{"id":3075,"date":"2020-12-15T15:30:31","date_gmt":"2020-12-15T21:30:31","guid":{"rendered":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/?p=3075"},"modified":"2021-05-20T16:25:12","modified_gmt":"2021-05-20T22:25:12","slug":"impact-of-tobacco-in-wyoming-4","status":"publish","type":"post","link":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/2020\/12\/15\/impact-of-tobacco-in-wyoming-4\/","title":{"rendered":"Impact of Tobacco in Wyoming"},"content":{"rendered":"<h1>Context for Tobacco Prevention in Wyoming<\/h1>\n<p>There is no safe level of exposure to tobacco smoke. Each year, an estimated 800 Wyoming adults die prematurely from smoking-attributable illnesses such as heart disease, lung diseases, and cancers (primarily of the respiratory system; Centers for Disease Control and Prevention [CDC], 2014a). In 2010, tobacco-related healthcare cost Wyoming nearly $240 million, including private and public costs\u2014more than alcohol and other drugs (Wyoming Survey &amp; Analysis Center at the University of Wyoming [WYSAC], 2012).<\/p>\n<p>The Wyoming Tobacco Prevention and Control Program (TPCP) shares four goals with the national tobacco prevention and control program led by the CDC. <em>The Impact of Tobacco in Wyoming: 2019 Annual Summary<\/em> provides data on the prevalence of tobacco use and data associated with these four goals:<\/p>\n<ul>\n<li>Reduce youth initiation (CDC, 2014c),<\/li>\n<li>Reduce exposure to secondhand smoke (CDC, 2017),<\/li>\n<li>Promote tobacco cessation (CDC, 2015b), and<\/li>\n<li>Minimize disparities in the burden of tobacco use (CDC, 2014c; 2015b; 2017).<\/li>\n<\/ul>\n<p>The TPCP and CDC goals tend to focus specifically on smoking cigarettes, though they are also applicable to other combustible tobacco products, smokeless tobacco, and vaping. Nationally and in Wyoming, cigarettes tend to be the focus of prevention work because of the high public health burden associated with them. Vaping tends to be another focus because of a recent surge in youth vaping and concerns that vaping will eventually show a substantial public health burden and may be linked with future cigarette smoking.<\/p>\n<p>This <em>Annual Summary<\/em> also includes a discussion about the economic and health burdens of tobacco use in Wyoming. Details about the analyses and reporting in this annual summary are at the end of this document in the Methods Appendix. Although the estimates provided in this document are the best, most current, publicly available data, they are not without limitations. The Methods Appendix also includes a discussion of the limitations of the data sources based on technical details of the data collection and analyses. Differences noted as significant in this document are statistically significant.<\/p>\n<p><style>@media only screen and (max-width: 1200px){.fullWidth {width: 100% !important; height: auto;}}@media only screen and (max-width: 700px){.alignright, .alignleft, .alignnone, .card-body img {display: inline;float: none;margin: 20px 0;width: 100%;height: auto;}}<\/style>\n<p><!--nextpage--><\/p>\n<h1>Prevalence of Tobacco Use in Wyoming<\/h1>\n<h2>Youth Cigarette Smoking and Vaping<\/h2>\n<h2><img loading=\"lazy\" decoding=\"async\" class=\" wp-image-3078 alignleft\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Prev-call-out-300x138.png\" alt=\"\" width=\"270\" height=\"124\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Prev-call-out-300x138.png 300w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Prev-call-out.png 491w\" sizes=\"auto, (max-width: 270px) 100vw, 270px\" \/><\/h2>\n<p>National comparisons for youth smoking and vaping rates are not available (see Methods Appendix). In Wyoming, the percentage of high school students who smoke declined by more than half (52%) between 2004 and 2018, based on smoking one or more days during the 30 days before the survey was administered. (Figure 1; Prevention Needs Assessment [PNA], 2018). Efforts by the Wyoming Department of Health (WDH), the CDC, and other public health organizations (e.g., Campaign for Tobacco-Free Kids) likely played a role in this success for tobacco prevention.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-3105 \" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Prev-fig-1.png\" alt=\"\" width=\"376\" height=\"316\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Prev-fig-1.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Prev-fig-1-300x252.png 300w\" sizes=\"auto, (max-width: 376px) 100vw, 376px\" \/><\/p>\n<p>Electronic nicotine delivery systems (ENDS; also known as e-cigarettes, e-cigs, or vape pens) are battery powered devices that create an aerosol by heating a liquid instead of making smoke by burning tobacco. Contents of the liquid vary across products, and some models allow for customized liquids. Many ENDS liquids contain nicotine. In 2018, 36% of Wyoming high school students currently vaped (used ENDS at least once in the previous 30 days). This rate is higher than current use of any other substances of abuse on the PNA, including alcohol and other drugs, presenting a new challenge for tobacco prevention in Wyoming (PNA, 2018).<\/p>\n<h2>Adult Cigarette Smoking and Vaping<\/h2>\n<h2><img loading=\"lazy\" decoding=\"async\" class=\" wp-image-3080 alignright\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Cig-call-out-300x167.png\" alt=\"\" width=\"255\" height=\"142\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Cig-call-out-300x167.png 300w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Cig-call-out.png 444w\" sizes=\"auto, (max-width: 255px) 100vw, 255px\" \/><\/h2>\n<p>Current smokers are those who have smoked at least 100 cigarettes in their lifetime and currently smoke every day or some days. According to the 2017 BRFSS, 19% of Wyoming adults are current smokers, slightly more than the national median of 17%. Wyoming has the 18<sup>th<\/sup> highest smoking rate of all the states, territories, and Washington, DC (range 9%\u201326%). In the region, South Dakota has a similar smoking rate and Montana has a smoking rate that, though slightly lower, is not significantly different from Wyoming\u2019s.<\/p>\n<h2><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-3106 \" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Prev-table-1.png\" alt=\"\" width=\"288\" height=\"396\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Prev-table-1.png 305w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Prev-table-1-218x300.png 218w\" sizes=\"auto, (max-width: 288px) 100vw, 288px\" \/><\/h2>\n<p>The other four states in the region have significantly lower smoking rates than Wyoming (Table 1). The smoking rate in Wyoming has declined by almost one fifth, 18%, since 2011, when the smoking rate recently peaked at 23%. WDH efforts, the efforts of the CDC, and the efforts of other public health organizations (e.g., American Cancer Society) probably contributed to this success in tobacco prevention.<\/p>\n<p>In both 2016 and 2017, 6% of Wyoming adults currently vaped (used ENDS some days or every day). This is similar to both the 2017 national median of 5% and the rates for all bordering states (Table 1). The lowest vaping rate is 1% in Puerto Rico; the highest is 7% in Oklahoma; six states have vaping rates that round to 6% (BRFSS, 2017).