DATA AND TRENDS ON

TOBACCO USE IN NEBRASKA

2017

UNDERSTANDING THE BURDEN OF TOBACCO

1

DATA AND TRENDS ON

TOBACCO USE IN

NEBRASKA 2017

UNDERSTANDING THE BURDEN OF TOBACCO

Nebraska Department of Health and Human Services Division of Public Health

P.O. Box 95026 301 Centennial Mall South

Lincoln, NE 68509 (402) 471-3121

www.dhhs.ne.gov/TFN

Acknowledgements

This report was prepared to provide the citizens of Nebraska, the Nebraska Department of Health and

Human Services (NE DHHS), the Division of Public Health, Tobacco Free Nebraska (TFN) and

constituents a comprehensive summary of tobacco use in Nebraska. The report is the result of a

collaboration with multiple state government agencies and other constituents.

Prepared by Kevin Horne in TFN with assistance from other TFN colleagues Amanda Mortensen,

Suzanne Forkner, Kathy Burklund, Ashley Wolfe, and Jeff Soukup.

Special thanks to the following experts who provided data and feedback on the report: Kimberly

Meiergerd, Nikki Gohring and Lindsey Witt-Swanson (BOSR, UNL), Carmen Flynn (Nebraska State

Fire Marshal’s Office), Marcia Rasmussen (Nebraska Regional Poison Center), Julane Hill (Nebraska

Department of Education), Jessica Seberger (PRAMS, NE DHHS), Jeff Armitage (BRFSS, NE DHHS),

and Derry Stover (Occupational Safety and Health Surveillance Program, NE DHHS).

2

TABLE OF CONTENTS

Organization of This Report ................................................................................................................... 5

Forward ................................................................................................................................................. 6

Risk Factors Leading to Mortality ....................................................................................................... 6

Tobacco Product Sales .......................................................................................................................... 7

Annual Cigarette Sales in Nebraska, in Millions of Packs 1950-2015 ................................................. 7

Average Retail Price – Not Adjusted for Inflation ................................................................................ 8

Average Retail Price – Adjusted for Inflation ...................................................................................... 9

Taxes as a Percentage of Retail Price.............................................................................................. 10

History of Funding for State Tobacco Program .................................................................................... 11

Statutory Cigarette Tax History in Nebraska ..................................................................................... 12

Nebraska State Cigarette Excise Tax – Actual and Adjusted ............................................................ 13

State Comparison on Cigarette Tax ................................................................................................. 14

Gross Cigarette Tax Receipts for Nebraska 1950-2014 ................................................................... 14

Tobacco Master Settlement Agreement ........................................................................................... 15

Funding for Comprehensive Tobacco Control ...................................................................................... 16

CDC Recommended Budget for Tobacco Control ............................................................................ 17

Summary of Revenue & Tobacco Control Appropriations .................................................................... 18

Age of Cigarette Smoking Initiation in Nebraska ............................................................................... 19

Self-reported Age of Initiation Among Adult Smokers ....................................................................... 19

Current Tobacco use by Youth in Nebraska ......................................................................................... 20

Youth Who Have Tried Cigarette Smoking – Nebraska .................................................................... 20

Ever Try/Current Smoker Ratio ........................................................................................................ 21

Current Cigarette Smoking Rate for Nebraska Youth (1991-2016) ................................................... 22

Youth Cigar, Cigarillo, and Little Cigar Use ...................................................................................... 23

Youth Smokeless Tobacco Use in Nebraska .................................................................................... 24

Illegal Sales of Tobacco Products to Minors ........................................................................................ 25

Tobacco Use by Adults in Nebraska .................................................................................................... 26

Cigarette Smoking ............................................................................................................................ 26

Adult Cigarette Smoking ................................................................................................................... 26

Trends in Adult Tobacco Use ........................................................................................................... 27

Adult Use of Smokeless Tobacco ..................................................................................................... 29

3

Electronic Nicotine Delivery Systems ................................................................................................... 32

Tobacco-related Disparities in Adult Tobacco Use ............................................................................... 34

Adult Cigarette Smoking by Sex ....................................................................................................... 34

Adult Cigarette Smoking by Age ....................................................................................................... 35

Adult Cigarette Smoking by Race and Ethnicity ................................................................................ 36

Adult Cigarette Smoking by Education ............................................................................................. 37

Adult Cigarette Smoking by Income ................................................................................................. 38

Adult Cigarette Smoking by Home Ownership .................................................................................. 38

Cigarette Smoking by Veteran Status ............................................................................................... 40

Cigarette Smoking by Marital Status ................................................................................................ 41

Cigarette Smoking by Employment Status ....................................................................................... 41

Tobacco Use by Geographic Area .................................................................................................... 42

Smoking Prevalence: 500 Cities Project .......................................................................................... 44

Current Adult Smoking Rates by Census Tract - Omaha .................................................................. 44

Current Adult Smoking Rate by Census Tract - Lincoln .................................................................... 45

Cigarette Smoking During Pregnancy .............................................................................................. 46

Smoking-Related Fires ........................................................................................................................ 48

Nicotine Poisoning in Nebraska ........................................................................................................ 49

Tobacco Cessation in Nebraska .......................................................................................................... 50

Use of Quit Aids ............................................................................................................................... 51

Awareness of the Nebraska Tobacco Quitline 2016 ......................................................................... 51

Volume of Calls to the Nebraska Tobacco Quitline ........................................................................... 52

Health Impacts of Smoking on Nebraska Residents ............................................................................ 53

Asthma ............................................................................................................................................. 53

COPD, Emphysema or Chronic Bronchitis ....................................................................................... 53

Cancer ............................................................................................................................................. 54

Diabetes ........................................................................................................................................... 54

Arthritis, Rheumatoid Arthritis, Gout, Lupus, or Fibromyalgia ........................................................... 55

Depressive Disorder ........................................................................................................................ 55

Heart Attack (Myocardial Infarction) ................................................................................................. 56

Stroke .............................................................................................................................................. 56

Kidney Disease ................................................................................................................................ 57

4

Secondhand Smoke and Smoke/Tobacco Free Policies in Nebraska .................................................. 58

Protection from Secondhand Smoke in Homes ................................................................................ 58

Protection from Secondhand Smoke in Vehicles .............................................................................. 59

Support for Smoke-Free Parks ......................................................................................................... 60

Support for Smoke-Free Outdoor Sporting Events ........................................................................... 60

Support for Smoke-Free Outdoor Public Events ............................................................................... 61

Support for Smoke-Free Outdoor Dining Areas ................................................................................ 61

Protection from Secondhand Smoke at Work ...................................................................................... 62

Summary of Data Sources Included In This Report ............................................................................. 63

5

ORGANIZATION OF THIS REPORT

During 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, known as Tobacco Free Nebraska.

There are four major themes identified by the CDC and 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

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.

6

FORWARD

Despite successful international, national, state, and local 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.2

The efforts of Tobacco Free Nebraska, participating sub-grantees,

and others are an important piece of the global public health fight

against tobacco products. More than 6 million deaths worldwide will

be attributable to direct tobacco use in 2018 and an additional

890,000 deaths a result of exposure to secondhand smoke. 3

Right: Poster from World Health Organization promoting World No Tobacco

Day 2017

Risk Factors Leading to Mortality

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 as a result of tobacco use in 2017.4

In addition to the significant mortality, at least 75,000 Nebraskans are suffering from at least one

serious smoking-attributable illness such as coronary heart disease, stroke, lung cancer, emphysema,

and chronic bronchitis.5

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 is available.

Please contact Tobacco Free Nebraska at (402) 471-2101 or dhhs.tfn@nebraska.gov with requests for

additional information.

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/ 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.

