The Surgeon General declared vaping (the use of e-cigarettes or electronic nicotine delivery systems [ENDS]; also known as e-cigarettes or vaping devices) an epidemic among youth and young adults in 2018 (USDHHS, 2018). Research indicates that vaping can lead to cigarette smoking (Berry et al., 2019; Hair et al., 2021). However, the CDC also states that vaping could be better than smoking for non-pregnant adult smokers if they completely switch from smoked tobacco products to ENDS (CDC, 2022a). More research is needed to learn about the long-term effects of vaping and breathing secondhand aerosol exhaled from someone who is using ENDS (CDC, 2022a).<\/p>\n
Certain groups of people are more at risk of suffering the impacts of tobacco use than others. Research has repeatedly shown that tobacco companies have targeted promotional efforts toward certain neighborhoods, the LGBTQ+ community, people of color, people with lower incomes, Indigenous people, and people experiencing behavioral health conditions (D\u2019Silva et al., 2018; Farber & Folan, 2017; Lee et al., 2015; Prochaska et al., 2017). As a result, people in these groups are more likely to smoke. That puts these populations at a disproportionate risk of smoking-related disease and death. These inequities have a greater impact on health outcomes than individual choices.<\/p>\n
The Wyoming Substance Use and Tobacco Prevention Program (SUTPP) and the CDC share four goals:<\/p>\n
- \n
- Preventing initiation of tobacco use (CDC, 2014b)<\/li>\n
- Eliminating nonsmokers\u2019 exposure to secondhand smoke (CDC, 2017)<\/li>\n
- Promoting quitting among adults and young people (CDC, 2015)<\/li>\n
- Identifying and eliminating tobacco-related disparities (CDC, 2014b, 2015, 2017, 2021b)<\/li>\n<\/ol>\n
The SUTPP uses a variety of strategies as it focuses on reducing the impact of tobacco use in Wyoming by achieving these goals. The SUTPP monitors its progress on these goals by tracking the use and availability of tobacco products including cigarettes, ENDS, and other forms of tobacco.<\/p>\n
The achievement of tobacco prevention outcomes is the collective result of the work of many organizations over time. The efforts of state government programs including the SUTPP, multiple federal agencies, county prevention specialists, and other groups have all played a part in tobacco prevention and control in Wyoming. Key federal agencies include the U.S. Food and Drug Administration (FDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the CDC. Non-governmental groups include the Robert Wood Johnson Foundation, the Campaign for Tobacco-Free Kids, the American Nonsmokers\u2019 Rights Foundation, the American Cancer Society, and the American Lung Association. Changes also reflect influences of the tobacco industry, such as changes in marketing practices or the release of new products such as ENDS.<\/p>\n
The Wyoming Adult Tobacco Survey (ATS) is a telephone survey administered by the Wyoming Survey & Analysis Center (WYSAC) at the University of Wyoming under contract to the Wyoming Department of Health (WDH), Public Health Division (PHD). Its purpose is to collect state- and county-level data about tobacco use, the four SUTPP\/CDC goals, and the broader goal of reducing tobacco-related disease and death. In addition to analyzing the 2021 data, WYSAC used data from previous versions of the survey to analyze trends.<\/p>\n
<\/p>\n
2021 ATS Methods<\/h1>\n
This report summarizes results from the 2021 ATS and trend analyses using previous versions of the ATS.<\/p>\n
In this section, WYSAC provides a general summary of the methods used to collect and analyze the data for the 2021 ATS. Additional technical details, including criteria for determining statistical significance, are in the appendices.<\/p>\n
Appendix A provides the technical details of the methods used to collect the data for the 2021 ATS as reported by WYSAC\u2019s Survey Research Center.<\/p>\n
Appendix B provides tables reporting Wyoming\u2019s state-level unweighted counts, weighted percentages, and 95% confidence intervals (CIs) for weighted percentages for every survey item and WYSAC-calculated variable.<\/p>\n
Appendix C provides details of statistical analyses summarized in the body of this report.<\/p>\n
Trained WYSAC telephone interviewers conducted the telephone interviews. Calling began on April 15, 2021, and ended on September 2, 2021. WYSAC callers completed 1,999 surveys (52% on cell phones; 48% on landlines).<\/p>\n
In some figures and tables, percentages may not total 100% because respondents could choose more than one response. Occasionally, rounding of the actual percentages may result in reporting percentages that do not total 100.<\/p>\n
Key Limitations<\/h2>\n
Most ATS survey items have been tested and validated by the CDC and reused over time. However, the ATS relies on self\u2010reported data, respondents\u2019 memory of events, and their interpretation of the survey items. Therefore, the results presented here might include recall errors or respondent bias (such as not reporting embarrassing or unpopular behaviors).<\/p>\n
In addition, the 2021 ATS was administered during the ongoing COVID-19 pandemic. This presented logistical difficulties in hiring callers to conduct the interviews and maintaining a safe environment within the call center. Most results do not give a reason to suspect the pandemic had a large impact on the estimates reported in this document. That is, they are generally consistent with patterns from past data. Exceptions to this are noted in the report as needed.<\/p>\n
The ATS has a complex skip pattern that means not all respondents are asked each question. For example, people who have never smoked are not asked about quitting smoking. In some cases, fewer than 50 people were asked an item. Estimates generated from such small groups are extremely imprecise, so WYSAC does not report them in the body of the report. This follows the example set by the CDC in reporting Behavioral Risk Factor Surveillance System (BRFSS) statistics (https:\/\/www.cdc.gov\/brfss\/brfssprevalence\/<\/a>).<\/p>\n
<\/p>\n
Electronic Nicotine Delivery Systems (ENDS)<\/h1>\n
Background<\/h2>\n
ENDS are electronic nicotine delivery systems, also known as e-cigarettes or vapes. When people use ENDS, they are vaping. Studies show that many young adults who have never smoked start using nicotine products by using ENDS (Bandi et al., 2021). They are then more likely to begin smoking combustible cigarettes (Berry et al., 2019; Hair et al., 2021).<\/p>\n
Although ENDS use is less common among adults than smoking cigarettes or chewing tobacco, their recent emergence on the market and surging use among youth and young adults make them a key tobacco prevention issue. In 2018, the U.S. Surgeon General officially called youth and young adult vaping an epidemic (USDHHS, 2018).<\/p>\n
ENDS Use in Wyoming<\/h2>\n
A limitation of the ATS is difficulty getting young adults to respond. With a small subset of the respondents being young adults, it is necessary to report on the full adult population. That may hide some key findings that would be clearer in a survey of young adults.<\/p>\n
Most Wyoming adults (68%) have never tried ENDS, and few are current ENDS users (8%, Figure 1). For this report, current ENDS users are the respondents who said they use ENDS every day or some days.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_01-300x296.png\")