<\/p>\n<h2>Adult Use of Other Tobacco<\/h2>\n<p>In 2017, 9% of Wyoming adults reported using chewing tobacco, snuff, or snus every day or some days, compared to 4% of U.S. adults. Wyoming\u2019s rate of adult smokeless tobacco use was the highest in the nation. In Wyoming, adult men (17%) are much more likely than adult women (1%) to<\/p>\n<p>use smokeless tobacco. Wyoming\u2019s percentage of men who use smokeless tobacco is second highest in the nation (slightly behind West Virginia with a rate that also rounds to 17%), and compares to a national median of 7%. For Wyoming men, the slight difference between the 2017 rate and the 2013 rate (16%, the oldest available year) was not significant (BRFSS, 2017).<\/p>\n<p>In 2017, 6% of Wyoming adults had used cigars or cigarillos at least once in the past 30 days, an estimate that has not varied significantly since it was 8% in 2010, the first year questions regarding cigars\/cigarillos were asked (WYSAC, 2018a).<\/p>\n<p><style>@media only screen and (max-width: 1200px){.fullWidth {width: 100% !important; height: auto;}}@media only screen and (max-width: 700px){.alignright, .alignleft, .alignnone, .card-body img {display: inline;float: none;margin: 20px 0;width: 100%;height: auto;}}<\/style>\n<p><!--nextpage--><\/p>\n<h1>Reduce Smoking Initiation<\/h1>\n<h2>Smokers Usually Start Young<img loading=\"lazy\" decoding=\"async\" class=\" wp-image-3101 alignright\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-G1-call-out-1-300x229.png\" alt=\"\" width=\"254\" height=\"194\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-G1-call-out-1-300x229.png 300w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-G1-call-out-1.png 374w\" sizes=\"auto, (max-width: 254px) 100vw, 254px\" \/><\/h2>\n<p>Smoking initiation is defined as the age at which a person first smokes one whole cigarette. According to the 2018 Prevention Needs Assessment (PNA), 19% of high school smokers started smoking before turning 11. This has declined by 34% since 2004 when it was 29% (Figure 2). WDH efforts, the efforts of the CDC, and the efforts of other public health organizations (e.g., the Campaign for Tobacco-Free Kids) probably contributed to this success in tobacco prevention.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-2.png\" alt=\"\" width=\"323\" height=\"319\" \/> <img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/2021-01-05-14_39_18-2019-Annual-Summary-2020-12-18-lrt-Word.png\" alt=\"\" width=\"362\" height=\"291\" \/><\/p>\n<p>More than two thirds (69%) of Wyoming adults who had smoked a whole cigarette started smoking (smoked their first whole cigarette) before the age of 18; 91% started smoking before the age of 21. Few (8%) started smoking after the age of 20 (Figure 3; WYSAC, 2018a).<\/p>\n<h2 style=\"text-align: left;\">Preventing Youth Access<\/h2>\n<p>Part of stopping youth from starting to use tobacco is limiting access to tobacco products (CDC, 2014c). The Substance Abuse and Mental Health Services Administration (SAMHSA) requires states to complete annual, random, unannounced inspections of tobacco retailers, known as Synar inspections. SAMHSA requires the noncompliance rate for Synar inspections to be below 20%. Exceeding that rate may result in loss of federal funding for substance abuse prevention and treatment (SAMHSA, 2010). During Wyoming\u2019s Synar inspections, trained 16- and 17-year-olds use a script to try to purchase cigarettes or smokeless tobacco from a sample of Wyoming tobacco retailers accessible to minors. Violations during Synar inspections do not result in actual sales, so citations are not issued.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3148  alignleft\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/2021-01-05-17_54_27-2019-Annual-Summary-2020-12-18-lrt-Word.png\" alt=\"\" width=\"364\" height=\"290\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/2021-01-05-17_54_27-2019-Annual-Summary-2020-12-18-lrt-Word.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/2021-01-05-17_54_27-2019-Annual-Summary-2020-12-18-lrt-Word-300x239.png 300w\" sizes=\"auto, (max-width: 364px) 100vw, 364px\" \/>Wyoming\u2019s Synar violation rates have usually been similar to the national violation rates (Figure 4). In 2016, however, Wyoming\u2019s Synar noncompliance rate was unusually high because specific geographic areas had high violation rates. Since 2007, clerks failing to ask inspectors for identification has been the strongest predictor of retailer violations (WDH &amp; WYSAC, 2018; WYSAC, 2017b).<\/p>\n<p>Each year, the Wyoming Association of Sheriffs and Chiefs of Police (WASCOP) conducts additional inspections of tobacco retailers. During WASCOP inspections, adolescent inspectors attempt to purchase cigarettes or smokeless tobacco. Unlike Synar inspections, these compliance checks allow law enforcement officers to issue warnings or citations to merchants who sell to minors (WYSAC, 2016; 2017c; 2018b). Violation rates treat repeated visits to outlets as unique inspections and are generally slightly higher for WASCOP inspections (Figure 5) than Synar inspections (Figure 4).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3096  alignleft\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-5.png\" alt=\"\" width=\"364\" height=\"304\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-5.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-5-300x250.png 300w\" sizes=\"auto, (max-width: 364px) 100vw, 364px\" \/>Wyoming retailers are generally compliant with laws limiting youth access to tobacco products (WDH &amp; WYSAC, 2018; WYSAC, 2016; 2017b; 2017c; 2018b). A challenge for tobacco prevention remains because data show that underage youth get tobacco despite legal restrictions. Besides buying tobacco for themselves, sources include relatives, unrelated adults or minors, taking it, and other non-specified sources (PNA, 2018 [based on 2014 data as the most recent year the question was asked]; Youth Risk Behavioral Surveillance System [YRBSS], 2015).<\/p>\n<p>In 2018, 25% of Wyoming middle-school students and 57% of Wyoming high-school students under the age of 18 said it would be easy (either sort of easy or very easy) to get some cigarettes. Students in higher grades reported easier access to cigarettes (Figure 6; PNA, 2018). Synar compliance checks in Wyoming have shown that clerks are more likely to sell tobacco to older or older-looking minors (WDH &amp; WYSAC, 2019; WYSAC, 2017b). Together, these findings suggest that it is easier for youth to illegally purchase or otherwise access cigarettes as they and fellow students approach the age of 18.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-3097 \" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-6.png\" alt=\"\" width=\"353\" height=\"308\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-6.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-6-300x262.png 300w\" sizes=\"auto, (max-width: 353px) 100vw, 353px\" \/>Increasing the price of tobacco products, usually by increasing taxes, is another strategy to keep youth from starting to use tobacco (CDC, 2014c; Chaloupka et al., 2012; Guide to Community Preventive Services, 2015). State tax rates vary from a low of $0.17 per pack in Missouri to a high of $4.35 per pack in New York and Connecticut (Figure 7). The average state tax rate on cigarettes is $1.79 (not including the federal tax or territories, but including the District of Columbia). Wyoming\u2019s tax is the eighth lowest in the nation (CDC, 2019).