7

TOBACCO PRODUCT SALES

Frequently cigarette sales volume is used in place of tobacco sales volume because of the historically

dominant sales position of cigarettes. While Nebraska levies excise taxes on other tobacco products in

addition to cigarettes, by far the majority (88.8%) of tobacco tax revenue is generated by cigarette

sales. In 2015 (the most recent year complete data is available), there were approximately 87,700,000

packs of cigarettes sold in Nebraska. The peak period of cigarette sales was in the 1970s and 1980s

during which the number of packs sold annually exceeded 180 million.

87.7 MILLION

CIGARETTE PACKS

SOLD IN

NEBRASKA 2015

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1,434,151

ADULT

POPULATION IN

NEBRASKA

2015

61.3

CIGARETTE PACKS

PER CAPITA

(ADULTS) IN

NEBRASKA 2015

Number of Cigarette Packs Sold in Nebraska, 1950-2015

Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2015

8

Average Retail Price – Not Adjusted for Inflation

From the initiation of the state excise tax (1947) through 2002 the average retail price in Nebraska

closely mirrored the average of all states. Beginning in 2002, however, the average retail price in

Nebraska slipped lower than the national average and remains so today due primarily to the failure of

Nebraska to maintain excise taxes at or above average levels. A pack of cigarettes, on average, is

about 10% less expensive in Nebraska when compared to other states.

$3.65

$4.69

$4.98

$5.33

$0.23 $0.26 $0.28 $0.33$0.40 $0.48$0.70

$0.95

$1.19

$1.74

$2.18

$3.05

$3.37

$3.72

$3.89

$4.20

$5.55

$5.96

$0

$1

$2

$3

$4

$5

$6

19

54

19

56

19

58

19

60

19

62

19

64

19

66

19

68

19

70

19

72

19

74

19

76

19

78

19

80

19

82

19

84

19

86

19

88

19

90

19

92

19

94

19

96

19

98

20

00

20

02

20

04

20

06

20

08

20

10

20

12

20

14

Average Retail Price of Cigarettes Nebraska/National Average

NE Avg. Price National Avg.

Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2015

9

Average Retail Price – Adjusted for Inflation

While cigarette prices have increased over time due to both manufacturer and retailer cost increases

and federal and state excise taxes, when adjusted for inflation the change is not as significant as it first

appears. In the 1950s and 60s, consumers were paying approximately $2 per pack in 2017 dollars.

Today, the average price is approximately $5.50 per pack in Nebraska. This amount does not factor in

the significant price discounts tobacco companies issue in direct-to-consumer coupons and discounts

that ultimately decrease the consumer cost of tobacco products.

$1.95$2.24

$2.24

$2.36

$1.94

$2.57$2.97

$2.94

$4.51

$4.63

$5.72$5.53

$2.11 $2.21

$2.55

$2.00

$3.29

$4.58

$5.41

$6.22 $6.30

$0

$1

$2

$3

$4

$5

$6

19

54

19

56

19

58

19

60

19

62

19

64

19

66

19

68

19

70

19

72

19

74

19

76

19

78

19

80

19

82

19

84

19

86

19

88

19

90

19

92

19

94

19

96

19

98

20

00

20

02

20

04

20

06

20

08

20

10

20

12

20

14

Average Cigarette Retail Price in Nebraska

NE Avg. Price-Unadjusted

All State Avg. Retail Price - Unadjusted

NE Avg. Price - 2017 Dollars (Adjusted for Inflation)

National Avg. Price - 2017 Dollars (Adjusted forInflation)

Average retail prices INCLUDE

state and federal excise taxes.

Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2015

10

Taxes as a Percentage of Retail Price

There is a common misconception that the increase in retail cost over time is due primarily to excise tax

levies. However, much of the cost increase is due to product cost increases implemented by tobacco

manufacturers as well as retailers maintaining their revenue during a reduction in demand. An analysis

of the percentage of the purchase price dedicated to tax payments shows that the average of this

amount has steadily decreased over time. Today in Nebraska, approximately 1/3 of the pack cost is

attributable to excise taxes. In 1954, more than 50% of the purchase price was tax-related.

52%53%

43%

51%

38%

36% 34%

19%

27%

32%

47%

49%

51%

41%

27%

31%

23%

44%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

60%Taxes as a Percent of Retail Price in Nebraska

Taxes as a % of Retail Price - All StatesTaxes as a % of Retail Price - NELinear (Taxes as a % of Retail Price - All States)Linear (Taxes as a % of Retail Price - NE)

Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2015

Average retail prices INCLUDE

state and federal excise taxes.

11

HISTORY OF FUNDING FOR STATE TOBACCO PROGRAM

Tobacco excise taxes have the dual purpose of revenue generation for state operations and increasing

the cost of tobacco products which decreases demand thereby impacting the use of tobacco among

adults and youth and improving the health of Nebraskans.

Note: There is a federal per-pack excise tax of $1.01. Unless 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 passed the first

cigarette excise tax law in 1947. Currently, the tobacco excise tax in Nebraska is $.64 per pack of 20

cigarettes, $.80 per pack of 25 cigarettes, $.44 per ounce of snuff and 20% of the wholesale purchase

price for other tobacco products.

The current state tobacco tax rate went into effect in 2002 and has no provision for inflation adjustment.

The tax can only be changed by legislative action.

Statutory Tobacco Excise Taxes in Nebraska, 2018

Tobacco Product Tax

Cigarettes

$.64 per pack of 20 cigarettes

$.80 per pack of 25 cigarettes

Snuff

Snuff is any finely cut, ground, or powdered tobacco that is

not intended to be smoked and includes “moist snuff” that is

intended to be placed in the mouth and “dry snuff” that is

intended to be inhaled or sniffed through the nose.6

$.44 per ounce

Other tobacco products (cigars, pipe tobacco,

loose tobacco, etc.)

20% of the wholesale purchase price

6 Nebraska Department of Revenue

Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2015

12

Tobacco sales and excise tax receipts are a source of revenue for the state. In addition to state

revenue, research finds that as the cost of tobacco products increases the demand and consumption

decreases.7

Current Tax

in NE

$.64 per pack

National

Average

$1.72 per pack

Highest State

Tax (NY & CT)

$4.35 per pack

Lowest State

Tax (MO)

$.17 per pack

Statutory Cigarette Tax History in Nebraska

The original tax of $.03 per pack went into effect in 1947. The following table details the tax changes

over time.

Tax Increase Effective

Date

Years 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

The last Nebraska state cigarette tax increase was in 2002. Hypothetically, if a tax increase took effect

7/1/2018, nearly 16 years will have passed since the last increase, the largest gap in state history.

.03 .04.06.08

.13.14

.18

.23 .27.34

.64

.08 .16

.20.24

.34

.39

1.01

19

54

19

56

19

58

19

60

19

62

19

64

19

66

19

68

19

70

19

72

19

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19

76

19

78

19

80

19

82

19

84

19

86

19

88

19

90

19

92

19

94

19

96

19

98

20

00

20

02

20

04

20

06

20

08

20

10

20

12

20

14

Federal and State Excise Taxes - Cents Per Pack

State Excise Tax

Federal Tax

Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2015

This Graph Is Not Adjusted For Inflation

7 Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2014.

13

Nebraska State Cigarette Excise Tax – Actual and Adjusted

This graph displays the actual cigarette tax as defined by statute over time and also presents an

inflation-adjusted line depicting the excise tax in constant 1947 dollars.

While the state excise tax has increased several times and has moved from $.03 to $.64 over the past

70 years – the inflation-adjusted value has only small changes. In 1947, purchasers were being taxed

3 cents per pack of cigarettes and in 2017 purchasers are being taxed an inflation-adjusted 6 cents per

pack.

Without a change in the rate of tax, the spending power of the current tax ($.64) will continue to

diminish over time.

Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2015

0.03 0.040.06 0.08

0.13

0.18

0.27

0.34

0.64

0.030.02 0.03

0.070.05 0.04

0.03

0.05 0.05 0.040.07 0.06

19

47

19

49

19

51

19

53

19

55

19

57

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59

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61

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01

20

03

20

05

20

07

20

09

20

11

20

13

20

15

20

17

DO

LL

AR

S

Nebraska State Cigarette Excise Tax - Actual and Adjusted

Statutory Tax Amount

Value in 1947 Dollars

14

State Comparison on Cigarette Tax

Source: Campaign for Tobacco Free Kids, State Cigarette Excise Tax Rates and Rankings. Updated January 9, 2018

States in bold have not had a tax increase in 10 years or more.

Gross Cigarette Tax Receipts for Nebraska 1950-2014

Tax receipts have an overall increasing trend although during the last decade the gross receipts have

declined due to decreasing rates of tobacco use and the lack of an adjustment in taxes compared to

most states.

4.0 4.2 5.26.8 9.3

10.4 12.814.2

20.622.2 23.6

26.6

31.6 32.4

37.8

40.538.7

48.5 49.0

40.6

45.0

60.9

68.871.8

68.2

62.5

56.6

0

10

20

30

40

50

60

70

19

50

19

52

19

54

19

56

19

58

19

60

19

62

19

64

19

66

19

68

19

70

19

72

19

74

19

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19

78

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80

19

82

19

84

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86

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92

19

94

19

96

19

98

20

00

20

02

20

04

20

06

20

08

20

10

20

12

20

14

MIL

LIO

NS

($

)

Gross Cigarette Tax Reciepts for Nebraska 1950-2014

Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2015

15

Tobacco Master Settlement Agreement

In the 1990s, several states initiated legal action against the major cigarette manufacturers, including

Philip Morris USA, R. J. Reynolds, Brown & Williamson, and Lorillard, to recover Medicaid and other

costs the states incurred in treating sick and dying cigarette smokers. On November 23, 1998, the

cigarette manufacturers, along with forty-six states and six other U.S. jurisdictions (the “Settling

States”), entered into what is called the Tobacco Master Settlement Agreement (MSA), the largest civil

litigation settlement in U.S. history. The MSA pays these settling states a yearly settlement amount.

There is no scheduled termination of these payments.

27.5

34.236.1

41.2

34.537.4 37.9

34.736.1

42.9

46.8

39.236.9 37.7

56.1

37.3 37.1

0

10

20

30

40

50

60

199

9

200

0

200

1

200

2

200

3

200

4

200

5

200

6

200

7

200

8

200

9

201

0

201

1

201

2

201

3

201

4

201

5

Mill

ions $

Tobacco Master Settlement Agreement Payments to Nebraska

Source: The Tax Burden on Tobacco, Orzechowski and Walker, 2015

16

FUNDING FOR COMPREHENSIVE TOBACCO CONTROL

In 2000, the Nebraska Unicameral passed Legislative Bill (LB) 1436, marking a milestone in Nebraska’s

tobacco prevention and cessation efforts. The bill allocated $21 million over three years to the Tobacco

Free Nebraska program from the multi-state Tobacco Master Settlement Agreement (MSA). This

marked the first time the Unicameral allocated state funds for comprehensive tobacco prevention and

cessation efforts. In 2004, the Nebraska Legislature passed LB 1089 which allocated $2.5 million a

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. A history of program funding is presented in the chart below.

Source: Nebraska Department of Revenue

7.0 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 2.42.6 2.6

0

1

2

3

4

5

6

7

8

200

0

200

1

200

2

200

3

200

4

200

5

200

6

200

7

200

8

200

9

201

0

201

1

201

2

201

3

201

4

201

5

201

6

Mill

ions (

$)

Funding for the Tobacco Free Nebraska Program

17

CDC Recommended Budget for Tobacco Control

The Centers for Disease Control and Prevention (CDC) provides states with a recommended budget for

tobacco control in order to fully fund and sustain a comprehensive tobacco control program with

resources sufficient to most effectively reduce tobacco use. The current funding of Tobacco Free

Nebraska is 12.4% of the $20.8 million recommended by the CDC for comprehensive implementation

and management of a state-wide tobacco control program.8

8 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 and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

$2.58 Million

0

5

10

15

20

CDC Recommended Actual

Mill

ion

s (

$)

CDC-Recommended Annual Tobacco Control Funding Compared to Current Nebraska Funding - 2017

$20.8 Million

18

SUMMARY OF REVENUE & TOBACCO CONTROL APPROPRIATIONS

The graph below details the revenue (in millions) from cigarette excise taxes (dark blue), other tobacco

products (green) and the Tobacco Master Settlement Agreement (red). The total yearly revenue from

tobacco-related sources is located in the rectangular box above each bar. In addition, the net tobacco

control appropriation is displayed as a line graph.

Summary of Revenue from Tobacco-Related Sources

and Tobacco Control Appropriations in Nebraska, 2000-2015

In Millions ($)

19

Age of Cigarette Smoking Initiation in Nebraska

Slightly more than 75% of respondents indicated that they had not tried a cigarette.

75.5%

2.7% 1.8%4.0%

8.2% 6.6%

1.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Never Tried 8 or Younger 9 or 10 11 or 12 13 or 14 15 or 16 17 or Older

Age of First Cigarette (even 1 or 2 puffs) - Nebraska, 2016

Source: 2016 NE YRBS

Self-reported Age of Initiation Among Adult Smokers

The 2016 Nebraska Adult Tobacco Survey found that 73% of adult Nebraska smokers indicate they

began smoking before age 18 and nearly all by the age of 21. To help curb adult smoking, many states

and jurisdictions are raising the minimum legal sale age for tobacco products to 21.

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 42 44 45 48 50 54 58

Self-Reported Age of Initiation Among Adult Smokers in Nebraska, 2016

Source: 2016 NE Adult Tobacco Survey

21 18

20

CURRENT TOBACCO USE BY YOUTH IN NEBRASKA

Tobacco use by youth and young adults causes both immediate and long-term health impacts. One of

the most serious health effects is nicotine addiction, which prolongs tobacco use and can lead to

severe health consequences.

Youth Who Have Tried Cigarette Smoking – Nebraska

Tracking the lifetime use of cigarettes is important as some of these youth will become regular adult

smokers. The rate of youth cigarette experimentation has continued to decline, from more than 60% in

2003 to 24% in 2016.

60%

53%

39%

32% 31%

24%

0%

10%

20%

30%

40%

50%

60%

70%

2003 2005 2007 2009 2010 2012 2014 2016

Nebraska Youth Who Have Tried Cigarettes, 2003-2016*

* Years with Unweighted

Data Have Been Omitted

Source: 2016 NE YRBS

21

72%

67%

39%

32% 31%

24%

29%

34%

15%11%

13%

7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2003 2005 2007 2009 2010 2012 2014 2016

Nebraska Youth Who Have Tried Cigarette Smoking and Current Smoking Rate, 2005-2016*

Ever Try Cigarette

Current Smoker

Source: NE YRBS

* Years with Unweighted

Data Have Been Omitted

Ever Try/Current Smoker Ratio

While both trend lines displayed above show a similar pattern of decline, the decreasing gap between

the lines indicates an increasing ratio of try/regular smoker between the two measures. Of those who

do try a cigarette it is more likely that they will become regular smokers. This finding underscores the

importance of preventing youth from even trying a cigarette. In 2003, 72% of youth tried a cigarette but

only 29% became regular smokers. This is a 43 percentage-point difference between the two. In 2016,

24% indicated they had tried a cigarette and 7% were regular smokers. This is a 17 point difference.