<\/p>\nENDS use was about as common in 2021 as it was in 2015 (Figure 2), the first time this question was asked on the ATS. The two-percentage-point increase from 2019 to 2021 was not significant.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_02-300x294.png\")
<\/p>\nFlavored ENDS Use<\/h3>\n
In 2020, the FDA partially banned ENDS flavors except menthol and tobacco. However, the ban has large loopholes. It only applies to the cartridge-style ENDS, like JUUL. These products have closed, pre-filled e-liquid cartridges that the user replaces when empty. The ban does not include ENDS with refillable e-liquid tanks or single-use or disposable products, like Puff Bar. According to the FDA, these exceptions avoided restricting all flavor options for adults who may be using ENDS to stop smoking (FDA, 2020). However, research shows that youth and young adults are using menthol instead of mint and are switching to the types of ENDS that can still have flavors (Truth Initiative, 2020).<\/p>\n
In 2021, the use of flavored ENDS was common for Wyoming adults:<\/p>\n
- \n
- 82% of current ENDS users had used products flavored to taste like mint, candy, fruit, chocolate, or other flavors besides tobacco in the past 30 days.<\/li>\n
- 46% of adults who had tried ENDS in their lifetime did so for reasons related to flavor.<\/li>\n<\/ul>\n
Wyoming adults\u2019 use of flavored ENDS products has not significantly changed between 2017 and 2021. Because the use of flavored ENDS is common among Wyoming adult ENDS users, it will be important to monitor how the use of ENDS among Wyoming adults changes in response to the FDA ban.<\/p>\n
Preferred ENDS Type<\/h3>\n
In 2021, the most popular type of ENDS was a customized commercial juice from a vape shop. Most adult ENDS users (74%) said they had used that type of ENDS in the past 30 days. The FDA\u2019s 2020 flavor ban did not cover these types of ENDS.<\/p>\n
JUUL was by far the most preferred cartridge-style ENDS brand; 27% of ENDS users reported using JUUL most often in the previous 30 days. The next most frequently used brand was Vuse at 19% of users.<\/p>\n
Reasons for Trying ENDS<\/h3>\n
Curiosity was the most popular reason for trying ENDS (61%) among all adults who had ever tried ENDS. Reasons for trying ENDS show a different pattern for current users.<\/p>\n
For current ENDS users, the top four reasons for trying ENDS were to reduce cigarette use (52%), for the flavoring (51%), ENDS taste better (50%), and to quit smoking cigarettes (49%; Figure 3). These results have not changed significantly since these questions were first asked in 2015.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_03-190x300.png\")
<\/p>\nHowever, comparisons of 2019 and 2021 data may indicate emerging trends. There was a significant decrease for current ENDS users trying ENDS to reduce cigarette use, from 76% to 52%. There was a significant decrease for current ENDS users trying ENDS to quit smoking cigarettes, from 72% to 49%.<\/p>\n
Some research suggests that use of ENDS with nicotine is associated with quitting smoking. The CDC has said that smokers may see benefits from completely switching from smoking to ENDS (CDC, 2022a). However, there is not enough evidence to be sure (CDC, 2020). More research is needed to learn if ENDS are a broadly successful tobacco-related harm reduction tool. The FDA has not approved ENDS as a cessation aid (FDA, 2022).<\/p>\n
Do People Think ENDS Use is Harmful?<\/h3>\n
The 2021 ATS included a series of questions regarding how harmful people think ENDS use is. Perceived harmfulness of ENDS has significantly increased since 2017 (Figure 4).\u00a0<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_04-276x300.png\")
<\/p>\nOne reason for this change may be that the public health community, including the SUTPP and county partners, sponsored media messaging about the harms of ENDS use after 2017.<\/p>\n
In 2021, compared to 2017, more adults said that vaping was at least as harmful as smoking (Table 1).<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Table_01-300x233.png\")
<\/p>\nStarting ENDS Use<\/h2>\n
Current smokers (see Table 2 for a summary of the four smoking status categories) who had also tried ENDS were asked whether they used cigarettes or ENDS first. For about half of these smokers (51%), this question was not applicable because ENDS were not on the market (to their knowledge) when they started smoking. Most current smokers reported using ENDS before cigarettes (Figure 5). There was no significant difference from 2017 to 2021.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_05-216x300.png\")
<\/p>\nAlthough a different research approach would provide stronger evidence, the 2021 ATS data support emerging research (such as Berry et al., 2019 and Hair et al., 2021) that vaping may lead people to smoke, including some people who would not otherwise have started smoking.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Table_02-1024x433.png\")
<\/p>\nQuitting ENDS Use<\/h2>\n
In 2021, 34% of adults who were current ENDS users tried to quit in the past year or in their lifetime (Figure 6).\u00a0<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_06-300x281.png\")
<\/p>\nConclusion<\/h2>\n
These findings reflect the full adult population of Wyoming. Surveys focused on young adults or youth may find different patterns.<\/p>\n
Many current ENDS users tried ENDS for the flavor or to try to quit or cut back on smoking. Current research (CDC, 2022a; CDC, 2020) does not show a consistent benefit of using ENDS to quit smoking. The FDA has not approved ENDS as a cessation aid (FDA, 2022).<\/p>\n
Perceived harm of ENDS has grown over time. Compared to 2017, more Wyoming adults say vaping is at least as harmful as smoking.<\/p>\n
Many ENDS users want to quit. Just over one third of current ENDS users had tried to quit ENDS in the past year or in their lifetime.<\/p>\n
<\/p>\n
Cigarette Smoking and Use of Other Commercial Tobacco and Nicotine Products<\/h1>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Sidebar_01_Tobacco-Use-273x300.png\")
<\/h2>\nCigarette Smoking in 2021<\/h2>\n
Most adults (58%) have never been regular smokers. That is, they have not smoked at least 100 cigarettes in their lifetime. Adult Tobacco Survey (ATS) responses were divided into four key categories of smoking status, described in Table 3.\u00a0Most adults (84%) were not current smokers; 16% of adults were current smokers. About one quarter (26%) of adults were former smokers, and about one third (32%) were experimental smokers. About one quarter (26%) of all adults had never tried smoking (Figure 7).<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_07-300x226.png\")
<\/p>\n<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Table_03-1024x453.png\")
<\/p>\nCigarette Use Over Time<\/h2>\n
On December 20, 2019, President Trump signed a bipartisan bill that raised the minimum legal sales age for all commercial tobacco\/nicotine products in the U.S. (including ENDS) to 21 (Carlisle, 2020). On March 13, 2020, Governor Gordon signed a similar law specific to Wyoming (Angell, 2020). These changes in laws did not affect most of the ATS respondents.<\/p>\n
Cigarette smoking has become less common since a recent peak of 21% in 2006. Since then, the smoking rate has dropped significantly to 16% in 2021. The three-percentage-point difference between the 2019 and 2021 smoking rates was not significant (Figure 8).<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_08-1024x486.png\")
