1
Data and Trendson Tobacco Use
in Nebraska2018
UNDERSTANDING
THE BURDEN
OF TOBACCO
2018 - DATA AND TRENDS ON TOBACCO USE IN NEBRASKA
Prepared by the Nebraska Department of Health and Human Services
Division of Public Health TOBACCO FREE NEBRASKA PROGRAM
Contact Information: Tobacco Free Nebraska Nebraska Division of Public Health
P.O. Box 95026 301 Centennial Mall South
Lincoln, NE 68509
(402) 471-2101 www.dhhs.ne.gov
Acknowledgments  Prepared by Kevin Horne (TFN) with assistance from other TFN staff, Amanda
Mortensen, Ashley Wolfe, and Jeff Soukup with layout and graphic design expertise by Cynthia Schneider and Emily Bunch.
 Additional contributors include Kimberly Meiergerd, Nikki Gohring and Lindsey Witt-Swanson (UNL-BOSR), Marcia Rasmussen (Nebraska Regional Poison Center), Jessica Seberger (PRAMS), Jeff Armitage (BRFSS, NE DHHS) and Derry Stover (Occupational Safety and Health Surveillance Program), and others.
 In addition, many thanks to the citizens of Nebraska who provided responses to questionnaires about their health and health behaviors.
 Suggested Citation: Nebraska Department of Health and Human Services. Data and Trends on Tobacco Use in Nebraska. Lincoln, NE. Nebraska Department of Health and Human Services, Division of Public Health, Community and Environmental Health, Health Promotion, Tobacco Free Nebraska, 2018.
1
Table of ContentsAcknowledgements
Table of Contents .................................................................................................................... 1
Statistical Summary ................................................................................................................ 6
Nebraska Tobacco Facts ........................................................................................................ 7
Introduction ............................................................................................................................. 8
Global and Local Problem ...................................................................................................... 9
Tobacco Control Vaccine ........................................................................................................ 11
Secondhand SmokeOpinion that Smoking Should be Prohibited in Public Locations ........................................... 12
Where are Nebraska’s Youth Exposed to Secondhand Smoke ............................................. 13
Youth Exposure to Secondhand Smoke in Homes and Cars ................................................ 14
Adult Non-Smoker Exposure to Secondhand Smoke ............................................................ 15
Smoke-Free Home Rule Trend ............................................................................................... 16
Smoke-Free Rule in Family Car ............................................................................................. 17
Adult Tobacco Use in NebraskaAdult Tobacco Product Use Characteristics ........................................................................... 18
Impact of Declining Smoking Rates Factoring in Population Changes .................................. 19
Cigarettes
Lifetime Cigarette Use by Adults ............................................................................................. 20
Adult Cigarette Smoking Rate ................................................................................................ 21
Three-Category Cigarette Smoking Status ............................................................................ 22
Adult Cigarette Smoking Compared to U.S. Median .............................................................. 23
2
Map — Adult Cigarette Smoking Prevalence by Health Department ..................................... 24
Adult Smoking Rate by Census Tract — Lincoln.................................................................... 25
Adult Smoking Rate by Census Tract — Omaha ................................................................... 26
Adult Cigarette Rate by State ................................................................................................. 27
Adult Smokeless Tobacco
Adult Smokeless Tobacco Prevalence in Nebraska ............................................................... 28
Adult Smokeless Tobacco Prevalence Compared to U.S. Median ........................................ 29
Adult Smokeless Tobacco Prevalence by Category Compared to U.S. Median ................... 30
Adult Smokeless Prevalence by Frequency of Use and Year ................................................ 31
Map — Adult Smokeless Tobacco User by Health Department ............................................. 32
Smokeless Tobacco Use by State .......................................................................................... 33
Adult Use of Electronic Cigarettes
Ever Use and Current Use of E-Cigarettes ............................................................................ 34
Adult E-Cigarette Prevalence Compared to U.S. Median ...................................................... 35
Map — Adult E-Cigarette Prevalence by Health Department ................................................ 36
Special Populations and Disparities in Tobacco Use in NebraskaCigarette Use During Pregnancy ............................................................................................ 37
Trend of Cigarette Smoking Before Pregnancy ...................................................................... 38
Trend of Cigarette Smoking During Pregnancy ...................................................................... 39
Trend of Cigarette Smoking After Pregnancy ......................................................................... 40
Cigarette Smoking During Pregnancy by Race and Ethnicity ................................................ 41
Cigarette Smoking Among Behavioral Health Consumers .................................................... 42
Cigarette Smoking Adult Behavioral Health............................................................................ 43
Cigarette Smoking by Employment Status ............................................................................. 44
3
Cigarette Smoking by Gender ................................................................................................ 45
Proportion of Each Gender Among Cigarette Smokers ......................................................... 46
Cigarette Smoking by Age Category ...................................................................................... 47
Tobacco Product Use by Marital Status .................................................................................. 48
Tobacco Product Use by Veteran Status ................................................................................ 49
Cigarette Smoking by Race and Ethnicity .............................................................................. 50
Cigarette Smoking by Education ............................................................................................ 51
Cigarette Smoking Rate by Housing Type and Ownership Status ......................................... 52
Tobacco Product Use by Home Ownership Status ................................................................ 53
Cigarette Smoking by Occupation .......................................................................................... 54
CessationAdult Quit Attempts by Year .................................................................................................... 55
Advised to Quit Smoking by Health Care Providers ............................................................... 56
Average Number of Calls to Nebraska Quitline ...................................................................... 57
Calls to Nebraska Quitline by Month and Year ....................................................................... 58
Youth Tobacco Use in NebraskaYouth Ever Tried Tobacco Products ........................................................................................ 59
Youth Current Use of Tobacco Products by Type ................................................................... 60
Youth Cigarette Use
Youth Ever Tried and Current Cigarette Use .......................................................................... 61
Prevalence of Nebraska High School Youth Who Have Smoked in Last 30 Days ................ 62
Youth Current Cigarette Smoking Rate by State .................................................................... 63
Youth Current Smokeless Tobacco Use in Nebraska ............................................................. 64
Youth Current Smokeless Tobacco Use Compared to U.S. ................................................... 65
4
Youth Current Smokeless Tobacco Prevalence by State ....................................................... 66
Youth Cigar Use
Prevalence of Nebraska High School Youth Who Have Smoked Cigars in Last 30 Days .... 67
Youth E-Cigarette Use
Youth E-Cigarette Use Compared to U.S. Median ................................................................. 68
Youth Lifetime E-Cigarette Use Compared to U.S. Median ................................................... 69
Youth E-Cigarette Use by State .............................................................................................. 70
Tobacco Retail Environment in NebraskaOpinion: Should Retail Stores be Penalized for Selling Tobacco to Minors ........................... 71
Opinion: Importance of Preventing Retail Stores from Selling Tobacco to Minors ................ 72
Retailer Compliance Check Results (Synar) .......................................................................... 73
Tobacco Product Revenue and Prevention Funding
Nebraska Tobacco Excise Taxes ............................................................................................ 74
Statutory Cigarette Tax History in Nebraska ........................................................................... 74
Nebraska and U.S. Median Pack Price Over Time ................................................................ 75
Per-Capita Cigarette Sales in Nebraska and U.S. ................................................................. 76
State Excise Tax Comparison ................................................................................................. 77
Master Settlement Agreement Payments to Nebraska .......................................................... 78
Sources of Tobacco-Related Revenue in Nebraska .............................................................. 79
CDC Recommended Annual Tobacco Control Funding in Nebraska .................................... 80
Funding for the Tobacco Free Nebraska Program ................................................................. 81
Smoking-Related FiresSmoking-Related Fires, Deaths, Injuries and Economic Losses in Nebraska ....................... 82
5
Tobacco-Related PoisoningsTobacco-Related Calls to Nebraska Regional Poison Center ................................................ 83
AppendicesSummary of Data Sources ...................................................................................................... 84
6
Statistical SummaryAdult Tobacco Use
Adult cigarette smoking rate1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.4% (BRFSS 2017)
Adult smokeless tobacco use rate. . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3% (BRFSS 2017)
Adult e-cigarette use rate2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.8% (BRFSS 2017)
Adult quit attempt rate among current smokers . . . . . . . . . . . . . . . . 55.6% (BRFSS 2017)
Youth Tobacco Use
Evertriedsmokingcigarettes,evenoneortwopuffs.. . . . . . . . . . . . 24.0% (YRBS 2017)
Ever used e-cigarette. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.1% (YRBS 2017)
Youth cigarette smoking rate3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4% (YRBS 2017)
Youth smokeless tobacco use rate . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3% (YRBS 2017)
Youth e-cigarette use rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4% (YRBS 2017)
Exposure to Secondhand Smoke
Non-smokers’ exposure to secondhand smoke at home . . . . . . . . . 2.7% (ATS 2017)
Homes with a smoke-free rule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.0% (BRFSS 2017)
Non-smokers’ exposure to secondhand smoke in family car . . . . . . 8.6% (ATS 2017)
Family vehicles with a smoke-free rule . . . . . . . . . . . . . . . . . . . . . . . 87.1% (BRFSS 2017)
Morbidity and Mortality Associated with Tobacco in Nebraska
Annual smoking-related deaths in Nebraska4 . . . . . . . . . . . . . . . . . . 2,500 (CDC 2014)
Annual smoking-related healthcare cost5 . . . . . . . . . . . . . . . . . . . . . $795 million (CDC 2014)
Annual smoking-related healthcare cost per household . . . . . . . . . . $737 (CDC 2014)
Annual smoking-related years of productive life lost . . . . . . . . . . . . . 10 years (CDC 2014) Sources: Adult Tobacco Survey (ATS); Behavioral Risk Factor Surveillance System (BRFSS); Youth Risk Behavior Surveillance System (YRBS)
1 Adult smoking rate includes individuals who have smoked 100 cigarettes in their lifetime and who currently smoke every day or some days.
2 E-cigarettes refer to all varieties of electronic products.
3 Youth smoking rate includes individuals who have smoked cigarettes in the last 30 days.
4 CDC, Best Practices for Comprehensive Tobacco Control Programs, 2014.
5 Annual Healthcare Spending Attributable to Cigarette Smoking: An Update, Am J Prev Med, 2014.
7
Nebraska Tobacco Facts
Every year, Nebraska spends at least $737 per household for smoking related medical expenses and lost productivity.
 Adult smoking rate: 15.4% in 2017.
 Youth (grades 9-12) smoking rate: 7.4% in 2017 — down from 34% in 1993.
 Youth who use smokeless tobacco (chew): 5.3% in 2017 — down from 10.1% in 2003.
 Youth who use cigars, cigarillos, or little cigars: 6.7% in 2017 — down from 18.2% in 2003.
 Over 2,500 Nebraskans die each year from smoking-attributable causes.
 Number of kids now under 18 who will likely die early from smoking (if current trends continue): 38,000
 Nebraska kids (under 18) who will become new daily smokers each year: 700
 Annual smoking-related medical expenses: $795 million
 Annual cost of lost productivity due to smoking: $605 million
 93% of Nebraskans agree that inhaling secondhand smoke is harmful to children and adults.