Youth Ever Try/Current Smoker Ratio in Nebraska, 2003-2016

2003 2005 2007 2009 2010 2012 2014 2016

Ever Try % 72 67 60 53 39 32 31 24

Current

Smoker %

29 34 24 22 15 11 13 7

Gap 43 33 36 31 24 21 18 17

Source: NE YRBS

22

Current Cigarette Smoking Rate for Nebraska Youth (1991-2016)

The youth cigarette smoking rate continued to decline after a small increase in 2014. The current youth

cigarette smoking rate is 7%, the first time it has reached single-digits in Nebraska. Given that most

adult smokers began smoking in their youth, this graph suggests that the adult tobacco rate will

continue to decline over time as these youth age.

29.3%

33.7%30.5%

21.9% 21.8%

15.0%10.9%

13.3%

7.4%

27.6%

30.5%

34.8%36.4%

34.8%

28.5%24.1% 23.0%

20.0% 19.5%18.1%

15.7%

10.8%

8.0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2010 2012 2014 2016

Nebraska Youth Smoking Rate Compared to National Youth Smoking Rate, 1991-2016

Nebraska National

Years with Unweighted

Data Have Been Omitted

Source: 2016 YRBS Source: NE YRBS

23

Youth Cigar, Cigarillo, and Little Cigar Use

There is heavy marketing and promotion of products in this category, with many flavors and many price

promotions as well as packaging that appeals to youth. Despite this, youth cigar, cigarillo and little

cigar use in Nebraska continues to decline. Seven percent of this population reported using these

products in the last 30 days.

18%17%

8%

8%

7%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

2003 2005 2007 2009 2010 2012 2014 2016

Youth Cigar, Cigarillo, and Little Cigar Use in Nebraska, 2003-2016*

*Years with Unweighted

Data Have Been Omitted

Source: NE YRBS

Source: 2016 YRBS

24

Youth Smokeless Tobacco Use in Nebraska

Statewide smokeless tobacco use (chewing tobacco, snuff, dip, snus, and dissolvable tobacco products

– does not include e-cigarettes) is slightly under six percent (5.7%), which is a decrease from 9%

during the previous NE YRBS administration. After increasing for several years, the smokeless rates

decreased to the lowest point reported.

10%9%

6%

8%

9%

5%

17%

15%

10%

13%15%

8%

3%2% 2% 2%

3%2%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

2003 2005 2007 2009 2010 2012 2014 2016

Youth Smokeless Tobacco Use in Nebraska, 2003-2016*

Overall Smokeless Tobacco Use Male Female

*Years with Unweighted

Data Have Been Omitted

Source: 2016 YRBS Source: NE YRBS

25

ILLEGAL SALES OF TOBACCO PRODUCTS TO MINORS

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.

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 to 89% in 2011 and remains

near this rate, though the most recent data shows an increase to 91%.

57

68

76 76 77

8581 81 81

84 8489

8589 88 89 89

86 84 84

91 91

0

10

20

30

40

50

60

70

80

90

100

199

5

199

6

199

7

199

8

199

9

200

0

200

1

200

2

200

3

200

4

200

5

200

6

200

7

200

8

200

9

201

0

201

1

201

2

201

3

201

4

201

5

201

6

Perc

ent

In C

om

plia

nce

Nebraska Statewide Compliance Rate for Sale ofTobacco Products to Minors

Source: Nebraska Annual Synar Report

26

TOBACCO USE BY ADULTS IN NEBRASKA

Cigarette Smoking

Nearly all smokers in the United States are aware of the many health risks related to cigarette use. In

addition, the personal and/or family financial toll of tobacco use, and inconvenience of smoking

restrictions in many public and private locations demonstrates the addictive nature of nicotine

dependence. Financially, an individual who smokes one-pack of cigarettes per day spends $2,011 per-

year on cigarettes (assuming average price of $5.50 per pack). This amount does not factor in other

costs such as higher insurance premiums and healthcare costs.

Adult Cigarette Smoking

In 2016, the Nebraska Behavioral Risk Factor Surveillance System (BRFSS) found that 17.0% of the

adult population (age 18 and older) smoked cigarettes. About a quarter of adults (24.6%) were former

smokers and nearly 59% had never smoked. Among the current smokers, 74.5% smoked cigarettes

every day, while 25.5% smoked only on some days.

Based on the prevalence rate and the estimated 2016 adult population (1,434,151) 9 there were

approximately 243,800 adults in Nebraska in 2016 who smoked cigarettes.10

9 Population estimate: US Census Bureau Fast Facts. Estimate of adult population. 10 Estimate based on adult smoking rate of 17.0% from the 2016 BRFSS.

58.5%24.6%

17.0%

Adult Cigarette Smoking Status Among Nebraskans, 2016

Never Smoked Former Smoker Current Smoker

Source: 2016 NE BRFSS

27

Trends in Adult Tobacco Use

There is a gradual but consistent increasing trend in the “never smoked” category from 55.7% in 2011

to 58.5% in 2016. The rate of “former smokers” has remained nearly unchanged at approximately

24.5%, but the rate of “daily smokers” has trended downward from 14.5% to the most recent value of

12.1%. The rate of occasional smokers has remained mostly steady with a gradual decrease to about

5%. As seen in the trend line, the change in the overall value is mostly attributable to a decrease in

daily smokers and an increase in never smokers.

55.7% 55.9% 56.9% 58.0% 58.5% 58.5%

24.3% 24.4% 24.7% 24.7% 24.4% 24.6%

14.5% 14.5% 13.7% 12.2% 12.5% 12.1%

5.4% 5.2% 4.7% 5.1% 4.7% 4.9%

0%

10%

20%

30%

40%

50%

60%

70%

2011 2012 2013 2014 2015 2016

Adult Cigarette Smoking Status Trend in Nebraska, 2011-2016

Never Smoked Former Smoker Smoke Everyday Smoke Some Days

Source: NE BRFSS

28

20.0%19.7%

18.5%

17.3%17.1% 17.0%

21.2%

19.6%

19.0%

18.1%

17.5%

17.1%

16%

17%

18%

19%

20%

21%

22%

2011 2012 2013 2014 2015 2016

Nebraska Adult Cigarette Smoking Comparison to National Median, 2011-2016

Nebraska National Median

Source: NE BRFSS

Note: Axis scale has

been expanded to

emphasize changes

The adult smoking rate in Nebraska has been trending below the median value for all states, though in

2016 the values are very similar (17.0% vs. 17.1%) As of 2016, the State of Nebraska estimate was

that 17% of adults smoked compared to 17.1% nationally.

29

Adult Use of Smokeless Tobacco

Smokeless tobacco includes products such as chewing tobacco, snuff, and snus. Generally the tobacco

is placed in the mouth between the cheek and gum or the upper lip. The U.S. Surgeon General has

Reported the association between smokeless tobacco and diseases such as oral cancer, gum disease,

coronary artery disease, peripheral vascular disease, hypertension and peptic ulcer disease since their

report in 1986.11

11 United States Surgeon General, The Health Consequences of Using Smokeless Tobacco, https://profiles.nlm.nih.gov/ps/access/NNBBFC.pdf, 1986.

96.0%

2.1% 1.8%

Nebraska Smokeless Tobacco Use Status Among Adults, 2016

Don't Use Smokeless Tobacco Use Every Day Use Some Days

Source: 2016 NE BRFSS

At first glance, one might have the perspective that the use of smokeless tobacco is not a major

problem in Nebraska, as 94% of the adult population do not use this product. However, it is a product

used nearly exclusively by young males in primarily rural settings. When analyzing the results by sex,

more than 1 in 10 males use smokeless tobacco. Because the majority of the state’s population

resides in the Omaha and Lincoln metropolitan areas, the statewide smokeless rate masks the much

higher utilization in rural counties, especially in western counties.

30

The geographic differences noted earlier can be easily seen in the map of smokeless tobacco

prevalence below.

The rate of smokeless tobacco use ranges from a low of under 2% in Sarpy and Cass counties but

reaches 12% in the Panhandle Public Health District. If only looking at young males, the rate is much

higher.