<\/p>\nOther Commercial Tobacco and Nicotine Products (Including ENDS)<\/h2>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_09-264x300.png\")
<\/p>\nCigarettes, ENDS, and chewing tobacco were the most commonly used commercial tobacco\/nicotine products. Cigarettes remained the preferred tobacco\/nicotine product (Figure 9).<\/p>\n
Use of non-cigarette commercial tobacco\/nicotine products has remained consistent since 2010. The use of ENDS and chewing tobacco was about the same in 2021 as in 2019, but slight changes in the percentages made ENDS use rise from third to second most popular. Chewing tobacco dropped from second to third most popular.<\/p>\n
Conclusions<\/h2>\n
The adult smoking rate has decreased significantly since its recent peak in 2006. However, since 2010, use of all commercial tobacco\/nicotine products has remained fairly consistent.<\/p>\n
Cigarettes, ENDS, and chewing tobacco were the three most popular commercial tobacco\/nicotine products for adults. ENDS are a subject of concern for youth and young adults because of national trends showing increased use (Gentzke et al., 2022) and the potential for them to lead to cigarette smoking (Berry et al., 2019; Hair et al., 2021). Their relative popularity is also increasing.<\/p>\n
<\/p>\n
Commercial Tobacco and Nicotine Taxes<\/h1>\n
Preventing new cigarette smoking and decreasing the use of other commercial tobacco and nicotine products are key goals of the SUTPP and the CDC.<\/p>\n
According to the CDC, increasing tobacco product prices is an effective way to prevent youth from starting to smoke (CDC, 2014b). It also encourages adults to quit smoking (CDC, 2015).<\/p>\n
Taxes are one way that state governments can influence tobacco prices. Nationally, every 10% increase in cigarette prices decreases cigarette use by 3\u20135%. Raising cigarette prices prevents youth and people with lower incomes from smoking and reduces the average number of cigarettes smoked (U.S. Department of Health and Human Services [USDHHS], 2014).<\/p>\n
In one study of adults aged 50 years and older, a $1 increase in the price of cigarettes was associated with a 6% higher quit rate (Stevens et al., 2017). Increasing cigarette taxes could encourage quitting among older adults and could decrease the risk of smoking-related diseases.<\/p>\n
Commercial Tobacco and Nicotine Tax Rates<\/h2>\n
Cigarettes<\/h3>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_10-300x297.png\")
At the time of data collection, Wyoming\u2019s cigarette excise tax was $0.60 per pack, the second lowest in the region (Figure 10). Wyoming ranks 44th out of 51 states (including DC) on cigarette taxes (CDC, 2021c). Wyoming\u2019s cigarette excise tax has not changed since 2003.<\/p>\nSmokeless Tobacco<\/h3>\n
At the time of data collection, Wyoming\u2019s smokeless tobacco (chewing tobacco, snuff, dip, or snus) tax had a minimum tax of $0.60 per ounce, with an additional $0.60 per ounce for packaging larger than one ounce.<\/p>\n
Electronic Nicotine Delivery System<\/h3>\n
Since July 2020 and through the time of data collection, Wyoming has had a default ENDS tax at the rate of 15% of the wholesale purchase price. If the tax is not paid by the wholesaler, consumers pay 7.5% of the retail purchase price (2021 Wyoming Statute 39-18-104[g] https:\/\/wyoleg.gov\/NXT\/gateway.dll?f=templates&fn=default.htm<\/a>).<\/p>\n
Support for Evidence-Based Policy Has Declined<\/h2>\n
In the 2019 ATS, over half of Wyoming adults supported increasing the taxes on cigarettes (52%) and smokeless tobacco (54%; WYSAC, 2022). In 2021, support for increasing cigarette and smokeless tobacco tax had significantly decreased to just under half\u201444% and 46% respectively.<\/p>\n
Support for increases in taxes on ENDS was stronger than for other taxes on tobacco or nicotine products (Table 4).<\/p>\n
- \n
- More than half (55%) of Wyoming adults would support an increase in the ENDS tax,<\/li>\n
- Less than half (44%) of Wyoming adults would support a cigarette tax increase, and<\/li>\n
- Less than half (46%) of Wyoming adults would support a tax increase on chewing tobacco, snuff, dip, or snus.<\/li>\n<\/ul>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Table_04-1024x545.png\")
<\/p>\nCost of Smoking<\/h2>\n
Smoking is the leading preventable cause of illness and death in the United States. In 2018, the costs of smoking-related illness totaled more than $600 billion. This includes more than $240 billion for direct medical care and more than $372 billion in lost productivity (CDC, 2022b). In 2009, Wyoming\u2019s tobacco-related healthcare costs were $258 million (CDC, 2021a).<\/p>\n
Commercial tobacco\/nicotine prevention programs have been shown to reduce smoking rates and smoking-related costs. A study of Washington State\u2019s tobacco\/nicotine control program showed that for every $1 spent on the program between 2000 and 2009, $5 was saved in tobacco-related hospitalization costs (Dilley et al., 2012).<\/p>\n
Conclusions<\/h2>\n
Wyoming adults\u2019 support for increasing taxes on commercial tobacco\/nicotine has decreased. In 2021, support for increasing cigarette and smokeless tobacco tax significantly decreased compared to 2019. Throughout the ATS 2021 data, there seems to be a decrease in support for government interventions that would benefit public health, including tax increases and smokefree indoor air policies and laws.<\/p>\n
Between ATS 2019 and ATS 2021, there was a decline in support for public health policies as it related to the COVID pandemic (WYSAC, 2020). It is possible that this decrease has spilled over to other public health interventions.<\/p>\n
Wyoming\u2019s cigarette excise tax has remained at $0.60 per pack since 2003. Higher commercial tobacco taxes are an evidence-based way to keep youth from starting to smoke (CDC, 2014b). Increasing commercial tobacco and nicotine product pricing through taxation, minimum price laws, or other means is an evidence-based strategy for encouraging people to quit using commercial tobacco products (CDC, 2015). Wyoming could benefit from raising its tobacco or nicotine taxes.<\/p>\n
<\/p>\n
Goal Area 1: Preventing Commercial Tobacco Use<\/h1>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Sidebar_02_Goal-1-261x300.png\")
The SUTPP and the CDC share the goal of reducing the health burdens of tobacco use by preventing new tobacco use (CDC, 2014b).<\/p>\nA related effort in some local and state tobacco prevention programs has been to raise the legal age of purchase from 18 (or 19 in some jurisdictions) to 21 (see https:\/\/tobacco21.org\/<\/a>). President Trump signed a bipartisan bill that raised the minimum legal sales age for all tobacco products in the U.S. (including ENDS) to 21 (FDA, 2021). This legislation, known as Tobacco 21 (T21), went into effect on December 20, 2019. On March 13, 2020, Governor Gordon signed a similar law specific to Wyoming, and the law became effective on July 1, 2020 (SF0050, 2020). Broad surveys, such as the ATS, with few young adults in the sample are not strong methods for showing short-term effects of T21.<\/p>\n
A key limitation for findings in this section is that many of the relevant survey questions ask about events (such as when someone first smoked a whole cigarette) that happened years before data collection. Therefore, responses to such questions are especially subject to memory errors. However, precise recall is not critical to the conclusions in this report.<\/p>\n
