Tobacco Program Evaluation Group Adult tobacco use and exposure, Colorado 2001 and 2005

Transcription

1 Tobacco Program Evaluation Group Adult tobacco use and exposure, Colorado and Prepared for the State Tobacco Education and Prevention Partnership, Colorado Department of Public Health and Environment

2 Contents Background... 1 Summary of Findings... 2 About the Report... 3 Smoking and Quitting... 4 Secondhand Tobacco Smoke... 9 Disparities in Tobacco Burdens Young Adults Seniors Men and Women Social and Economic Disadvantage Ethnicity Non-Cigarette Tobacco Use... 28

3 Background The Colorado Tobacco Attitudes and Behaviors Survey (TABS) of adults was first conducted in and repeated in. The survey was funded in by tobacco litigation settlement proceeds, and in by a voter-approved tobacco tax increase. This report uses TABS results to highlight progress in the four-year period between surveys. The report provides details about cigarette smoking prevalence and cessation, exposure to secondhand smoke, disparities in tobacco burdens, and use of other tobacco products. In both survey years, TABS randomly selected adults (aged 18+) from all Colorado households with telephones, and respondents were interviewed in their choice of English or Spanish. In both years, the sample was designed to include extra interviews with smokers and former smokers, African American adults, and adults living in certain parts of the state. This "oversampling" allowed for more accurate analysis of these groups. The total number of interviews was 13,006 in and 12,257 in. TABS is directed by the Tobacco Program Evaluation Group (TPEG), University of Colorado Denver / AMC Cancer Center. This report was prepared by TPEG under a grant from the State Tobacco Education and Prevention Partnership (STEPP), Colorado Department of Public Health and Environment. 1

4 Summary of Findings Between and, the following progress occurred in Colorado: * Cigarette smoking among adults declined from 19.7% to 17.3%. Smoking among women declined from 19.1% to 15.1%. Smoking among young adults aged declined from 30.3% to 24.5%. Smokers who tried to quit during the year increased from 64.2% to 68.3%. The state-sponsored telephone support service for smoking cessation (QuitLine) attracted 8.6% of smokers trying to quit. The state-sponsored internet support service for smoking cessation (QuitNet) attracted 3.1% of smokers trying to quit. Homes with smoke-free indoor rules increased from 75.1% to 81.3%. Personal vehicles with smoke-free rules increased from 63.1% to 69.. Indoor work areas that were actually smoke-free increased from 85.3% to 89.. Work vehicles with smoke-free rules increased from 64.7% to 71.1%. The following disparities arose in : Smoking became more common among: o Men compared to women (19.5% vs. 15.1%), because the rate declined among women but was unchanged among men. o Hispanic adults compared to Anglo adults (22.8% vs. 15.6%), because the rate declined among Anglo adults but was unchanged among Hispanic adults. The following disparities remained similar to : Smoking remained more common among: o young adults compared to adults aged (24.5% vs. 17.7%). o American Indian adults compared to white adults (34.9% vs. 15.6%). o adults in poverty (32.4%) or near poverty (22.6%) compared to others (15.4%). o high school non-completers compared to completers (35.3% vs. 16.). o adults without health insurance compared to the insured (31.1% vs. 14.). o adults who were disabled or unable to work compared to others (38.7% vs. 16.8%). Use of pharmaceutical aids to quit smoking remained less common among: o young adults compared to adults aged (7.7% vs. 22.). o men compared to women (15.7% vs. 22.4%). o non-anglo adults compared to Anglo adults (rates vary by ethnic group). Smoking in homes with children was more common among: o young adults not in school compared to adults aged (19.8% vs. 9.6%). o seniors compared to adults aged (38.1% vs. 9.6%). o socio-economically disadvantaged adults compared to others (20.8% vs. 5.8%). * Rates on this page represent the actual population in each year. Comparisons are adjusted for age, sex, and ethnicity to ensure that the differences seen are not due to changes in the population age, sex, or ethnicity between and. 2

5 About the Report This report focuses on changes in tobacco-related behaviors between and. In assessing whether changes occurred and how large or small they were, the rates were adjusted "behind the scenes" to match the population in age, sex, and ethnic makeup. This adjustment (standardization) accounts for natural population changes such as aging. In this report, comparisons are standardized, rates that are presented are non-standardized. Some apparent differences between years represent real change, while others are merely chance findings that can arise when studying samples instead of the whole population. This report uses a "95% confidence" standard (p<0.05) to decide between the two possibilities. In the text, a rate that appears in bold typeface is "significantly" or "statistically" different from the comparable rate. In charts, a rate in boxed bold typeface means the same thing, that there is at least a 95% probability that the difference is what it seems to be and not merely due to chance. The report also compares rates between population groups in the same year. Where one group has a higher-than-average problem or burden, the rate appears in a red background. 3