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3098  alignright\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-7.png\" alt=\"\" width=\"271\" height=\"370\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-7.png 305w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-7-220x300.png 220w\" sizes=\"auto, (max-width: 271px) 100vw, 271px\" \/>Consistent with CDC\u2019s approach to prevention (CDC, 2014c; 2015b), states that have low cigarette smoking rates tend to have relatively high excise tax rates (Figure 8).<\/p>\n<p>Like every state that has implemented a significant cigarette tax increase (Farrelly et al., 2003), Wyoming experienced a decrease in cigarette consumption and an increase in tax revenue when it last raised its cigarette excise tax on July 1, 2003. Cigarette tax revenue increased from $6.6 million (in 2014 dollars; equivalent to $5.1 million in 2003, but adjusted for inflation to allow direct comparison to the 2014 amount) in the fiscal year before the tax increase took effect to $19.1 million in fiscal year 2014 (Wyoming Department of Revenue [WYDOR], ca. 2014). In 2014, WYSAC estimated that a $1.00 price increase would decrease the amount of cigarettes adults in Wyoming smoke by 6% while generating $30.1 million (adjusted for inflation from $29.2 million as estimated in 2014) of additional revenue during the first year (WYSAC, 2014).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"fullWidth\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-8.png\" alt=\"\" width=\"553\" height=\"454\" \/><\/p>\n<p><style>@media only screen and (max-width: 1200px){.fullWidth {width: 100% !important; height: auto;}}@media only screen and (max-width: 700px){.alignright, .alignleft, .alignnone, .card-body img {display: inline;float: none;margin: 20px 0;width: 100%;height: auto;}}<\/style>\n<p><!--nextpage--><\/p>\n<h1>Exposure to Secondhand Smoke<\/h1>\n<p><img loading=\"lazy\" decoding=\"async\" class=\" wp-image-3137 alignright\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-G2-call-out-1-1-300x263.png\" alt=\"\" width=\"257\" height=\"225\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-G2-call-out-1-1-300x263.png 300w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-G2-call-out-1-1.png 348w\" sizes=\"auto, (max-width: 257px) 100vw, 257px\" \/>Wyoming adults generally recognize the overall risk of breathing secondhand smoke: 97% think breathing secondhand smoke is very (62%) or somewhat (35%) harmful to one\u2019s health (WYSAC, 2018a). Smokefree indoor air policies and laws have demonstrated effectiveness in reducing youth initiation, reducing exposure to secondhand smoke, and increasing cessation of tobacco use (Guide to Community Preventive Services, 2015).<\/p>\n<h2>Smokefree Indoor Air Laws<\/h2>\n<p>The District of Columbia and 27 states (55% of states and DC) have comprehensive smokefree indoor air laws that cover private workplaces, restaurants, and bars. Overall, 75% of states (and DC) have some sort of smokefree indoor air law; 74% of those laws are comprehensive. When including territories such as Guam and Puerto Rico (all of which have some sort of smokefree indoor air law), 88% of the states and territories have enacted some sort of smokefree indoor air law; 71% of them are comprehensive (CDC, 2019). Based on broad success in implementing smokefree indoor air laws, a developing public health concern is whether such laws address secondhand aerosol from vaping (e.g., Marynak et al., 2014).<\/p>\n<p>Wyoming, unlike all of the bordering states, does not have a statewide smokefree indoor air law (Figure 9). Five of the six bordering states have a comprehensive smokefree indoor air law. Idaho\u2019s law covers restaurants (CDC, 2019).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"fullWidth\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-9.png\" alt=\"\" width=\"531\" height=\"540\" \/><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-3081 \" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-10.png\" alt=\"\" width=\"348\" height=\"368\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-10.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-10-284x300.png 284w\" sizes=\"auto, (max-width: 348px) 100vw, 348px\" \/>In the absence of a statewide smokefree indoor air law, 10 Wyoming municipalities have enacted local smokefree indoor air laws (Figure 10). Laramie enacted Wyoming\u2019s first smokefree indoor air law in 2005. (That law was expanded to include vaping in 2014). Since then, nine other municipalities have enacted smokefree indoor air laws. However, the law in Lyman includes a clause that allows business owners to opt out by prominently displaying signs \u201con or near every public entrance\u201d identifying the business as a \u201csmoking place\u201d (Lyman Municipal Code 4-4-5, 2011). Without complete data about the decisions of individual business owners in Lyman, WYSAC does not include Lyman residents in calculations of Wyoming residents protected by a smokefree indoor air law. In total, the remaining nine laws cover 35% of the state\u2019s population (based on estimates from U.S. Census Bureau, 2019). Currently, six <img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-3082 \" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-11.png\" alt=\"\" width=\"261\" height=\"325\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-11.png 305w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-11-241x300.png 241w\" sizes=\"auto, (max-width: 261px) 100vw, 261px\" \/>towns in Wyoming have comprehensive smokefree indoor air laws that include indoor workplaces, indoor areas of restaurants, and indoor areas of bars. These comprehensive laws cover 29% of Wyoming residents. The enactment of these laws between 2005 and 2015 demonstrates progress in public health policy, though this progress appears to have stalled.<\/p>\n<p>In 2017, most Wyoming adults reported they would support individual laws making indoor workplaces, indoor areas of restaurants, or indoor areas of casinos and clubs smokefree. Half of Wyoming adults would support a law making bars smokefree (Figure 11; WYSAC, 2018a).<\/p>\n<h2>Other Clean Air Policies<\/h2>\n<h2><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3107  alignleft\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-2.png\" alt=\"\" width=\"340\" height=\"385\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-2.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-2-265x300.png 265w\" sizes=\"auto, (max-width: 340px) 100vw, 340px\" \/><\/h2>\n<p>Voluntary smokefree policies in restaurants, bars, and other businesses also provide some protection from secondhand smoke (Guide to Community Preventive Services, 2015). In 2016, about half (55%) of Wyoming dining businesses (including bars) had a written policy protecting customers from secondhand smoke, indicating a challenge for public health efforts in Wyoming. Written policies prohibiting smoking and vaping for all indoor areas (clean air policies) were most common among fast food restaurants, possibly reflecting corporate policies set by national chains. Full service restaurants were more likely to have clean air policies than full service restaurants with attached bars. Bars, taverns, and saloons (as a single category) were the least likely business type to have clean air policies (Table 2; WYSAC, 2017a).