31

STATE COMPARISON -

SMOKELESS TOBACCO USE,

2016

Compared to other states and the national average,

Nebraska has a higher prevalence rate of smokeless

tobacco use than the majority of states.

In general, states with a higher percentage of land

classified as “rural” have a much higher rate of

smokeless tobacco use. For example, the District of

Columbia (D.C.) has the lowest reported rate of

smokeless tobacco use and 0% of the land area

classified as rural. Wyoming with 99.8% land area

classified as rural has the highest reported smokeless

tobacco rate.

Given the popularity of this product with adolescent

males, they are at higher risk for smokeless tobacco-

induced health problems.

Source: 2016 BRFSS

32

ELECTRONIC NICOTINE DELIVERY SYSTEMS

Electronic Nicotine Delivery Systems (ENDS) is an umbrella term for the many types of electronic vapor

products. ENDS are a rapidly emerging and diversified product class. These devices typically deliver

nicotine, flavorings, and other additives to users via an inhaled aerosol. These devices are referred to

by a variety of names including, e-cigs, e-hookahs, mods, vape pens, vapes, and tank systems.

The 2016 Behavioral Risk Factor Surveillance System (BRFSS) asked a core question about the use of

ENDS. While the specific health impacts are still being researched, the U.S. Surgeon General has

indicated that the use of ENDS is a public health issue and the U.S. Food and Drug Administration is

planning a public education campaign centered on reducing and preventing youth e-cigarette use.

Source: 2016 BRFSS

Current E-Cigarette User Every Day, 1.5%

Current E-Cigarette User Some Days, 3.5%

Former E-Cigarette User, 17.7%

Never Used E-Cigarettes, 77.4%

Nebraska ENDS Use Status, 2016

Source: 2016 NE BRFSS

33

STATE ENDS

COMPARISON,

2016

While Nebraska has a higher rate

of ENDS use than many states,

there is relatively little variation with

about 5% of the adult population

using e-cigarettes in most states.

The highest rate of ENDS use is in

Oklahoma (7%).

Source: 2016 BRFSS

34

TOBACCO-RELATED DISPARITIES IN ADULT TOBACCO USE

The use of tobacco products is not equal when analyzing results by population subgroup. For many

years, tobacco product manufacturers specifically targeted certain populations for sales expansion

(behavioral health, African-American, low-income, LGBTQ, military, and others).12 Reducing or

eliminating tobacco-related disparities is one of Tobacco Free Nebraska’s (TFN) four primary goal

areas. Disparities exist in smoking rates between groups and exposure to secondhand smoke. In

addition, these groups often have less access to healthcare and other resources that may result in

treatment deficits for tobacco-related illnesses.

Tobacco-related disparities affect many different population groups such as age, disability, education,

income, occupation, geographic location, race, ethnicity, sex, gender identity, mental health status,

substance abuse, and military status.

Adult Cigarette Smoking by Gender

Smoking rate differences between genders have been observed for many years with men smoking at a

higher rate than women, although only by a few percentage points. This is a small but consistent

disparity. Differences by gender identity or sexual orientation are not available although disparities have

been reported in other studies.

12 UCSF Smoking Cessation Leadership Center, Vulnerable Populations, https://smokingcessationleadership.ucsf.edu/vulnerable-populations, 2018.

22.1%21.4%

19.8%

18.5% 18.4% 18.6%

17.9% 18.1%17.2%

16.2%15.8%

15.4%

2011 2012 2013 2014 2015 2016

Nebraska Current Cigarette Smoking by Gender, 2011-2016

Male Female

Source: NE BRFSS

35

Adult Cigarette Smoking by Age

In 2016, as in all years with reportable data, young adults in the 25-34 cohort have the highest rate of

smoking. On the other end of the scale, the 65+ group has demonstrated the lowest smoking rate

since 2011. Older smokers have had additional years to successfully quit and are most affected by

higher mortality of smokers. Several age categories (18-24, 25-34, 45-54) have shown long-term

gradual declines. The youngest group (18-24) has dropped from the second-highest rate of smoking to

the second-lowest.

Source NE BRFSS

22.6% 22.6%

18.6%17.9%

17.4%

14.9%

28.6%

27.2%

25.3%

22.5%23.3%

22.6%

22.0%

22.2%

21.4%20.8%

19.2%20.3%

21.4%22.0%

21.9%20.4%

19.2% 18.4%

17.8% 17.5%16.2%

15.8% 16.3%

17.6%

8.6% 8.4% 8.6% 8.1%8.8% 9.3%

2011 2012 2013 2014 2015 2016

Nebraska Cigarette Smoking Among Adults by Age Category, 2011-2016

18-24 25-34 35-44 45-54 55-64 65+

36

Adult Cigarette Smoking by Race and Ethnicity

The cigarette smoking rate varies by race and ethnicity. The cohort with the highest reported rate of

tobacco use is the American Indian population. The white, non-Hispanic population has experienced

slow gradual declines while African-American and Hispanic populations have been increasing. The

multiracial, non-Hispanic category has seen a large decline after peaking in 2014.

With the lower number of smoker’s across the entire population, this data should be reviewed

knowing that the number of smokers in any given cohort is limited and thus the estimate may

have a high degree of measurement error. Use caution when reporting data broken out by race

and ethnicity. For example, in the graph below the American Indian population had sufficient

data to graph for only two time periods (2015 & 2016).

Source: NE BRFSS

19.5% 19.2%18.5%

17.0% 16.7% 16.5%

28.0%

30.1%

22.2%

19.9%23.0% 23.6%

30.9%

38.3%

21.1%

24.0%

21.4%

21.4%

37.7%

35.4%

28.1%

37.4%

21.2%

16.4%

18.4%16.5%

13.6%

14.0%15.2%

17.5%

2011 2012 2013 2014 2015 2016

Nebraska Adult Cigarette Smoking by Race/Ethnicity 2011-2016

White, non-Hispanic Black, non-Hispanic

American Indian, non-Hispanic Other, non-Hispanic

Multiracial, non-Hispanic Hispanic (any race)

37

Adult Cigarette Smoking by Education

There is a strong negative correlation between the level of education attained and the smoking rate (the

higher the education, the lower the smoking rate). Most of these categories have been stable over

time, but the “less than high school” category did increase more than 6% from 2015 to 2016 after

declining for several years. Nearly 30% of individuals with less than a high-school education smoke

cigarettes.

Source: NE BRFSS

29.8%

33.2%

28.2%27.2%

23.6%

29.7%

24.7%23.8% 23.3%

22.5%

22.3%

22.6%21.3%

20.0% 19.9%

17.7%

18.1%

17.0%

8.7%

9.2%7.1%

7.5%7.8%

6.6%

2011 2012 2013 2014 2015 2016

Nebraska Adult Cigarette Smoking by Education Attainment, 2011-2016

Less than HS HS or GED Some Post-HS College Grad

38

Adult Cigarette Smoking by Income

Educational attainment is a good proxy for income. For this reason the results follow a similar pattern,

with a strong negative correlation between income and smoking prevalence (as income rises, smoking

rates decrease).

34.0%

36.1%

34.8%

31.6%

33.5%31.5%

27.2%25.5%

30.4%

24.1%23.4%

24.5%25.1%

23.2%21.3% 22.8%

23.5%

22.8%20.9%

19.8%

18.5% 18.7%

18.8%

17.7%

13.2% 13.2%

11.4%10.7% 10.9%

11.7%

2011 2012 2013 2014 2015 2016

Nebraska Adult Cigarette Smoking by Income Category, 2011-2016

Less than $15,000 $15-24,999 $25-34,999 $35-49,999 $50,000+

Source: NE BRFSS

39

Adult Cigarette Smoking by Home Ownership

Similar to findings from previous years, home ownership is strongly related to likelihood to use

cigarettes. In fact, those who own a home are less than half as likely as renters to use cigarettes. This

finding underscores the importance of maintaining efforts on elimination of smoking in multi-unit

housing due to the popularity of multi-unit housing in the rental sector.