 The smoking rate among pregnant women in Nebraska is 9%.
Sources: Nebraska Behavioral Risk Factor Surveillance System (BRFSS), Nebraska Youth Risk Behavior Survey (YRBS), Nebraska Vital Statistics, Nebraska Adult Tobacco Survey, Nebraska Pregnancy Risk Assessment Monitoring System (PRAMS), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Centers for Disease Control and Prevention, Campaign for Tobacco-Free Kids. Updated: October 2018.
8
Introduction
D uring the development and subsequent revisions of the national tobacco control program, the Centers for Disease Control and Prevention (CDC) developed Key Outcome Indicators for use by state tobacco control programs. These indicators were summarized in the May 2005 publication,
Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs1 and subsequent updates and revisions.
The State of Nebraska used the framework detailed in this document, in addition to future revisions, to develop and implement the tobacco control program for Nebraska, knownasTobaccoFreeNebraska.TherearefourmajorthemesidentifiedbytheCDCand focused on by Tobacco Free Nebraska. In addition to background information, this report presents information focused on these areas.
 Goal 1: Preventing Initiation of Tobacco Use Among Young People
 Goal 2: Promoting Quitting Among Adults and Young People
 Goal 3: Eliminating Nonsmokers’ Exposure to Secondhand Smoke
 Goal 4: Eliminating Tobacco-related Disparities
9
Tobacco Use is an International, National, State, County, Local,
and Neighborhood ProblemDespite successful initiatives to reduce the number of individuals using tobacco products, tobacco use remains the leading cause of preventable death in the United States and worldwide. Progress has been made, as evidenced by the recently reported decline in cancer deaths in the U.S., primarily due to a reduction in smoking.
TheeffortsofTobaccoFreeNebraska,participatingsub-grantees,andothersareanimportantpieceoftheglobalpublichealthfightagainsttobaccoproducts.Morethan7 million deaths worldwide will be attributable to direct tobacco use in 2019 and an additional 890,000 deaths a result of exposure to secondhand smoke.
1 Starr G, Rogers T, Schooley M, Porter S, Wiesen E, Jamison N. Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs. Atlanta, GA: Centers for Disease Control and Prevention; 2005.
2 www.nbcnews.com/health/health-news/cancer-deaths-fall-thanks-mostly-drop-smoking-n834686
3 The World Health Organization, Tobacco Fact Sheet, www.who.int/mediacentre/factsheets/fs339/en/
7 million deaths per year
480,000 deaths per year
2,500 deaths per year
10
Of the many risk factors leading to human mortality, smoking ranks as one of the largest contributors. In Nebraska, an estimated 2,500 Nebraskans will die prematurely asaresultoftobaccousein2019.Inadditiontothesignificantmortality,atleast75,000Nebraskansaresufferingfromatleastoneserioussmoking-attributableillnesssuchascoronary heart disease, stroke, lung cancer, emphysema and chronic bronchitis.
This report summarizes data on the use, attitudes, policies and consequences of tobacco use in Nebraska. When available, trend data is provided to illustrate changes over time.
The Department of Health and Human Services Division of Public Health provides resources to the public and regional tobacco control coalitions via Tobacco Free Nebraska (TFN) to help reduce the burden of tobacco use in the state. Evidence- based tobacco control initiatives, such as providing the Nebraska Tobacco Quitline (1-800-QUIT-NOW) and other services are provided by Tobacco Free Nebraska.
This report presents the highlights of tobacco control initiatives and tobacco use in Nebraska; however, additional detail and information about tobacco use, prevention, and control in Nebraska are available. Please contact:
Tobacco Free Nebraska at (402) 471-2101
or [email protected] with requests for additional information.
4 The Centers for Disease Control and Prevention, Extinguishing the Tobacco Epidemic in Nebraska, www.cdc.gov/tobacco/about/ osh/program-funding/pdfs/nebraska-508.pdf, 2017.
5 Centers for Disease Control and Prevention, Health Effects of Cigarette Smoking, www.cdc.gov/tobacco/data_statistics/fact_ sheets/health_effects/effects_cig_smoking/index.htm, 2017.
11
Tobacco Control VaccineSince1964,whenthefirstSurgeonGeneralReportonthehealthconsequencesofsmoking was released, state and local governments, the federal government, and other advocacy and special interest organizations organized to reduce the prevalence of tobaccouse.Sincethefirstreportcameout,organizationstrieddifferentmethodsandstrategies to impact the use of tobacco products.
A vaccine is a combination of ingredients that, when given to a person, causes the immune system to develop immunity or resistance to a certain infection. Over the years,tobaccocontrolhassolidifiedthestrategies(ingredients)thatwillhelptoreducethe burden of tobacco use. Four key strategies emerged as an evidence-based approach to tobacco control. If a tobacco control program, such as Tobacco Free Nebraska, successfully implements these four strategies, the tobacco use rate is expected to decline.
Thesefourstrategieswhenimplementedcorrectly,ineffectcreateanimmunitytotheinfluencesoftobacco.
100%
Smoke-FreePolicies
CessationAccess
Tobacco Price Increases
Hard HittingMedia Campaigns
Adapted from: The Tobacco Control Vaccine: a population-based framework for preventing tobacco- relateddiseaseanddeath,BrianAKing,CorinneGraffunder,CentersforDiseaseControlandPrevention, 2018.
12
2017: Opinion That Smoking Should be Prohibited at:
31.8%
49.4%
36.4%
66.4%
14.6%
30.5%
16.1%
53.2%
37.1%
55.3%
42.6%
70.4%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Outdoor Parks
Outdoor Sporting Events
Outdoor Public Events (fairs, concerts)
Outdoor Dining
Non-Tobacco Users Tobacco Users All Respondents
Strong support for additional smoking limitations are present in several settings, most notably outdoor dining. Two-thirds of all respondents believe that smoking should be prohibited completely in outdoor dining areas. Over half of tobacco users share this opinion as well.
Inthefigureaboveonecaneasilyseethedifferenceinopinionbetweentobaccousers(green bar) and non-users (red bar). It is important to remember, however, that the population of non-tobacco users is much larger than the tobacco users.
Includes the percentage of responses answering “not at all” to the following question: “At {setting}, do you think smoking should be allowed in all areas, some areas, or not at all?”
Source: Nebraska ATS
13
2017: Where are Nebraska Youth Exposed to Secondhand Smoke
Youth report continued exposure to secondhand smoke in a variety of settings. The highest rate of exposure was reported at indoor or outdoor public places. At school, vehicles, and homes approximately 20 percent of the respondents indicate exposure to secondhand smoke. Finally, despite Nebraska’s comprehensive clean indoor air laws, 12% reported exposure in the workplace.
20%
23%
21%
34%
12%
0% 5% 10% 15% 20% 25% 30% 35% 40%
In Homes
In Vehicles
In School
Indoor or Outdoor Public Places
At Work
2017: Where Are Nebraska Youth Exposed to Secondhand Smoke
Source: Nebraska YTS
Youth report continued exposure to secondhand smoke in a variety of settings. The highest rate of exposure was reported at indoor or outdoor public places. At school, vehicles, and home approximately 20% of the respondents indicate exposure to secondhand smoke. Finally, despite Nebraska’s comprehensive clean indoor air laws, 12% reported exposure in the workplace.
Source: Nebraska YTS
14
2000 - 2017: Youth Exposure to Secondhand Smoke in Homes and Cars in Nebraska
The exposure to secondhand smoke in homes and cars has decreased substantially in the last two decades. This reduced exposure to secondhand smoke will directly benefit the health of these residents. Despite this reduction, since 2013 the exposure in homes and cars has remained nearly unchanged or increased. Today, approximately 20% of youth are exposed to secondhand smoke.
This rate consists of the proportion of respondents who indicated exposure to secondhand smoke at their homes or car in the previous seven days.
Source: Nebraska YTS
71% 70%
61%
23%
19% 20%
54% 55%
47%
13%
24% 23%
0%
10%
20%
30%
40%
50%
60%
70%
80%
2000 2002 2006 2013 2015 2017
2000 - 2017: Youth Exposure to Secondhand Smoke in Homes and Cars in Nebraska
Home Car
The exposure to secondhand smoke in homes and cars has decreased substantially in thelasttwodecades.Thisreducedexposuretosecondhandsmokewilldirectlybenefitthe health of these residents. Despite this reduction, since 2013 the exposure in homes and cars has remained nearly unchanged or increased. Today, approximately 20% of youth are exposed to secondhand smoke.
This rate consists of the proportion of respondents who indicated exposure to secondhand smoke at their homes or car in the previous seven days.
Source: Nebraska YTS
15
2017: Adult Non-Tobacco User Exposure to Secondhand Smoke in Nebraska
8.6%
2.7%
0% 2% 4% 6% 8% 10%
In A Car
At Home
Adults who do not use any type of tobacco are still sometimes exposed to secondhand smoke. A small number are exposed at home (2.7%) while about nine percent (8.6%) reported exposure in a car.
Includes adults who reported no tobacco use but exposure at home or in a car at least one day in the last seven days.
Source: Nebraska ATS
16
2013 - 2017: Smoke-Free Home Rule in Nebraska Trend
88.8% 88.8%
90.3%91.2%
92.0%
80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
2013 2014 2015 2016 2017
Numericscaleonverticalaxis(%)hasbeenexpandedtohighlightdifferences.
The number of homes with a smoke-free rule (no smoking anywhere inside the home at any time) continued to gradually increase and has maintained a rate of over 90% since 2015. The current rate of 92% is the highest rate observed since this question was added to the questionnaire in 2013.
Includes the percentage of responses answering “Smoking is not allowed anywhere inside the home” to the following question: “Which statement best describes the rules about smoking inside your home? Do not include decks, garages, or porches.”
 Smoking is not allowed anywhere inside your home.
 Smoking is allowed in some places or at some times.
 Smoking is allowed anywhere inside your home.
Source: Nebraska BRFSS
17
2017: Smoke-Free Family Car Rule
87.1%
12.9%
Yes, Have Rule
No Rule
Nearly 9 out of 10 respondents indicated they have a rule prohibiting smoking in their family vehicle.
This question was added to the BRFSS questionnaire in 2017, therefore there is no trending data.
Source: Nebraska BRFSS
18
2017: Adult Tobacco Product Use Characteristics in Nebraska
0.5%
0.8%
5.2%
5.7%
6.8%
21.9%
59.1%
0% 20% 40% 60%
Smokeless & E-cig.
Use All Three
E-cigarette Only
Cigarettes and Smokelesss
Cigarettes & E-cigarettes
Smokeless Only
Cigarettes Only
Source: Nebraska BRFSS
The Nebraska Behavioral Risk Factor Surveillance System (BRFSS) questionnaire collectsinformationabouttheuseofdifferenttobaccoproducts.Usingthisinformation,analysis of product use patterns is possible. Cigarettes are by far the most commonly used without the use of other tobacco products. Nebraskans who use smokeless tobacco are often not using other tobacco products.