Age of Smoking a Whole Cigarette for the First Time<\/h2>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_11-291x300.png\")
<\/p>\nThe age of first smoking a whole cigarette is related to long-term smoking habits (CDC, 2014b).<\/p>\n
In 2021, almost all (91%) of the Wyoming adults who had ever smoked an entire cigarette smoked their first one before the age of 21 (Figure 11). Moreover, the vast majority of them smoked their first cigarette before they were 18, with an average age of 16. This pattern has remained consistent since comparable questions were first asked in 2010.<\/p>\n
Conclusions<\/h2>\n
The vast majority of smokers begin when they are under the age of 21, especially under the age of 18. ATS data are consistent with other research findings that the earlier someone starts smoking, the more likely they are to continue smoking (Dierker et al., 2012; Sharapova et al., 2020). Wyoming may benefit from continued tobacco prevention efforts focusing on youth, though ATS data may not show results until years after success with youth happens.<\/p>\n
<\/p>\n
Goal Area 2: Eliminating Nonsmokers\u2019 Exposure to Secondhand Smoke<\/h1>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Sidebar_03_Goal-2-174x300.png\")
The SUTPP and the CDC share the goal of reducing the health burdens of commercial tobacco or nicotine use by eliminating nonsmokers\u2019 exposure to secondhand smoke.<\/p>\nSupport for Smokefree Indoor Air Policies and Laws<\/h2>\n
The ATS gathered information regarding Wyoming adults\u2019 opinions on smokefree indoor air policies and laws. Different ATS questions asked about support for policies, rules put in place by individual businesses, and statewide laws. These questions asked about smoking, not vaping.<\/p>\n
Support for Smokefree Indoor Air Policies<\/h3>\n
The ATS items about smokefree indoor air policies asked adults if they think smoking should be allowed indoors at workplaces, restaurants, bars, and casinos and clubs. (Casinos and clubs were combined on the survey, so WYSAC treated them as a single venue type.)<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_12-300x300.png\")
<\/p>\nIn 2021, most adults (82%; Figure 12) supported smokefree indoor air policies for workplaces. Three-fourths (75%) of adults supported smokefree indoor air policies for restaurants. Slightly less than half (47%) of adults supported smokefree indoor air policies for casinos and clubs. Under half (45%) of adults supported smokefree indoor air policies for bars.<\/p>\n
<\/p>\n
Between 2019 and 2021, support for smokefree indoor air policies for restaurants and casinos and clubs significantly decreased. No other differences between 2019 and 2021 were significant.<\/p>\n
Wyoming adults\u2019 support for indoor air policies has remained strong and consistent between 2015 and 2021.<\/p>\n
Support for Smokefree Indoor Air Laws<\/h3>\n
Additional survey questions asked respondents if they support or oppose statewide smokefree indoor air laws in Wyoming for the same venues. Support for smokefree air laws was similar to support for smokefree air policies. Details are in Appendix B: Wyoming 2021 ATS Frequency Tables and Appendix C: Statistical Analysis Methods and Detailed Results.<\/p>\n
Support for Other Smokefree Air Policies and Laws<\/h2>\n
Smokefree Parks Policies<\/h3>\n
In 2021, four out of five Wyomingites (80%) thought smoking should be restricted at outdoor parks, at least in some manner. This support has remained consistent since 2010. In 2021, 27% of adults thought that smoking should never be allowed, and 53% of adults thought that smoking should be allowed only at some times or in some places.<\/p>\n
Smokefree Workplaces Laws<\/h3>\n
Support for laws making outdoor workplaces smokefree was substantially lower than support for laws making indoor workplaces smokefree: In 2021, only 22% of adults supported a statewide smokefree air law for all outdoor workplaces, compared to 77% for indoor workplaces. The level of support for such a law has not changed significantly since comparable questions were first asked in 2015. There was no question about support for policies against smoking outdoors at work.<\/p>\n
Tobacco-Free School Policies<\/h3>\n
In 2021, most adults (85%) thought commercial tobacco and nicotine use should be completely banned at schools. This support has been consistent since 2010. There was no significant difference of support between adults who were living with a child aged 17 or younger and those adults who were not.<\/p>\n
Exposure to Secondhand Smoke<\/h2>\n
Smoking Regulations at Work<\/h3>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_13-300x288.png\")
<\/p>\nMost employed adults (89%; Figure 13) reported that smoking was never allowed in indoor areas (including inside a vehicle) at their place of work. The question asked since 2019 does not allow direct comparison to earlier data but does not show a dramatic change over time.<\/p>\n
About one third (33%) of adults reported that smoking was not allowed in outdoor areas. This has significantly increased since 2012 (25%). There is still a large gap between indoor and outdoor policies at work. Workers are better protected indoors than outdoors at work.<\/p>\n
Exposure to Secondhand Smoke at Work and in Public Places<\/h3>\n
In 2021, most employed adults (82%) were not exposed to secondhand smoke at their workplace. Still, 18% of employed adults reported experiencing secondhand smoke at their workplace either indoors or outdoors. There\u2019s been no significant difference over time between 2010 and 2021.<\/p>\n
In 2021, most adults (66%) were not exposed to secondhand smoke in public places, indoors and outdoors. About one third (34%; Figure 14) of adults reported breathing someone else\u2019s secondhand smoke in an indoor or outdoor public place. Almost one third (30%) of adults reported experiencing exposure to secondhand smoke in outdoor public places. Very few (8%) adults reported being exposed to secondhand smoke in indoor public places. Although still a cause for concern, exposure to secondhand smoke has significantly decreased in public places, indoors and outdoors, between 2012 and 2021.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_14-1024x551.png\")
<\/p>\nIn 2021, the chances of being exposed to secondhand smoke while in a public place were not significantly different between current smokers and nonsmokers:<\/p>\n
- \n
- 42% of current smokers reported exposure to secondhand smoke.<\/li>\n
- 32% of nonsmokers reported exposure to secondhand smoke.<\/li>\n<\/ul>\n
Opinions about Harmfulness of Secondhand Smoke<\/h3>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_15-300x288.png\")
<\/p>\nOver the years, adults have almost unanimously agreed that breathing someone else\u2019s secondhand smoke is harmful to one\u2019s health (Figure 15). In 2021, the majority (96%) believed secondhand smoke was very or somewhat harmful to one\u2019s health. Only 4% believed that it was not harmful. These levels of agreement have not changed significantly over time between 2010 and 2021.<\/p>\n
Conclusions<\/h2>\n
Over the years, exposure to secondhand smoke has significantly decreased in public places, indoors and outdoors. Two-thirds of adults reported that they were not exposed to secondhand smoke in public places, indoors or outdoors.<\/p>\n
Adults have shown consistent and strong support for indoor air policies for workplaces and restaurants. Most adults thought that smoking should be restricted at outdoor parks. Wyoming adults continue to support a complete ban of commercial tobacco and nicotine use at schools.<\/p>\n