Respondents indicating “other” includes group homes, staying with friends or family, university housing

and other settings where rent is not paid.

13.3%

27.7%

15.1%

0%

5%

10%

15%

20%

25%

30%

Adult Cigarette Smoking by Home Ownership in Nebraska

Own Home Rent Home Other

Source: 2016 NE BRFSS

40

Cigarette Smoking by Veteran Status

Historically, tobacco companies have identified military personnel as marketing targets and they had

higher tobacco-use rates. In Nebraska, however, individuals identifying as a veteran have a slightly

lower smoking rate than non-veterans in Nebraska.

15.3%

17.2%

0% 5% 10% 15% 20% 25% 30%

Cigarette Smoking by Veteran Status in Nebraska, 2016

Non-Veteran Veteran

Source: 2016 NE BRFSS

41

Cigarette Smoking by Marital Status

Unmarried individuals (for any reason) have a higher rate of smoking than others. Divorced or

separated individuals have the highest smoking rate, with approximately 1/3 of the population smoking.

12.1%

32.2%

12.9%

34.6%

21.4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Married Divorced Widowed Separated Never Married

Cigarette Smoking by Marital Status in Nebraska, 2016

Source: 2016 NE BRFSS

Cigarette Smoking by Employment Status

On average, individuals who are employed, self-employed, or retired have the lowest prevalence of

cigarette use. Those who indicate they are unable to work (disabled) or have been long-term

unemployed (over one year) have a much higher rate of cigarette use.

Source: 2016 NE BRFSS

17.0%13.9%

37.6%

24.9%

19.2% 18.1%

6.9%

42.1%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Cigarette Smoking by Employment Status in Nebraska, 2016

42

Tobacco Use by Geographic Area

43

44

Smoking Prevalence: 500 Cities Project

The Robert Wood Johnson Foundation and the CDC Foundation partnered to conduct the 500 Cities

Project. This project is designed to provide city and census-tract level data using a statistical technique

called small-area estimation. A total of 27 chronic disease measures for the 500 largest cities in the

United States are available. More information about the 500 Cities Project can be found here

(https://www.cdc.gov/500cities/about.htm). Both Omaha and Lincoln are included in the 500 Cities

Project.

Current Adult Smoking Rates by Census Tract - Omaha

Smoking follows a pattern with higher smoking rate in the eastern areas of the city and lower use as

you move west. This greater level of detail will help areas most in need of tobacco prevention and

cessation interventions.

Source: CDC – 500 Cities Project - www.cdc.gov/500cities/

45

Current Adult Smoking Rate by Census Tract - Lincoln

Smoking by residents of Lincoln shows a distinct pattern the western part of the city and downtown

having the highest rate of cigarette use. Residents in the southeast parts of town have the lowest rates

smoking rates.

Source: – 500 Cities Project - www.cdc.gov/500cities/

46

Cigarette Smoking During Pregnancy

The health consequences of tobacco use during pregnancy are well-known. In particular, women who

smoke during pregnancy are at risk for preterm births, low birth-weight newborns, increased odds of

sudden infant death syndrome (SIDS), and having weaker lungs at birth.13

13 Centers for Disease Control, Smoking and Tobacco Use During Pregnancy, www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm

19.6%

8.8%

12.8%

Smoked 3 Months BeforePregnancy

Smoked During Last 3 Months ofPregnancy

Smoke Post-Pregnancy

Smoking Status by Pregnancy Stage in Nebraska, 2016

Source: 2016 NE PRAMS

According to the Nebraska Pregnancy Risk Assessment Monitoring System (PRAMS), nearly 20% of

women who had pregnancies in Nebraska smoked prior to their pregnancy. More than half of these

women reported that they did not smoke during their pregnancy, however, nearly 9% of women

reported smoking during their pregnancy. After pregnancy, almost 13% reported smoking. These 13%

may be exposing their newborn or other members of the family to secondhand smoke.

47

+

19.5%

8.8%

12.8%

21.7%

10.1%

14.1%

21.2%

10.6%

17.0%

44.4%

16.2%

28.4%

5.6%

1.9%3.1%

7.9%

2.2% 4.3%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Before Pregnancy During Pregnancy After Pregnancy

Nebraska Cigarette Smoking Rate Before, During, and After Pregnancy by Race/Ethnicity, 2016

Total White Black Native Asian Hispanic

Source: 2016 NE PRAMS

All race and ethnicity categories follow the same general pattern. There are higher smoking rates prior

to pregnancy. The smoking rates drop during pregnancy (to almost zero for Hispanic and Asian

populations) and then some women begin smoking again after pregnancy. The Hispanic and Asian

population have a lower than average smoking rate but the Native American population have a smoking

rate much higher than average.

48

SMOKING-RELATED FIRES

Not only do smoking materials cause many health issues, combustible tobacco products are a common

cause of accidental fires. These fires result in the loss of life and property as well as increased burden

on public safety systems.

Smoke-free policies in homes and multi-unit housing can reduce the risk of smoking-related fires and

prevent deaths, injuries, and subsequent damages. Many fires are of unknown origin and some of

these fires are related to smoking materials. Therefore, the information in the table below

underestimates the smoking-related fires.

Smoking-Related Fires, Deaths, Injuries and Economic Losses in Nebraska, 2012-2015

2013 2014 2015 Total

Smoking-Related Fires 167 198 156 521

Civilian/Firefighter Deaths 2/0 3/0 5/0 10/0

Civilian/Firefighter Injuries 2/3 12/5 6/7 20/15

Total Loss $ 2.55M $ 2.74M $ 2.64M $ 7.9M

The Data About Multi-unit Housing (below) is a Subset of the Overall Information Above

Smoking-Related Multi-family Dwelling Fires

29 50 25 104

Civilian/Firefighter Deaths 0/0 0/0 1/0 1/0

Civilian/Firefighter Injuries 0/2 1/3 2/1 3/6

Total Loss $1.28M $ 0.59M $1.13M $ 3M

Source: Nebraska State Fire Marshal’s Office/National Fire Incident Reporting System (NFIRS)

Source: Tobacco Free Nebraska, “Going Smokefree In Your Home,”

http://dhhs.ne.gov/publichealth/TFN%20Docs/Going%20Smoke%20Free%20in%20Your%20Ho

me%20One-Sheet.pdf, accessed on 5/29/2018.

49

Nicotine Poisoning in Nebraska

Nicotine is not only very addictive but poisonous as well. The amount of nicotine in one cigarette butt is

enough to poison a child.14 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.15

From January 2011 to September 30, 2017, a total of 560 emergency calls related to tobacco/nicotine

poisoning were received in Nebraska Regional Poisoning Center, with a significant increase in the

number of nicotine liquid poisoning cases in 2014 and 2015. Most of the tobacco-related emergencies

(82%) were involving young children less than age 6.

Number of Nicotine-Related Calls to Nebraska Regional Poison Center

2011 2012 2013 2014 2015 2016 2017 (through 9/30/17)

Total

Cigarettes 51 45 43 43 49 51 34 316

Smokeless Tobacco 6 9 6 17 11 12 10 71

Other (Including Unknown)

3 4 10 5 1 6 5 34

Electronic Cigarette or Nicotine Liquid

4 2 11 36 37 32 17 139

Total 64 60 70 101 98 101 66 560

14 WebMD, Nicotine Poisoning, www.webmd.com/smoking-cessation/nicotine-poisoning-can-you-overdose#1 15 WebMD, Nicotine Poisoning, www.webmd.com/smoking-cessation/nicotine-poisoning-can-you-overdose#1

Source: Nebraska Regional Poison Control

50

TOBACCO CESSATION IN NEBRASKA

Nicotine is a highly addictive substance found in most tobacco products. Most smokers are nicotine-

dependent thus making tobacco cessation difficult. People who quit using tobacco greatly reduce their

risk of disease and premature death. Quitting tobacco is difficult and often requires multiple attempts.