Among those who use at least one tobacco product, 59% report that they only use cigarettes while nearly 22% only use smokeless tobacco.
The introduction of e-cigarettes caused concern about tobacco users using both e-cigarettes and traditional cigarettes. While dual-use of both variations of cigarette is the most common dual-use type, it still remains relatively rare (6.8%). Dual use of smokeless and e-cigarettes is almost zero, as are individuals who report using all three products.
This item is calculated by analyzing the responses to each type of tobacco and whether the respondent has used the product in the last 30 days.
Of those who use a tobacco product . . .
19
Impact of Declining Smoking Rates Factoring in Population Changes
Year 2011 2012 2013 2014 2015 2016 2017Estimated Population of Nebraska1 1,842,283 1,855,725 1,868,559 1,881,145 1,893,765 1,907,116 1,920,076
Benchmark Smoking Rate (2011)2 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0%
Actual observed smoking rate3 20.0% 19.7% 18.5% 17.3% 17.1% 17.0% 15.4%
Proportion under 184 0.251 0.2495 0.2495 0.2495 0.2495 0.2495 0.248
Estimated Adult Population 1,379,870 1,392,722 1,402,354 1,411,799 1,421,271 1,431,291 1,443,897
Number of Cigarette Smokers at Benchmark Rate
275,974 278,544 280,471 282,360 284,254 286,258 288,779
Number of Smokers at Actual Rate 275,974 274,366 259,435 244,241 243,037 243,319 222,360
Number of Adults Not Smoking Due to Rate Decrease
0 4,178 21,035 38,119 41,217 42,939 66,419
Using the 2011 smoking rate as a benchmark, the slowly but steadily declining cigarette smoking rate and steadily increasing state population allows one to understand the significantimpactthedecliningcigarettesmokingrateandpopulationchangehasonpublic health.
If Nebraska’s cigarettesmoking rate had not declined since 2011,
an additional
66,000Nebraskans would be
cigarette smokerstoday!
1 United States Census Bureau
2 Nebraska BRFSS 2011 (methodology was changed in 2011. Dates prior to 2011 are not comparable therefore 2011 is used as the benchmark.)
3 Nebraska BRFSS 2011 - 2017
4 United States Census Bureau
20
2011 - 2017: % Yes by Date - Lifetime Cigarette Use by Adults in Nebraska
44.3% 44.1%43.2%
42.0% 41.5% 41.6%40.1%
30.0%
32.0%
34.0%
36.0%
38.0%
40.0%
42.0%
44.0%
46.0%
48.0%
50.0%
2011 2012 2013 2014 2015 2016 2017
Note: Vertical scale axis has been expanded to emphasize the decreasing value.
Similar to the trend observed with youth, fewer adults are reporting use of cigarettes during their lifetime. In 2017, only 40% of adults in Nebraska report the regular use of a cigarette at some point during their lifetime. Regular use is determined by identifying respondents who have smoked at least 100 cigarettes during their life.
Responses of ‘Yes’ to the question: “Have you smoked at least 100 cigarettes in your entire life?” are included in the calculation.
Source: Nebraska BRFSS
21
2011 - 2017: Adult Cigarette Smoking Rate in Nebraska
20.0% 19.7%18.5%
17.3% 17.1% 17.0%15.4%
0%
5%
10%
15%
20%
25%
2011 2012 2013 2014 2015 2016 2017
After remaining nearly unchanged near 17% since 2014, the Nebraska adult smoking rate decreased in 2017 to 15.4%. While this is the lowest rate since measurement began, there are still approximately 224,000 adults in Nebraska who smoke cigarettes.
Includes responses to the question: “Do you now smoke cigarettes every day, some days, or not at all?”
The rate for “every day” and “some days” are added together to calculate the current smoking rate.
Source: Nebraska BRFSS
22
2011 - 2017: Three-Category Cigarette Smoker Status in Nebraska
14.5% 14.5% 13.7%12.2% 12.5% 12.1% 11.1%
5.4% 5.2% 4.7% 5.1% 4.7% 4.9% 4.3%
24.3% 24.4% 24.7% 24.7% 24.4% 24.6% 24.6%
0%
5%
10%
15%
20%
25%
30%
2011 2012 2013 2014 2015 2016 2017
Every Day Some Days Former
The percentage of Nebraska adults smoking every day has declined to 11.1%, the lowest rate since the Nebraska Behavioral Risk Factor Surveillance System (BRFSS), began collecting information. In addition, respondents who indicated that they do smoke cigarettes, but not every day decreased to 4.3%. The rate of former smokers remains nearly unchanged over this time period. The number of individuals who have never smoked (not shown) has increased over time.
Includes responses to the question: “Do you now smoke cigarettes every day, some days, or not at all?”
Former smokers are determined by respondents who indicate they have tried cigarettes, have smoked at least 100 cigarettes in their life, and respond that they now smoke “not at all.”
Source: Nebraska BRFSS
23
2011 - 2017: Adult Cigarette Smoking Rate in Nebraska - Compared to U.S. Median
20.0% 19.7%18.5%
17.3% 17.1% 17.0%
15.4%
21.2%
19.6%19.0%
18.1%17.5% 17.1% 17.1%
10%
12%
14%
16%
18%
20%
22%
2011 2012 2013 2014 2015 2016 2017
Nebraska U.S. Median
The median value of the cigarette smoking rate in the U.S. was 21.2% in 2011 and has steadily declined in the past six years to 17.1%. While only a 4 point drop, each 1% change represents approximately 2.5 million people (1% of the U.S. adult population). There are millions of adults who don’t smoke cigarettes that would have just a few years ago. During the past six years the Nebraska rate has remained similar to the U.S. median. However, in 2017, the smoking rate in Nebraska dropped to 15.4% while the U.S. median remain unchanged at 17.1%.
Includes responses to the question: “Do you now smoke cigarettes every day, some days, or not at all?”
The rate for “every day” and “some days” are added together to calculate the current smoking rate.
Source: Nebraska BRFSS
24
2017: ADULT CIGARETTE SMOKING PREVALENCE
T obacco use is the leading preventable cause of death and disease in the United States and Nebraska. Approximately 16 million Americans live with a disease caused by tobacco use. Tobacco-related disease will take the lives of
480,000 Americans (and 2,500 Nebraskans) this year. Of the many varieties of tobacco products, cigarettes remain the most commonly used form of tobacco nationally and in Nebraska.1 Despite declines in recent decades, the adult smoking rate in Nebraska (2017) is 15.4% according to the Nebraska Behavioral Risk Factor Surveillance System (BRFSS).2 Based on current population estimates, approximately 224,000 adults in Nebraska regularly smoke cigarettes.
The map above shows the smoking prevalence for each of Nebraska’s Health Districts. Cigarette smoking rates vary regionally from a low of 11.8% in the North Central District Health Department counties to a high of 19.4% in the Public Health Solutions District Health Department counties in Southeast Nebraska.
1 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: 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, 2014.
2 Nebraska BRFSS, 2017
Lincoln Lancaster CountyHealth Department
12.5%
Sarpy/CassDepartment of
Health & Wellness15.1%
Douglas CountyHealth Department
16.6%
Dakota County HealthDepartment
18.4%
Source: Nebraska Behavioral Risk Factor Surveillance System (BRFSS), 2017
2017 Statewide Adult Cigarette Prevalence = 15.4%Approximately 222,000 Nebraska Adults Smoke Cigarettes
Cigarette Smoking12.5% and lower
12.6% - 14.4%
14.5% - 15.9%
16.0% - 17.7%
17.8% and over
Panhandle Public Health District
18.6%
West Central District Health Department
18.1%
Loup Basin Public Health Department
13.7%
North Central District Health Department
11.8%
Southwest NebraskaPublic Health Department
17.6%
Two Rivers Public Health Department
14.4%
NortheastNebraska Public HealthDepartment 14.2%
Elkhorn Logan ValleyPublic Health Department
15.9%
Three RiversPublic Health Department15.6%
SoutheastDistrict HealthDepartment 15.2%
Public Health Solutions District Health
Department19.4%
South HeartlandDistrict Health
Department14.3%
East Central District Health Department
16.9%
Central DistrictHealth Department
15.6%
Four Corners Health
Department 15.6%
2017 Statewide Adult Cigarette Prevalence = 15.4%
Approximately 224,000 Nebraska Adults Smoke Cigarettes
25
CURRENT ADULT SMOKING RATE BY CENSUS TRACT - LINCOLN
The 500 Cities project is a collaboration between CDC, the Robert Wood Johnson Foundation, and the CDC Foundation. The purpose of the 500 Cities Project is to provide city- and census tract-level small area estimates for chronic disease risk factors, health outcomes and clinical preventive service use for the largest 500 cities in the United States. These small area estimates will allow cities and local health departments to better understand the burden and geographic distribution of health-related variables in their jurisdictions, and assist them in planning public health interventions.
Smoking by residents of Lincoln shows a distinct pattern in the western part of the city and downtown having the highest rate of cigarette use. Residents in the southeast parts of Lincoln have the lowest smoking rates.
Source: CDC 500 Cities
Project 2016 Update
26
CURRENT ADULT SMOKING RATE BY CENSUS TRACT - OMAHA
Source: CDC 500 Cities
Project 2016 Update
Cigarette smoking in Omaha follows a distinct pattern of increasing prevalence as one moves from west to east with the highest rates both north and south of downtown.
27
2017: Adult Cigarette Smoking Rate - All States in Rank Order (low rate is best)
8.9%11.3%
12.7%12.8%
13.5%13.7%13.7%13.9%14.1%14.4%14.4%14.5%14.6%
15.0%15.4%15.5%15.6%15.7%15.7%15.8%16.0%16.1%16.1%16.4%
17.0%17.1%17.1%17.2%17.2%17.3%17.4%17.5%17.5%17.6%
18.3%18.7%18.8%18.8%
19.3%19.3%
20.2%20.8%20.9%21.0%21.1%
21.8%22.2%22.3%22.6%
23.1%24.6%
26.0%
UtahCalifornia
ConnecticutHawaii
WashingtonMassachusetts
New JerseyMarylandNew York
District of ColumbiaIdaho
MinnesotaColorado
Rhode IslandNebraska
IllinoisArizona
New HampshireTexas
VermontWisconsin
FloridaOregonVirginia
Delaware
IowaMontana
North CarolinaMaineKansas
GeorgiaNew Mexico
NevadaNorth Dakota
WyomingPennsylvania
South CarolinaMichigan
South DakotaOklahoma
MissouriAlabama
AlaskaOhio
IndianaMississippi
ArkansasTennessee
LouisianaKentucky
West Virginia
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%
All States & DC (median) **
Source: BRFSS
27
28
2011 - 2017: Adult Smokeless Tobacco Use in Nebraska
5.7%5.1% 5.3%
4.7%5.5% 5.6% 5.3%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
2011 2012 2013 2014 2015 2016 2017
Theincidenceofsmokelesstobacco(chewingtobacco,snuff,snus)usehasremainedessentially stable since 2011.
Includes responses to the question: “Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?”
The rate for “every day” and “some days” are added together to calculate the current rate.