<\/p>\n<p>In 2016, the prevalence of clean air policies differed across lodging business type. Indoor clean air policies were most common in multi-use businesses (e.g., a business that is both a motel and campground). Motels were the least likely to have clean air policies (WYSAC, 2017a; Table 3).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-3108 \" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-3.png\" alt=\"\" width=\"354\" height=\"347\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-3.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-3-300x294.png 300w\" sizes=\"auto, (max-width: 354px) 100vw, 354px\" \/><\/p>\n<p>Most Wyoming adults who work primarily indoors are covered by policies prohibiting smoking in the indoor areas of their workplaces. However, these policies do not completely protect Wyoming workers from secondhand smoke (Table 4); 20% of adults reported breathing secondhand smoke at work in the past week (WYSAC, 2018a). Because workers in small communities may not be able to realistically factor a potential employer\u2019s smoking policy into their decision about where to work, ensuring the protection of these workers from involuntary exposure to tobacco smoke remains a public health challenge in Wyoming.<\/p>\n<p>Between 2002 and 2017, the percentage of Wyoming adults who did not allow smoking inside their homes increased from 72% to 89%, possibly as a result of efforts from the TPCP, CDC, and other public health organizations (e.g., the Americans for Nonsmokers\u2019 Rights Foundation) to discourage smoking in the home\u2014such as around children (WYSAC, 2018a).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3109  alignleft\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-4.png\" alt=\"\" width=\"360\" height=\"238\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-4.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-4-300x198.png 300w\" sizes=\"auto, (max-width: 360px) 100vw, 360px\" \/>According to the <em>Wyoming 2016 School Health Profiles Report: Trend Analysis Report<\/em> (2017), schools qualify as tobacco-free when there is a policy that specifically prohibits the use of <em>all types of tobacco<\/em> (including cigarettes, smokeless tobacco, cigars, and pipes, but not necessarily ENDS\/e-cigarettes) <em>by all people<\/em> (all students, faculty\/staff, and visitors) <em>at all times<\/em> (including during non-school hours) <em>and in all places<\/em> (including school-sponsored events held off campus). In 2016, 40% of Wyoming schools had tobacco-free policies, a significant decrease from 50% in 2014. This decrease, after having increased between 2010 and 2014, indicates a developing public health challenge in Wyoming.<\/p>\n<p>Since the most recent data, teen vaping has become an epidemic (FDA, 2018; USDHHS, 2018). Concerns about teen vaping may create an opportunity for schools to review their overall tobacco policies.<\/p>\n<p>Support for smokefree policies in indoor workplaces has steadily increased from 71% in 2002 to 83% in 2017. Support for smokefree policies in restaurants has also steadily increased from 57% in 2002 to 79% in 2017 (WYSAC, 2018a). Educational and social norming efforts implemented by the Wyoming TPCP, the CDC, and other organizations (e.g., the Americans for Nonsmokers\u2019 Rights Foundation) that promote public health probably contributed to these changes in opinion. More Wyoming adults stated that smoking should never be allowed in casinos, clubs, or bars in 2017 than in 2015, but support for smokefree bars was lower than for other venues, marking a challenge for protecting customers and employees from the health impacts of secondhand smoke in Wyoming (Figure 12; WYSAC, 2018a). Recent national data are not available for comparison, likely because of the large number of comprehensive smokefree indoor air laws. <img loading=\"lazy\" decoding=\"async\" class=\"fullWidth\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-12.png\" alt=\"\" width=\"544\" height=\"445\" \/><\/p>\n<p><style>@media only screen and (max-width: 1200px){.fullWidth {width: 100% !important; height: auto;}}@media only screen and (max-width: 700px){.alignright, .alignleft, .alignnone, .card-body img {display: inline;float: none;margin: 20px 0;width: 100%;height: auto;}}<\/style>\n<p><!--nextpage--><\/p>\n<h1>Encourage Tobacco Users to Quit<\/h1>\n<h2>Benefits of Cessation<img loading=\"lazy\" decoding=\"async\" class=\" wp-image-3103 alignright\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-G3-call-out-1-300x137.png\" alt=\"\" width=\"265\" height=\"121\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-G3-call-out-1-300x137.png 300w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-G3-call-out-1.png 420w\" sizes=\"auto, (max-width: 265px) 100vw, 265px\" \/><\/h2>\n<p>Smoking cessation has short- and long-term health benefits (Table 5). Some health effects of smoking cessation (e.g., increased lung functioning) are evident within a few weeks or months of quitting, suggesting that relatively brief periods of abstinence have health benefits. Others (e.g., reduced risk of stroke) are not fully evident for five years or longer, reflecting the long-term benefits of successful smoking cessation (as compiled by the American Cancer Society, 2015). Smoking cessation stops the processes which lead to cancer (CDC, 2010).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"fullWidth\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-5.png\" alt=\"\" width=\"555\" height=\"441\" \/><\/p>\n<h2>Cessation Among Wyoming Smokers<\/h2>\n<p>In 2017, most (87%) adults in Wyoming who smoked every day or some days had stopped smoking for at least one day in their lifetime because they were trying to quit smoking for good, likely a success from public health efforts from groups such as the TPCP, CDC, and U.S. Surgeon General\u2019s Office. This statistic has remained fairly steady since 2010. Of those smokers who had tried to quit in their lifetime, over half tried to quit smoking at least once in the past year. Nicotine replacement therapies (NRTs) are the most popular type of cessation aid in Wyoming; 31% of current smokers who had made a quit attempt within the past year used NRTs. Common barriers for people trying to quit smoking were loss of a way to handle stress, cravings for a cigarette, and other people smoking around them (WYSAC, 2018a). Evidence-based programs like the Wyoming Quit Tobacco (WQT) program include coaching to address these barriers.<\/p>\n<h2>The Wyoming Quit Tobacco (WQT) Program<\/h2>\n<p>The WQT program assists Wyoming residents who want to quit using tobacco by offering them telephone-based cessation coaching, NRTs, and prescription medications. In addition, the WQT program offers online, texting, and email support services. National Jewish Health has been the WQT program service provider since 2013.<\/p>\n<p>In 2017, 49% of non-tobacco users and 77% of tobacco users said they were aware of telephone quitline services, such as the WQT program, that are available to help people quit using tobacco (WYSAC, 2018a).