6 Smoking and Quitting Introduction In 2004, the Surgeon General reviewed and reported the health effects of active smoking, and the list of diseases it causes continued to expand. Cigarette smoking is now known to cause bladder cancer, cervical cancer, esophageal cancer, kidney cancer, laryngeal cancer, leukemia, lung cancer, oral cancer, pancreatic cancer, stomach cancer, abdominal aortic aneurysm, atherosclerosis, cerebrovascular disease, coronary heart disease, chronic obstructive pulmonary disease, pneumonia, respiratory effects in utero and childhood and adolescence and adulthood, sudden infant death syndrome, fertility problems, low birth weight, pregnancy complications, cataracts, diminished health status, hip fractures, low bone density, and peptic ulcer disease. 1 Each year in Colorado, cigarette smoking is to blame for 1,472 premature deaths from cancer, 1,316 from cardiovascular disease, and 1,509 from respiratory disease among adults aged 35 and older. 2 The economic burden to Coloradans exceeds $1 billion per year. 3 In recent years, Colorado has responded to this public health threat by enacting two statewide measures previously shown to reduce cigarette smoking. In November 2004, voters increased the state tobacco excise tax and earmarked 16 percent of the revenues for programs to prevent and reduce tobacco use. 4 As a result, Colorado is one of only four states that funds tobacco control programs at the minimum level recommended by the Centers for Disease Control and Prevention (CDC). 5 And, in 2006, the General Assembly enacted a smoke-free workplace measure that protects most workers from exposure to other people's cigarette smoke. Such measures have been shown elsewhere to encourage and help people to quit smoking. This section presents Colorado s progress in reducing cigarette smoking. 4

7 Smoking Status In, fewer Coloradans had ever started smoking and fewer were currently smoking cigarettes compared with. Women aged accounted for most of the decrease in current smoking. Daily and heavy smoking became less common. More than half of adults who once smoked were no longer smoking in (data not graphed) % 24.2% Smoking status of Colorado adults (% of population), to 19.9% 19.7% 17.3% 15.6% 13.3% 4.2% % never former current daily non-daily heavy do not currently smoke but have smoked 100 lifetime cigarettes 100 lifetime cigarettes and now smoke every day or some days currently smoke every day 25 cigarettes per day 1.9% In, current smokers made up 17.3% of Colorado adults. Never-smokers were 62.2%, and former smokers were 19.9%. Nationally, 20.9% of the adult population smoked in, including 23.4% of men and 18.3% of women, 6 compared to 22.6% of all adults in including 24.9% of men and 20.5% of women. 7 Colorado men and women both appear to smoke at lower rates than nationally. Approximately three-fourths of current smokers smoked daily (76.9%, similar to ) and about one in ten current smokers smoked 25 or more cigarettes per day (10.8%, similar to ). Percent of adults who currently smoke, by sex and age age men women all men women all year olds 29.1% 31.6% 30.3% 27.3% 21.4% 24.5% year olds 21.8% 19.9% 20.9% 20.4% 14.4% 17.5% year olds 17.9% 17.7% 17.8% 18.6% 16.7% 17.7% 65+ year olds 9.4% 9.1% 9.2% 7.4% 8.2% 7.8% Total 20.4% 19.1% 19.7% 19.5% 15.1% 17.3% *figures in bold are significantly different from rates In, daily smokers smoked an average of 16.7 cigarettes per day (similar to ). Women who smoked daily smoked less in than in (15.2 cigarettes per day, down from 15.9) Cigarettes per day (CPD) by daily and non-daily smoking status men women all men women all CPD among daily smokers CPD among non-daily smokers 5

8 In, women who smoked daily smoked fewer cigarettes per day than men, while women who smoked non-daily smoked more cigarettes per day than men. Daily smokers aged smoked the fewest cigarettes per day (12.9, similar to ) (age groups not graphed). Households with no smokers In, almost three-fourths of Colorado households had no adult smokers (74.4%, up from 72.). Quitting in Colorado In, smokers were more likely to try to quit smoking than in (68.3%, up from 64.2%). The largest gains in quit attempts were among men and young adults aged Among those who tried quitting in, 7.7% were successful for three months or longer Smokers (%) who tried to quit (24+ hours abstinence in past year) 88.1% Among smokers who 68.3% 70.6% 65.3% 67.9% saw a doctor in the % 56.5% past year, more than 6 half reported being advised to quit smoking in (58.7%, up from 54.6%). About a all men women third of smokers who received advice reported that their doctor also referred them to a smoking cessation program (31.7%, similar to ). One fourth of smokers who were advised to quit by their doctor reported trying to quit (28.2%, similar to ). Of those referred to a specific smoking cessation program, 26.5% were referred to the QuitLine, 0.7% to the QuitNet, and 13.8% to a class or group. In, 16.3% of quit attempters used nicotine replacement therapy (NRT) in their quit attempt. NRT use rates were similar to among men, women and all age groups. NRT use among quit attempters in 22.9% 21.5% 19.2% 16.3% % 7.6% all men women

9 In, women used NRT more often than men. In general, NRT use increased with age, although there were no appreciable changes above age 64. The use of non-nicotine cessation medication (such as bupropion) decreased (4.6%, down from 7.7%) among quit attempters. The decline was more prominent among men than women and age groups other than year olds (results not shown). Cessation counseling remained infrequently used (2.5%, similar to ), with more women than men using it (3.6% vs. 1.7% in ). The use of alternative remedies in quit attempts (herbal medicine, chiropractic therapy, acupuncture, massage, hypnosis, and other methods) was slightly more common than counseling (6.3%, similar to ). As with counseling, women used alternative remedies in quit attempts more often than men (8.6% vs. 4.7% in ). QuitLine and QuitNet Colorado first introduced its State-sponsored telephone (QuitLine) and internet (QuitNet) coaching services in late, and few people surveyed that year knew about these services. Awareness and use among quit attempters increased by large percentages between and. QuitLine and QuitNet awareness and use among quit attempters QuitLine awareness 10.3% 69.3% QuitLine use 1.2% 8.6% QuitNet awareness 1.5% 14.5% QuitNet use 0.1% 3.1% *rates in bold differ signficantly from rates In, slightly more female than male quit attempters were aware of the QuitLine (73.7% vs. 66.2%) and the QuitNet (17.6% vs. 12.3%). Fewer quit attempters aged used the QuitNet than those aged (0.6% (aged 18-24) vs. 3.9% (aged 25-44) and 4.4% (aged 45-64)). Quitting intentions and methods of current smokers Intentions to quit and plans to quit indicate that attempts to quit are likely to occur. In, one in nine smokers said they would Current smokers who never intend to quit, by gender and age in 34.2% never quit smoking (11., similar to ). Men more than women, and smokers aged 65+ were most likely to intend never to quit % 12.3% 8.8% 9.3% 5.9% all men women Overall in, one in seven smokers (14.2%, similar to ) were planning to quit in the next month, with no differences by sex or age. 7