Source: Nebraska BRFSS
29
2013 - 2017: Adult Smokeless Tobacco Prevalence
in Nebraska - Compared to U.S. Median
5.3%
4.7%
5.5% 5.6%5.3%
4.2%4.1% 3.9% 3.9%
4.1%
0%
1%
2%
3%
4%
5%
6%
2013 2014 2015 2016 2017
NE Prevalence U.S. MedianSource: Nebraska BRFSS
ThischartfiguredisplaystheoverallsmokelesstobaccouseprevalenceforNebraska compared to the United States median value since 2013. The U.S. Median is consistently close to 4% whereas the Nebraska rate is consistently about 1.5 percentage points higher, closer to 5.5%.
30
2013 - 2017: Adult Smokeless Tobacco Prevalence in Nebraska - All Categories
Compared to U.S. Median
This chart breaks the overall numbers into categories. The smokeless tobacco rate, both for the United States overall and Nebraska are not showing an increasing or decreasing trend during the past five years
Displays the percentage of respondents who reported their use of smokeless tobacco, cross-tabulated by frequency of use and measurement year.
3.1%2.8% 3.0% 3.2% 3.5%
2.2%
1.9%
2.5% 2.4%
1.8%
5.3%4.7%
5.5% 5.6%5.3%
2.2%2.2%
2.1%
2.1% 2.2%
2.0% 1.9% 1.8% 1.8% 1.9%
4.2%4.1% 3.9% 3.9% 4.1%
0%
1%
2%
3%
4%
5%
6%
2013 2014 2015 2016 2017
2013 - 2017: Adult Smokeless Tobacco Prevalence in Nebraska -- All Categories Compared to U.S. Median
NE Every Day NE Some Days NE Total US Every Day US Some Days US Total
Source: Nebraska BRFSS Source: Nebraska BRFSS
This chart breaks the overall numbers into categories. The smokeless tobacco rate, both for the United States overall and Nebraska are not showing an increasing or decreasingtrendduringthepastfiveyears.
Displays the percentage of respondents who reported their use of smokeless tobacco, cross-tabulated by frequency of use and measurement year.
31
2013 - 2017: Adult Smokeless Tobacco Prevalence in Nebraska by Frequency and Year
3.1%2.8%
3.0%3.2%
3.5%
2.2%1.9%
2.5% 2.4%
1.8%
5.3%
4.7%
5.5% 5.6%5.3%
0%
1%
2%
3%
4%
5%
6%
2013 2014 2015 2016 2017
Every Day Some Days TotalSource: Nebraska BRFSS
The prevalence of smokeless tobacco use has been fairly constant over the last severalyearswithsomeminorfluctuationintheproportionofthepopulationthatusessmokeless products every day or on some days. The total percentage using smokeless tobacco remains close to 5%.
Includes the percentage of respondents who indicate how often they have used smokeless tobacco in the last 30 days.
32
2017: ADULT SMOKELESS TOBACCO PREVALENCE
Central DistrictHealth Department
6.4%
Source: Nebraska Behavioral Risk Factor Surveillance System (BRFSS), 2017
Smokeless Tobacco Use3.7% and under
3.8% - 5.2%
5.3% - 7.3%
7.4% - 9.3%
9.4% and over Lincoln Lancaster CountyHealth Department
3.2%
Sarpy/CassDepartment of
Health & Wellness5.2%
Douglas CountyHealth Department
3.3%
Dakota County HealthDepartment
2.5%
2017 Statewide Adult Smokeless Tobacco Prevalence = 5.3%Approximately 76,500 Nebraska Adults Use Smokeless Tobacco
Panhandle Public Health District
10.7%
West Central District Health Department
8.2%
Loup Basin Public Health Department
8.7%
North Central District Health Department
8.8%
Southwest NebraskaPublic Health Department
11.1%
Two Rivers Public Health Department
7.4%
NortheastNebraska Public HealthDepartment 9.3%
Elkhorn Logan ValleyPublic Health Department
6.7%
Three RiversPublic Health Department7.3%
SoutheastDistrict HealthDepartment 8.6%
Public Health Solutions District Health
Department7.4%
South HeartlandDistrict Health
Department4.8%
East Central District Health Department
3.7%
Four Corners Health
Department 5.0%
Central District Health Department
6.4%
Smokeless tobacco is associated with many health conditions. Using smokeless tobacco can lead to nicotine addiction; cancers of the mouth, esophagus and pancreas; and is associated with diseases of the mouth.1 According to
the Nebraska Behavioral Risk Factor Surveillance System (BRFSS), 5.3% of adults — or nearly 77,000 people — use smokeless tobacco in Nebraska.
This map shows the prevalence of smokeless tobacco use in each of Nebraska’s Health Districts. In general, smokeless tobacco use is higher in Western districts. Nationally rural areas have a higher rate of smokeless tobacco use than populations in urban cities.
1 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: 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, 2014.
2 Nebraska BRFSS, 2017
33
2017: Adult Smokeless Tobacco Prevalence by State
1.6%1.6%
1.8%2.0%2.1%
2.3%2.5%2.6%2.6%2.6%2.7%2.8%2.9%3.0%
3.2%3.4%3.5%3.5%
3.7%3.9%4.0%4.0%4.0%4.0%4.1%
4.2%4.3%
4.5%4.5%
4.8%5.0%5.1%
5.3%5.3%
5.5%5.5%5.6%
6.0%6.0%6.1%6.2%
6.4%6.8%6.8%
7.2%7.4%
7.6%7.8%
8.9%9.1%
CaliforniaMaryland
ConnecticutNew Hampshire
New JerseyMassachusetts
New YorkIllinoisHawaii
VermontFlorida
ArizonaDelaware
UtahMaine
WashingtonNevadaOregon
New MexicoSouth Carolina
ColoradoMichigan
PennsylvaniaVirginia
All States and DCTexas
WisconsinGeorgia
North CarolinaMinnesota
IndianaOhio
IdahoNebraska
IowaKansas
MissouriLouisiana
TennesseeSouth DakotaNorth Dakota
AlabamaArkansas
AlaskaMississippiOklahomaKentuckyMontana
West VirginiaWyoming
0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%
Source: BRFSS
34
2016 - 2017: Ever Use and Current Use of E-Cigarettes by Adults in Nebraska
22.6%20.7%
4.9%3.8%
0%
5%
10%
15%
20%
25%
2016 2017
Ever Use Currently Use
Source: Nebraska BRFSS
Electronic cigarettes are relatively new to the tobacco marketplace and thus surveillance of e-cigarette use began in 2016.
As can be seen in the chart (above), both the percentage of adults who report they have ever used an e-cigarette and the percentage currently using has declined. Today, less than 4% of Nebraska adults report current use of e-cigarettes.
Includes the percentage of responses answering ‘yes’ to the following question: “Have you ever used an e-cigarette or other electronic ‘vaping’ product, even just one time, in your entire life.”
Includes the percentage of respondents who answered “every day” or “some days” to the question: “Do you now use e-cigarettes or other electronic ‘vaping’ products every day, some days, or not at all?”
35
2016 - 2017: Adult E-Cigarette Prevalence in Nebraska - Compared to U.S. Median
4.9%
3.8%
4.7%
4.6%
2%
3%
4%
5%
6%
2016 2017NE Total US Total
Source: BRFSS
E-cigarettes are a relatively new tobacco product that has gained in popularity in recent years.Thecategoryofe-cigarettesincludesmanydevicesofdifferentnamessuchase-cigs, e-hookahs, hookah pens, vapes, vape pens, and mods (customizable, more powerful vaporizers), ENDS (Electronic Nicotine Delivery System), and others. All contain a battery and a heating element that converts a liquid into an aerosol that is inhaled into the lungs, similar to cigarette smoking.
The prevalence of e-cigarette use among adults in Nebraska is low. In 2016 less than 5% of the adult population used e-cigarette products. This prevalence declined in 2017 to 3.8%. The median for adults in the United States remained essentially unchanged moving from 4.7% to 4.6%.
Calculated by analyzing the response to the question about the use of e-cigarettes in the previous month and cross-tabulated by measurement year.
36
2017: ADULT E-CIGARETTE PREVALENCE
Source: Nebraska Behavioral Risk Factor Surveillance System (BRFSS), 2017
E-Cigarette Use
2017 Statewide Electronic Cigarette Prevalence = 3.8%Approximately 54,900 Nebraska Adults Use E-Cigarettes
Lincoln Lancaster CountyHealth Department
3.4%
Sarpy/CassDepartment of
Health & Wellness4.8%
Douglas CountyHealth Department
5.0%
Dakota County HealthDepartment
2.2%
1.8% and under
1.9% - 2.7%
2.8% - 3.7%
3.8% - 4.8%
4.9% and over
Panhandle Public Health District
2.6%
West Central District Health Department
4.4%
Loup Basin Public Health Department
3.7%
North Central District Health Department
1.5%
Southwest NebraskaPublic Health Department
2.2%
Two Rivers Public Health Department
1.8%
NortheastNebraska Public HealthDepartment 2.1%
Elkhorn Logan ValleyPublic Health Department
7.1%
Three RiversPublic Health Department2.9%
SoutheastDistrict HealthDepartment 3.6%
Public Health Solutions District Health
Department2.9%
South HeartlandDistrict Health
Department3.3%
East Central District Health Department
2.3%
Central DistrictHealth Department
2.7%
Four Corners Health
Department 3.5%
E lectronic cigarettes (E-cigarettes) come in many shapes and sizes but typically include a battery, a heating element, and a place to hold a liquid (often referred to as “juice”). E-cigarettes produce an aerosol (sometimes referred to as vapor).
Users inhale the aerosol into their lungs and bystanders can also inhale this aerosol when the user exhales. Using an e-cigarette is sometimes called “vaping.”
E-cigaretteshavethepotentialtobenefitadultsmokersifthee-cigaretteisusedasa complete substitute for regular cigarettes and other smoked tobacco products. However, e-cigarettes are not safe for use by anyone, particularly youth and young adults and pregnant women. E-cigarettes are fairly new products, so scientists have a lottolearnabouthowe-cigarettesaffecthealthorwhethertheyareeffectiveforquittingsmoking.
E-cigarette use rates are well below conventional cigarette use in Nebraska, with the statewide average approximately 4% of the adult population (3.8%). This is a decrease of approximately one point since 2016. However, there is variation in use with a prevalence of 7.1% in Elkhorn Logan Valley Public Health Department counties and a low of 1.5% in the North Central District Health Department counties.2
1 Centers for Disease Control and Prevention. Electronic Cigarette webpage: https://www.cdc.gov/tobacco/basic_information/ e-cigarettes/index.htm Accessed 10/17/2018.
2 Nebraska BRFSS, 2017
37
2016: Cigarette Use During Pregnancy in Nebraska
The use of tobacco, and smoking in particular, increases the risk of many health conditions for both the newborn and the mother. Specifically:
Smoking makes getting pregnant more difficult Smoking increases the risk of miscarriage Smoking can cause women to deliver their baby earlier than a full-term infant Smoking increases the risk of sudden infant death syndrome (SIDS) Smoking increases the risk of some birth defects.
