Maryland Department of HealthTobacco Control Updates

Dawn Berkowitz, MPH, CHESDirector, Center for Tobacco Prevention and Control

Prevention and Health Promotion AdministrationJanuary 18, 2018

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MISSION AND VISION

MISSIONThe mission of the Prevention and Health Promotion Administration is to protect, promote and improve the health and well-being of all Marylanders and their families through provision of public health leadership and through community-based public health efforts in partnership with local health departments, providers, community based organizations, and public and private sector agencies, giving special attention to at-risk and vulnerable populations.

VISIONThe Prevention and Health Promotion Administration envisions a future in which all Marylanders and their families enjoy optimal health and well-being.

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NATIONAL UPDATES

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Maryland Ranks 20th in Protecting Kids From Tobacco

Maintained position at #20 from 2016.

Maryland will spend only 2% of the

$538.3 million in revenue from the 1998 tobacco settlement and

tobacco taxes on tobacco prevention

programs.

Tobacco companies spend $121.9

million each year to market their deadly and

addictive products in Maryland.

That’s more than 11x what the state is

allocated annually for tobacco prevention.

4Source: https://www.tobaccofreekids.org/what-we-do/us/statereport/Release date: December 13, 2017

“Broken Promises to Our Children: A State-by-State Look at the 1998 State Tobacco Settlement 19 Years Later” Report by The Campaign for Tobacco Free Kids

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“The overwhelming amount of death and disease attributable to tobacco is caused by addiction to cigarettes – the only legal consumer product that, when used as intended, will kill half of

all long-term users,” - FDA Commissioner Scott Gottlieb, M.D

• Nicotine, while highly addictive, is delivered through products that present a continuum of risk.

• Start a public dialogue to lower nicotine levels in combustible cigarettes to non-addictive levels.

• Timelines for applications for newly-regulated combustible products August 2021, electronic August 2022.

• Rollout will not take place for years.

HUD Rule Implementation for PHAs

• Requires public housing agencies (PHAs) to implement a smoke-free policy• Included in the policy are cigarettes, cigars, pipes, and

waterpipes (hookahs)• PHAs must design and implement a policy prohibiting use in all

public housing living units and interior areas

• Implementation of smoke-free policies must be in effect no later than July 31, 2018.

• Guidance and Resources• HUD’s Smoke-Free Policy Guidebook• Established Smoke-Free PHAs• MDH• LHDs

MARYLAND TOBACCO USE UPDATES

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19.4

16.2

2.04.4

19.0

14.6

3.24.5

1.7

16.6

13.7

3.2 3.71.6

0

5

10

15

20

25

Any Tobacco Product Use Cigarettes E-Cigarettes Cigars Smokeless

ADULT USE OF TOBACCO PRODUCTS2012, 2014, 2016

2012 2014 2016

*E-Cigarette Data was not collected in 2012

Maryland Data: Adult Tobacco Use

Source: Maryland Department of Health. BRFSS Data 2000-2016. Unpublished.

Maryland Data: Youth Tobacco Use

9Source: Maryland Department of Health. Monitoring Changing Tobacco Use Behaviors: 2000 - 2016. Unpublished.

0.8%1.3%

1.7%

5.8%6.4%

7.9%

11.8%

1.7%2.5%

3.1%

6.0%

7.2%

9.3%

12.8%

1.2%1.9%

2.4%

4.4%5.1%

6.3%

7.8%

2.1%

4.7%

7.1%

10.4%

11.6%

13.4%

17.7%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

% A

do

lesc

ent

Usi

ng

Pro

du

ct

Current Adolescent Use of Products, By Grade2016

Cigarettes Cigars Smokeless Tobacco E-cigarettes

Tobacco Use: Electronic Smoking Devices (ESDs)

• In 2016, 13.3% of HS youth reported ESD use (down from 20.0% in 2014).

• Flavored ESD products are almost 10 times more popular than tobacco or menthol flavored e-cigarettes – 64% of youth e-cigarette users reported using fruit flavored ESD products.

• 34% of youth ESD users also use cigarettes, 35% use cigars, and 25% use smokeless tobacco.

• Seven percent of HS youth – an estimated 14,000 students – reported that they used e-cigarettes exclusively.

• Youth e-cigarette use, like tobacco use, is highly correlated with other risk behaviors including drinking alcohol, marijuana use, and prescription drug abuse.

