1. Wisconsin Department of Health Services January 2014 P-00522O Healthiest Wisconsin 2020 Baseline and Health Disparities Report Tobacco Use and Exposure

2. TOBACCO Background Overview of Healthiest Wisconsin 2020 Baseline and Health Disparities Report Healthiest Wisconsin 2020 objectives and indicators Rationale Key points Data Tobacco use among youth Tobacco use and exposure among adults Tobacco cessation among adults References Links to additional reports and resources Contacts Chapter Outline 2 Chapter outline

3. TOBACCO Report Overview This chapter is part of a larger report created by the Wisconsin Department of Health Services to track progress on the objectives of Healthiest Wisconsin 2020 (HW2020) and identify health disparities in the state. The full report is available at: http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf The report is designed to address the Health Focus Areas in HW2020. Where direct measures exist, data are presented; where direct measures are not available, related information may be included. Information about populations experiencing health disparities is provided in the Health Focus Area chapters and is summarized in separate chapters devoted to specific populations. Technical notes are available at: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf Report overview 3

4. TOBACCO Report Format Full Report Format: PDF Intended use: reference document Chapters Format: Annotated PowerPoint slide set Intended uses: presentations to –Decision-makers –Service providers –Community leaders –The public Sample annotated slide Report overview 4

5. TOBACCO Report Outline Executive Summary Section 1: Introduction Section 2: Demographic overview Section 3: Health focus areas Section 4: Infrastructure focus areas Section 5: Data summaries by population Section 6: Technical notes Report overview 5

6. TOBACCO Report Outline: Detail Section 3: Health focus areas Alcohol and other drug use Chronic disease prevention and management Communicable diseases Environmental and occupational health Healthy growth and development Injury and violence Mental health Nutrition and healthy foods Oral health Physical activity Reproductive and sexual health Tobacco use and exposure Section 4: Infrastructure focus areas Access to health care Report overview 6

7. TOBACCO Report Outline: Detail Section 5: Data summaries by population  Racial/ethnic minority populations o American Indians o Asians o Blacks o Hispanics  People of lower socioeconomic status  People with disabilities  Lesbian, gay, bisexual, and transgender populations  Geography Report overview 7

8. TOBACCO Data notes Please refer to the Technical Notes chapter for a more detailed description of limitations and methods: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf The 95% confidence intervals are denoted by error bars. Where confidence intervals do not overlap, as shown in the example on the right, differences are statistically significant. Larger confidence intervals may indicate less reliable estimates that should be interpreted with caution. Population estimates that are considered unreliable are excluded. Misclassification of racial/ethnic groups may affect the accuracy of rates. Unless otherwise indicated, the Hispanic population may include people of various races; Whites, Blacks, Asians, and American Indians are non- Hispanic. Report overview 8

9. TOBACCO Factors that influence health Social determinants of health Source: University of Wisconsin Population Health Institute. County Health Rankings 2013, http://www.countyhealthrankings.org/our-approach Report overview 9

10. TOBACCO Healthiest Wisconsin 2020 objectives and indicators Objective 1 By 2020, reduce tobacco use and exposure among youth and young adults by 50%. Objective 1 Indicators Proportion of youth and young adults using tobacco. Proportion of smoke-free homes. Percent of Wisconsin children in smoke-free homes. Source: Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Tobacco Use Focus Area Profile. 10 HW2020 objectives

11. TOBACCO Healthiest Wisconsin 2020 objectives and indicators Objective 2 By 2020, reduce tobacco use and exposure among the adult population by 25%. Objective 2 Indicators Proportion of adults using tobacco products. Proportion of smoke-free workplaces. Proportion of smoke-free homes. Source: Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Tobacco Use Focus Area Profile. 11 HW2020 objectives

12. TOBACCO Objective 3 By 2020, decrease the disparity ratio by 50% in tobacco use and exposure among diverse populations Objective 3 Indicators Proportion of adults and youth using tobacco and exposed to tobacco in diverse populations Source: Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Tobacco Use Focus Area Profile, 2010. Healthiest Wisconsin 2020 objectives and indicators 12 HW2020 objectives

13. TOBACCO Rationale Tobacco use continues to create a devastating health and economic burden in Wisconsin. Individuals, families and communities across Wisconsin suffer from the effects of tobacco use and addiction. Smoking causes cancer, heart disease, stroke, and lung diseases. For every person who dies from a smoking-related disease, 20 more people experience at least one serious illness from smoking. On average, smokers die 10 years earlier than nonsmokers. Tobacco use leads to disease and disability and is the leading cause of preventable death. 6 Smoking prevalence and exposure to secondhand smoke remain high among youth and young adults, and among people in low socioeconomic groups (defined by income, education, and type of occupation). By adopting and building on policies and programs that have been proven to work, societal norms, systems, and networks can change and play a significant role in improving health across the life span. Source: Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Tobacco Use Focus Area Profile. 13 Rationale