10 In, more than half of current smokers (57.3%) planned to quit unassisted ("cold turkey"), while one-fourth planned to use NRT (25.7%). In general, more smokers aged planned to quit cold turkey (72.) and fewer planned to use NRT (16.8%). Buying cigarettes in Colorado In, the percentage of Colorado smokers who bought their cigarettes in state decreased very slightly (98.1%, down from 99.4% in ). The decrease was seen among males and smokers aged Slight increases were reported in buying cigarettes out of state (1., up from 0.5%) or over the Internet (0.9%, up from 0.1%). The increase in buying out of state was seen primarily among males, while the increase in buying over the Internet was seen among males and smokers aged Cigarette price increases are known to reduce smoking. The average Colorado price of a pack of cigarettes in was $3.67, up 41 cents from. During the same period (-05), the actual cost of a pack of cigarettes rose by 97 cents due to inflation (33 cents) 8 and new State excise taxes (64 cents). If cigarette companies had passed on the true cost to consumers, a pack of cigarettes would have cost $4.23 in. Based on well-established formulas, nearly 36,000 more Colorado adults would have quit smoking. References 1 U.S. Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC): Average annual smokingattributable mortality (Colorado, 1997-). Accessed at on October 13, Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC): Smoking-attributable expenditures, Accessed at on October 13, State Legislated Actions on Tobacco Issues (SLATI) State Information:Colorado, American Lung Association. Accessed at on October 12, Maurice, E, Thorne, S, Ajani, U, Malarcher, A, Merritt, R, Husten, C. (2006) State-specific prevalence of current cigarette smoking among adults and secondhand smoke rules and policies in homes and workplaces-united States,. MMWR;55(42): Pleis JR, Lethbridge-Cejku M. Summary health statistics for U.S. adults: National health interview survey,. National Center for Health Statistics. Vital Health Stat 10(232) Lucas JW, Schiller JS, Benson V. Summary health statistics for U.S. Adults: National Health Interview Survey,. National Center for Health Statistics. Vital Health Stat 10(218) Federal Reserve Bank of Minneapolis. What is a dollar worth? [Online inflation calculator.] Accessed at on December 22,

11 Secondhand Tobacco Smoke Introduction Secondhand smoke (SHS), which drifts into the air from the lit end of a cigarette, is the main source of cigarette smoke exposure for the general population. SHS increases the risk of lung cancer and heart disease. Among children, it increases the risk of more severe asthma, acute respiratory infections, ear problems, and sudden infant death syndrome. 1 SHS exposure is readily detected by measuring nicotine byproducts in a nonsmoker's saliva or other body fluid. These measures show that the U.S. nonsmoking public is less exposed to SHS today than a decade ago, reflecting the national decline in smoking rates. Levels of cotinine a byproduct of nicotine exposure have decreased 68% in children, 69% in nonsmoking adolescents, and 75% in nonsmoking adults since the early 1990s. However, levels among children are still twice the levels among nonsmoking adults, and some ethnic populations have higher levels than others. 2 In addition, conclusive evidence shows that there are no safe levels of SHS exposure. Separating smokers from nonsmokers, or ventilating and cleaning the air, cannot eliminate SHS exposure. 3 In short, the general nonsmoking public faces less and less SHS exposure, but some groups still face higher exposure levels. Before Colorado policy made nearly all workplaces smoke-free on July 1, 2006, 79% of indoor workers were covered by smoke-free work area policies, * and a majority of Coloradans (6) favored a smoke-free policy for all workplaces including restaurants and bars. This section compares SHS exposure in Colorado in and, before the Colorado Clean Indoor Air Act was adopted. * Some localities in Colorado already had smoke-free laws covering all work places: Arvada, Boulder, Boulder County, Fort Collins, Pueblo, Snowmass Village, Superior, Firestone, Steamboat Springs, Timnath, Avon, and Eagle County. (Source: American Nonsmokers Rights Foundation, Nationwide, the prevalence of smoke-free workplace policies ranges from 54.8% to 85.8% by state and the prevalence of smoke-free home rules ranges from 63.6% to 82.9% by state. (Source: Maurice et al. MMWR ; 55(42): ) 9