Source: Centers for Disease Control and prevention, Reproductive Health: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/tobaccousepregnancy/index.htm
11.3%
8.5%
18.7%
0% 5% 10% 15% 20% 25%
AfterPregnancy
DuringPregnancy
BeforePregnancy
2016: Cigarette Use During Pregnancy in Nebraska
Source: Pregnancy Risk Assessment Monitoring System (PRAMS) Source: Pregnancy Risk Assessment Monitoring System (PRAMS)
The use of tobacco, and smoking in particular, increases the risk of many health conditionsforboththenewbornandthemother.Specifically:
 Smokingmakesgettingpregnantmoredifficult.
 Smoking increases the risk of miscarriage.
 Smoking can cause women to deliver their baby earlier than a full-term infant.
 Smoking increases the risk of sudden infant death syndrome (SIDS).
 Smoking increases the risk of some birth defects.
Source: Centers for Disease Control and prevention, Reproductive Health: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/tobaccousepregnancy/index.htm
38
2012 - 2016: Trend of Cigarette Smoking Before Pregnancy in Nebraska
22.2% 21.9% 21.9%20.4%
18.7%22.3% 21.3% 21.1%
19.4%
0%
5%
10%
15%
20%
25%
2012 2013 2014 2015 2016
Nebraska All Participating States
Source: Pregnancy Risk Assessment Monitoring System (PRAMS)
In 2016 (the most recent data available), the rate of smoking for women who became pregnant was almost 19% (18.7%) in the months prior to pregnancy. Many of these individuals may not have been aware of the pregnancy. This is similar to but higher than the overall smoking rate among all adults (15.4%).
The rate of smoking prior to pregnancy has declined over time. Nebraska has performed very similarly to the average for all participating states. The decline is likely due to the decreasing overall rate of smoking among adults in Nebraska.
39
2012 - 2016: Trend of Cigarette Smoking During Pregnancy in Nebraska
10.0% 9.7%
11.5%10.3%
8.5%
10.5% 10.1%
9.9%8.8%
0%
5%
10%
15%
20%
25%
2012 2013 2014 2015 2016
Nebraska All Participants
Source: Pregnancy Risk Assessment Monitoring System (PRAMS)
Fewer than 10% of women reported they smoked cigarettes during their pregnancy. The last few years saw a slight decrease over earlier rates. The most recent value of 8.5% is the lowest in Nebraska since measurement began. In general, the prevalence of tobacco use in Nebraska closely mirrored and was slightly higher than the average for other participating states.
40
2012 - 2016: Trend of Cigarette Smoking After Pregnancy in Nebraska
14.4%12.8%
14.6% 14.1%
11.3%
15.4%14.2%
13.9%12.6%
0%
5%
10%
15%
20%
25%
2012 2013 2014 2015 2016
Nebraska All Participants
Source: Pregnancy Risk Assessment Monitoring System (PRAMS)
Many women who smoked prior to pregnancy resumed smoking after delivery. The post-partum smoking rate is 11.3%.
Note: The rate for all participating sites is not available for 2016.
41
2016: Cigarette Smoking Before/During/After Pregnancy by Race/Ethnicity in Nebraska
Before Pregnancy
During Pregnancy
After Delivery
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
White Black NativeAmerican
Asian/PacificIsland
Hispanic(any race)
20.4%23.3%
46.9%
4.0%
9.5%
9.6% 13.3% 20.6%
1.5%
2.2%
12.2%
17.1%
30.0%
1.8%5.2%
Source: Pregnancy Risk Assessment Monitoring System (PRAMS)
The PRAMS questionnaire also collects the respondent’s race and ethnicity. This information can be used to analyze race/based disparities.
When analyzing the PRAMS data by race and ethnicity, several patterns emerge in the data, including:
 Black and Native American respondents smoke at the highest rate.
 Asian/PacificandHispanicrespondentseachhavelowcigaretteuserates.
42
2011 - 2017: Cigarette Smoking Among Behavioral Health Consumers in Nebraska
53.2%
47.4%46.0%
43.3%45.3%
42.0%43.2%
30%
35%
40%
45%
50%
55%
60%
2011 2012 2013 2014 2015 2016 2017
Source: Nebraska Behavioral Health Consumer Survey
Individuals in treatment for behavioral health conditions smoke cigarettes at a much higher rate than the general population. While the rate has dropped over time from over50%ofpatientstovaluesinthelow40s,thereissignificantprogresstobemadeamong this population.
Includes patients who are or have received mental health services (not substance abuse treatment). Includes the percent of respondents answering “every day” or “some days” to the question asking if the respondent smokes cigarettes.
43
2011 - 2017: Smoking Rate - Adult Behavioral Health vs. State Average
53.2%47.4% 46.0% 43.3% 45.3%
42.0% 43.2%
72.7%
64.2% 66.8%62.3%
65.7%
57.2%
67.2%
20.0% 19.7% 18.5% 17.3% 17.1% 17.0% 15.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
2011 2012 2013 2014 2015 2016 2017
Mental Health Substance Abuse Nebraska
Source: Nebraska Behavioral Health Consumer Survey/Nebraska BRFSS
Behavioral health patients use cigarettes at a much higher rate than the total Nebraska population. As seen in the chart (above), the cigarette-use rate of the mental health population is more than 20 points higher than the average of the state while patients who receive substance abuse services are approximately 40 points higher.
Includes the percentage of respondents who answered “every day” or “some days” to the question: “Do you now use cigarettes every day, some days, or not at all?”
44
2017: Adult Cigarette Smoking Prevalence by Employment Status in Nebraska
8.5%
9.0%
11.7%
12.2%
16.1%
28.0%
34.0%
35.1%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Student (over 18)
Retired
Homemaker
Self-employed
Employed for Wages
Unemployed Less than 1 year
Unemployed 1+ Years
Unable to Work (disabled)
Source: Nebraska BRFSS
Most categories fall into the 8-16% range. The disabled (unable to work), short-term unemployed and long-term unemployed have dramatically higher rates of cigarette use when compared to the employed population.
This item is calculated by analyzing the responses to cigarette use and cross-tabulating with the self-reported employment status.
45
2011 - 2017: Adult Cigarette Smoking Rate in Nebraska by Gender
22.1% 21.4%19.8%
18.5% 18.4% 18.6%16.4%
17.9% 18.1% 17.2%16.2% 15.8% 15.4% 14.5%
0%
5%
10%
15%
20%
25%
2011 2012 2013 2014 2015 2016 2017
Male Female
Source: Nebraska BRFSS
45
Calculatingthesmokingratebyrespondentgendertellsadifferentstorythanjuststudying the overall results. For example, we know that the overall smoking rate is 15.4% but this is an aggregate of the male smoking rate of 16.4% and the female smoking rate of 14.5%.
The graph (above) provides several pieces of information, such as:
 Males have consistently had a higher smoking rate than females.
 Both sexes have experienced declining smoking rates.
 Thedifferencebetweenthegendersisdeclining.Thelinesaregettingclosertogether,thusindicatingthedifferencebetweenthegendersisgoingdown.
 In the last year, the largest change was among males (note the steeper decline in the last year).
46
2017: Proportion of Each Gender Among Cigarette Smokers in Nebraska
47.7%52.3%
Female Male
Source: Nebraska BRFSS
The pie graph above details the proportion of each gender represented among cigarette smokers. The population is nearly evenly divided between men and women.
47
2011 - 2017: Cigarette Smoking by Age Category
22.6% 22.6%
18.6%17.9%
17.4%
14.9%
13.8%
28.6%27.2%
25.3%
22.5%23.3%
22.6%
19.9%21.4%
20.8%19.2% 20.3%
19.0%
17.8% 17.5%16.2% 15.8% 16.3%
17.6% 15.4%
8.6% 8.4% 8.6% 8.1%8.8% 9.3%
8.0%5%
10%
15%
20%
25%
30%
35%
2011 2012 2013 2014 2015 2016 2017
18-2425-3435-4445-5455-6465+
Source: Nebraska BRFSS
When analyzing smokers by age category, several patterns emerge, such as:
 In every age group, the cigarette use rate is lower today than it was in 2011.
 The young adult group (18-24) had a meaningful decrease from scores in the low 20s to scores in the low teens.
 The retired group (over 65) consistently has a smoking prevalence between 8 and 9 percent.
 The group with the highest cigarette smoking rate are the mid-adults (25-34).
48
2017: Tobacco Product Use by Marital Status in Nebraska
10.1%
4.7%
2.0%
21.8%
5.9% 6.0%
0%
5%
10%
15%
20%
25%
Smoke Cigarettes Use Smokeless Use E-cigarettes
Married Not Married
Source: Nebraska BRFSS
Married respondents reported a much lower rate of tobacco product use than unmarried individuals (includes all categories of unmarried respondents). For example, married respondents smoke cigarettes at less than half the rate of unmarried respondents (10.1% vs. 21.8%). The rate of smokeless tobacco use was similar between married and unmarried respondents (4.7% vs. 5.9%). E-cigarette use, however highlights the disparity once again with unmarried individuals reporting a prevalence rate three times that of married individuals (2.0% vs. 6.0%).
This item is calculated by analyzing the responses to each type of tobacco used and cross-tabulating with the reported marital status.
49
2017: Tobacco Product Use by Veteran Status in Nebraska
13.1%
9.4%
2.4%
15.7%
4.8% 4.0%
0%
5%
10%
15%
20%
25%
Smoke Cigarettes Use Smokeless Use E-cigarettes
Veteran Not VeteranSource: Nebraska BRFSS
Use Smokeless
Not Veteran
Many national studies have found higher smoking and tobacco-use rates among veterans when compared to the total population.
Nebraskadatarevealsadifferentpatternwithcigarettesmoking(13.1%vs.15.7%)and e-cigarette use (2.4% vs. 4.0%) where the non-veteran population uses products at a higher rate than veterans.
Interestingly, the smokeless tobacco use rate among veterans is nearly twice the rate of non-veterans. Smokeless tobacco is most prevalent among males and is more prevalent in younger populations. The veteran population is primarily male and younger, on average, than the total population. These characteristics may at least partially explain the higher rate.
This item is calculated by analyzing the responses to each type of tobacco used and cross-tabulating with the self-reported veteran status.
50
2011 - 2017: Cigarette Smoking by Race/Ethnicity in Nebraska
19.5%19.2%
18.5%17.0% 16.7%
16.5%
14.9%
28.0%30.1%
22.2%19.9%
23.0% 23.6%21.7%
30.9%
38.3%
44.8%
21.1%
24.0%21.4%
18.4%16.5%
13.6%
16.5%15.2%
17.5%
13.1%10%
15%
20%
25%
30%
35%
40%
45%
50%
2011 2012 2013 2014 2015 2016 2017
Native Hawaiian, Non-Hispanic
White, Non-Hispanic
Black, Non-Hispanic
Asian, Non-Hispanic
Other, Non-Hispanic
Hispanic
Multi-Racial, Non-Hispanic
American Indian or Alaskan Native, Non- Hispanic
*
Source: Nebraska BRFSS
* Populations with insufficientdataare not reported on the chart.