14. TOBACCO Key points Youth According to the 2012 Youth Tobacco Survey, smoking rates among high school students in Wisconsin have continued to decline. 11 American Indian youth have the highest rates of current smoking among all racial and ethnic groups. Sexual minority youth, defined as those who have had same-sex sexual contact, have higher rates of tobacco use and exposure. This puts them at risk of tobacco-related health disparities. 14 Key points

15. TOBACCO Key points Adults Each year, approximately 15% of all deaths in Wisconsin are from illnesses directly related to smoking. Cigarette smoking causes an estimated 79% of all lung cancer deaths and 14% of deaths from cardiovascular disease in Wisconsin. 16 Rates of tobacco use were estimated to be significantly higher among: o Males compared to females; o Adults ages 25-44, compared to those age 45 and older; o American Indians, Blacks, and Hispanics, compared to Whites; o Populations with less formal education and lower incomes; o People with a disability. 15 Key points

16. TOBACCO Indicator, yearWisconsin rateWisconsin rank Adult cigarette use, 201220.4%21 st highest of 50 states, Range: 10.6%-28.3% Youth cigarette use, 201114.6%31 st highest of 44 participating states Range: 5.9% - 24.1% Per cigarette pack excise tax, 2012 $2.528 th highest of 50 states Range: $0.17 - $4.35 Legislation: In 2010, Wisconsin enacted smoke-free workplace legislation One of 33 states with a smoking ban in restaurants, as of 2012 Wisconsin in the National Context Source: CDC State Tobacco Activities Tracking and Evaluation (STATE) System. 16 Context

17. TOBACCO Tobacco use among youth 17

18. TOBACCO Initiation of tobacco use among Wisconsin high school students, by race/ethnicity, 2007-2011 Tobacco use among youth Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. 18

19. TOBACCO Tobacco use among Wisconsin high school students, by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Tobacco use among youth 19

20. TOBACCO Use of chewing tobacco and cigars among Wisconsin high school students, by race/ethnicity, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Tobacco use among youth 20

21. TOBACCO Tobacco use and exposure among Wisconsin middle school students, 2012 4% of middle school students currently use a tobacco product. 17% of middle school students have used a tobacco product in their lifetime: o 6 th grade = 11% o 7 th grade = 19% o 8 th grade = 21% 35% of middle school students live in homes where others smoke. 88% of middle school students believe that smoking tobacco products should never be allowed inside the home. Source: Wisconsin Department of Health Services, Tobacco Prevention and Control Program, Youth Tobacco Survey 2012. Tobacco use among youth 21

22. TOBACCO Tobacco use and exposure among adults 22

23. TOBACCO Smoking rates among Wisconsin adults, by sex, 2009-2011 Tobacco use and exposure among adults Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 combined landline-cell dataset. 23

24. TOBACCO Smoking rates among Wisconsin adults, by age, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 combined landline-cell dataset. Tobacco use and exposure among adults 24

25. TOBACCO Age-adjusted rates of smoking among Wisconsin adults, by race/ethnicity, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Tobacco use and exposure among adults 25

26. TOBACCO Age-adjusted rates of smoking among Wisconsin adults, by household income, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Tobacco use and exposure among adults 26

27. TOBACCO Age-adjusted rates of smoking among Wisconsin adults, by education level, 2008-2011 Question asked in years 2009 and 2010. Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline only dataset Tobacco use and exposure among adults 27

28. TOBACCO Smoking among Wisconsin adults, ages 18-64, by disability status, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Tobacco use and exposure among adults 28

29. TOBACCO Smoking among Wisconsin adults, by sexual orientation, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. 29 Tobacco use and exposure among adults

30. TOBACCO Rates of secondhand smoke exposure among Wisconsin adults, by race/ethnicity, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: The smoking at work question was only asked in years 2009 and 2010. Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Tobacco use and exposure among adults 30

31. TOBACCO Rates of secondhand smoke exposure among Wisconsin adults, by household income, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: The smoking at work question was only asked in 2009 and 2010. Tobacco use and exposure among adults 31

32. TOBACCO Rates of secondhand smoke exposure among Wisconsin adults, by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: The smoking at work was only asked in 2009 and 2010. Tobacco use and exposure among adults 32

33. TOBACCO Rates of secondhand smoke exposure among Wisconsin adults ages 18-64, by disability status, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: The smoking at work was only asked in 2009 and 2010. Tobacco use and exposure among adults 33

34. TOBACCO Rates of secondhand smoke exposure among Wisconsin adults by sexual orientation, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline only dataset Note: The smoking at work was only asked in 2009 and 2010. Tobacco use and exposure among adults 34

35. TOBACCO Estimated prevalence of smoking among Wisconsin adults, by county, 2006-2008 Source: Wisconsin Department of Health Services, Division of Public Health, Tobacco Prevention and Control Program, The Burden of Tobacco in Wisconsin, 2010. Tobacco use and exposure among adults 35