12 Smoking at home More Colorado households had smoke-free rules in than in (81.3%, up from 75.1%). The increase occurred in households with and without smokers. More than 9 in 10 households without smokers were smoke-free, however, only half of households with smokers were smokefree. Smoke-free rules also became more common in households with children under age 18 (87., up from 79.9%). In, households with children continue to have smoke-free rules slightly more often than those without children (87. vs. 78.6%). Percent of households with smoke-free rule, by household smoker status 81.3% 75.1% 86.9% 91.3% Percent of households with smoke-free behavior, by household smoker status 95.7% 97.2% 86.2% 82.8% 44.6% 52.4% 49.6% 54.4% all no smoker lives in household smoker(s) living in household all no smoker lives in household smoker(s) living in household Smoke-free behavior in homes continued to be slightly more common than smoke-free rules. In, most Coloradans reported that no smoking occurred in their homes during the previous 30 days (86.2%, up from 82.8%), including almost all households without smokers but slightly more than half of households with smokers. Reasons for smoke-free homes, percent who say reason is "very important" avoid odor protect discourage sensitive annoys encourage 90.4% 82.9% 78.5% 76.9% 75.1% 54.1% % 80.7% 76.8% 73.3% 56.5% People's reasons for making homes smoke-free remained similar between and. Avoiding odor, protecting the family, and discouraging youth smoking remained the most common reasons rated as "very important." Encouraging quitting remained the least common reason but was very important to more than half of Coloradans; nearly two-thirds of women cited this reason, compared to nearly half of men (63.5% vs %). Women were also more likely than men to cite discouragement of youth smoking as a reason (85.3% vs. 76.). 10

13 In, more than two-thirds of Coloradans had smoke-free rules for their personal vehicles, a significant increase from. Improvements occurred in both smoker and nonsmoker households, although nearly three-fourths of Colorado vehicle owners in smoker households still did not have smoke-free Percent of personal vehicles with smoke-free rules, by household smoker status % all 82.6% 77.8% no smoker in household 24.8% 28.8% smoker(s) in household rules for personal vehicles. In both years, households with children younger than 18 were about 5% to 6% more likely than households without minor children to have smokefree vehicle rules. In, 71.7% of households with minor children had smoke-free rules for personal vehicles. Professional drivers represent approximately one-sixth of the workforce. In, almost threefourths reported that 10 their employer had a 8 smoke-free policy for work vehicles (71.1%, 6 up from 64.7%). More than half of drivers who smoke still did not have smoke-free vehicle policies in. (One in four professional drivers was a current smoker in.) Percent of work vehicles with smoke-free rules, by employee smoker status 64.7% 71.1% 78.7% 75.4% % total driver is nonsmoker driver is smoker 11

14 Community awareness and response to exposure Percent who heard of community activities to reduce SHS 27.5% 28.8% 26.2% 16.4% 29.4% 30.8% 24.8% total men women Awareness of community activities to reduce SHS exposure more than doubled. In, more than one-fourth of Coloradans had heard of such activities in their community (27.5%, up from 11.1%). The rate of increase was similar among men, women, and all age groups. Young adults (aged 18-24) were least likely to be aware of the activities. Seniors were less likely to be aware than adults aged About three in ten Coloradans asked someone not to smoke around them or their family in the previous year (30.6%, down from 34.7% in ). Young adults were more likely than other age groups to make this request (46.3% in ). References 1 The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. (2006) [Atlanta, GA]: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2 CDC s Third National Report on Human Exposure to Environmental Chemicals: Spotlight on Cotinine. NCEH publication July. 3 The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. (2006) [Atlanta, GA]: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 12

15 Disparities in Tobacco Burdens Introduction In recent years, Colorado has begun to see a lowering of the burdens from tobacco. But not everyone has benefited. For example, cigarette addiction remains significantly more common among young adults, Hispanics, American Indians, and people with social or economic disadvantages. The current report shows that gaps in tobacco burdens widened between and for many Coloradans. The burdens discussed in the report include cigarette smoking, not quitting smoking, not getting help or advice to quit, using snuff or chewing tobacco, and being exposed to secondhand smoke. Most of these burdens originate with cigarette smoking. The table at the right shows the number and percent of current smokers in each group. The population groupings presented in this report include age, sex, ethnicity, and several categories of social and economic disadvantage. Changes in a Burden Current smoking in and number that smoked percent that smoked group all adults 613, , SEX female 296, , male 317, , AGE GROUP , , , , ,725 34, ETHNICITY white (non-hispanic) 459, , Hispanic or Latino (all) 98, , black or African American 19,713 21, American Indian 15,445 11, Asian American 9,731 5, all other 10,279 11, SEXUAL PREFERENCE heterosexual n/a 382,363 n/a 16.8 gay/lesbian n/a 6,400 n/a 35.2 bisexual n/a 5,984 n/a 36.8 other/don t know/refused n/a 10,894 n/a 15.6 INCOME RELATIVE TO POVERTY 20 or more of poverty 384, , to 199% of poverty 126, , below poverty level 42,861 57, COMPLETED HIGH SCHOOL yes 538, , no 75,975 80, HAS HEALTH INSURANCE yes 394, , no 132, , DISABLED / UNABLE TO WORK no 584, , yes 28,461 34, RURAL nonrural counties 480, , rural counties 133, , Bold means significantly improved from to, after adjustment for sex, age, and ethnicity. No rate was significantly worse in. Red means significantly higher than the average rate. Sexual preference was not asked in. People with unknown group status are omitted. 13