Over half of adult cigarette smokers in Nebraska have stopped smoking for one day or longer during

the past 12 months in an attempt to stop tobacco use. After steadily increasing for five years, the

percentage who have attempted to quit has decreased this past year. The reason for this decrease is

not evident. Continual monitoring of this rate is warranted.

55.6%

57.1% 57.1%58.2%

59.1%

54.6%

50%

55%

60%

65%

70%

75%

2011 2012 2013 2014 2015 2016

Attempted to Quit Smoking in Last 12 Months - Nebraska, 2011-2016

Source: NE BRFSS

51

Use of Quit Aids

There are a variety of FDA-approved products to help tobacco users break their addiction to nicotine.

These include products that replace nicotine (nicotine replacement therapy or NRT) and products to

assist with the management of the addictive nature of tobacco use. Despite the availability of nicotine

replacement products and pharmaceutical intervention, nearly 75% of individuals attempted to stop

smoking without assistance.

25.5%

74.5%

Use of Quit Aids in Nebraska, 2016

Yes No

Source: 2016 NE ATS

Awareness of the Nebraska Tobacco Quitline 2016

Nearly 60% of tobacco users in the state are aware of the Nebraska Tobacco Quitline, a telephone

counseling service provided free of charge to Nebraska residents by Tobacco Free Nebraska.

33.1%

57.2%

25.3%

0%

10%

20%

30%

40%

50%

60%

70%

Tobacco Quitline Awareness in Nebraska, 2016

All Respondents Tobacco User Non-Tobacco User

Source: 2016 NE ATS

Volume of Calls to the Nebraska Tobacco Quitline

The Nebraska Tobacco Quitline has provided assistance with cessation to Nebraska residents free-of-

charge since July 2006. Telephone counseling is a proven evidence-based method to reduce tobacco

use. Beginning in 2015, the type of caller was collected (tobacco-user vs. non-tobacco user). In

general, this differentiates between the individual who would receive direct cessation counseling (the

tobacco user) vs. other types of callers such as those calling for a family member or friend or

requesting other information.

On average, call volume is higher and move variable in the first half of the year and is reduced with

much less variability in the later months of the year. This is likely due to the common New Year’s

resolution to stop smoking or using tobacco.

33123505 3417

29382691

2957

2076

2737

0

500

1000

1500

2000

2500

3000

3500

4000

2011 2012 2013 2014 2015 2016

Annual Nebraska Tobacco Quitline Call Volume, 2011-2016

All Caller Types Tobacco Users

*Tobacco user specific data not collected prior to 2015

52

276 269

328 319294

272246 255

228243

225 215

233216

271 270 270256

226 228

193 200 194 196

0

50

100

150

200

250

300

350

Nebraska Tobacco Quitline Average Monthly Call Volume, 2016

All Callers Tobacco Users

53

HEALTH IMPACTS OF SMOKING ON NEBRASKA RESIDENTS

Asthma

Tobacco smoke is a common asthma trigger. Tobacco smoke – including secondhand smoke – is

unhealthy for all people, especially those with asthma.

32.6%

12.0% 11.6%

10%

15%

20%

25%

30%

35%

40%

Smokers with Asthma Former Smokers withAsthma

People Who Have NeverSmoked with Asthma

Nebraska Adults - Percent with Asthma by Smoking Status

Source: 2016 NE BRFSS

COPD, Emphysema or Chronic Bronchitis

Chronic Obstructive Pulmonary Disease (COPD) is currently the fourth leading cause of mortality in the

United States and is typically not diagnosed until an advanced stage. The relationship between

smoking and these diseases of the respiratory system is evident when looking at the prevalence by

smoking status displayed in this graph.

23.2%

9.8%

2.2%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Smokers with COPD Former Smokers withCOPD

People Who Have NeverSmoked with COPD

Nebraska Adults - Percent with COPD, Emphysema, or Chronic Bronchitis, 2016

Source: 2016 NE BRFSS

54

Cancer

Carcinogens in tobacco smoke bond to cells in the body. This damage leads to cell mutations, such as

cancer. Smoking increases the risk of dying from cancer and other diseases in cancer patients and

survivors16.

16 The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014. 17 The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014.

12.2%9.5%

5.9%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Smokers with Cancer Former Smokers withCancer

People Who Have NeverSmoked with Cancer

Nebraska Adults - Percent Diagnosed with Cancer Other than Skin Cancer, by Smoking

Status, 2016

Source: 2016 NE BRFSS

Diabetes

The Surgeon General has found that smoking complicates the treatment of diabetes and that smokers

with diabetes are at a higher risk for kidney disease, blindness, and circulatory problems. Diabetes has

also been causally linked to smoking17.

14.0% 13.2%

7.2%

0%

5%

10%

15%

20%

25%

30%

Smokers with Diabetes Former Smokers withDiabetes

People Who Have NeverSmoked with Diabetes

Nebraska Adults - Percent Diagnosed with Diabetes, by Smoking Status, 2016

Source: 2016 NE BRFSS

55

Arthritis, Rheumatoid Arthritis, Gout, Lupus, or Fibromyalgia

It is believed that cigarette smoke alters immune system homeostasis.18 These conditions are believed

to be autoimmune conditions. There is evidence of a causal relationship between cigarette smoke and

these medical conditions.

18 The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014.

52.1%

34.6%

19.8%

0%

10%

20%

30%

40%

50%

60%

Smokers with Arthritis orOther

Former Smokers withArthritis

People Who Have NeverSmoked with Arthritis

Nebraska Adults - Percent Diagnosed with Arthritis, Gout, Lupus, Fibromyalgia, by Smoking Status, 2016

Source: 2016 NE BRFSS

Depressive Disorder

The relationship between tobacco use and depression and other behavioral health conditions is well

known. In the chart below, there is a clear relationship between smoking and the diagnosis of

depression.

61.1%

18.6%13.9%

0%

10%

20%

30%

40%

50%

60%

70%

Smokers with Depression Former Smokers withDepression

People Who Have NeverSmoked with Depression

Nebraska Adults - Percent Diagnosed with Depressive Disorder, by Smoking Status,

2016

Source: 2016 NE BRFSS

*Including Depression, Major Depression,

Dysthymia, or Minor Depression

56

Cardiovascular Disease

Cigarette use causes cardiovascular disease and other heart problems. Cardiovascular disease

includes all diseases of the heart and blood vessels. Cardiovascular disease include conditions such as

coronary artery disease (narrowing of the arteries), heart attack (myocardial infarction), abnormal heart

rhythms, heart failure, heart valve disease, congenital heart disease, heart muscle disease

(cardiomyopathy), pericardial disease, aorta disease, and vascular disease.

Heart Attack

(Myocardial

Infarction)

Respondents are asked

if they have ever had a

heart attack. As can be

seen in the graph,

individuals who report

that they “never

smoked” are more than

half as likely to have a

heart attack as

compared to current

and former smokers.

Stroke

Similar to the heart attack

data, individuals who report

that they “never smoked” are

much less likely than current

or former smokers to report

having had a stroke.

9.2%7.2%

2.5%

0%

5%

10%

15%

20%

25%

30%

Smokers Who Have HadHeart Attack/MI

Former Smoker Who HaveHad Heart Attack/MI

Never Smoked and NeverHad Heart Attack/MI

Nebraska Adults - Percent Who Have Ever Had a Heart Attack (Myocardial Infarction), by Smoking

Status

6.5%4.6%

1.7%

0%

5%

10%

15%

20%

25%

30%

Smokers Who Have HadA Stroke

Former Smokers WhoHave Had A Stroke

Never Smoked andNever Had A Stroke

Nebraska Adults - Percent Who Have Ever Had A Stroke, by Smoking Status, 2016

Source: 2016 NE BRFSS

Source: 2016 NE BRFSS

57

Kidney Disease

The rate of kidney disease is low in the population in general, and this result is seen in the data

below. If a larger population was studied, it is likely the patterns that smoking is positively correlated

with a current or previous history of smoking.