Most employed adults are not exposed to secondhand smoke indoors at work.<\/p>\n
Wyoming still has room for improvement. Adults are less protected in outdoor areas including at work and in public places. Adult support for outdoor policies at work and for indoor air policies at adult-oriented establishments was weak. Wyoming may benefit from focusing prevention efforts in these areas.<\/p>\n
<\/p>\n
Goal Area 3: Promoting Quitting<\/h1>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Sidebar_05_Goal-3-234x300.png\")
The SUTPP and the CDC share the goal of reducing the health burdens of commercial tobacco and nicotine use by promoting and supporting quitting among adults and young people.<\/p>\nIn this section, we explore smokers\u2019 desire to quit and quit attempts. We look at awareness of quitlines (for all tobacco and nicotine users, including current ENDS users), use of quit aids, and barriers to quitting. This section also covers commercial tobacco and nicotine users\u2019 visits to healthcare providers and conclusions and recommendations based on the data and best practices in helping people quit.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Sidebar_04_Goal-3-300x228.png\")
<\/p>\nEfforts to Quit Smoking<\/h2>\n
Smokers\u2019 Desire to Quit<\/h3>\n
More than half of smokers (57%) wanted to quit smoking cigarettes (Figure 16). The 11-point difference between 2019 and 2021 for smokers who want to quit was not significant, probably because relatively few people answered the questions. There were no significant changes from 2015\u20132021.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_16-300x269.png\")
<\/p>\nSmokers\u2019 Quit Attempts<\/h3>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_17-300x271.png\")
At some point in their lives, about four out of five current smokers (82%) had stopped smoking for at least one day because they were trying to quit for good.<\/p>\nAbout one third (32%) of current smokers have tried to quit smoking at least once in the past year because they were trying to quit for good (Figure 17).<\/p>\n
Smokers\u2019 quit attempts have not changed significantly between 2010 and 2021.<\/p>\n
Aids to Quit Smoking<\/h2>\n
Awareness of Quitlines<\/h3>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_18-298x300.png\")
<\/p>\nMost commercial tobacco and nicotine users (including ENDS users, 68%) were aware of telephone quitline services (Figure 18). About half (49%) of non-tobacco and non-nicotine users were aware of telephone quitline services.<\/p>\n
This may demonstrate the success of media campaigns by SUTPP and their partners, including county-level efforts.<\/p>\n
<\/p>\n
<\/p>\n
Smokers\u2019 Use of Quit Aids<\/h3>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/WQT_PhoneNumber_ForLight-300x189.png\")
<\/p>\nMost (54%) smokers who tried to quit in the last year used at least one quit aid. Nicotine re-placement therapy (NRT) was the most popular aid used by smokers (Figure 19). This may have included people buying them over the counter or getting them from the Wyoming Quit Tobacco (WQT) program.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_19-201x300.png\")
<\/p>\nSmokers\u2019 Obstacles to Quitting Cigarettes<\/h3>\n
Cravings for a cigarette was the most common obstacle for current smokers the last time they tried to quit (75%; Figure 20). Current smokers said other obstacles to quitting cigarettes included the loss of a way to handle stress (65%) and worsening anxiety (50%). For smokers, the loss of a way to handle stress has decreased significantly over time from 2017 to 2021. Other barriers have been relatively stable over the same timeframe.<\/p>\n
The WQT program specifically targets the most common barriers to quitting smoking (https:\/\/www.quitwyo.org<\/a>). In particular, the medications provided are designed to reduce cravings. Coaching can include strategies to deal with other barriers.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_20-963x1024.png\")
<\/p>\nHealth Professionals\u2019 Involvement in Quitting Commercial Tobacco and Nicotine Use<\/h2>\n
Visits with Health Professionals<\/h3>\n
The 2021 ATS asked respondents if they had seen a health professional (a doctor, dentist, nurse, or other health professional) in the past year and if so, if the health professional asked if they smoked cigarettes or used any other tobacco product or nicotine products, including ENDS.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_21-247x300.png\")
<\/p>\nMost commercial tobacco and nicotine users had seen a health professional in the past year (76%; Figure 21). Still, commercial tobacco and nicotine use was related to lower likelihood of seeing a health professional. This difference might be due, in part, to barriers to seeking care that might be linked to tobacco and nicotine use, such as lower income.<\/p>\n
<\/p>\n
Health Professionals\u2019 Support for Quitting Tobacco and Nicotine Use<\/h3>\n
Adults are often asked about their commercial tobacco or nicotine use when visiting a health professional:<\/p>\n
- \n
- 72% of all adults were asked if they smoked cigarettes or used any other tobacco or nicotine products.<\/li>\n
- 82% of tobacco or nicotine users were asked if they smoked cigarettes or used any other tobacco or nicotine products, significantly more than 67% for non-users.<\/li>\n<\/ul>\n
We do not know to what extent health professionals use medical records to identify tobacco and nicotine users (and non-users) during a visit. This may be a limitation when health professionals had records of their patients\u2019 tobacco or nicotine use and did not ask if they used tobacco or nicotine products.<\/p>\n
Less than half of tobacco and nicotine users received support with quitting, even when focusing on those who say a professional asked them about their tobacco or nicotine use (Figure 22).<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_22-1024x580.png\")
<\/p>\nWhen commercial tobacco or nicotine users were offered assistance, health professionals pro-vided WQT information (87%; Figure 23), recommended NRTs (51%), and prescribed medication (39%). These protocols align with best practices in support of quitting.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_23-300x227.png\")
<\/p>\nConclusions<\/h2>\n
Most smokers want to quit smoking cigarettes and have tried to quit at some point in their lives. When they try to quit or want to quit, smokers face obstacles such as cravings for a cigarette, loss of a way to handle stress, and worsening anxiety. The WQT program is designed to assist with these obstacles. Media emphasizing how the WQT program addresses common barriers to quitting smoking may increase enrollment in the WQT program.<\/p>\n
Most tobacco and nicotine users are aware of quitline services. Most who had tried to quit in the last year used a quit aid the last time they tried to quit.<\/p>\n
Visits to health professionals are opportunities for connecting current commercial tobacco and nicotine users to available resources and to address barriers to quitting. Most adults were asked by a health professional if they used commercial tobacco or nicotine products. Adult commercial tobacco and nicotine users were less likely to report that health professionals followed up or offered help with quitting. Greater collaboration with health professionals could result in more commercial tobacco and nicotine users becoming aware of, and receptive to, services that could increase their chances of quitting (CDC, 2015).<\/p>\n