16 Young Adults Young adults (ages 18-24) became less likely to be smokers in (24.5%, down from 30.3% in ). However, nonstudents in this age group continued to have the highest current smoking rate, and young adults who had ever smoked were about half as likely as those aged to have quit smoking. Current smokers (% of group) 30.7% 17.8% 16.7% nonstudent age age student 6 Former smokers (% of ever-smokers in group) 51.3% 27.5% age age In, young adult smokers were more likely than those aged to try to quit. Among young adult smokers, students (but not nonstudents) were more likely to try quitting in than in. But all young smokers trying to quit were one-third as likely as those aged to use nicotine replacement therapy (NRT) or cessation medicines known to increase success. 9 7 Attempted to quit in past year (% of smokers at start of year) 64.3% 84.9% nonstudent age age student 95. Used NRT or cessation medicine (% of quit-attempters in group) % age age A doctor's advice to quit smoking increases the likelihood of trying to quit. In, young adult smokers out of school had lost ground and were less likely than either young adult students or adult smokers aged to see a doctor, and less likely to do so than in. More encouraging was that students who smoked and saw a doctor were more likely to be advised to quit. 9 7 Saw doctor in past year (% of smokers at start of year) 79.7% 69.6% 57.2% 9 7 Doctor advised quitting (smokers who saw doctor in year) 61.3% 59.6% 66.4% nonstudent student age age all ages age age nonstudent student 14

17 More Coloradans had smoke-free rules at home in (81.3%, up from 75.1% in ), including young adults (80.5%, up from 71.7% in ). But in multi-person households where nonsmokers can be exposed to secondhand smoke, young adults not in school were more likely than adults aged to say smoking occurred in their homes, including homes with children under age 18. Smoking in multi-person homes (% of group, past 30 days) 12.5% 20.8% 12.8% Smoking in homes with kids (% of group, past 30 days) 9.6% 19.8% 11.4% nonstudent age age student nonstudent age age student Heard of community action to reduce SHS (% of group) % nonstudent 12.7% student Although Coloradans were more aware in of community activities to reduce secondhand smoke exposure, young adults, and especially those who were students, were less likely than adults aged to be aware of these activities. age age Still Getting Hooked A Special Burden for Young Adults In, more than three-fourths (78.1%) of current adult smokers in Colorado had tried their first cigarette before they turned 18 years old. But trying a cigarette doesn't always lead to addiction. Almost half (47.6%) of Colorado's adult smokers in didn't smoke regularly until they were young adults. The 18-to-24 age group thus faces not only problems with quitting and exposure to secondhand smoke, but a unique adult risk of getting hooked on cigarettes. 15

18 Seniors In, the smoking rate among seniors remained lower than the rate among adults aged (7.8% vs. 17.7%). However, seniors continued to have higher rates of other tobacco burdens. A special burden for senior smokers is a widespread expectation among them that they will never quit smoking (38.8% vs. 11.1% among smokers aged 25-64). At the same time, senior smokers closed a gap in actual attempts to quit smoking. In, they had been roughly one-fourth less likely to try quitting than smokers aged 25-64, while in, quit-attempt rates were not detectably different between the age groups. Senior smokers and smokers aged were similarly likely in to: use nicotine replacement therapy (NRT) or cessation medicines in trying to quit (23. among seniors vs. 22. among those aged 25-64); 6 Attempted to quit in past year (% of smokers at start of year) 64.3% 56.5% age age 65+ receive a doctor's advice to quit smoking (56.4% among seniors vs. 61.6% among those aged who saw a doctor). Homes with smoke-free rules increased among both age groups. Seniors were somewhat less likely than those aged to live in such homes, but actual smoking inside multi-person households was lower among seniors and declined in both age groups. Seniors were more likely to report smoking occurring in homes with children, but in most cases the smoker was another household adult, not the senior Smoke-free rule in home (% of age group) 82.2% 77.2% 10 % Smoke in multi-person homes (% of group, past 30 days) 12.5% 9.2% Smoke in homes with kids (% of group, past 30 days) 9.6% 38.1% 6 age age 65+ age age 65+ age age 65+ Awareness of community activities to reduce secondhand smoke exposure rose in among seniors (and others) but was less common among seniors than those aged (24.8% vs. 30.). Why do fewer seniors smoke? On average, nonsmokers live 14 years longer than smokers. By age 65, early death has claimed many smokers. Also, the longer someone smokes, the more likely they will quit. So, living seniors are more likely than other age groups to be nonsmokers or ex-smokers. 16

19 Men and Women During the period between and, smoking in Colorado shifted from an "equal opportunity burden" between the sexes to a significantly less common behavior among women. In, men and women who had ever smoked were equally likely to be ex-smokers. Current smokers (% of group) Former smokers (% of ever-smokers in group) 19.5% 15.1% % 54.7% men women men women In, men who smoked were more likely than women, and more likely than men had been in, to try quitting. However, use of NRT or cessation medicines in quit-attempts was less common among men than women, and less common among men than it had been in. Use of cessation medicines for quitting was less common among men in than it had been in, while NRT use remained similar among both sexes (results not shown). Attempted to quit in past year (% of smokers at start of year) Used NRT or cessation medicine (% of quit-attempters in group) % 65.3% 15.7% 22.4% men women men women In both years, women who smoked were more likely to see a doctor than men who smoked. Women smokers who saw a doctor were more likely to receive advice to quit in than in. Advice rates in each year were similar between men and women. Doctor advised quitting (smokers who saw doctor in year) Doctor advised quitting (smokers who saw doctor in year) % 63.7% % 63.7% men women men women 17

20 Among both men and women, household protection from secondhand smoke increased slightly, recent exposure to secondhand smoke decreased slightly, and awareness of community protection efforts increased substantially (results not shown). Differences between the sexes were negligible. Sexual Preference In, TABS respondents were asked about their sexual preference. Current smoking was more common among self-identified gay, lesbian, and bisexual adults compared to selfidentified heterosexual adults. Quit attempts and use of NRT or cessation medicines in quit attempts appeared similar among all three groups, heterosexuals, gays/lesbians, and bisexuals. While fewer gay/lesbian (68.9%) and bisexual (68.5%) adults reported having smoke-free rules in their home comnpared to heterosexual adults (81.6%), the differences were not statistically significant, possibly due to small samples of gay/lesbian/bisexual adults. Awareness of community activities to reduce secondhand smoke exposure was similar across sexual preference groups. 16.8% Current smokers (% of group) 35.2% 36.8% heterosexual gay/lesbian bisexual 18

