Final Project Milestone One: Problem Identification and Statement : (Tobacco use and dependence in New Hampshire)

New Hampshire Department of Health and Human Services  Division of Public Health Services  Tobacco Prevention & Control Program

Data Brief: Tobacco Use Among Youth in New Hampshire August 2012

CURRENT ESTIMATES OF CIGARETTE USE

Overview

Preventing young people from starting to use tobacco begins with increasing their knowledge of the dangers of tobacco use, changing their attitudes toward tobacco use, and increasing public support for policies that reduce the likelihood that they will use tobacco. The tobacco industry spends more than $10.5 billion per year on marketing17. Young people are heavily exposed to pro-tobacco messages in and around retail stores, in magazines, in movies, and by smokers around them. Evidence shows that media campaigns, when combined with other interventions, are effective in reducing tobacco use by youth and keeping them from starting smoking.

Figure 1. Comparison of Current NH Youth Cigarette Use in Selected States in the United States, High School Students, NH YRBS, 2011

Healthy People 2020 Health Objective 16.0%

NH High School Students 19.8%

US High School Students 18.1%

YOUTH SMOKING: 2011 Youth Risk Behavior Survey

KY NH ME CT MA NY RI UT

[HIGHEST] [LOWEST]

24.1% 19.8% 15.2% 15.9% 14.0% 12.5% 11.4% 5.9%

www.TryToStopNH.org 1-800-QUIT-NOW New Hampshire Department of Health and Human Services  Division of Public Health Services  Tobacco Prevention & Control Program 2

The 2011 Youth Risk Behavior Survey (YRBS) shows that 19.8% of New Hampshire high school students smoked cigarettes. In New Hampshire, the purchase or possession of tobacco by individuals under age 18 years and selling tobacco to a minor is illegal (RSA 126-K: 1-14). Students access tobacco products through different sources such as by: giving someone older money to buy them; borrowing them from someone; taking them from adults; or buying them illegally. In addition to changing young people’s attitudes toward tobacco use, there is evidence that certain policies, when implemented, reduce the likelihood that young people will begin smoking. Such policies include: increasing cigarette and other tobacco excise taxes; mass media campaigns; passing and enforcing laws that decrease young people’s access to tobacco; and implementing tobacco-free school policies14,15 . Policies such as these can help create an environment that supports a tobacco-free lifestyle among young people. Parents, guardians, doctors, dentists and other health professionals, teachers, and community members can also play an important role in helping kids to choose and maintain healthy behavior.

This data brief covers the most recent estimates and some trend data on tobacco use among youth in New Hampshire. The data were collected by surveying students in randomly selected New Hampshire high schools (grades 9 through 12).

YRBS is funded through a Centers for Disease Control and Prevention (CDC) grant and administered jointly by the NH Department of Health and Human Services (DHHS) and the NH Department of Education (DOE). For details on YRBS and the survey methodology, please visit http://www.cdc.gov/healthyyouth/yrbs/brief.htm.

Figure 2. Trends in Current Cigarette Smoking Among High School Students, NH YRBS, 1991 – 2011

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Figure 3. Trends in Current Cigarette Smoking by Grade Level, NH YRBS, 1993 – 2011

Figure 4. Trends in Current Cigarette Smoking by Gender, High School Students, NH YRBS, 1993 – 2011

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

9th 10th 11th 12th

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Trends in Current Cigarette Smoking Among High School Students* by Grade Level, NH YRBS, 1993 - 2011

1993 1995 2003 2005 2007 2009 2011

* Percentage of New Ham pshire high school students who smoked cigarettes on at least 1 day (during the 30 days before the survey)

35.1

39.9

19.8 22.5

17.2 20.0

17.5

36.1

32.0

18.2 19.0

20.6 21.6 22.1

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1993 1995 2003 2005 2007 2009 2011

P e

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Years

Trend in Current Cigarette Smoking* Among High School Students by Gender,

NH YRBS, 1993-2011

Fem ale

Male

* Smoked cigarettes on at least 1 day (during the 30 days bef ore the survey).