<\/p>\n
Goal Area 4: Identifying and Eliminating ENDS-Related Disparities<\/h1>\n
Generations-long inequities in social, economic, and environmental conditions contribute to poor health outcomes. Breakdowns by race, ethnicity, or socioeconomic status may reflect where a person lives, works, or plays rather than the individual\u2019s characteristics or personal choices (CDC, 2022c). These inequities have a greater impact on health outcomes than individual choices.<\/p>\n
Addressing these health inequities is the fourth goal of the SUTPP and the CDC with the aim to reduce commercial tobacco and nicotine use and the related health burdens among populations disproportionately impacted by tobacco-related disease and death.<\/p>\n
Starting in 2019, the SUTPP identified two priority groups that were unequally impacted by ENDS use: people experiencing behavioral health conditions and young adults (age 18\u201329). The SUTPP has two other priority populations to tobacco and nicotine prevention efforts: American Indians and people with low incomes.<\/p>\n
The ENDS industry has targeted American Indians with ENDS marketing efforts (Field, 2020). However, in Wyoming, the data do not consistently show disproportionate ENDS use for American Indians. This may be a result of the small sample size for this population. For the 2021 ATS, fewer than 50 ENDS users said they were American Indians, including multi-racial people who included American Indian as part of their identification.<\/p>\n
Unlike for smoking, income does not appear related to adults\u2019 ENDS use in the ATS 2021 data.<\/p>\n
For each population, we analyzed three key indicators: the prevalence of use, quit attempts, and exposure to secondhand smoke or ENDS aerosol.<\/p>\n
The 2021 ATS included follow-up questions about quitting ENDS use. Fewer than 50 ENDS users within each priority population answered those questions. That is insufficient data for a precise estimate of lifetime and past year quit attempts in this report. WYSAC is available to discuss the data and associated limitations with interested parties.<\/p>\n
For context, the overall vaping rate is 8%.<\/p>\n
Behavioral Health<\/h2>\n
Historically, the tobacco industry has targeted people experiencing behavioral health conditions (such as depressive disorder, bipolar disorder, substance use disorder, and psychotic disorder; Prochaska et al., 2017; Campbell et al., 2016). More research is needed to understand if the ENDS industry is also using focused marketing toward people experiencing behavioral health conditions.<\/p>\n
For context, the 2021 ATS asked respondents \u201cDo you have any mental health conditions, such as an anxiety disorder, depression disorder, bipolar disorder, schizophrenia, Attention-Deficit\/Hyperactivity Disorder (ADHD), Post-Traumatic Stress Disorder (PTSD) or substance use disorder?\u201d About one fifth (22%) of adults reported having at least one behavioral health condition.<\/p>\n
As with any self-report data, it is possible that people under-reported health conditions on the ATS, especially those conditions that may have stigma attached such as behavioral health conditions.<\/p>\n
ENDS Use<\/h3>\n
Adults who said they had at least one behavioral health condition (15%) were statistically significantly more likely to use ENDS than adults who did not have at least one behavioral health condition (6%).<\/p>\n
Adults with behavioral health conditions are over-represented among ENDS users (Figure 24). Only 22% of adults who responded to the survey reported having behavioral health conditions, yet they made up 43% of current ENDS users in the survey.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_24-300x300.png\")
<\/p>\nExposure to ENDS Aerosol in Indoor Public Places<\/h3>\n
In 2021, 81% of adults with behavioral health conditions were not exposed to someone else\u2019s ENDS aerosol in indoor public places in the past seven days. Significantly more adults with behavioral health conditions were exposed to ENDS aerosol in indoor public places than those with no behavioral health conditions (Figure 25).<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_25.png\")
<\/p>\nYoung Adults<\/h2>\n
Much like the tobacco industry has targeted youth (Farber & Folan, 2017), the ENDS industry has targeted young adults with advertising and marketing (Lee et al., 2020). The ENDS industry uses social media as a pathway to reach young adults (Lee et al., 2020). The ENDS industry\u2019s focused efforts have contributed to disproportionately higher ENDS use rates for young adults.<\/p>\n
WYSAC considered respondents as young adults when they were between the ages of 18 and 29 to increase the sample size and improve the reliability of estimates for this group. In 2021, 15% of Wyoming\u2019s population was young adults (CDC, 2023).<\/p>\n
ENDS Use<\/h3>\n
Young adults (18%) were statistically significantly more likely to use ENDS than other adults (6%). ENDS use may lead to later initiation of smoking, but more research is needed to investigate this potential pathway to smoking.<\/p>\n
Young adults are over-represented among ENDS users (Figure 26). Only 21% of adults who responded to the survey were between the ages of 18 and 29, yet they made up 45% of current ENDS users in the survey.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_26-261x300.png\")
<\/p>\nExposure to ENDS Aerosol in Indoor Public Places<\/h3>\n
In 2021, 76% of young adults were not exposed to someone else\u2019s ENDS aerosol in indoor public places in the past seven days. Exposure to ENDS aerosol in indoor public places was about three times more common for young adults than for other adults (Figure 27).<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_27-300x213.png\")
<\/p>\nConclusions<\/h2>\n
The 2021 ATS data highlight the impact of the ENDS industry\u2019s targeted efforts to engage already vulnerable populations in nicotine use. People experiencing behavioral health conditions and young adults (ages 18-29) are disproportionately affected by ENDS use.<\/p>\n
People experiencing behavioral health conditions were significantly more likely to use ENDS than those without behavioral health conditions. They were also significantly more likely to be exposed to someone else\u2019s ENDS aerosol in a public place in the last week.<\/p>\n
Young adults are significantly more likely to use ENDS than other adults (age 30 and older).<\/p>\n
Although most adults were not exposed to ENDS aerosol in public places, exposure was significantly higher for young adults.<\/p>\n
These communities carry disproportionate burdens of ENDS use. Work related to Goal 4 of the SUTPP is essential to combat targeted efforts from the ENDS industry to eliminate these disparities and work toward health equity. Evidence-based ways to reduce these disparities include developing equitable policies, programs, and systems (CDC, 2022c).<\/p>\n
Acknowledgement<\/h2>\n
Proportion plots adapted from a template distributed by Stephanie Evergreen: https:\/\/stephanieevergreen.com\/proportion-plots\/<\/a><\/p>\n
<\/p>\n
Goal Area 4: Identifying and Eliminating Smoking-Related Disparities<\/h1>\n
Generations-long inequities in social, economic, and environmental conditions contribute to poor health outcomes. Breakdowns by race, ethnicity, or socioeconomic status may reflect where a person lives, works, or plays rather than the individual\u2019s characteristics or personal choices (CDC, 2022c). These inequities have a greater impact on health outcomes than individual choices.<\/p>\n