<\/p>\n<p>Most people who enroll in the WQT program do so to get help quitting cigarettes, though some seek help quitting smokeless tobacco, ENDS\/e-cigarettes, and\/or other tobacco (e.g., cigars, cigarillos, little cigars, hookah, and pipes). Since July 2013, when National Jewish Health became the WQT program service provider, 30% of enrollees had not used any tobacco products for at least 30 days when they answered the Follow-Up Survey seven months after enrolling. This success rate is a key success of efforts funded by the WDH. Enrollees who use phone coaching and prescription medication such as Chantix often see the greatest success rates, including a substantial improvement over using phone coaching alone (currently, enrollees must use phone coaching to obtain medications).<\/p>\n<p><style>@media only screen and (max-width: 1200px){.fullWidth {width: 100% !important; height: auto;}}@media only screen and (max-width: 700px){.alignright, .alignleft, .alignnone, .card-body img {display: inline;float: none;margin: 20px 0;width: 100%;height: auto;}}<\/style>\n<p><!--nextpage--><\/p>\n<style>@media only screen and (max-width: 1200px){.fullWidth {width: 100% !important; height: auto;}}@media only screen and (max-width: 700px){.alignright, .alignleft, .alignnone, .card-body img {display: inline;float: none;margin: 20px 0;width: 100%;height: auto;}}<\/style>\n<\/p>\n<h1>Tobacco-Related Disparities<\/h1>\n<h2>Smoking<\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"fullWidth\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-13.png\" alt=\"\" width=\"566\" height=\"300\" \/><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-3085 \" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-14.png\" alt=\"\" width=\"315\" height=\"245\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-14.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-14-300x233.png 300w\" sizes=\"auto, (max-width: 315px) 100vw, 315px\" \/><\/p>\n<p>Young men (11%) and young women (11%) in high school smoke at about the same rate, but we do see a significant difference when it comes to race and ethnicity. Native American and Hispanic students smoke at higher rates than their counterparts do. Asian students stand out as having a low smoking rate (Figure 13, PNA, 2018).<\/p>\n<p>Among adults, two broad demographic groups stand out as having low smoking rates: adults 65 years of age and older (to a lesser degree, adults between the ages of 45 and 64) and adults with more than a high school education (Figure 14 &amp; Figure 15).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3086  alignright\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-15.png\" alt=\"\" width=\"312\" height=\"313\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-15.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-15-300x300.png 300w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-15-150x150.png 150w\" sizes=\"auto, (max-width: 312px) 100vw, 312px\" \/><\/p>\n<p>For Wyoming, the 2017 BRFSS only reported smoking rates for three racial and ethnic groups: (a) Hispanic (21%) adults, (b) Non-Hispanic White (18%) adults, and (c) Non-Hispanic American Indian or Alaskan Native (24%) adults. These smoking prevalence rates were not significantly different, mainly because the confidence intervals for the minority groups were very large, a result of the relatively low numbers of adults from these groups in Wyoming (BRFSS, 2017).<\/p>\n<h2>Vaping<\/h2>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"fullWidth\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-16.png\" alt=\"\" width=\"557\" height=\"417\" \/><\/p>\n<p>Young men (37%) and young women (35%) in high school vape at about the same rate, but there are disparities by race and ethnicity. Hispanic high school students stand out as having a high vaping rate and Asian students stand out as having a low vaping rate (Figure 16; PNA, 2018).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-17.png\" alt=\"\" width=\"251\" height=\"294\" \/> <img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-18.png\" alt=\"\" width=\"355\" height=\"279\" \/><\/p>\n<p>Because vaping is relatively rare among Wyoming adults (6% overall), 2017 BRFSS data do not allow for full exploration of demographic differences. Young adults (aged 18-24) stand out as having a high vaping prevalence, and college graduates stand out as having a low vaping prevalence (Figure 17 &amp; Figure 18). CDC only reports the current vaping rate for White, Non-Hispanic adults and no other racial or ethnic group.<\/p>\n<p>&nbsp;<\/p>\n<h1>\n<style>@media only screen and (max-width: 1200px){.fullWidth {width: 100% !important; height: auto;}}@media only screen and (max-width: 700px){.alignright, .alignleft, .alignnone, .card-body img {display: inline;float: none;margin: 20px 0;width: 100%;height: auto;}}<\/style>\n<p><!--nextpage--><\/h1>\n<h1>Burdens of Tobacco Use<img loading=\"lazy\" decoding=\"async\" class=\" wp-image-3079 alignright\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Burdens-call-out-1-300x200.png\" alt=\"\" width=\"261\" height=\"174\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Burdens-call-out-1-300x200.png 300w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-Burdens-call-out-1.png 419w\" sizes=\"auto, (max-width: 261px) 100vw, 261px\" \/><\/h1>\n<h2>Economic Burdens<\/h2>\n<p>The death and disease caused by tobacco has economic costs. In 2010, tobacco-related healthcare cost Wyoming nearly $240 million, including private and public costs\u2014more than alcohol and other drugs (Figure 19; WYSAC, 2012).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-3090 \" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-19.png\" alt=\"\" width=\"337\" height=\"290\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-19.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-19-300x258.png 300w\" sizes=\"auto, (max-width: 337px) 100vw, 337px\" \/>There are also less direct economic costs of tobacco use. Smoking is associated with lost productivity both nationally (USDHHS, 2015) and in Wyoming. Tobacco cost the state of Wyoming nearly $450 million in total productivity losses in 2010 (Table 6; WYSAC, 2012).<\/p>\n<p>Workers who smoke are generally less healthy and more costly for employers. Employing smokers is also associated with increased property loss and occupational disease (USDHHS, 2015). Berman et al. (2013) estimated that, on average, it costs $5,816 more per year to employ a smoker than a nonsmoker. Smokers are more likely to be injured at work than nonsmokers (Craig et al., 2006; USDHHS, 2015). These costs could be reduced by employers if they implement smokefree air policies and\/or offer their employees access to cessation services (and those smokers use those services to successfully quit).<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3111  alignleft\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-6.png\" alt=\"\" width=\"367\" height=\"233\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-6.