Racialandethnicdifferencesordisparitieshavebeenpresentsincehealthsurveillancebegan. Healthy People 2020 provides this explanation: “Powerful, complex relationships exist between health and biology, genetics, and individual behavior, and between health and health services, socioeconomic status, the physical environment, discrimination, racism, literacy levels, and legislative policies. These factors, which influence an individual’s or population’s health, are known as determinants of health.”1
In Nebraska, the black, non-Hispanic population consistently has a higher prevalence of cigarette smoking when compared to white, non-Hispanic and the population identifying as Hispanic.
The American Indian population has the highest rate of cigarette use at nearly 45%, however,correctlymeasuringtobaccoproductuseinthispopulationisdifficultduetothe ceremonial use of tobacco.
Insomecases,thereareinsufficientdatatoreportinformation.Forexample,therewereinsufficientdatatoreportresultsfortheAsianpopulationfortheentiretimeperiod.
1 HealthyPeople.gov, Disparities section, https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities, accessed 2/7/2019.
51
2017: Adult Cigarette Smoking Prevalence by Education in Nebraska
24.4%
21.3%
15.9%
5.9%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Less than high school
High school/GED
Some college/tech
College graduate
Source: Nebraska BRFSS
There is a strong negative correlation between educational attainment and likelihood to smoke cigarettes. As the level of education increases, the prevalence of cigarette smoking decreases.
This item is calculated by analyzing the responses to cigarette use and cross-tabulating with the self-reported education attainment.
52
2017: Adult Cigarette Smoking Rate by Housing Type and Ownership Status
23.4%26.8%
13.0% 13.1%
0%
5%
10%
15%
20%
25%
30%
Single Family Home Multi-family Housing Single Family Home Other Housing
RENT OWN
Source: Nebraska ATS
Home ownership has a relationship with smoking and tobacco use. Individuals who own their home have a much lower rate of tobacco use when compared to renters. There is also a correlation between multi-unit housing and cigarette smoking where individuals who live in multi-unit homes that are renters have the highest rate of smoking at nearly 27% (26.8).
53
2017: Tobacco Product Use by Home Ownership Status in Nebraska
11.3%
5.3%
2.3%
25.9%
5.1%
8.6%
0%
5%
10%
15%
20%
25%
30%
Smoke Cigarettes Use Smokeless Use E-cigarettes
Own Home Rent HomeSource: Nebraska BRFSS
Individuals who own their home are much less likely to smoke cigarettes or use e-cigarettes than renters. Interestingly, the rate of smokeless tobacco use is almost identical between owners and renters.
This item is calculated by analyzing the responses to each type of tobacco used and cross-tabulating with the home ownership status.
54
2012 - 2015: Adult Cigarette Smoking by Occupation in Nebraska
Food Preparation & Serving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.2% Construction & Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32.7% Transportation & Material Moving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.8% Production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.0% Building & Grounds Cleaning & Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.9% Installation, Repair, & Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23.8% Healthcare Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.4% Personal Care & Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.9% Sales & Related . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.7% Arts, Design, Entertainment, Sports, & Media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.2% Community & Social Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.5% Farming, Forestry, & Fishing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.5% Office&AdministrativeSupport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.9% Business & Financial Operations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.3% Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.5% Architecture & Engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.3% Healthcare Practitioners & Technical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.7% Computer & Mathematical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.5% Protective Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6% Life, Physical, & Social Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.0% Legal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.6% Education, Training, & Library . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2%
Source: Nebraska BRFSS
Thereissignificantvariationinsmokingrateswheninterpretingtheresultsbyoccupation. As observed in past studies, employees working in the food industry have the highest rate of smoking, at nearly 40 percent (38.2%). Education and cessation effortsshouldfocusontheseemploymentgroupsthatcarryagreaterburdenoftobacco use.
55
2011 - 2017: Cigarette Quit Attempt in Previous Year by Adult Smokers in Nebraska
55.6%57.1% 57.1%
58.2%59.1%
54.6%55.6%
45%
50%
55%
60%
65%
70%
2011 2012 2013 2014 2015 2016 2017
Source: Nebraska BRFSS
Most cigarette smokers have a desire to quit, as demonstrated by the nearly 60% who indicate at least one quit attempt in the previous year.
Includes responses of ‘yes’ to the question: “During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?”
56
2017: Received Advice from Providers to Quit Smoking
75%
25%
Yes No
61%
39%
Yes No
Doctor, Nurse, or Other Provider Dentist
Amedicalprovidercanofteninfluencehealthcaredecisionsofpatients.Forthisreason,respondentsareaskedaseriesofquestionsaboutwhethertherewasanofficevisit and whether the provider advised them to stop using tobacco products.
Source: Nebraska ATS
57
Average Number of Calls to the Nebraska Quitline by Month - All Call Types
277
235
278 288 297273
237261
220 228 227 229
0
50
100
150
200
250
300
350
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
Source: Quitline Productivity and Project Reports
Average number of calls to the Nebraska Tobacco Quitline from 2016 to 2018:
Jan Feb Mar April May June July Aug Sept Oct Nov Dec Total
2015 246 224 229 224 220 230 255 246 192 220 192 193 2671
2016 233 281 317 266 279 240 200 233 197 225 245 241 2957
2017 298 196 312 355 362 346 253 279 208 181 206 218 3214
2018 329 238 253 288 327 275 241 286 281 287 263 264 3332
Avg. 277 235 278 283 297 273 237 261 220 228 227 229 12174
This graph and table display the average (mean) number of calls to the Nebraska Tobacco Quitline regardless of the reason for the call. Individuals call to get information for family members, ask a question for themselves, have a short coaching session, or for many other reasons. During the last four years, over 11,000 calls were placed to the Quitline (number of unique individuals is lower because some people will call multiple times).
58
Calls to the Nebraska Quitline by Month and Year 2015 - 2018 / Actual Count - All Call Types
0
50
100
150
200
250
300
350
400
1-Jan 1-Feb 1-Mar 1-Apr 1-May 1-Jun 1-Jul 1-Aug 1-Sep 1-Oct 1-Nov 1-Dec
All 2015 All 2016 All 2017 All 2018
Source: Quitline Productivity and Project Reports
This table above is similar to the previous table, except actual call count is included and each year is displayed.
59
2017: Percentage of Nebraska Youth That Ever Tried Tobacco
41%38% 39%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2013 2015 2017
Source: Nebraska YTS
Despite new products and changing regulation, the proportion of students who have tried any tobacco product has remained consistent at about 40 percent.
The term “any tobacco product” includes multiple tobacco product use. This category includes cigarettes, cigars, smokeless tobacco, pipe, hookah or water pipe, bidis, kreteks,ande-cigarettesintheformofflavoredorregulartobaccoproducts.
60
2017: Youth Current Use of Tobacco Products by Type in Nebraska
16.1%
9.4%
7.4%
6.7%
5.3%
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
Any Tobacco Product
E-cigarettes
Cigarettes
Cigar
Smokeless
Source: Nebraska YRBS
Just over three of every 20 high-school students in Nebraska report using a tobacco product in the last 30 days. When reviewed by type, e-cigarettes are the most prevalent at 9.4%. After being the most prevalent for many years, the use of cigarettes has declined to 7.4%, making it the second most prevalent. Cigars, which are readily availableinlow-costpackagesandamyriadofflavors,areusedbynearlysevenpercent (6.7%) of youth. The least prevalent product used by high school youth was smokeless tobacco, at 5.3%, however historically smokeless tobacco use has varied significantlybygeographicregionandotherfactors.
Note: The individual product prevalence rates amount to more than the overall of 16.1% because some youth use more than one tobacco product.
61
1991 - 2017: Youth Cigarette Use in Nebraska
72.4%67.1%
60.2%
53.4%
38.7%
31.9% 31.4%
24.0%29.2%
33.7%
24.1% 21.8%
15.0%10.9%
13.3%
7.4%
0%
10%
20%
30%
40%
50%
60%
70%
1991 1993 2003 2005 2011 2013 2015 2017
Ever Tried Cigarette Currently Smoke CigarettesSource: Nebraska YRBS
Both experimentation (ever tried) with cigarettes and current smoking rates have decreased dramatically since the 1990s. In the early nineties, over 70% of youth tried cigarette smoking and nearly 30% of those converted to become regular smokers. By 2017, the youth cigarette experimentation and use had decreased dramatically. Today, less than a quarter of youth have tried cigarettes and the current smoking rate is just over 7%.
Includes responses of ‘yes’ to the question about ever trying cigarettes, even once and includes youth who answered “every day” or “some days” to the question: “Do you smoke cigarettes currently.”
62
1991 - 2017: Prevalence of Youth in Nebraska Who Have Smoked Cigarettes
in the Last 30 Days
29.2%
33.7%
24.1%21.8%
15.0%
10.9%13.3%
7.4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
1991 1993 2003 2005 2011 2013 2015 2017
Source: Nebraska YRBS
The high school youth cigarette smoking rate has dramatically declined since the early nineties. At that point in time approximately 1/3 of high school students reported smoking cigarettes in the last 30 days. Currently the percentage of students reporting smoking cigarettes in the last 30 days is in the single digits at 7.4%.
Calculated by summarizing the percentage of students who answered the question about smoking cigarettes in the previous 30 days.
63
2017: Youth Current Cigarette Smoking Rate by State
26 States Have a Higher YouthSmoking Rate
12States Have a Lower Youth
Smoking Rate
3.8%5.4%5.5%
5.7%6.1%6.2%
6.4%6.5%
6.7%7.0%7.1%7.2%
7.4%7.4%
7.6%7.8%7.8%7.9%
8.1%8.2%
8.7%8.7%8.8%
9.1%9.2%9.3%9.4%
9.9%10.0%
10.5%10.6%
10.9%12.1%12.1%
12.3%12.5%12.6%
13.7%14.3%
14.4%
UtahCaliforniaNew York
FloridaRhode Island
DelawareMassachusetts
VirginiaNevada
ColoradoArizonaKansas
NebraskaTexas
IllinoisNew Hampshire
WisconsinConnecticut
HawaiiMaryland
MainePennsylvania
United StatesIdaho
MissouriVermont
TennesseeIowa
South CarolinaMichigan
New MexicoAlaska
MontanaNorth Carolina
LouisianaOklahoma
North DakotaArkansasKentucky
West Virginia
0% 2% 4% 6% 8% 10% 12% 14%
Some states did not participate in YRBS and are not displayed.
Source: YRBS 2017
64
2017: Youth Smokeless Tobacco Use in Nebraska
Used Smokeless Tobacco Last 30
Days, 5.3%
Did not use smokeless tobacco,
94.7%
Source: Nebraska YRBS
Close to 1 in 19 students (5.3%) reported using smokeless tobacco (chewing tobacco, snuff,dip,snus,ordissolvabletobaccoproducts)duringthepast30days.
Trend data for smokeless tobacco use during the past 30 days are not available due to changes in how the question was asked.