21 Social and Economic Disadvantage In, more than one-third of Coloradans reported a social or economic disadvantage they had not graduated from high school, or lived in or near poverty, or had no health insurance, or were unable to work. (The disadvantaged population was larger in than in.) Any of these disadvantages was linked with higher odds of smoking, as well as lower odds of quitting and greater odds of being exposed to secondhand smoke. Between and, the smoking rate declined among the disadvantaged but was still twice as high as the rate among other adults (graph, below left). In, half of adult smokers had one or more social or economic disadvantages (graph, below right). Current Smoking Rates 27.8% Adults w ith any disadvantage 12.6% Adults w ith no disadvantage 6 Changes in social disadvantage and smoking 32.1% 52.4% % of pop. % of smokers 36.7% 55.8% Current Smoking Rates in by Social and Economic Status 40.5% 34.8% 33.7% 33.4% 38.6% 27.4% 43.2% 38.2% 15.6% 14.7% 20.8% % 28.4% no yes above poverty near poverty below poverty yes no no yes above poverty near poverty below poverty yes no disability annual household income* health insurance disability annual household income* health insurance did not complete high school completed high school * Near poverty means 10 to 199% of federal poverty level, above poverty means 20+ of federal poverty level. Boxed bold typeface means rate significantly improved during

22 In, socio-economically disadvantaged (SED) people who had ever started smoking were far less likely than others to be former smokers but similarly likely as other smokers to try to quit (69., up from 67.5%). They were less likely to use NRT or cessation medicines when trying to quit (13.8% vs. 23.1% in ). SED smokers remained less likely than other smokers to see a doctor, and those who did see a doctor did not experience an increase in advice to quit. 7 Former smokers (% of ever-smokers in group) no SED 62.5% SED 40.1% Saw doctor in past year (% of smokers in group at start of year) Doctor advised quitting (smokers who saw doctor in year) % 61.9% % 58.1% no SED SED no SED SED Social and economic disadvantages are also linked to smoke exposure. Although smoke-free home rules increased and actual smoking in multi-person homes decreased in Colorado, the disadvantaged remained less likely to have smoke-free rules and more likely to report smoking occurring in their homes, including homes with children % 8 6 Smoke-free rule in home (% of group) 85.6% 72.6% 10 % Smoke in multi-person homes (% of group, past 30 days) 8.7% 22.5% Smoking in homes with kids (% of group, past 30 days) 5.8% 20.8% no SED SED no SED SED no SED SED Awareness of community activities to reduce secondhand smoke exposure rose among both groups of adults but was less common in among the disadvantaged than among other adults (21.6% vs. 32.). 20

23 The odds of having a tobacco burden are shown here for different types of social or economic disadvantage. For example, the table shows that people who did not complete high school are 1.8 times as likely to be current smokers as people who did complete high school, even after other disadvantages are taken into account. Odds of tobacco burdens with social and economic disadvantages Colorado adults, disadvantage no high school no health near poverty burden graduation insurance disability poverty current smoking not having quit not trying to quit not using quit medicine * 3.5 not seeing doctor * saw doctor, wasn't advised to quit 1.5 no smoke-free rule at home smoking occurs inside home smoking occurs in home with kids Multivariate models (odds for each disadvantage adjusted for other disadvantages). Comparison groups are: high school graduation, health insurance, able to work, 20 or more of poverty level. Odds ratio is omitted because not detectably different from comparison group. * Odds of burden are lower than comparison group. 21

24 Ethnicity Most Colorado smokers are white non-hispanic (Anglo) adults, simply because three-fourths of Colorado adults identify themselves as white non-hispanic. But several tobacco burdens are higher than average among nonwhite populations. (In this section of the report, results are presented separately for Spanish-dominant and English-dominant Hispanics, whose tobacco-related behaviors differ considerably.) * The only groups in which smoking rates declined from to were Anglo men (16.9%, down from 19.9%), Anglo women (14.5%, down from 18.3%), and black women (13.8%, down from 24.2%). Smoking was higher in than in among Spanish-dominant Hispanic men (33.2%, up from 18.9%) and black men (24.4%, up from 12.3%). Rates among other groups were statistically unchanged between surveys. Current smokers (% of adults in group) 33.2% 33.7% 28.6% 36.2% 31.7% 26.8% 16.9% 24.4% 20.3% 6.3% 21.5% 14.5% 13.8% 10.2% Hisp. (Sp.) Hisp. (Engl.) Anglo black Asian Amer. Amer. Indian other Hisp. (Sp.) Hisp. (Engl.) Anglo black Asian Amer. Amer. Indian other male f emale In, smoking rates among men were detectably higher than the Anglo rate for Spanish- and English-dominant Hispanics and American Indians. Among women, rates in were detectably lower for Spanish-dominant Hispanics but were higher for English-dominant Hispanics, American Indians, and self-identified other ethnicities. Nationally in, current smoking rates were as follows among ethnic groups: Anglo men, 24.2%; Anglo women, 20.8%; Hispanic men, 19.7%; Hispanic women, 10.7%; black men, 25.9%; black women, 16.9%. 1 * Spanish dominance was defined by having completed the survey interview in Spanish and/or reporting that Spanish was the main spoken language at home. 22