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-6-300x190.png 300w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-table-6-317x200.png 317w\" sizes=\"auto, (max-width: 367px) 100vw, 367px\" \/>Tobacco-attributable health costs also affect the U.S. military and veterans. A history of smoking has been associated with increased risk of injury for men in U.S. Army basic combat training (Bulzacchelli et al., 2014). In 2010, smoking-attributable medical costs for the Veterans Health Administration were approximately $2.7 billion (Barnett et al., 2015). More broadly, the U.S. Surgeon General, surgeon general of the Air Force (Adams et al., 2019), the U.S. Navy and Marines (Adams et al., 2019; Navy and Marine Corps Public Health Center, n.d.) and U.S. Army (Adams et al., 2019; Army Public Health Center, 2019) have identified tobacco use as a threat to readiness of military personnel.<\/p>\n<h2>Health Burdens<\/h2>\n<p>Each year, an estimated 800 Wyoming adults die prematurely from smoking-attributable illnesses such as heart disease, lung diseases, and cancers (CDC, 2014a), an average of over two deaths per day. Each year, 480,000 people in the U.S. die prematurely from smoking or from exposure to secondhand smoke (USDHHS, 2015), an average of over 1,300 deaths per day. Tobacco use causes one in five deaths, more than the number of deaths attributable to alcohol, car crashes, suicides, AIDS, homicides, and illegal drugs <em>combined<\/em> (CDC, 2015a). Reducing deaths caused, in whole or in part, by tobacco use is the primary long-term goal of public health organizations working in tobacco prevention, including the TPCP and CDC. A related intermediate-goal is reducing the disease burden caused by tobacco use.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"fullWidth\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-20.png\" alt=\"\" width=\"581\" height=\"408\" \/><\/p>\n<p>Chronic diseases are leading causes of death and sickness in the U.S. and Wyoming (Centers for Disease Control and Prevention, National Center for Health Statistics [CDC, NCHS], 2015). Smoking is the leading preventable cause of chronic disease and death in the U.S. (USDHHS, 2010). Although there is no safe level of exposure to tobacco smoke, greater exposure increases the risk for and severity of chronic disease. Cigarette smoke contains cancer-causing agents and chemicals that cause heart (cardiovascular) and lung (pulmonary and respiratory) diseases and contribute to poor reproductive and dental health. There are more than 7,000 toxic chemicals in cigarette smoke, including ammonia, tar, and carbon monoxide. These chemicals increase the risk for developing several preventable chronic diseases for smokers and those who breathe secondhand smoke (Figure 20; USDHHS, 2014).<\/p>\n<p>Compared to Wyoming nonsmokers, current and former smokers were more likely to have been diagnosed with several chronic illnesses (Figure 21; WYSAC, 2018a):<\/p>\n<ul>\n<li>5 times more likely to have been diagnosed with chronic lung disease,<\/li>\n<li>8 times more likely to have heart disease,<\/li>\n<li>7 times more likely to have diabetes,<\/li>\n<li>4 times more likely to have cancer (other than skin cancer),<\/li>\n<li>3 times more likely to have high blood pressure, and<\/li>\n<li>2 times more likely to have high cholesterol.<\/li>\n<\/ul>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-3093  alignleft\" src=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-21.png\" alt=\"\" width=\"359\" height=\"387\" srcset=\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-21.png 410w, https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2020\/12\/Annual-Summary-2019-fig-21-278x300.png 278w\" sizes=\"auto, (max-width: 359px) 100vw, 359px\" \/><\/p>\n<p>ENDS\/e-cigarettes are a new tobacco product. Therefore, research on the contents of their liquid, aerosol, and health effects is limited. Long-term health effects of ENDS use are still unknown. However, research does shows that vaping harms lung function (Cressey, 2014). Early studies about the contents of the liquid and aerosol show the presence of varying levels of nicotine and cancer-causing chemicals such as formaldehyde (American Lung Association, 2016). Overdoses have been reported, including among children, from drinking the nicotine liquid or spilling the liquid on their skin (CDC, 2014b). The nicotine in most e-liquids is known to be addictive, can harm the developing brains of youth and young adults, and may make it more likely that youth will go on to develop other addictions (USDHHS, 2016). Labels on e-liquid have also presented inaccurate information about nicotine concentrations, meaning users might vape a nicotine-containing liquid contrary to their intention to avoid nicotine (Goniewicz et al., 2015). Aerosol from ENDS also contains chemicals linked to lung disease and heavy metals like lead (USDHHS, 2016).<\/p>\n<p>&nbsp;<\/p>\n<h1>\n<style>@media only screen and (max-width: 1200px){.fullWidth {width: 100% !important; height: auto;}}@media only screen and (max-width: 700px){.alignright, .alignleft, .alignnone, .card-body img {display: inline;float: none;margin: 20px 0;width: 100%;height: auto;}}<\/style>\n<p><!--nextpage--><\/h1>\n<h1>References<\/h1>\n<p>Adams, J., West, N., Faison, F., &amp; Hogg, D. (2019). Tobacco product use threatens military readiness. <em>Stars &amp; Stripes.<\/em> Retrieved July 25, 2019, from <a href=\"https:\/\/www.stripes.com\/opinion\/tobacco-product-use-threatens-military-readiness-1.589063\">https:\/\/www.stripes.com\/opinion\/tobacco-product-use-threatens-military-readiness-1.589063<\/a><\/p>\n<p>Afton, Wyoming, Municipal Code \u00a76-8-04 (2008).<\/p>\n<p>American Cancer Society. (2015). <em>Benefits of quitting smoking over time<\/em>. Retrieved April 18, 2016, from <a href=\"http:\/\/www.cancer.org\/healthy\/stayawayfromtobacco\/benefits-of-quitting-smoking-over-time\">http:\/\/www.cancer.org\/healthy\/stayawayfromtobacco\/benefits-of-quitting-smoking-over-time<\/a><\/p>\n<p>American Lung Association. (2016). <em>E-cigarettes and lung health<\/em>. Retrieved July 27, 2017, from <a href=\"http:\/\/www.lung.org\/stop-smoking\/smoking-facts\/e-cigarettes-and-lung-health.html?referrer=https:\/\/www.google.com\/\">http:\/\/www.lung.org\/stop-smoking\/smoking-facts\/e-cigarettes-and-lung-health.html?referrer=https:\/\/www.google.com\/<\/a><\/p>\n<p>Army Public Health Center. (2019). <em>Tobacco-free living &amp; vaping. <\/em>Retrieved June 12, 2019, from <a href=\"https:\/\/phc.amedd.army.mil\/topics\/healthyliving\/tfl\/Pages\/default.aspx\">https:\/\/phc.amedd.army.mil\/topics\/healthyliving\/tfl\/Pages\/default.aspx<\/a><\/p>\n<p><em>Behavioral Risk Factor Surveillance System<\/em> [Data file 2011-2017]. (2017). Centers for Disease Control and Prevention. Retrieved June 10, 2019, from <a href=\"https:\/\/www.cdc.gov\/brfss\/data_tools.htm\">https:\/\/www.cdc.gov\/brfss\/data_tools.htm<\/a><\/p>\n<p>Barnett, P. G., Hamlett-Berry, K., Sung, H. Y., &amp; Max, W. (2015). Health care expenditures attributable to smoking in military veterans. <em>Nicotine &amp; Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco, 17<\/em>(5), 586\u2013591. doi:10.1093\/ntr\/ntu187<\/p>\n<p>Berman, M., Crane, R., Seiber, E., &amp; Munur, M. (2013). Estimating the cost of a smoking employee. <em>Tobacco Control, 23<\/em>, 428-433. doi 10.1136\/tobaccocontrol-2012-050888<\/p>\n<p>Bulzacchelli, M. T., Sulsky, S. I., Rodriguez-Monguio, R., Karlsson, L. H., &amp; Hill, O. T. (2014). Injury during U.S. Army basic combat training: A systematic review of risk factor studies. <em>American Journal of Preventive Medicine, 47<\/em>(6), 813\u2013822.