Includes responses to the question: During the past 30 days, on how many days did youusechewingtobacco,snuff,dip,snus,ordissolvabletobaccoproducts,suchasRedman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, Copenhagen, Camel Snus, Marlboro Snus, General Snus, Ariva, Stonewall, or Camel Orbs? (Do not count any electronic vapor products.)
65
2017: Youth Current Smokeless Tobacco Use - Nebraska vs. U.S.
5.3%
5.5%
0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%
Nebraska
United States
Source: Nebraska YRBS
The percentage of Nebraska youth who have used smokeless tobacco in the last 30 days (5.3%) is very similar to the median for the United States (5.5%).
Includes responses to the question: During the past 30 days, on how many days did you use chewing tobacco, snuff, dip, snus, or dissolvable tobacco products, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, Copenhagen, Camel Snus, Marlboro Snus, General Snus, Ariva, Stonewall, or Camel Orbs? (Do not count any electronic vapor products).
Note: Trend data for smokeless tobacco for youth is not available due to a change in the wording of the question. The description of smokeless tobacco was expanded toexplicitlyincludesnuff,snus,anddissolvabletobacco.Theseproductswerenotspecificallylistedbeforethe2017administration.
66
2017: Youth Current Smokeless Tobacco Prevalence by State
2.8%
3.0%
3.0%
3.5%
4.2%
4.6%
4.6%
4.7%
4.8%
5.0%
5.0%
5.2%
5.3%
5.3%
5.4%
5.5%
5.6%
5.9%
6.0%
6.1%
6.2%
6.2%
6.3%
7.3%
8.0%
8.2%
8.4%
9.0%
9.2%
9.8%
10.6%
10.7%
11.5%
12.7%
California
Nevada
Utah
Delaware
Virginia
Arizona
New York
Idaho
Massachusetts
Maine
Rhode Island
Vermont
Kansas
NebraskaTexas
United StatesIllinois
Wisconsin
Pennsylvania
Missouri
Iowa
Maryland
Michigan
Tennessee
North Dakota
New Mexico
South Carolina
Alaska
Oklahoma
Montana
Kentucky
Louisiana
West Virginia
Arkansas
0% 2% 4% 6% 8% 10% 12% 14%
Source: YRBS
67
1999 - 2017: Prevalence of High School Youth in Nebraska Who Have Smoked Cigars in the Last 30 Days
18.2%16.8%
9.6% 8.3% 8.1%6.7%
17.7%
15.2% 14.8% 14.0%13.1% 12.6%
10.3%
8.0%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
1999 2001 2003 2005 2011 2013 2015 2017
NE Median U.S. MedianSource: YRBS
Before 2005 the prevalence of high school youth using cigars in Nebraska exceeded the average for the United States. The rate for Nebraska was approaching 20% while the Median for the United States was closer to 15%. The use of cigars by youth in Nebraskasignificantlydecreasedfrom16.8%in2005tounder10%(in2011).Sincethat time (2008-2010) youth in Nebraska have used cigars at a lower rate than the median for the United States though the most recent data shows this gap narrowing (6.7%) Nebraska and (8.0% for the United States).
Calculated by calculating the percentage of students who answered the question about smoking cigars in the previous 30 days.
68
2017: Youth E-Cigarette Use in Nebraska
36.1%
42.2%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Nebraska United StatesSource: Nebraska YRBS
United States
Slightly more than 1 in 3 Nebraska youth report having tried electronic cigarettes in their lifetime. This is lower than the median value of 42.2% for all participating states.
This item is calculated by reporting the percentage that marked ‘yes’ to the question “Have you ever used an electronic vapor product?”
69
2015 - 2017: Youth E-Cigarette Use in Nebraska
44.9%42.2%
38.2%36.1%
24.1%
13.2%22.3%
9.4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2015 2017
Ever Used United States Ever Used Nebraska Current Use United States Current Use Nebraska
Source: YRBS
The median rate for ever trying e-cigarettes for United States youth was nearly 45% in 2015. This rate decreased by almost three points (2.7) in 2017 to 42.2%. Fewer youth in Nebraska have tried e-cigarettes in 2015 (38.2%) and 2017 (36.1%).
Current use of e-cigarettes decreased from 24.1% in 2015 (U.S. Median) to 13.2%. The current use rate for Nebraska youth decreased from 22.3% to 9.4%.
Becauseofrecentproductlaunchandmarketingeffortsamonge-cigaretteproducers(for example, JUUL Labs), many experts believe the rate of youth e-cigarette use will increase in 2018-2019.
This measure is calculated by using responses to the questions “Have you ever used an electronic vapor product?” and “During the past 30 days, on how many days did you use an electronic vapor product?”
70
2017: Youth E-Cigarette Use by State
26.2%25.5%
24.7%23.8%
22.5%22.1%
20.6%20.1%20.1%
17.3%16.4%
16.1%15.8%15.7%
15.5%14.8%
14.5%14.3%14.3%
14.1%13.9%
13.6%13.3%13.2%13.2%
12.2%12.0%11.9%11.8%
11.6%11.5%
11.3%10.9%
10.6%10.3%
9.4%9.0%
7.6%
ColoradoHawaii
New MexicoNew Hampshire
MontanaNorth Carolina
North DakotaMassachusetts
Rhode IslandCalifornia
OklahomaArizona
MaineAlaska
NevadaMichigan
New YorkIdaho
West VirginiaKentuckyArkansasDelawareMaryland
IllinoisLouisianaVermont
South Carolina
VirginiaWisconsin
TennesseePennsylvania
MissouriKansas
Texas
IowaUtah
0 5 10 15 20 25 30
Some states did not conduct the YRBS
survey on this schedule.
Therefore, not every state is represented.
Source: YRBS
Nebraska
United States
71
2017 Opinion: Should Nebraska Retail Stores be Penalized for Selling Tobacco to Minors
61.2%58.2%
62.2%
32.3%34.8%
31.5%
4.9% 4.8% 5.0%1.5% 2.2% 1.4%
0%
10%
20%
30%
40%
50%
60%
70%
All Respondents Tobacco Users Non-Tobacco Users
Strongly Agree Agree Disagree Strongly Disagree
There is strong and consistent support for penalizing retailers that sell tobacco products to minors (under age 18). When analyzing all respondents, 93.5% either agree or strongly agree stores should be penalized for the sale of tobacco products to those under 18. Among those who use tobacco, 93% either agree or strongly agree with penalties (nearly identical). Individuals who do not use tobacco have a slightly stronger preference at 93.7%.
The graph (above) summarizes responses to the question: “Stores should be penalized for the sale of tobacco products to persons under the age of 18.”
Source: Nebraska ATS
72
2017: Importance of Preventing Retail Stores from Selling Tobacco to Minors in Nebraska
61.2%
58.2%
61.2%
31.5%
34.8%
32.3%
5.0%
4.8%
4.9%
1.3%
2.2%
1.5%
Non-tobacco Users
Tobacco Users
All Respondents
Not Important At All Not Very Important Somewhat Important Very Important
Source: Nebraska ATS
There is almost universal agreement among all respondents when asked “How important is it that communities keep stores from selling products to teenagers?”
Calculated by determining the valid percent who answered the question about retail control, “How important is it that communities keep stores from selling products to teenagers” and then splitting the results by tobacco use status.
73
Retailer Compliance with State Law Restricting the Sale of Tobacco Products to Minors in Nebraska
57.1
67.8
61.0
76.6 76.2
76.8
85.0
81.1
81.0
84.5
84.5
89.3
85.5
88.6 87.9
86.5
89.3 89.4
86.0
83.6
83.7
91.0
90.1
89.8
50
55
60
65
70
75
80
85
90
95
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Perc
ent I
n Co
mpl
ianc
e
Source: Substance Abuse and Mental Health Services Administration (SAMHSA) Synar Program
The Nebraska State Patrol conducts random, unannounced compliance checks of tobacco retailers to determine the state’s compliance rate as required by the Federal Substance Abuse and Treatment Block Grant. The results are used for the annual Synar report.
In 1995, only 57% of tobacco retailers checked complied with the law that restricts the sale of tobacco products to minors. Since then, compliance has substantially increased with compliance rates near or slightly exceeding 90% for the last three years.
74
Nebraska Tobacco Excise TaxesTobacco excise taxes have the dual purpose of revenue generation for state operations and increasing the cost of tobacco products. An increase in retail cost is a best practice for reducing the prevalence of tobacco use and preventing youth from ever starting.
Federal Excise Taxes: A federal per-pack excise tax of $1.01 is in place. Unless otherwise noted, this tax is not included in per-pack costs or retail prices in this report.
In Nebraska, the tobacco excise tax has been collected since the State Legislature passedthefirstcigaretteexcisetaxlawin1947.Currently,thetobaccoexcisetaxinNebraska is $.64 per pack of 20 cigarettes, $.80 per pack of 25 cigarettes, $.44 per ounceofsnuffand20%ofthewholesalepurchasepriceforothertobaccoproducts.
Thecurrentstatecigarettetaxratewentintoeffectin2002andhasnoprovisionforinflationadjustment.
Tobacco Excise Taxes in Nebraska, 2018Tobacco Product Tax
Combustible Cigarettes $.64 per pack (20 cigarettes) $.80 per pack (25 cigarettes)Electronic Cigarettes (E-cigarettes) None
Snuff(finelycut,ground,orpowderednot intended to be smoked) $.44 = per ounce
Other Tobacco Products (cigars, pipe tobacco, loose tobacco, etc.) 20% of wholesale price
Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2017
Statutory Cigarette Tax History in NebraskaTheoriginaltaxof$.03perpackwentintoeffectin1947.Thefollowingtabledetailsthetax changes over time.
Tax Increase Effective DateYears Between
Increases (rounded to
nearest year)Tax Increase Effective Date
Years Between Increases (rounded to
nearest year)The original $.03 tax went into effect on 7/1/1947
$.03 to $.04 9/20/1957 10 $.14 to $.18 5/1/1982 1$.04 to $.06 6/1/1963 6 $.18 to $.23 3/1/1986 4$.06 to $.08 4/1/1965 2 $.23 to $.27 7/1/1987 1$.08 to $.13 4/28/1971 6 $.27 to $.34 7/1/1993 6$.13 to $.14 8/30/1981 10 $.34 to $.64 10/1/2002 9
Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2017
The last Nebraska state cigarette tax increase was in 2002. Hypothetically, if a tax increasetookeffect7/1/2019,nearly16yearswillhavepassedsincethelastincrease,the largest gap in state history.
75
Nebraska and U.S. Median Pack Price, 1954 - 2017 Inflation Adjusted, Generics
Included, Tax Increases Noted
$1.99 $2.15
$2.54
$2.12$1.86
$2.39
$5.41
$4.32
$5.76 $5.53
$2.13
$3.21
$2.97
$3.35
$5.21
$5.28
$6.43 $6.56
$0.00
$1.00
$2.00
$3.00
$4.00
$5.00
$6.00
$7.00
NebraskaUnited States
N N N N NN NN N N
N
Federal Cigarette Tax Increase
State Cigarette Tax Increase
Source: Orzechowski and Walker
From the time Nebraska started taxing cigarettes until the most recent tax increase (2002), Nebraska’s cigarette retail cost mirrored the U.S. median. Beginning in 2002, the averages diverge as other states implemented new tax strategies. In 2017, the average per-pack cost of cigarettes (including generic brands) in Nebraska is $5.53. That is $1.03 less per pack than the U.S. median cost of $6.56.