25 In, Colorado's adult population was one-sixth Hispanic. Other ethnic groups each made up one to four percent of the adult population. The tobacco survey interviewed many adults from Colorado's three largest ethnic groups. * As a result, large enough samples are available to estimate tobacco cessation burdens separately for and and for men and women among Anglo adults, Englishdominant Hispanic adults, and black adults. non- Hispanic Colorado adults, est. pop. no. of interviews white ,000 black 3.8% 582 Amer Ind 1.2% 136 Asian/PI 3.1% 104 Hispanic all 16.9% 1291 est. pop. source: U.S. Census Bureau. Smaller numbers of interviews were completed among Asian American and American Indian adults, as well as Spanish-dominant Hispanic adults. Results for these groups are presented for sexes and years combined, in order to provide the most reliable information currently available. Anglo, English-dominant Hispanic, and black adults From to, attempts to quit smoking grew slightly more common among Anglo men. Attempts to quit in past year, men (% of smokers at start of year) Attempts to quit in past year, women (% of smokers at start of year) % 67.1% 72.8% % 62.2% 80.2% Hisp. (Engl.) Anglo black Hisp. (Engl.) Anglo black In, use of NRT or cessation medicines was less common among English-dominant Hispanic men than Anglo men and among black and English-dominant Hispanic women than Anglo women. Used NRT or cessation medicine, men (% of quit-attempters in group) 6.1% 20.8% 19. Used NRT or cessation medicine, women (% of quit-attempters in group) 27.4% 12.6% 6.4% Hisp. (Engl.) Anglo black Hisp. (Engl.) Anglo black * Black or African American adults were purposefully interviewed in larger proportion than their population size. 23

26 In, black men who smoked were more likely than white men who smoked to see a doctor (79. vs. 62.3% in ). No ethnic difference was seen in doctor visits among women who smoked. (Results not graphed.) Changes in doctor advice to quit smoking were minimal, and no inter-ethnic differences were detectable in. 7 Doctor advised quitting, men (smokers who saw doctor in year) 59.5% 58.5% 54.2% Doctor advised quitting, women (smokers w ho saw doctor in year) % 64.2% 71.4% Hisp. (Engl.) Anglo black Hisp. (Engl.) Anglo black From to, smoke-free rules became slightly more common among Anglo and black households. In, smoke-free rules were less common in English-dominant Hispanic households than in Anglo households. Indoor smoking in multi-person households declined among Anglos, and it was higher in among English-dominant Hispanic households than among Anglo households. Indoor smoking in households with children declined among blacks, resulting in blacks smoking in homes with kids less often than Anglos in Smoke-free rule in home (% of group) 75.3% Hisp. (Engl.) 82.1% Anglo 79.5% black Smoke in multi-person homes (% of group, past 30 days) 18.8% Hisp. (Engl.) 12.1% Anglo 16.3% black Smoking in homes with kids (% of group, past 30 days) 14.3% Hisp. (Engl.) Anglo 10.5% 4.8% black From to, adults in the three ethnic groups became more aware of community activities to reduce secondhand smoke. Awareness was lower in among black and Englishdominant Hispanic adults compared to Anglo adults. Heard of community action to reduce SHS (% of group) 23.9% Hisp. (Engl.) 30. Anglo 17.3% black 24

27 Asian American, American Indian, and Spanish-dominant Hispanic adults For and combined, Asian American, American Indian, and Spanish-dominant Hispanic adults who smoked were similarly likely to try quitting. Asian American and Spanishdominant Hispanic adults who smoked were also more likely to try quitting than Anglo adults who smoked (63.1% of Anglo smokers made quit-attempts for '01-'05 combined). Among smokers trying to quit, use of NRT or cessation medicines was less common among each of the three groups than among Anglo adults (24.4% of Anglos used NRT or cessation medicines for '01-'05 combined). NRT or cessation medicine use was more common among American Indian than Asian American quit attempters. Attempts to quit in past year (men & w omen, '01-'05 combined) Used NRT or cessation medicine (men & women, '01-'05 combined) % 82.8% 72.4% 15% 5% 6.3% 4.3% 15.7% Hispanic (Sp.) Asian American American Indian Hispanic (Sp.) Asian American American Indian Spanish-dominant Hispanics who smoked were less likely to see a doctor than Anglo adults who smoked (71.9% of Anglo smokers saw a doctor for '01-'05 combined). Frequency of advice to quit smoking was not detectably different among ethnic groups or compared to Anglos. Saw doctor in past year (men & w omen, '01-'05 combined) Doctor advised quitting (smokers w ho saw doctor in year) % 76.2% 68.7% % 58.5% Hispanic (Sp.) Asian American American Indian Hispanic (Sp.) Asian American American Indian 25

28 For and combined, Asian American households reported smoke-free rules more often, and American Indian households less often, than Anglo households. Overall, Spanish-dominant Hispanic households (smoking in multi-person home) and Asian American households were less likely to report secondhand smoke exposure, and American Indian households had more exposure, than Anglo households (among Anglo households: rules, 79.; smoke in multi-person homes, 14.; smoking in homes with kids, 12.4%. All rates for '01-'05 combined) Smoke-free rule in home (men & women, '01-'05 combined) 85.1% Hispanic (Sp.) 86.9% Asian American 64.2% American Indian Smoke in multi-person homes (men & women, '01-'05 combined) 27.8% 7.9% 7.1% Hispanic Asian American (Sp.) American Indian Smoking in homes with kids (% of group, past 30 days) 24.1% 8.3% 2.6% Hispanic Asian American (Sp.) American Indian Heard of community action to reduce SHS (% of group) For and combined, Asian American and Spanish-dominant Hispanic households were less likely to have heard of community activities to reduce secondhand smoke than Anglo households (21. of Anglos for '01-'05 combined). 8.8% Hispanic (Sp.) 10.9% Asian American 17.8% American Indian 26