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Changes in prevalence from 1993 - 20111

While there was an overall significant decrease in the current use of cigarettes by high school students over time, the behavior has either leveled off or begun to move in the opposite direction (Fig. 2). However for female students there has been a steady decrease in current cigarette smoking over time (Fig. 4).

Change in prevalence from 2009 - 20112

No Change

Figure 5. Current Cigarette Smoking for High School Student Among New England States, NH YRBS, 2005 and 2011

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Figure 6. Current Cigarette Smoking by Youth and Adults, NH YRBS and BRFSS, 2003 and 2011

CURRENT ESTIMATES OF OTHER TOBACCO USE

Overview

The two main types of smokeless tobacco in the United States are chewing tobacco and snuff 3,4. Smokeless tobacco is not a safe alternative to smoking cigarettes4, because its use can cause cancer, oral health problems, and nicotine addiction. The five largest tobacco manufacturers have spent record amounts of money on advertising and promotions of this product3. The two leading smokeless tobacco brands for users aged 12 years or older are—Skoal® (with 25% of the market share) and Copenhagen® (with 24% of the market share 5.

Among the health effects caused by smokeless tobacco, cancer and poor oral health are more common. This product contains 28 cancer-causing agents (carcinogens)4,6, is a known cause of cancer in humans, and increases the risk of developing cancer of the oral cavity6,7. It is also strongly associated with leukoplakia—a pre-cancerous lesion of the soft tissue in the mouth that consists of a white patch or plaque that cannot be scraped off. Oral health issues like recession of the gums, gum disease, and tooth decay are also associated with the use of smokeless tobacco.

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Figure 7. Trends in Current Use of Other Tobacco Products, NH YRBS, 1991 – 2011

Figure 8. Trends in Current Use of Other Tobacco Products by Grade Level, NH YRBS, 1995 – 2011

0%

2%

4%

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Trends in Current Use of Other Tobacco Products by Grade Level, New Hampshire YRBS, 1995 - 2011

1995 2003 2005 2007 2009 2011

* Percentage of New Hampshire High School students who used chewing tobacco, snuff, or dip on at least 1 day (during the 30 days before the survey).

4 .3

%

6 .5

%

7 .2

%

8 .4

%

8 .4

% 6.9%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

2003 2005 2007 2009 2011 Healthy People 2020 Target

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Trends in Current Use of Other Tobacco Products Among High School Students* New Hampshire YRBS, 1991 - 2011

* Percentage of high school sudents who used chewing tobacco, snuff, or dip on at least 1 day during the 30 days before the survey. Missing bars indicate that data were either unavailable or not weighted for the corresponding years for NH.

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Figure 9. Trends in Current Use of Other Tobacco Products by Gender, NH YRBS, 1995 – 2011

Change in prevalence from 1995 - 20111

The percentage of high school students who used chewing tobacco, snuff, or dip on one or more of the past 30 days increased over time, but then leveled off (Fig. 7). The same trend in the behavior was observed for both males and females (Fig. 9). The percentage of female other tobacco users is significantly lower than the male students.

Change in prevalence from 2009 - 20112

No Change

3.0

1.1 1.7 1.8

2.6 2.2

17.6

7.3

11.1 12.3

13.8 14.2

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

1995 2003 2005 2007 2009 2011

P e rc

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e

Trend in Current Other Tobacco Product Use* Among High School Students by Gender, New Hampshire, YRBS, 1995-2011

Female

Male

* Percentage of New Hampshire High School students who used chewing tobacco, snuff, or dip on at least 1 day (during the 30 days before the survey).

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CURRENT ESTIMATES OF CIGAR USE

Overview

A cigar is defined as a roll of tobacco wrapped in leaf tobacco or in a substance that contains tobacco (as opposed to a cigarette, which is defined as a roll of tobacco wrapped in paper or in a substance that does not contain tobacco)8,9. The three major types of cigars sold in the United States are large cigars, cigarillos, and little cigars8, 9,10.