76
1955 - 2017: Per-Capita Cigarette Sales in Nebraska and U.S.
116.1
135.4
126.7
141.8145.3
131.1
139.8
125.1
113.2
103.0
91.0
74.571.7
55.1
50.1
44.7
39.4
101
119.4
110
104.9
118.1
101.3
89.985.9 85.5
69.8
61
63.2
53.5
43.4
25
45
65
85
105
125
145
Pack
s of
Cig
aret
tes
Year
United States
Nebraska
Source: Orzechowski and Walker
Until approximately 2000, the Nebraska per-capita sales of cigarettes lagged behind national averages. Since that time per-capita sales in Nebraska have outpaced the average for the United States.
77
State Excise Tax Per Pack of Cigarettes Current: 9/2018
$0.17 $0.30
$0.37 $0.44 $0.45
$0.57 $0.57
$0.60 $0.62 $0.64 $0.68 $0.68
$0.84 $1.00
$1.08 $1.10 $1.15 $1.20
$1.29 $1.33 $1.34 $1.36 $1.41
$1.53 $1.60
$1.66
$1.70 $1.70
$1.78 $1.78
$1.80 $1.98
$2.00 $2.00 $2.00 $2.00 $2.00
$2.03 $2.10
$2.52 $2.60
$2.70 $2.87
$3.03 $3.04 $3.08
$3.20 $3.51
$4.25
$4.35 $4.35
$4.50
Missouri Virginia Georgia
North DakotaNorth Carolina
South CarolinaIdaho
WyomingTennessee
NebraskaAlabama
Mississippi Colorado
IndianaLouisianaKentucky Arkansas
West VirginiaKansas
OregonFlorida
Iowa Texas
South Dakota Ohio
New Mexico
UtahMontana
New Hampshire All State Avg
NevadaIllinois
MichiganMaryland
Maine Arizona
Alaska
Oklahoma Delaware
Wisconsin Pennsylvania
New JerseyCalifornia
WashingtonMinnesota
Vermont Hawaii
MassachusettsRhode Island
New York Connecticut
Washington, DC
$0.00 $0.50 $1.00 $1.50 $2.00 $2.50 $3.00 $3.50 $4.00 $4.50 $5.00
= No tax Increase in ten years or more
9 States
Have LowerTaxes
41 States Have
Higher Cigarette
Taxes
Source: Orzechowski and Walker, 2017
78
1999 - 2017: Master Settlement Agreement Payments to Nebraska
$27.5
$34.2$36.1
$41.2
$34.5 $34.4
$37.9$34.7
$36.1
$42.9
$46.8
$39.2
$36.9 $37.6
$56.1
$37.3
$37.1
$36.7
$37.7
$0
$10
$20
$30
$40
$50
$60
Mill
ons
Millions / Year
Source: Orzechowski and Walker, 2017
The Tobacco Master Settlement Agreement (MSA) was completed in 1998 between fivemajortobaccocompaniesandtheattorneysgeneralfrom46states.Thisagreement set forth a number of activities tobacco companies may not conduct (like marketing to children). In addition, tobacco companies pay the participating states anannualpaymentundertheMSA.Annuallythetobaccocompaniesmakefinancialpayments to the states and Nebraska’s portion is displayed above.
79
2017: Sources of Tobacco-Related Revenue in Nebraska
Net State Cigarette Tax, $52,042,742
Net State Tax on Other Tobacco Products, $9,811,280
General Sales Tax, $24,026,000
Master Settlement Agreement$37,741,463
Total = $123,621,485
Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2017
Revenue from the sale of tobacco products has been an important source of revenue for Nebraska. In 2017, taxes and fees related to tobacco products totaled more than $123 million.
80
CDC - Recommended Annual Tobacco Control Funding Compared to Current
2017 Nebraska Funding
$3.10 Million
0
5
10
15
20
CDC Recommended Actual
Mill
ions
($)
$20.8 Million
Source: Nebraska Department of Administrative Services - State Budget Division
1 Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs – 2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control andPrevention,NationalCenterforChronicDiseasePreventionandHealthPromotion,OfficeonSmoking and Health, 2014.
81
Funding for the Tobacco Free Nebraska Program
$7.0 $7.0
$0.4
$2.5 $2.5 $2.5
$3.0 $3.0 $3.0 $2.9
$2.4 $2.4 $2.4 $2.4$2.6 $2.6
$3.1
$0
$1
$2
$3
$4
$5
$6
$7
$8
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Mill
ions
($)
Source: Nebraska Department of Administrative Services - State Budget Division
In 2000, the Nebraska Unicameral passed Legislative Bill (LB) 1436, marking a milestoneinNebraska’stobaccopreventionandcessationefforts.Thebillallocated$21 million over three years to the Tobacco Free Nebraska program from the multi- stateTobaccoMasterSettlementAgreement(MSA).ThismarkedthefirsttimetheUnicameral allocated state funds for comprehensive tobacco prevention and cessation efforts.In2004,theNebraskaLegislaturepassedLB1089whichallocated$2.5milliona year of MSA payments to the program.
In 2007 and 2009, state funding was $3 million per year and in 2010 the allocation was cut by 5.0% to $2,930,850. In 2011 the funding was again cut by 19% to $2.37 million. In 2015 funding increased to $2.58 million. In 2018, $500,000 was added to the budget. A history of program funding is presented in the chart above.
82
2012 - 2017: Smoking-Related Fires, Deaths, Injuries, and Economic Losses in Nebraska
Housing Type Injuries Fatalities Property Loss1 or 2 Family
Multi- Family Civilian Fire
Fighter Civilian Fire Fighter
Estimate Made by Fire Department
2012 103 44 3 10 2 0 $3.74M
2013 138 29 2 3 2 0 $2.55M
2014 148 50 12 5 3 0 $2.74M
2015 131 25 6 7 5 0 $2.64M
2016 65 34 1 8 3 0 $2.63M
2017 72 45 0 3 1 0 $1.32M
Total 657 227 24 36 16 0 $15.6M
Combustible tobacco products cause many health-related deaths and are a common causeofaccidentalfires.Thesefiresresultinthelossoflifeandpropertyaswellasincreased burden on public safety systems.
Smoke-free policies in homes and multi-unit housing can reduce the risk of smoking- relatedfiresandpreventdeaths,injuries,andsubsequentdamage.Manyfiresareofunknownoriginandsomeofthesefirescouldberelatedtosmokingmaterials.Therefore,the information in the table (above) underestimatesthesmoking-relatedfires.
Source:NebraskaStateFireMarshal’sOffice/NationalFireIncidentReportingSystem(NFIRS),U.S.DepartmentofHomeland Security
83
Number of Tobacco-Related Calls to Nebraska Regional Poison Center
2011 2012 2013 2014 2015 2016 2017 2018 Total
Cigarettes 51 45 43 43 49 51 37 25 344
Smokeless Tobacco 6 9 6 17 11 12 15 14 90
Other Tobacco (Including Unknown)
3 4 10 5 1 6 11 4 44
Electronic Cigarette or Nicotine Liquid
4 2 11 36 37 32 23 27 172
Total 64 60 70 101 98 101 86 70 650
Source: Nebraska Regional Poison Center
Nicotine is not only very addictive, but poisonous as well. The amount of nicotine in one cigarette butt is enough to poison a child. Nicotine can be found in many tobacco products including cigarettes, cigars, chewing tobacco, pipe tobacco, nicotine gum, nicotine patches, and liquid nicotine used for electronic cigarettes. When an individual is exposed to nicotine, their symptoms are directly related to the dose of nicotine they received. Mild nicotine poisoning causes nausea, vomiting, dizziness, tremors, sweating and high blood pressure. Severe poisoning can be life-threatening and lead to seizures or even death.
From January 2011 to August 30, 2018, a total of 650 emergency calls related to tobacco/nicotine poisoning were received by the Nebraska Regional Poisoning Center, withasignificantincreaseinthenumberofnicotineliquidpoisoningcasesin2014and2015. Most of the tobacco-related emergencies (82%) were involving young children less than age 6.
Source: WebMD, Nicotine Poisoning, www.webmd.com/smoking-cessation/nicotine-poisoning-can-you-overdose#1
84
Summary of Data Sources Included in This Report
Behavioral Risk Factor Surveillance System (BRFSS): The BRFSS is a telephone survey that uses CDC-developed questions to monitor health behaviors across the nation. The core BRFSS survey is conducted in every state. Each state can choose to conduct additional,supplementalBRFSSquestionnairesthatmeasurespecifichealthbehaviors.In2011, the BRFSS implemented cell phone sampling and a new weighting methodology.
Nebraska Adult Tobacco Survey (ATS): The Nebraska Adult Tobacco Survey is a population based ongoing telephone survey. The Nebraska ATS is a CDC and state-developed random-digit-dialing (RDD) telephone survey. The survey provides tobacco-related information on Nebraska’s adult population not captured through the BRFSS. In 2015, the ATS implemented cell phone sampling and a new weighting methodology.
Nebraska Annual Synar Report: The Nebraska State Patrol conducts random, unannounced compliance checks of businesses to monitor sales of tobacco products to minors. The State Patrol recruits underage persons to attempt to purchase tobacco products in stores throughout the state. Results of the purchase attempts are used to calculate Nebraska’s compliance rate for the Substance Abuse Prevention and Treatment Block Grant.
Pregnancy Risk Assessment Monitoring System (PRAMS): The Pregnancy Risk Assessment Monitoring System is a joint project between the Nebraska Department of Health&HumanServices,OfficeofFamilyHealthandtheCDC.PRAMSisanongoingstudy that provides data from a representative sample of Nebraska women before, during and shortly after pregnancy.
The Tax Burden on Tobacco — Historical Compilation: The Tax Burden on Tobaccowasfirstproducedin1949andtodayisproducedbyeconomicconsultingfirmOrzechowski and Walker. This report provides both the historical and current state of taxes on tobacco product.
Youth Risk Behavior Survey (YRBS): The YRBS is used to monitor health behaviors that contribute to the leading causes of death, disability and social problems among youth in the United States. The YRBS includes national, state and local school-based surveys of representative samples of 9-12th grade students. A degree of caution must be used when interpreting Nebraska YRBS data for years when the data was not weighted. Due to low student response rate to the YRBS in these years, the results are representative of only those students who completed the questionnaires and not of all students statewide.
Youth Tobacco Survey (YTS): The YTS is a statewide school-based survey that provides information on Nebraska youth behaviors and attitudes toward tobacco. The survey is part of the CDC’s national youth tobacco surveillance system to help states improve the capacity to design, implement and evaluate their own tobacco prevention and control programs. The survey gathers tobacco-related information not captured through the YRBS.
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