6.6%

3.2% 2.5%

0%

5%

10%

15%

20%

25%

30%

Everyday Smoker withKidney Disease

Former Smoker withKidney Disease

People Who Have NeverSmoked with Kidney

Disease

Nebraska Adults - Percent Diagnosed with Kidney Disease, by Smoking Status, 2016

Source: 2016 NE BRFSS

58

SECONDHAND SMOKE AND SMOKE/TOBACCO FREE POLICIES IN

NEBRASKA

Protection from Secondhand Smoke in Homes

Virtually all (98%) of homes without an occupant that smokes maintain a smoke-free home. Households

with at least one smoker are less likely to be smoke-free.

89.1%

67.7%

97.8%

7.1%

20.6%

1.5%3.8%11.7%

0.7%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total At least One Smoker inHousehold

No Smoker in Household

Rules About Smoking Inside the Home in Nebraska, 2016

Smoking Not Allowed Allowed Sometimes/Some Places Allowed at All Times

Source: 2016 NE ATS

59

Protection from Secondhand Smoke in Vehicles

The 2015 ATS found that, on average, 82% of vehicles were reported to be smoke-free. This has

increased to just over 83% for 2016. For households without a smoker nearly all (97%) vehicles were

smoke-free. Smoking in the family vehicle is still pretty common in households with a smoker (50%).

83.2%

50.3%

96.6%

11.1%

33.7%

1.8%5.1%

14.7%

1.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Total At least One Smoker inHousehold

No Smoker in Household

Rules About Smoking Inside Vehicle in Nebraska, 2016

Smoking Not Allowed Allowed Sometimes Allowed at All Times

Source: 2016 NE ATS

60

Support for Smoke-Free Parks

Opinions about smoke free parks are nearly unchanged from the previous year. A significant majority

of Nebraskans (85%) support some restrictions and a full 1/3 of those surveyed believe parks should be

completely smoke free.

34.1%

51.6%

14.3%

Nebraskans: Should Smoking Be Allowed in Outdoor Parks?

Not At All In Some Areas In All Areas

Source: 2016 NE ATS

Support for Smoke-Free Outdoor Sporting Events

Over 97% of Nebraskans support some type of smoking restriction at outdoor sporting events. Over

half of the respondents feel that smoking should not occur at outdoor sporting events.

3.2%

44.7%52.0%

Nebraskans: Should Smoking Be Allowed at Outdoor Sporting Events?

In All Areas In Some Areas Not at All

Source: 2016 NE ATS

61

Support for Smoke-Free Outdoor Public Events

Almost 95% of respondents feel that outdoor public events such as state & county fairs, outdoor

concerts, and farmer’s markets should have some smoking restrictions with over 1/3 believing that

smoking should be prohibited completely.

5.1%

59.5%

35.4%

Nebraskans: Should Smoking Be Allowed at Outdoor Public Events?

In All Areas In Some Areas Not at All

Source: 2016 NE ATS

Support for Smoke-Free Outdoor Dining Areas

The majority of Nebraskans (66.3%) feel that outdoor dining should be smoke free.

3.8%

29.8%

66.3%

Nebraskans: Should Smoking Be Allowed at Outdoor Dining Areas?

In All Areas In Some Areas Not at All

Source: 2016 NE ATS

62

PROTECTION FROM SECONDHAND SMOKE AT WORK

Since the Nebraska Clean Indoor Air Act was implemented on June 1, 2009, smoking has been

prohibited in the vast majority of indoor workplaces in Nebraska. Many employers have also

implemented outdoor workplace smoking restrictions in addition to the indoor restrictions already in

place and have also added policies and guidelines for their employees that support the reduction of

tobacco use including smoke-free outdoor work policies.

61%

60%

44%

52%

47%

42%

60%

63%

39%

52%

49%

22%

34%

55%

33%

45%

36%

20% 25% 30% 35% 40% 45% 50% 55% 60% 65%

Has adopted policy restricting smoking a certaindistance from building entrances

Allows smoking outside only in certain places

Has a policy that prohibits smoking in outdoor workareas

Has adopted a policy that prohibits smoking in allcompany vehicles

Has adopted a policy that prohibits the use of chewingtobacco, snuff, snus, or dip in the workplace

Has adopted a policy that prohibits the use of electronictobacco products such as e-cigarettes in the workplace

Percentage of Nebraska Worksites with Tobacco Policies, by Survey Year

2010 2013 2016

Source: NE Worksite Wellness Survey

This question was not asked in 2010.

63

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, supplemental BRFSS questionnaires that measure specific health behaviors. In 2011, 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 on-going 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 & Human Services, Office of Family Health and the CDC. PRAMS is an ongoing study that provides data from a representative sample of Nebraska women before, during and shortly after pregnancy.

School Health Profile Report (SHP) – The CDC School Health Profile Report is a biennial survey conducted by state. The survey provides information on health education practices and school health policies.

The Tax Burden on Tobacco – Historical Compilation – The Tax Burden on Tobacco was first produced in 1949 and today is produced by economic consulting firm Orzechowski and Walker. This report provides both the historical and current state of taxes on tobacco products.

Worksite Wellness Survey (WWS) – The Nebraska Worksite Wellness Survey is a randomly sampled mail survey developed and administered by the Nebraska Department of Health and Human Services (DHHS). The data is used to provide information on current worksite wellness policies and practices being implemented in businesses across the state.

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.

64

Where can I go for more information about these data sources?

BRFSS: Centers for Disease Control and Prevention: HTTPS://WWW.CDC.GOV/BRFSS/ABOUT/INDEX.HTM

Synar: Nebraska DHHS: HTTP://DHHS.NE.GOV/BEHAVIORAL_HEALTH/DOCUMENTS/ASRCY2014.PDF

PRAMS: Centers for Disease Control and Prevention - HTTPS://WWW.CDC.GOV/PRAMS/INDEX.HTM

Nebraska DHHS: HTTP://DHHS.NE.GOV/PUBLICHEALTH/PAGES/PRAMS.ASPX

School Health Profiles Report – Centers for Disease Control and Prevention:

HTTPS://WWW.CDC.GOV/HEALTHYYOUTH/DATA/PROFILES/INDEX.HTM

SAMMEC – Centers for Disease Control and Prevention: HTTPS://CHRONICDATA.CDC.GOV/HEALTH-

CONSEQUENCES-AND-COSTS/SMOKING-ATTRIBUTABLE-MORTALITY-MORBIDITY-AND-ECONO/3KJQ-J5DM

Tax Burden on Tobacco – Full Report: http://api.ning.com/files/c3ouOvTy211ZhsrfUKNSnueSeO5Qh7hSwWT-

hd4faf1CKObKVreuNWbaQTESxsw8kIThQHFKc4FPkhOQ8gM59ojsgYfxQf4O/TaxBurdenonTobaccoVol.502015.pdf

Nebraska Worksite Wellness Survey – Nebraska DHHS:

HTTP://DHHS.NE.GOV/PUBLICHEALTH/WORKPLACEWELLNESSTOOLKIT/PAGES/START.ASPX

YRBS – Centers for Disease Control and Prevention:

HTTPS://WWW.CDC.GOV/HEALTHYYOUTH/DATA/YRBS/INDEX.HTM

Youth Tobacco Survey (YTS) – Centers for Disease Control and Prevention:

https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

You may also contact Tobacco Free Nebraska for additional information. By

phone at (402) 471-2101 or e-mail at dhhs.tfn@Nebraska.gov