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0%

5%

10%

15%

20%

Fall 2014 Fall 2016

% Y

ou

th E

SD u

se

Youth Electronic Smoking Device Use 2014 - 2016

Source: Maryland Department of Health. Monitoring Changing Tobacco Use Behaviors: 2000 - 2016. Unpublished.

The Next Wave …

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PRODUCT AWARENESS: JUUL aka: “JUULing”

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Source: https://support.juulvapor.com/home/learn/faqs/juulpods-juice

JUUL Higher content than most

e-liquids

“Each JUULpod contains 59mg/mL of nicotine per

pod, approximately equivalent to 1 pack of

cigarettes or 200 puffs.” –JUUL website

• Considerably higher nicotine than traditional e-cigarettes.

• Contain nicotine ‘salts’ to create a smoother, stronger hit.

• Increases the ‘buzz’ and reduces the burn.

PRODUCT AWARENESS: JUUL aka: “JUULing”

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Vaping Tide Pod Challenge …

Please don’t try this at home …

or anywhere

… EVER!

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On the Horizon: Youth E-cigarette Prevention Campaign

Multiple creative concepts developed by Red House

Fall 2017.

Formative research completed in December 2017 among 13-24 year

olds in Maryland.

Currently fine-tuning based on research and will produce ads Winter 2018.

Anticipate the ads will begin to run in early

Spring 2018 on digital platforms, including:

Spotify, Instagram, X-box, and others.

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2017 QUALITATIVE RESEARCH

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QuitlineParticipants and Former

Smokers

Pregnant Women

Health Equity: African

American and LGBTQ

SmokersYouth

Access –tobacco and e-cigarettes

ENDS users

Quitline Participants and Former Smokers

Smokers need to be “ready to quit”.

Participants struggled to verbalize what this

means.

Participants are more open to advice from someone who has successfully quit.

Personal 1-1 support is essential to quitting tobacco, along with

free NRT.

Combination NRT most effective.

Quit Coaches often fill a personal void for

participants.

Being around other smokers can cause

smoking initiation and hinder quit attempts.

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“I kept rubbing my patch on my arm. It helped me out… It makes me feel like something’s protecting me. Like I’m not doing it alone.”

African-American and LGBTQ Smokers

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Menthol cigarettes overwhelmingly

preferred by African-American

residents participating in the

study.

Address the mental health challenges

linked with tobacco use.

Be inclusive of LGBTQ

communities without overtly targeting them.

Channel may be more important

than the message.

Consider empowering

secondary audiences.

Medical issues are a major fear, but

even with a serious diagnosis, quitting is still very difficult.

Pregnant Smokers

Feelings of shame, disappointment, and

embarrassment motivate smokers to try to quit via NRT, ENDS, and/or other

resources.

Personal support is essential to quitting

tobacco.

Quit Coaches are invaluable.

Stress is the primary trigger for women who relapsed post-

partum.

Family and friends impact achievement

in staying quit.

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“Honestly, like, even with talking to them, like, even without implementing everything, when you’re pregnant and your spouse is working you’re by yourself all the time and you don’t have somebody else to talk to. Them just calling and having someone else to talk to, that even helps a lot.”

“I went from a pack a day to a half a pack to between 6-10 cigarettes a day….Then, after the first 4 months, stress levels began shooting through the roof and I got back up to a pack a

day...”

Underage Access to Tobacco Products and ENDS

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TOBACCOHOW: Targeted smaller

retailers in neighborhoods/near schools/immigrant-owned

WHY: Stress relief

WHY NOT: Cost, smell, health, judgement of others

BOTH PRODUCTSHOW: Friends, family, gas

station/convenience store

WHY: Peer pressure, influence of family members

ENDSHOW: Vape shops or online

stores: preferable due to NO ID CHECK

WHY: Tricks/competitions, social, better/pleasant smell

INSTEAD OF SMOKING: Perceived to be healthier, less parent/peer disapproval, easier to hide/parents unfamiliar

MARYLAND TOBACCO QUITLINE - UPDATES

Free service available 24/7 to all Maryland residents over the age of 13

• Trained Quit Coaches• A free supply of NRT, while supplies last• Specialized programs for youth and

pregnant women• Phone, web-based, and text support

services• Information for non-smokers seeking to

help friends, families, patients, and clients

• Referrals to local resources, including Local Health Departments

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LHDs will have option

to obtain NRT directly

via QL distributors.

Maximize resources by direct-

billing Medicaid for NRT.

Quitline101 session tentatively planned for Spring 2018

webinar.