Cigars contain the same toxic and carcinogenic compounds found in cigarettes and are not a safe alternative to cigarettes8,9. Regular cigar smoking is associated with an increased risk for cancers of the lung, esophagus, larynx (voice box), and/or oral cavity (lip, tongue, mouth, throat)8, 9,10. Cigar smoking is linked to gum disease and tooth loss.11 Heavy cigar smokers and those who inhale deeply may be at increased risk of developing coronary heart disease8, 9,10. Heavy cigar smoking increases the risk for lung diseases such as emphysema and chronic bronchitis8, 9,11 .

Figure 10. Trends in Current Use of Cigars, Cigarillos, Or Little Cigars by Year, NH YRBS, 2003 – 2011

1 3 .5

%

1 7 .7

%

1 7 .2

%

1 6 .1

%

1 6 .4

%

8.0%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

2003 2005 2007 2009 2011 Healthy People 2020 Target

P e rc

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e

Trends in Current Cigar, Cigarillo, or Little Cigar Use Among High School Students, New Hampshire High School Survey (YRBS)

Sm oked cigars, cigarillos, or little cigars on at least 1 day (during the 30 days before the survey)

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Figure 11. Trends in Current Cigars, Cigarillos, or Little Cigars Use by Grade Level, NH YRBS, 2003 – 2011

Figure 12. Trends in Current Cigar, Cigarillos, Or Little Cigar Use by Gender, NH YRBS, 2003 - 2011

Change in prevalence from 2003 - 20111

The percentage of high school students who are current users of cigars, cigarillos, or little cigars on one or more of the past 30 days increased slightly over time, but not enough to be a significant linear change and then leveled off (Fig. 10).

Change in prevalence from 2009 - 20112

No Change

0%

5%

10%

15%

20%

25%

30%

9th 10th 11th 12th

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Grade Level

Trends in Percentage of NH High School Students Who Smoked Cigars, Cigarillos, or Little Cigars on at Least 1 Day (During the 30 Days Before the Survey) by Grade Level, NH YRBS, 2003 - 2011

2003 2005 2007 2009 2011

5.2

9.8 6.8

9.7 8.9

21.0

25.6 27.2

22.1 22.9

0%

5%

10%

15%

20%

25%

30%

2003 2005 2007 2009 2011

P e

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Years

Trend in Current Cigar, Cigarillo, or Little Ciagr Use* Among High School Students by Gender, NH YRBS, 2003-2011

Fem ale

Male

* Smo ked cig ars, cigarillos, or little cigars o n at least 1 day(during the 30 d ays befo re th e survey).

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Factors Associated with Youth Tobacco Use

Some factors associated with youth tobacco use include11,12:

 Use and approval of tobacco use by peers or siblings

 Lack of skills to resist influences to tobacco use

 Smoking by parents or guardians and/or lack of parental support or involvement

 Accessibility, availability, and price of tobacco products

 A perception that tobacco use is normal

 Aggressive behavior (e.g., fighting, carrying weapons)

Tobacco use during adolescence is associated with the following health risk behaviors3,13 :

 Use of alcohol

 Use of other drugs

 High-risk sexual behavior

Reducing Youth Tobacco Use

National, state, and local program activities that have reduced and prevented youth tobacco use in the past have included combinations of the following14,15 :

 Counter advertising mass-media campaigns (i.e., TV and radio commercials, posters, and other media messages targeted toward youth to counter pro-tobacco marketing)

 Comprehensive school-based and youth group-based, tobacco-use prevention policies and programs (e.g., tobacco-free campuses and educational campaigns, like Legacy’s truth campaign)

 Community interventions that reduce tobacco advertising, promotions, and commercial availability of tobacco products

 Higher costs for tobacco products through increased excise taxes

 Comprehensive smoke-free policies and other policies like the recent Food and Drug Administration policies with proper enforcement that are found to be more effective in preventing youth from smoking

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References

1. Based on trend analyses using a logistic regression model controlling for sex, race/ethnicity, and grade. Logistic regression analysis is used to test for change over all the years of available data. Logistic regression does not consider the oldest and the most recent data points only. Logistic regression analysis provides an appropriate test of change over long periods of time.