36. TOBACCO Tobacco cessation among adults 36

37. TOBACCO Attempts to quit smoking among adult smokers in Wisconsin, by sex, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 combined landline-cell dataset. Tobacco cessation among adults 37

38. TOBACCO Attempts to quit smoking among adult smokers in Wisconsin, by age, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 combined landline-cell dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Tobacco cessation among adults 38

39. TOBACCO Attempts to quit smoking among adult smokers in Wisconsin, by household income, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Tobacco cessation among adults 39

40. TOBACCO 1.University of Wisconsin Population Health Institute. County Health Rankings, 2013. http://www.countyhealthrankings.org/our-approach http://www.countyhealthrankings.org/our-approach 2.Center for Urban Population Health. Milwaukee Health Report, 2011. http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf 3.LaVeist TA, Gaskin DA, Richard P (2009). The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies. http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic%20 Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic%20 Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf 4.Thomas JC, Sage M, Dillenberg J, Guillory VJ (2002). A Code of Ethics for Public Health. Am Journal of Public Health. 92(7):1057–1059. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ 5.Wisconsin Department of Health Services (DHS). Healthiest Wisconsin 2020. http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf 6.CDC. Smoking and Tobacco Use: Fast Facts. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm#toll http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm#toll 7.Centers for Disease Control and Prevention (CDC). State Cigarette Excise Taxes — United States, 2010–2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6112a1.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm6112a1.htm 8.CDC. Smoking and Tobacco Use: Smoke-Free Policies Improve Air Quality. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/protection/ai r_quality/index.htm http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/protection/ai r_quality/index.htm References 40 References

41. TOBACCO 9.CDC. Smoking and Tobacco Use: Youth and Tobacco Use. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm 10.CDC. Current Tobacco Use Among Middle and High School Students, United States, 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a1.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a1.htm 11.DHS, Tobacco Prevention and Control Program. Middle School Fact Sheet 2012: Wisconsin Youth Tobacco Survey (YTS). http://www.dhs.wisconsin.gov/publications/p4/p43091.pdf http://www.dhs.wisconsin.gov/publications/p4/p43091.pdf 12.National Cancer Institute: Menthol and Tobacco. http://cancercontrol.cancer.gov/tcrb/research_topic-menthol.html http://cancercontrol.cancer.gov/tcrb/research_topic-menthol.html 13.Lee JGL, Griffin GK, Melvin CL (2009). Tobacco use among sexual minorities in the USA, 1987 to May 2007: A systematic review. Tobacco Control, 18, 275-282. http://tobaccocontrol.bmj.com/content/18/4/275.full http://tobaccocontrol.bmj.com/content/18/4/275.full 14.CDC. Smoking and Tobacco Use: Secondhand Smoke Facts. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/ index.htm http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/ index.htm 15.DHS, Bringing Everyone Along: A Strategic Plan to Eliminate Tobacco Related Disparities in Wisconsin http://www.dhs.wisconsin.gov/tobacco/pdffiles/DHSReport2008LowRes.pdfhttp://www.dhs.wisconsin.gov/tobacco/pdffiles/DHSReport2008LowRes.pdf 16.DHS, Burden of Tobacco in Wisconsin, 2010. http://sep.uwcarbone.wisc.edu/downloads/Documents/programbriefs/The%20Burden%20o f%20Tobacco%20Report%202010.pdf http://sep.uwcarbone.wisc.edu/downloads/Documents/programbriefs/The%20Burden%20o f%20Tobacco%20Report%202010.pdf 41 References

42. TOBACCO Links to additional reports and resources Wisconsin Department of Health Services, Wisconsin Tobacco Prevention and Control Program. http://www.dhs.wisconsin.gov/tobacco/informationdata.htm http://www.dhs.wisconsin.gov/tobacco/informationdata.htm The Burden of Tobacco in Wisconsin, 2010 Edition. http://sep.uwcarbone.wisc.edu/downloads/Documents/programbriefs/The% 20Burden%20of%20Tobacco%20Report%202010.pdf http://sep.uwcarbone.wisc.edu/downloads/Documents/programbriefs/The% 20Burden%20of%20Tobacco%20Report%202010.pdf Tobacco Related Disparities in Wisconsin. http://www.dhs.wisconsin.gov/publications/P0/P00142.pdf http://www.dhs.wisconsin.gov/publications/P0/P00142.pdf University of Wisconsin Center of Tobacco Research and Intervention. http://www.ctri.wisc.edu/ http://www.ctri.wisc.edu/ Centers for Disease Control and Prevention (CDC). Smoking and Tobacco Use. http://www.cdc.gov/tobacco/http://www.cdc.gov/tobacco/ 42 Links

43. TOBACCO Contact Randy Glysch Research Scientist Tobacco Prevention and Control Program Bureau of Community Health Promotion Division of Public Health Wisconsin Department of Health Services Email: Randall.Glysch@dhs.wisconsin.govRandall.Glysch@dhs.wisconsin.gov 43 Contacts