Maryland Tobacco Quitline 2016 Evaluation: Demographics

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• 96% tobacco users• 61% female• 47% White/47% Black or African

American• 54% between the ages of 41 and 60• 88% did not have HS degree or

education beyond high school• 56% live with a chronic health

condition• 52% Medicaid or uninsured

Users most often heard about the Quitline through TV (37.5%),

Health Professional (18.5%), and Family/Friends (17.4%).

Those who use Quitline counseling and medication are 30% more likely to successfully quit than those who use medication alone.

Using combination therapy (e.g. patch + gum) has also been shown to aid in quitting tobacco, especially for highly dependent smokers.

Callers who never used ENDS were 1.5 times more likely to quit than those who reported using ENDS in the past 30 days.

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Maryland Tobacco Quitline 2016 Evaluations: Quitting Successfully

Quitline Media

• Quitline Advertisements running from November 2017 – March 2018 on transit, TV, and web

• New Year’s Resolution Ads running from December 2017- January 2018

• Point of Care Marketing Campaign (pregnancy and general QL) running from November 2017 – March 2018.

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YOUTH ACCESS AND ENFORCEMENT

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SYNAR Compliance

26

24.1

31.4

13.810.8

13.9

0

5

10

15

20

25

30

35

2014 2015 2016 2017 2018

SYNAR Compliance Rates2014-2018

Enacted Legislation: Licensing and Enforcement

Licensing for ENDS Retailers

• House Bill 523/Senate Bill 119: Electronic Nicotine Delivery Systems and Vaping Liquid –Licensing

• Requires all businesses that mix or sell ENDS or vaping liquids to secure a special license.

• Licenses expire on April 30th and must be renewed annually.

Enforcement of Civil Penalties

• House Bill 185: Distribution of Tobacco Products to Minors - Prohibition and Enforcement

• Supplements existing criminal sanctions for illegal tobacco sales to minors with civil money penalties (i.e. fines).

• Businesses cited for distributing tobacco products to a minor face civil money penalties of up to $300/first violation, up to $1,000/second violation within 24 months after the first violation, and up to $3,000/each subsequent violation within 24 months.

27Source: http://www.law.umaryland.edu/programs/publichealth/documents/MGATobacco.pdf

Responsible Retailer Campaign

Advertisements

• Responsible Retailer ads will run April - June 2018 on various mediums: Transit, Gas Station TV, and

Digital platforms.

Mailings

• Postcards sent to licensed tobacco retailers and vape shops in November.

• Packets (2018 retailer calendar, updated quick reference guide, and window cling) sent to licensed

tobacco retailers and vape shops in December.

Printing

• Limited quantities of window clings, posters, quick guides, stickers/magnets, pledges, and checklists

are available for order/download on the website.

• Retailer guides and law charts are available for download only. The full toolkits will not be printed or

distributed this year.

• Materials available for order at NoTobaccoSalestoMinors.com

** Retailer Training has been updated and is available online**

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UPCOMING MEDIA EFFORTS AND EVENTS

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On the Horizon: Behavioral Health Campaign

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Source: https://www.cdc.gov/tobacco/disparities/mental-illness-substance-use/index.htm.

• Approximately 25% of adults in the U.S. have some form of mental illness or substance use disorder, and these adults consume almost 40% of all cigarettes smoked by adults

• Tobacco smoke can interact with and inhibit the effectiveness of certain medications taken by mental health and substance abuse patients

• MDH is developing a new Behavioral Health Campaign for 2018

Previous MDH Behavioral Health Campaign Brochure

10 Year AnniversaryPassage of Maryland’s Clean Indoor Air Law

The Maryland Clean Indoor Air Law’s 10

Year Anniversary is

February 2018!

Highlight the success of the

law in reducing

exposure to secondhand

smoke exposure

statewide.

Celebrating a Smoke-Free Generation

Success Stories from

local restaurants/

bars

We’ll be celebrating all

year!

Share success stories and

join the celebration.

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Statewide Program Evaluation

• The University of Baltimore, Schaefer Center has been contracted to conduct a statewide evaluation of the tobacco program.

• Items complete as of 1/18/18:• Interviews with key staff• Focus groups conducted • Document review/synthesis

• Upcoming:• CDC Evaluation report will be available mid-year.• Strategic planning will take place mid-year.

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Thank you!

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Dawn Berkowitz, MPH, CHESDirector, Center for Tobacco Prevention and Control

Maryland Department of Healthdawn.berkowitz@maryland.gov