<\/p>\n<p>Burlington, Wyoming, Municipal Code \u00a78-64-40 (2008).<\/p>\n<p>Casper, Wyoming, Municipal Code \u00a78-16 (2015).<\/p>\n<p>Centers for Disease Control and Prevention. (2010). <em>How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease\u20132010<\/em>. 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. Retrieved May 15, 2015, from <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK53017\/\">http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK53017\/<\/a><\/p>\n<p>Centers for Disease Control and Prevention. (2014a). <em>Best practices for comprehensive tobacco control programs \u2013 2014<\/em>. 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.<\/p>\n<p>Centers for Disease Control and Prevention. (2014b). Notes from the field: Calls to poison centers for exposures to electronic cigarettes\u2014United States, September 2010\u2013February 2014. <em>MMWR, 63<\/em>, 292\u2013293.<\/p>\n<p>Centers for Disease Control and Prevention. (2014c). <em>Preventing initiation of tobacco use: Outcome indicators for comprehensive tobacco control programs\u20132014<\/em>. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrieved October 23, 2017, from <a href=\"https:\/\/www.cdc.gov\/tobacco\/tobacco_control_programs\/surveillance_evaluation\/preventing_initiation\/pdfs\/preventing_initiation.pdf\">https:\/\/www.cdc.gov\/tobacco\/tobacco_control_programs\/surveillance_evaluation\/preventing_initia tion\/pdfs\/preventing_initiation.pdf<\/a><\/p>\n<p>Centers for Disease Control and Prevention. (2015a). <em>Health effects of cigarette smoking. <\/em>Retrieved March 30, 2016, from http:\/\/www.cdc.gov\/tobacco\/data_statistics\/fact_sheets \/health_effects\/effects_cig_smoking\/#definition<\/p>\n<p>Centers for Disease Control and Prevention. (2015b). <em>Promoting quitting among adults and young people: outcome indicators for comprehensive tobacco control programs\u20142015. <\/em>Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrieved October 23, 2017, from <a href=\"https:\/\/www.cdc.gov\/tobacco\/stateandcommunity\/tobacco_control_programs\/surveillance_evaluation\/key-outcome-2015\/pdfs\/KOI_Goal3_Update_12_28_15.pdf\">https:\/\/www.cdc.gov\/tobacco\/stateandcommunity\/ tobacco_control_programs\/surveillance_evaluation\/key-outcome-2015\/pdfs\/KOI_Goal3_Update_12_28_15.pdf<\/a><\/p>\n<p>Centers for Disease Control and Prevention. (2017). <em>Eliminating exposure to secondhand smoke: Outcome indicators for comprehensive tobacco control programs\u20132017<\/em>. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.<\/p>\n<p>Centers for Disease Control and Prevention. (2019). <em>State tobacco activities tracking and evaluation (STATE) system.<\/em> Retrieved June 10, 2019, from <a href=\"https:\/\/www.cdc.gov\/statesystem\/index.html\">https:\/\/www.cdc.gov\/ statesystem\/index.html<\/a><\/p>\n<p>Centers for Disease Control and Prevention, National Center for Health Statistics [Data File 1999- 2015]. (2015). <em>Underlying Cause of Death 1999-2015.<\/em> Retrieved July 19, 2017, from <a href=\"http:\/\/wonder.cdc.gov\/ucd-icd10.html\">http:\/\/wonder.cdc.gov\/ucd-icd10.html<\/a><\/p>\n<p>Chaloupka, F. J., Yurekli, A., Fong, G. T. (2012). <em>Tobacco taxes as a tobacco control strategy. Tobacco Control, 21<\/em>, 172-180. doi: 10.1136\/tobaccocontrol-2011-050417<\/p>\n<p>Cheyenne, Wyoming, Municipal Code \u00a78-64-040 (2006).<\/p>\n<p>Craig, C. N., Congleton, J. J., Kerk, C.J., Amendola, A.A., &amp; Gaines, W. G. (2006). Personal and non-occupational risk factors and occupational injury\/illness. <em>American Journal of Industrial Medicine, 49<\/em>, 249-206. doi: 10.1002\/ajim.20290<\/p>\n<p>Cressey, D. (2014). E-cigarettes: The lingering questions. <em>Nature, 513, <\/em>24-26. Retrieved October 31, 2017, from <a href=\"http:\/\/www.nature.com\/news\/e-cigarettes-the-lingering-questions-1.15762\">http:\/\/www.nature.com\/news\/e-cigarettes-the-lingering-questions-1.15762<\/a><\/p>\n<p>Evanston, Wyoming, Municipal Code \u00a710-4 (2007).<\/p>\n<p>Farrelly, M. C., Nimsch, C. T., &amp; James, J. (2003). <em>State cigarette excise taxes: Implications for revenue and tax evasion<\/em>. Retrieved November 9, 2016, from <a href=\"http:\/\/www.rti.org\/sites\/default\/files\/resources\/8742_Excise_Taxes_FR_5-03.pdf\">http:\/\/www.rti.org\/sites\/default\/files\/ resources\/8742_Excise_Taxes_FR_5-03.pdf<\/a><\/p>\n<p>Goniewicz, M. L., Gupta, R., Lee, Y. H., Reinhardt, S., Kim, S., Kim, B., Kosmider, L., &amp; Sobczak, A. (2015). Nicotine levels in electronic cigarette refill solutions: A comparative analysis of products from the U.S., Korea, and Poland. <em>The International journal on drug policy, 26<\/em>(6), 583\u2013588. doi:10.1016\/j.drugpo.2015.01.020<\/p>\n<p>Green River, Wyoming, Municipal Code \u00a718-93 (2007).<\/p>\n<p>Guide to Community Preventive Services. (2015). Reducing tobacco use and secondhand smoke exposure. Retrieved July 27, 2017, from <a href=\"https:\/\/www.thecommunityguide.org\/sites\/default\/files\/assets\/What-Works-Tobacco-factsheet-and-insert.pdf\">https:\/\/www.thecommunityguide.org\/sites\/ default\/files\/assets\/What-Works-Tobacco-factsheet-and-insert.pdf<\/a><\/p>\n<p>Laramie, Wyoming, Municipal Code \u00a78-56-030 (2005\/2014).<\/p>\n<p>Lyman, Wyoming, Municipal Code \u00a74-4-5 (2011).<\/p>\n<p>Marynak, K., Holmes, C. B., King, B. A., Promoff, G., Bunnell, R., &amp; McAfee, T. (2014). State laws prohibiting sales to minors and indoor use of electronic nicotine delivery Systems\u2014United States, November 2014. <em>MMWR, 63<\/em>(49), 1145\u20131150.<\/p>\n<p>Mountain View, Wyoming, Municipal Code \u00a7 4-6-5 (2011).<\/p>\n<p><em>Prevention Needs Assessment<\/em> [Data File 2001-2018]. (2018). Wyoming Survey &amp; Analysis Center, University of Wyoming.<\/p>\n<p>Navy and Marine Corps Public Health Center (n.d.). <em>Tobacco free living: No dips. No butts. More glory<\/em>. Retrieved June 12, 2019, from <a href=\"https:\/\/www.med.navy.mil\/sites\/nmcphc\/health-promotion\/tobacco-free-living\/Pages\/tobacco-free-living.aspx\">https:\/\/www.med.navy.mil\/sites\/nmcphc\/health-promotion\/tobacco-free-living\/Pages\/tobacco-free-living.aspx<\/a><\/p>\n<p>Rock Springs, Wyoming, Municipal Code \u00a74-1604 (2008).<\/p>\n<p>Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention. (2010). Implementing the Synar regulation: Tobacco outlet inspection. Retrieved October 1, 2010, from CSAP\u2019s State Online Resource Center (SORCE) <a href=\"http:\/\/sorce.e-prevention.org\">http:\/\/sorce.e-prevention.org<\/a><\/p>\n<p>Substance Abuse and Mental Health Services Administration. (2019). State target and reported retailer violation rates. Retrieved June 10, 2019, from <a href=\"https:\/\/www.samhsa.gov\/sites\/default\/files\/synar_program_rvr_table_1997-2018_dec_11_2018.pdf\">https:\/\/www.samhsa.gov\/sites\/default\/files\/synar_program_rvr_table_1997-2018_dec_11_2018.pdf<\/a><\/p>\n<p>U.S. Census Bureau. (2019). <em>American Fact Finder<\/em> [user interface tool]: <em>Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2018<\/em>. Retrieved June 10, 2019, from <a href=\"http:\/\/factfinder.census.gov\/faces\/nav\/jsf\/pages\/index.xhtml\">http:\/\/factfinder.census.gov\/faces\/nav\/jsf\/pages\/index.xhtml<\/a><\/p>\n<p>U.S. Department of Health and Human Services. (2010). <em>How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the Surgeon General<\/em>. 