoking in the
know about the harm from secondhand smoke exposure.
home during the past month than non-smokers.
• More than three in four adults know that breathing secondhand smoke causes lung cancer.
• Secondhand smoke exposure in homes with children increases by the age of the child. While
fewer than one in twenty homes with a child age 0-4 allowed smoking indoors, more than twice as
• About three out of five adults know that breathing secondhand smoke causes heart disease.
many allowed smoking with children ages 5 to 17.
• Nearly nine out of ten adults know that breathing secondhand smoke causes breathing problems
• Making rules against smoking in the home is effective. Homes with smoking bans were less likely
in children.
to have smoking occur indoors than homes without smoking bans.
• Only about two in five adults know that breathing secondhand smoke causes sudden infant death
High school youth are asked about their exposure to secondhand smoke indoors (anywhere) during the past week. syndrome (SIDS).
• Since 2003, the percentage of youth who report being exposed to secondhand smoke indoors
Conclusions
decreased. About two in every five high school-age youth report being exposed to secondhand
smoke indoors during the past week. We know how to end the epidemic of tobacco use and the staggering toll it takes on our families and
communities. Data show that many improvements in tobacco-related behaviors, exposure, and knowledge have
• Reported exposure for high school-age youth was similar across groups: for boys and girls, Alaska
Native and non-Native, and by grade. occurred since implementation of a strong tobacco control program. Despite great progress, more work
remains to be done, including in specific population groups. Using effective strategies such as policy-focused
interventions, community and school programs, hard-hitting media campaigns and support to help people
quit, Alaska can continue to achieve reductions in tobacco use and associated health damage among
viii ix
adults and youth statewide.
Executive Summary Executive Summary
. .

Part I - Burden of Tobacco Use in Alaska
Mortality and Cost
Introduction
Despite the many prior reports and the high level of public knowledge of the adverse effects of smoking
in general, tobacco use remains the leading preventable cause of disease and death in Alaska, causing
approximately 546 deaths each year and costing the State more than $500 million annually in direct medical
expenditures and lost productivity due to tobacco-related deaths. Although the adult smoking rate in
Alaska continues to decline, roughly 100,000 adults still smoked cigarettes in Alaska in 2008. More Alaskans
die annually from the effects of tobacco use than from suicide, motor vehicle accidents, liver disease and
cirrhosis, homicide, and HIV/AIDS combined. These tobacco-related deaths represent almost 17% of all
deaths in Alaska in 2008.
Figure 1. Number of Deaths Due to Selected Causes, Alaska, 2008
600
546
500
400
300
167
200
72 59
100
28
14
0
Tobacco Use Suicide Motor Vehicle Liver Homicide HIV/AIDS
Accidents Disease/Cirrhosis
Sources: Alaska Bureau of Vital Statistics (2008 deaths); CDC, Smoking Attributable Morbidity, Mortality, and Economic Costs
(SAMMEC). See Appendix C for complete description of SAMMEC.
1
Part I - Burden of Tobacco Use in Alaska
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