29 References 1 Pleis JR, Lethbridge-Cejku M. Summary health statistics for U.S. adults: National health interview survey,. National Center for Health Statistics. Vital Health Stat 10(232)

30 Non-Cigarette Tobacco Use Introduction Across most of Colorado, use of non-cigarette tobacco (NCT) products is less common than cigarette smoking. NCT products include smokeless tobacco, cigars and pipes. Nationwide, the most common NCT product smokeless tobacco (oral snuff and chew) is declining in use. However, men in some rural areas continue to have high use rates, 1 and tobacco companies are increasingly advertising smokeless tobacco to cigarette smokers for use when smoking is not allowed or accepted. Smokeless tobacco is not a safe alternative to smoking. 2 It is highly addictive and may make it easier for young nonsmokers to take up cigarette smoking. 3 It is known to cause cancer, with the level of risk varying by the product. 4 It also causes gum disease and tooth decay. The second most common NCT product, the cigar, was increasingly used nationwide during the 1990s. Cigar smoking increases the risk of cancers of the lung, oral cavity, larynx, and esophagus, and may increase risk for coronary heart disease and chronic obstructive pulmonary disease. 5 Tobacco pipe smoking poses the same risks as cigar smoking. Individual pipe use appears to be declining. Water-pipe use in hookah bars is a newer practice, and the extent of use among adults has not been studied. This section describes the use of NCT products in Colorado and reports changes in compared to. 28

31 Ever-use of NCT products In, more than half of Colorado men and almost one in eight women had ever used an NCT product. Ever-use declined slightly among men (53.2%, down from 56.7%). Women continued to report a much lower rate than men (12.7% vs. 53.2% in ). Current smokers were slightly more likely in to have ever used an NCT product (47.4%, up from 43.9% in ) Ever used a non-cigarette tobacco product (%) 53.2% 12.7% 34.8% 37.2% 30.7% 23.6% 47.4% all men women current smoker ex- or nonsmoker 30. Current use of NCT products The rate of current use of NCT products was unchanged in among men but increased slightly among women (1., up from 0.5%), especially among current cigarette smokers (3.7%, up from 1.6%). Men who were aged or who were cigarette smokers had the highest rates of current NCT product use. Current use of any NCT product 24% 16% 8% % % 1.5% 9.5% 0.5% 23.5% 3.7% 14.3% all men women men women men women men women men women men women age <45 age 45+ current former nonsmoker 1.1% smoker smoker* 0.7% * smoked 100 cigarettes in lifetime but did not currently smoke at the time of the survey 8.9% 0.5% 29

32 Chewing tobacco and moist snuff In, one in five men (21.1%) and one in 100 women (1.1%) had ever used chewing tobacco or snuff (20 times or more), rates that were similar to. Ever-use was most common among adults younger than 45 and current smokers (data not shown). Current use rates for smokeless tobacco were similar between years among men and women, and across age groups. Men aged continued to report the highest rates of current use in, and rural men continued to have higher rates than non-rural men of 6% 4% 2% Current use of chewing tobacco or moist snuff 2.3% 4.4% 0.1% all men w omen men aged use every day 6. men aged % 1.5% % 4.2% all men w omen men aged use some days every day use (6.8% vs. 3.7%). (Current use means used 20 times in lifetime and currently use every day or some days.) In, a technique for analyzing small-area rates * found that smokeless tobacco use was much more common among men on the West Slope and southeastern plains then elsewhere in Colorado (red areas on the map). In, men's use of smokeless tobacco in these areas seemed to have declined (13.7% vs. 19.1%), but the apparent change was not statistically significant. 1.3% men aged 45+ Male Current Smokeless Use lower than average average higher than average much higher than average too few data to analyze * binary segmentation classification 30

33 Cigars Fewer than one in 10 Colorado adults had ever smoked 50 cigars or more in (7.8% similar to ). Current smokers were more likely to have ever smoked 50 cigars or more (16.2%, similar to ) compared to nonsmokers (5.9%, down from 7.4%; actual rate was 6.1% in ). Current cigar smoking (%) 15% 12% 13.8% 9% 6% 6.1% 6.4% 5.7% 4.3% 3% 0.6% all aged aged 45+ cigarette smoker not cigarette smoker women men Current use of cigars ( 50 lifetime cigars and currently smoke every day or some days) was similar to except for a slight increase among men aged 45+ (5.7%, up from 4.4%). Cigar smoking was more common among cigarette smokers than among cigarette nonsmokers. Pipes In, one in eight adults had ever smoked tobacco in a pipe (12.8%, down from 15. in ), including more than one in five men (22.9%, down from 27.7% in ) and fewer than one in 30 women (2.6%, similar to ). 6% 4% 2% 1.1% Current pipe smoking (%) 0.3% 1.8% all 5. cigarette smoker all women men 1.1% not cigarette smoker Current pipe smoking (every day or some days) remained rare. The rate among women increased slightly (0.3%, up from 0.1%), but only one in 250 women were pipe smokers in. Current cigarette smokers were more likely than cigarette nonsmokers to smoke a pipe. 31