Addressing these health inequities is the fourth goal of the SUTPP and the CDC with the aim to reduce commercial tobacco and nicotine use and the related health burdens among populations disproportionately impacted by tobacco-related disease and death.<\/p>\n
Starting in 2019, the SUTPP identified four priority groups in Wyoming that were unequally impacted by smoking: people with low incomes, people who identify as American Indian, people experiencing behavioral health conditions, and young adults (aged 18-29).<\/p>\n
For each population and each smoking-related disparity, we analyzed three key indicators: the prevalence, quit attempts, and exposure to secondhand smoke.<\/p>\n
Because of the small number of ATS respondents who were smokers within each priority population, there is a high degree of uncertainty around the estimates for most of these groups. Therefore, WYSAC took a cautious approach and chose not to provide interpretations for statistical tests in which we had a low degree of confidence, including when fewer than 50 adults responded to a question. Because of this issue, we do not report quit attempts for people with low incomes, American Indians, or young adults. We also do not report a prevalence rate for American Indians.<\/p>\n
For context, the overall smoking rate in Wyoming adults is 16%.<\/p>\n
Adults with Low Annual Household Income<\/h2>\n
Tobacco industry marketing has targeted lower-income neighborhoods (Lee et al., 2015). With the tobacco industry\u2019s pointed strategies toward people with lower incomes, adults with lower incomes have a disproportionately high rate of commercial tobacco and nicotine use.<\/p>\n
An ideal measure for identifying people with low incomes would be the poverty level. However, this varies by size of household and other factors not included in the ATS. Based on practical considerations such as survey sample size, WYSAC and the SUTPP partners used a threshold of $30,000 in annual household income to identify adults with low incomes.<\/p>\n
For context, the median household income for Wyoming adults is $65,304 (U.S. Census Bureau, 2021). By definition, half of the adults in the state have an annual income less than the median.<\/p>\n
Smoking Prevalence<\/h3>\n
Adults with an annual household income of less than $30,000 (29%) had a significantly higher smoking rate than those with annual household incomes greater than $30,000 (14%).<\/p>\n
Adults living in households making less than $30,000 per year are over-represented among smokers (Figure 28). Only 14% of adults who responded to the survey were living in households with an income of less than $30,000, yet they made up 26% of current smokers in the survey.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_28-251x300.png\")
<\/p>\nExposure to Secondhand Smoke at Work<\/h3>\n
In 2021, 62% of adults with an annual income less than $30,000 were not exposed to someone else\u2019s secondhand smoke at work. Significantly more adults with an annual income less than $30,000 were exposed to secondhand smoke at work than working adults with an annual income of $30,000 or more (Figure 29).<\/p>\n
Occupational differences might explain this difference. For example, adults working in service industries are at a higher risk of exposure to secondhand smoke than those working in other industries (Holmes & Ling, 2017; Su et al., 2019), and they might have lower incomes. However, the ATS does not collect information about specific occupations.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_29.png\")
<\/p>\nAmerican Indian<\/h2>\n
WYSAC acknowledges that different terms refer to the Indigenous populations of the U.S. when unable to refer to specific tribes. In this report, use of the term American Indian mirrors the CDC-suggested survey item used for the ATS.<\/p>\n
Tobacco companies have long used the ceremonial significance of tobacco to encourage American Indians to use their commercial tobacco products (D\u2019Silva et al., 2018). Tobacco companies have a history of targeting this community, beginning with using American Indian imagery and symbols in marketing, often depicting negative stereotypes. The tobacco industry misled these communities by providing financial support for their cultural events and providing highly discounted prices on commercial tobacco and nicotine products (Lempert & Glantz, 2019). The tobacco industry\u2019s focused efforts have contributed to disproportionately high smoking rates for American Indians (D\u2019Silva et al., 2018).<\/p>\n
WYSAC considered respondents as American Indian when they self-identified as American Indian or multiracial including American Indian, regardless of whether they reported Hispanic ethnicity. This approach allowed for a larger sample from which to draw conclusions.<\/p>\n
For context, American Indian and Alaska Native people make up 2.8% of the Wyoming population, although that number excludes American Indian and Alaska Natives who identify as more than one race or ethnicity including Hispanic or Latinx (U.S. Census Bureau, 2021).<\/p>\n
Exposure to Secondhand Smoke at Work<\/h3>\n
In 2021, 80% of American Indian adults were not exposed to secondhand smoke at work. The difference between American Indian adults and non-American Indian adults who were exposed to secondhand smoke at work was not significantly different (Figure 30).<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_30.png\")
<\/p>\nBehavioral Health<\/h2>\n
Historically, the tobacco industry has targeted people experiencing behavioral health conditions (such as depressive disorder, bipolar disorder, substance use disorder, and psychotic disorder; Prochaska et al., 2017; Campbell et al., 2016).<\/p>\n
For this reason, studies (such as the Center for Behavioral Health Statistics and Quality, 2020; Talati et al., 2016) have demonstrated an association between cigarette smoking and behavioral health conditions. People with behavioral health conditions are more likely to smoke, and smokers with these conditions tend to smoke more cigarettes than smokers without behavioral health conditions (Center for Behavioral Health Statistics and Quality, 2020).<\/p>\n
For context, the 2021 ATS asked respondents \u201cDo you have any mental health conditions, such as an anxiety disorder, depression disorder, bipolar disorder, schizophrenia, Attention-Deficit\/Hyperactivity Disorder (ADHD), Post-Traumatic Stress Disorder (PTSD) or substance use disorder?\u201d About one fifth (22%) of adults reported having at least one behavioral health condition.<\/p>\n
As with any self-report data, it is possible that people under-reported health conditions on the ATS, especially those conditions that may have stigma attached such as behavioral health conditions.<\/p>\n
Smoking Prevalence<\/h3>\n
Adults with behavioral health conditions (28%) had a significantly higher smoking rate than those without a behavioral health condition (13%).<\/p>\n
Adults with behavioral health conditions are over-represented among smokers (Figure 31). Only 22% of adults who responded to the survey reported having behavioral health conditions, yet they made up 39% of current smokers in the survey.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_31-240x300.png\")
<\/p>\nCurrent Smokers\u2019 Quit Attempts: Lifetime and Past Year<\/h3>\n