2. Based on t–test analyses, p < 0.05. T-test analysis is used to test for change between just 2009 and 2011. 3. Federal Trade Commission. Smokeless Tobacco Report for 2007 and 2008. (PDF–137.24 KB) Washington: Federal Trade Commission, 2011 [accessed 2012 Aug 15]. 4. National Cancer Institute. Smokeless Tobacco or Health: An International Perspective . Bethesda: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 1992 [accessed 2012 Aug 15]. 5. Maxwell JC. The Maxwell Report: The Smokeless Tobacco Industry in 2009. Richmond, VA: John C. Max well, Jr., 2010 [cited 2012 Aug 15]. 6. World Health Organization. Smokeless Tobacco and Some Tobacco-Specific N-Nitrosamines . (PDF–3.18 MB) International Agency for Research on Cancer Monographs on the Evaluation of Carcinogenic Risks to Humans Vol. 89. Lyon (France): World Health Organization, 2007 [accessed 2012 Aug 15]. 7. World Health Organization. Summaries and Evaluations: Tobacco Products, Smokeless (Group 1) . Lyon (France): World Health Organization, International Agency for Research on Cancer, 1998 [accessed 2012 Aug 15]. 8. Campaign for Tobacco-Free Kids. The Rise of Cigars and Cigar-Smoking Harms . (PDF–49.78 KB) Washington: Campaign for Tobacco-Free Kids, 2009 [accessed 2012 Aug 15]. 9. National Cancer Institute. Cigars: Health Effects and Trends. Smoking and Tobacco Control Monograph No. 9 . Smoking and Tobacco Control Monograph No. 9. Bethesda (MD): National Institutes of Health, National Cancer Institute, 1998 [accessed 2012 Aug 15]. 10. American Cancer Society. Cigar Smoking. Atlanta: American Cancer Society, 2010 [accessed 2012 Aug 15].

CDC Recommendations on Funding

CDC makes recommendations on the level at which each state should fund state tobacco control activities. CDC’s recommendation for each state is in the range of $15 to $20 per capita, depending on the state’s population, demography, and prevalence of tobacco use16.

www.TryToStopNH.org 1-800-QUIT-NOW New Hampshire Department of Health and Human Services  Division of Public Health Services  Tobacco Prevention & Control Program 12

11. Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students— United States, 2000–2009. Morbidity and Mortality Weekly Report 2010;59(33):1063–8 [accessed 2012 Aug 15].

12. U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000 [accessed 2012 Aug 15].

13. Campaign for Tobacco-Free Kids. How Parents Can Protect Their Kids from Becoming Addicted Smokers. (PDF–259.13 KB). Washington: Campaign for Tobacco-Free Kids, 2009 [accessed 2012 Aug 15].

14. Centers for Disease Control and Prevention. Cigarette Use Among High School Students—United States, 1991–2009. Morbidity and Mortality Weekly Report 2010;59(26):797–801 [accessed 2012 Aug 15].

15. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2007. Atlanta: 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, 2007 [accessed 2012 Aug 15].

16. IOM (Institute of Medicine). Ending the Tobacco Problem: A Blue-print for the Nation. Washington, DC: The National Academies Press, 2007. 17. U.S. Federal Trade Commission. Cigarette Report for 2007 and 2008. U.S. Federal Trade Commission, 2011 [accessed 2012 Aug 15]. 18. National Cancer Institute. The Role of the Media in Promoting and Reducing Tobacco Use. Tobacco Control Monograph No. 19. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. NIH Pub. No. 07-6242, June 2008.