Monitoring Changing Tobacco Use Behaviors: Maryland 2000 - 2016 Maryland Department of Health Cigarette Restitution Fund Center for Tobacco Prevention and Control State Fiscal Year 2017 Larry Hogan Governor State of Maryland Boyd Rutherford Lieutenant Governor State of Maryland Robert Neall Secretary Maryland Department of Health Statutory Authority and Requirements Maryland's Health-General Article, Title 13, Subtitle 10, requires the Maryland Department of Health to conduct a biennial tobacco study on the changing tobacco-use behaviors of youth and adults, and report specific findings to the Maryland Governor and the General Assembly. The appendices to this report provide detailed data for the required indicators. THIS PAGE HAS BEEN LEFT BLANK INTENTIONALLY 2 | Page Table of Contents SUGGESTED CITATION ................................................................................................................................ 7 COVER LETTER .............................................................................................................................................. 8 KEY FINDINGS ............................................................................................................................................... 10 Future Challenges ........................................................................................................................................ 12 ABOUT THIS REPORT .................................................................................................................................. 13 Acronyms Found in this Report .................................................................................................................. 13 Data Sources ................................................................................................................................................. 13 Changes in Reporting of Youth Data ......................................................................................................... 13 Comparability of Data ................................................................................................................................. 14 Low Response Rates Affecting Jurisdiction-Level Youth Data ............................................................... 14 Reporting Race and Ethnicity ..................................................................................................................... 15 YRBS/YTS Survey Sample and Weighted Demographics ....................................................................... 15 BRFSS Survey Sample and Weighted Demographics .............................................................................. 16 TOBACCO AND HEALTH ............................................................................................................................ 17 Chapter Conclusions .................................................................................................................................... 20 ATTITUDES AND BELIEFS TOWARD TOBACCO USE ........................................................................ 22 Maryland Middle School and High School Youth..................................................................................... 22 Chapter Conclusions .................................................................................................................................... 24 INITIATION OF TOBACCO USE ................................................................................................................ 25 Progression to Nicotine Dependence – First Whole Cigarette to Everyday Smoking ............................ 26 Prevention Efforts ........................................................................................................................................ 27 Chapter Conclusions .................................................................................................................................... 29 PREVALENCE OF TRADITIONAL TOBACCO PRODUCTS ................................................................ 30 National Comparison – Current Cigarette Smoking ................................................................................ 30 Adults ........................................................................................................................................................ 30 Youth ......................................................................................................................................................... 30 Current Use of Tobacco Products – Adults ............................................................................................... 31 Adult Use of Combustible Tobacco Products ............................................................................................ 32 Current Use of Tobacco Products – Youth ................................................................................................ 33 High School Youth Use of Combustible Tobacco Products ...................................................................... 35 High School Youth Cigarette Smoking and Other Risk Behaviors ......................................................... 36 Types of Tobacco Products Used By Region .............................................................................................. 36 Use of More Than One Tobacco Product ................................................................................................... 37 Gender Differences in Tobacco Use ............................................................................................................ 37 Adults ........................................................................................................................................................ 37 3 | Page Youth ......................................................................................................................................................... 38 Race/Ethnicity Differences in Tobacco Use ............................................................................................... 39 Adults ........................................................................................................................................................ 39 Youth ......................................................................................................................................................... 40 Socioeconomic Differences in Tobacco Product Use ................................................................................. 41 Chapter Conclusions .................................................................................................................................... 42 PREVALENCE OF ESDs ................................................................................................................................ 43 Youth Use of ESDs ....................................................................................................................................... 44 Adult Use of ESDs ........................................................................................................................................ 47 Concurrent Use of ESDs and Traditional Tobacco Products................................................................... 48 Use of ESDs and Marijuana ........................................................................................................................ 48 The Dangers of E-Juices and E-Liquids ..................................................................................................... 49 Chapter Conclusions .................................................................................................................................... 49 TOBACCO-RELATED DISPARITIES ......................................................................................................... 50 Geography ..................................................................................................................................................... 50 Race/Ethnicity .............................................................................................................................................. 53 Socioeconomic Status ................................................................................................................................... 54 Sexual Orientation ....................................................................................................................................... 56 Behavioral Health (Mental Health and Substance Use Disorders) .......................................................... 57 Chapter Conclusions .................................................................................................................................... 58 UNDERAGE ACCESS TO TOBACCO AND ESDs ..................................................................................... 60 Federal Restrictions on Underage Sales ..................................................................................................... 60 Maryland’s Restrictions on Underage Sales and Possession of Tobacco ................................................ 60 Youth Access Sources – Tobacco and ESDs............................................................................................... 60 Tobacco Products ..................................................................................................................................... 60 Maryland Retailers Asking for Photo Identification ...............................................................................