Due in part to the small sample size for people with behavioral health conditions, the difference between quit attempts (including lifetime and past year) for smokers with behavioral health conditions and those without behavioral health conditions was not statistically significant.<\/p>\n
Lifetime quit attempts:<\/p>\n
- \n
- 77% of current smokers with behavioral health conditions had stopped smoking for at least one day because they were trying to quit for good, and<\/li>\n
- 85% of current smokers without behavioral health conditions had stopped smoking for at least one day because they were trying to quit for good.<\/li>\n<\/ul>\n
Past year quit attempts:<\/p>\n
- \n
- 27% of current smokers with behavioral health conditions had tried to quit smoking at least once in the past year, and<\/li>\n
- 35% of current smokers without behavioral health conditions had tried to quit smoking at least once in the past year.<\/li>\n<\/ul>\n
Smokers\u2019 Obstacles to Quitting Smoking Cigarettes<\/h3>\n
One obstacle to quitting was significantly more common among people with behavioral health conditions than among all others: worsening anxiety (Table 5).<\/p>\n
Current smokers with behavioral health conditions noted the top three obstacles to quitting cigarettes as cravings for a cigarette (72%), worsening anxiety (72%), and the loss of a way to handle stress (70%). The Wyoming Quit Tobacco (WQT) program is designed to address the common barriers that adults face when quitting smoking, including these three obstacles.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Table_05.png\")
<\/p>\nExposure to Secondhand Smoke at Work<\/h3>\n
In 2021, 75% of adults with any behavioral health conditions were not exposed to someone else\u2019s secondhand smoke at work. Slightly more adults with a behavioral health condition were exposed to secondhand smoke at work than adults without any behavioral health conditions (Figure 32). Due in part to the small sample size of people who reported behavioral health conditions, the difference between reports of secondhand smoke exposure was not statistically significant.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_32.png\")
<\/p>\nYoung Adults<\/h2>\n
ATS data (see the Goal Area 1: Preventing Commercial Tobacco Use section) showed that most smokers start smoking as youths or young adults. Young adulthood is an impressionable stage when people may begin a lifelong smoking habit or a habit begun during adolescence could become set (Biener & Albers, 2004; Lee et al., 2020), making them a priority population. The tobacco industry has targeted young adults with advertising and marketing that promises to help them create the attractive, successful, and popular personas they seek (Farber & Folan, 2017). Industry campaigns promote messages, values, and product features designed specific to young adults (Lee et al., 2020). Tobacco companies place these campaigns in places young adults frequent most, such as colleges, fraternities, and bars (Ling & Glantz, 2002). With such targeted industry efforts, young adults are a priority population and require equally targeted efforts for commercial tobacco and nicotine prevention and control strategies.<\/p>\n
WYSAC considered respondents as young adults when they were between the ages of 18 and 29 to increase the sample size and improve the reliability of estimates for this group. In 2021, Wyoming\u2019s population of young adults was 87,642 (CDC, 2023).<\/p>\n
Smoking Prevalence<\/h3>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_33-252x300.png\")
The smoking rate of young adults (18%) was similar to the smoking rate of other adults (15%; Figure 33).<\/p>\nHowever, young adults are about twice as likely to have never tried a cigarette: 41% of young adults have never tried a cigarette compared to 22% of other adults. Because so few adults begin smoking after the age of 21 (see the Goal Area 1: Preventing Commercial Tobacco Use section), this difference between age cohorts may indicate that experimentation with commercial tobacco and nicotine products is becoming less common over time. It may also demonstrate the collective success of CDC, SUTPP, multiple federal agencies, county prevention workers, and other groups.<\/p>\n
Young adults were statistically significantly less likely to be former smokers (7%) compared to other adults (32%).<\/p>\n
Young adults are more likely to use ENDS (18%), which may lead to later initiation of smoking cigarettes. More research is needed to investigate this potential pathway to smoking.<\/p>\n
Table 6 details the four categories of smoking status used in Figure 33.<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Table_06.png\")
<\/p>\nExposure to Secondhand Smoke at Work<\/h3>\n
In 2021, 73% of young adults were not exposed to someone else\u2019s secondhand smoke at work. Significantly more young adults were exposed to secondhand smoke at work than other working adults (Figure 34).<\/p>\n
![\"\"](\"https:\/\/wysac.uwyo.edu\/wyomingtobacco\/wp-content\/uploads\/2023\/10\/ATS_2021_Figure_34-1024x499.png\")
<\/p>\nA possible explanation for this is an occupational disparity, as young adults who work in the service, maintenance, and transportation industries are at a higher risk of exposure to secondhand smoke than those working in other industries (Holmes & Ling, 2017). However, the ATS does not collect information about specific occupations.<\/p>\n
Conclusions<\/h2>\n
The 2021 ATS data highlight the impact of the tobacco industry\u2019s targeted efforts to engage already vulnerable populations in commercial tobacco use. People with low incomes, people who identify as American Indian, and people experiencing behavioral health conditions are disproportionately affected by smoking. Young adults (aged 18-29) are a priority population because young adulthood is an impressionable stage when people may begin a lifelong smoking habit (Biener & Albers, 2004; Lee et al., 2020).<\/p>\n
Adults with an annual household income of less than $30,000 had a significantly higher smoking rate than those with annual household incomes greater than $30,000. They were also significantly more likely to be exposed to secondhand smoke at work.<\/p>\n
Previous ATS results have shown a smoking disparity for American Indian adults. In 2021, too few smokers identified as American Indian to detect a smoking disparity.<\/p>\n
People with behavioral health conditions were significantly more likely to smoke than those without a behavioral health condition. Current smokers with behavioral health conditions are significantly more likely to identify worsening anxiety as an obstacle to quitting than smokers without such conditions. Additional barriers for this group are craving cigarettes and the loss of a way to handle stress. Free coaching and free cessation aids from the WQT program address these obstacles.<\/p>\n
Young adults were more likely to have never tried a cigarette compared to other adults.<\/p>\n
These communities carry disproportionate burdens of smoking. Work related to Goal 4 of the SUTPP is essential to combat targeted efforts from the tobacco industry to eliminate these disparities and work toward health equity. Evidence-based ways to reduce these disparities include developing equitable policies, programs, and systems (CDC, 2022c).<\/p>\n
Acknowledgement<\/h2>\n
Proportion plots adapted from a template distributed by Stephanie Evergreen: https:\/\/stephanieevergreen.com\/proportion-plots\/<\/a><\/p>\n
<\/p>\n
References<\/h1>\n
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