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. Retrieved from <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK53017\/\">http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK53017\/<\/a><\/p>\n<p>U.S. Department of Health and Human Services. (2014). <em>The health consequences of smoking \u2013 50 years of progress: A report of the Surgeon General<\/em>. Retrieved January 21, 2014, from <a href=\"http:\/\/www.cdc.gov\/tobacco\/data_statistics\/sgr\/50th-anniversary\/index.htm\">http:\/\/www.cdc.gov\/tobacco\/data_statistics\/sgr\/50th-anniversary\/index.htm<\/a><\/p>\n<p>U.S. Department of Health and Human Services. (2015). <em>Promoting health and preventing disease and injury through workplace tobacco policie<\/em>s. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Retrieved from <a href=\"http:\/\/www.cdc.gov\/niosh\/docs\/2015-113\/pdfs\/cib-67_2015-113_v5.pdf\">http:\/\/www.cdc.gov\/niosh\/docs\/2015-113\/pdfs\/cib-67_2015-113_v5.pdf<\/a><\/p>\n<p>U.S. Department of Health and Human Services. (2016). <em>E-cigarette use among youth and young adults: A report of the Surgeon General.<\/em> 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. Retrieved June 11, 2019, from <a href=\"https:\/\/www.cdc.gov\/tobacco\/data_statistics\/sgr\/e-cigarettes\/pdfs\/2016_sgr_entire_report_508.pdf\">https:\/\/www.cdc.gov\/tobacco\/data_statistics\/sgr\/e-cigarettes\/pdfs\/2016_sgr_entire_report_508.pdf<\/a><\/p>\n<p>U.S. Department of Health and Human Services. (2018). <em>Surgeon General\u2019s advisory on e-cigarette use among youth.<\/em> Retrieved June 11, 2019, from <a href=\"https:\/\/e-cigarettes.surgeongeneral.gov\/documents\/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf\">https:\/\/e-cigarettes.surgeongeneral.gov\/documents\/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf<\/a><\/p>\n<p>U.S. Food and Drug Administration. (2018). <em>FDA statement: Statement from FDA Commissioner Scott Gottlieb, M.D., on new steps to address epidemic of youth e-cigarette use. <\/em>Retrieved June 11, 2019, from <a href=\"https:\/\/www.fda.gov\/news-events\/press-announcements\/statement-fda-commissioner-scott-gottlieb-md-new-steps-address-epidemic-youth-e-cigarette-use\">https:\/\/www.fda.gov\/news-events\/press-announcements\/statement-fda-commissioner-scott-gottlieb-md-new-steps-address-epidemic-youth-e-cigarette-use<\/a><\/p>\n<p><em>Wyoming 2016 School Health Profiles report: Trend analysis report<\/em>. (2017). Retrieved December 18, 2017, from <a href=\"https:\/\/1ddlxtt2jowkvs672myo6z14-wpengine.netdna-ssl.com\/wp-content\/uploads\/2015\/11\/2016WY-Trend-Report.pdf\">https:\/\/1ddlxtt2jowkvs672myo6z14-wpengine.netdna-ssl.com\/wp-content\/uploads\/2015\/11\/2016WY-Trend-Report.pdf<\/a><\/p>\n<p>Wyoming Department of Health &amp; WYSAC. (2019). Annual Synar report: FFY 2019 State: Wyoming.<\/p>\n<p>Wyoming Department of Revenue. [ca. 2014]. <em>Cigarette tax distribution, by year<\/em>. Retrieved April 7, 2014, from <a href=\"http:\/\/revenue.wyo.gov\/tax-distribution-reports\/cigarette-tax-distribution-by-uear\">http:\/\/revenue.wyo.gov\/tax-distribution-reports\/cigarette-tax-distribution-by-uear<\/a><\/p>\n<p>WYSAC. (2012). <em>Cost of substance abuse in Wyoming 2010<\/em>, by N. M. Nelson, M. Kato, &amp; H. Costello. (WYSAC Technical Report No. DER-1250). Wyoming Survey &amp; Analysis Center, University of Wyoming.<\/p>\n<p>WYSAC. (2014<em>). Tax revenue and cigarette consumption in Wyoming: May 1996 \u2013 April 2014, <\/em>by N. M. Nelson &amp; M. Kato. (WYSAC Technical Report No. DER-1211). Wyoming Survey &amp; Analysis Center, University of Wyoming.<\/p>\n<p>WYSAC. (2016) <em>Wyoming Alcohol and Tobacco Sales Compliance Checks, 2016, <\/em>by Holder, W. T. (WYSAC Technical Report No. SRC-1609). Wyoming Survey &amp; Analysis Center, University of Wyoming<\/p>\n<p>WYSAC. (2017a). <em>2016 Hospitality Survey: Smoke- and vape-free policies in Wyoming\u2019s dining, drinking, and lodging establishments<\/em>, by L. Wimbish &amp; L. H. Despain. (WYSAC Technical Report No. CHES-1660). Wyoming Survey &amp; Analysis Center, University of Wyoming.<\/p>\n<p>WYSAC. (2017b). <em>Synar 2017 (FFY 2018) report: Synar Inspection Study and Electronic Nicotine Delivery System (ENDS) Pilot Study<\/em>, by L. H. Despain &amp; J. Penner. (WYSAC Technical Report No. CHES-1736). Wyoming Survey &amp; Analysis Center, University of Wyoming.<\/p>\n<p>WYSAC. (2017c). <em>Wyoming alcohol and tobacco sales compliance checks, 2017<\/em>, by Holder, W.T. (WYSAC Technical Report No. SRC-1708). Wyoming Survey &amp; Analysis Center, University of Wyoming.<\/p>\n<p>WYSAC. (2018a). 2017 Wyoming Adult Tobacco Survey: Wyoming adults\u2019 use of and attitudes about tobacco products by M. Kato &amp; L. H. Despain. Wyoming Survey &amp; Analysis Center, University of Wyoming.<\/p>\n<p>WYSAC. (2018b). <em>Wyoming Alcohol and Tobacco Sales Compliance Checks, 2018<\/em>, by Dorssom, M. (WYSAC Technical Report No. SRC-1810). Wyoming Survey &amp; Analysis Center, University of Wyoming.<\/p>\n<p><em>Youth Risk Behavior Surveillance System<\/em> [Data File 1991\u20132015]. (2015). Centers for Disease Control and Prevention. Retrieved October 31, 2017, from <a href=\"http:\/\/www.cdc.gov\/healthyyouth\/yrbs\/index.htm\">http:\/\/www.cdc.gov\/healthyyouth\/yrbs\/index.htm<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Context for Tobacco Prevention in Wyoming There is no safe level of exposure to tobacco smoke. Each year, an estimated 800 Wyoming adults die prematurely from smoking-attributable illnesses such as heart disease, lung diseases, and cancers (primarily of the respiratory system; Centers for Disease Control and Prevention [CDC], 2014a). In 2010, tobacco-related healthcare cost Wyoming [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":1311,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[3],"tags":[7,10,92,62,75,43,9,74,8,73,89,38,45,72],"coauthors":[22,25],"class_list":["post-3075","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-reports","tag-use-adults","tag-cessation","tag-chronic-disease","tag-cigarettes","tag-disparities","tag-electronic-cigarettes","tag-health-econ","tag-secondhand-smoke","tag-laws","tag-tax","tag-tobacco","tag-tobacco-taxes","tag-wyoming","tag-youth-initiation"],"_links":{"self":[{"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/posts\/3075","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/comments?post=3075"}],"version-history":[{"count":67,"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/posts\/3075\/revisions"}],"predecessor-version":[{"id":3308,"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/posts\/3075\/revisions\/3308"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/media\/1311"}],"wp:attachment":[{"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/media?parent=3075"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/categories?post=3075"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/tags?post=3075"},{"taxonomy":"author","embeddable":true,"href":"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-json\/wp\/v2\/coauthors?post=3075"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}