Lane County Public Health Tobacco Prevention and

Education Program

March 2018

2017 Annual Report

Table of Contents

Why is tobacco prevention important?...................................................................................................3

Tobacco Prevention and Education Program.......................................................................................3

Tobacco Use.............................................................................................................................................3

Youth use...............................................................................................................................................4

Adult use................................................................................................................................................5

Pregnant Women Tobacco Use..........................................................................................................5

Tobacco Use by Race and Ethnicity..................................................................................................6

Smoking During Pregnancy by Lane County Jurisdiction...............................................................7

Tobacco Related Diseases and Death..................................................................................................8

Tobacco Related Death Rate by Lane County Jurisdiction.............................................................8

Cost of Tobacco........................................................................................................................................9

The Health and Economic Burden of Tobacco in Lane County......................................................9

Quitting Tobacco.....................................................................................................................................10

Health Care Providers............................................................................................................................10

Lane County Community Health Centers Tobacco Use Prevalence by Clinic...........................10

Trillium Members Who Use Tobacco...............................................................................................11

Health Care Providers Asking About Tobacco Use.......................................................................12

Retail Environment.................................................................................................................................13

Access to Tobacco vs. Fresh Fruits and Vegetables.....................................................................13

Synar and Oregon State Police Enforcement Inspections............................................................14

Lane County Tobacco Retailer Density...........................................................................................15

Cottage Grove Tobacco Retailer Density........................................................................................16

North Eugene Tobacco Retailer Density.........................................................................................17

Eugene Tobacco Retailer Density....................................................................................................18

Florence Tobacco Retailer Density..................................................................................................19

Springfield Tobacco Retailer Density...............................................................................................20

Tobacco Retail Marketing Strategies...............................................................................................20

Tobacco Product Placement.........................................................................................................21

Tobacco Product Discounts...........................................................................................................23

Flavored Tobacco Products...........................................................................................................25

1

Store Characteristics......................................................................................................................25

Oregon Indoor Clean Air Act.............................................................................................................26

Lane County Indoor Clean Air Act Complaints...............................................................................27

Lane County Indoor Clean Air Act Complaint Types.....................................................................28

Lane County Indoor Clean Air Act Complaints by City..................................................................29

Recommendations for improving Indoor Clean Air Act Compliance in Lane County................30

Secondhand smoke............................................................................................................................31

Perception of Harm of Secondhand Smoke....................................................................................31

Smoking in Homes..............................................................................................................................31

Smoke Exposure at Work..................................................................................................................32

References..........................................................................................................................................34

2

Why is tobacco prevention important?

Preventing tobacco use begins early on in life and throughout a person’s life course. Using strategies that create healthy environments to support people and give opportunities for healthy decision-making at home, during school, in the workplace, during recreation, and in all aspects of life is one of the best ways to live a life free of tobacco and tobacco-related diseases. The purpose of this report is to provide an overall description of how tobacco use affects health outcomes in Lane County. The data included in this report is from various local and state resources. Information from this report is used to inform public health practice so that Lane County can be the best county to live, learn, work, and play.

Tobacco Prevention and Education Program

Lane County’s Tobacco Prevention and Education Program (TPEP) was created in 1997 as a result of Measure 44, which raised state tobacco taxes and dedicated a portion of the revenue toward programs to prevent tobacco use and educate people about the harmful effects of tobacco. TPEP goals are to:

(1) Prevent youth from initiating tobacco use.

(2) Identify and eliminate tobacco disparities in all populations.

(3) Provide help to everyone who wants to quit tobacco.

(4) Eliminate exposure to secondhand smoke.

TPEP applies evidence-based public health practice and research to implement a policy, systems, and environmental change approach to tobacco control. Having a local tobacco prevention program protects the most vulnerable populations in the community from being targeted by the Tobacco Industry. The four components of a local comprehensive tobacco prevention program are: increasing the number of smoke tobacco free environments, increasing the price of tobacco, reducing the Tobacco Industry influence in retail stores, and providing support to those addicted to tobacco who want to quit.

Tobacco Use

Over the past few decades, tobacco use has decreased among adults. However, smoking affects some communities more than others. Lower income populations (household incomes less than $15,000 a year), for example, smoke at higher rates than higher income populations (household incomes of more than $50,000 a year). Recent data also indicate higher rates of tobacco use among Oregon youth, mainly due to e-cigarettes. Race and ethnicity are other factors that contribute to tobacco use. In Oregon, over 30% of American Indians and African American smoke compared to 20% of non-Hispanic White people. It is important to address tobacco use as a way to decrease health disparities and improve health equity in the community.

3

Youth use

The Oregon Healthy Teens (OHT) survey is an anonymous and voluntary research survey that is conducted among 8th and 11th graders statewide. The survey is conducted every two years. The 2013, 2015, and 2017 OHT surveys reveal that an increasing percentage of youth are using tobacco products (10.2% and 19.5% of 8th and 11th graders, respectively), especially non-cigarette tobacco products that tend to be flavored, such as electronic cigarettes, little cigars or cigarillos and smokeless tobacco. The 2017 OHT survey indicates that among 8th and 11th graders who used tobacco, most (70.5% and 64.2% of 8th and 11th graders, respectively) of the products were flavored tobacco or vaping products. Research reveals that availability of flavors is one of the main reasons why youth use electronic cigarettes.12

It is also important to note that most 8th and 11th graders visit a convenience store one or more times in a week and saw a tobacco advertisement on a storefront or in a store. Stores that teens visit the most have been found to contain more tobacco advertising than stores visited less often by teens. Several studies show that youth who regularly see tobacco ads are more likely to experiment with and continue using tobacco.2-7

Current tobacco use and related topics among 8th and 11th graders in Lane County, Oregon 2017

Any tobacco product use (%)

Non-cigarette tobacco product use (%)

Electronic cigarette or other vaping product (%)

Smoke-less tobacco use (males) (%)

Little cigar or cigarillo smoking (%)

Cigarette smoking (non-menthol or menthol) (%)

Hookah tobacco use (%)

Flavored tobacco or vaping product use among tobacco users (%)

Visit convenience store at least once a week (%)

Saw a tobacco ad on a storefront or in a store (%)

8th Graders

10.2 9.3 8.2 -- 2.1^ 3.6 1.2^ 70.5 61.1 74.5

11th Graders

19.5 18.0 13.6^ 10.1^ 8.3^ 7.4 3.8 64.2 64.2 78.8

--This number is suppressed because it is statistically unreliable.^This number may be statistically unreliable and should be interpreted with caution.Source: Oregon Healthy Teens, 2017.

4

Any Tobacc

o Product Use

Non-Cigarett

e Tobacc

o Prod...

Electr

onic nico

tine deliv

ery d...

Smokel

ess to

bacco (m

ales)

Large

cigar,

little c

igar o

r ciga

r...

Cigarett

es (non-m

enthol)

Hookah to

bacco

0%

5%

10%

15%

20%

25%

17.214.9

3.9

6.5 7.1 6.48.7

19.518.0

13.6

10.1 9.9

7.4

3.8

Tobacco Use by 11th Graders in Lane County

20132017

Note: 64.2% of 11th graders who used tobacco used flavored tobacco or vaping productsSource: OHA, Oregon Healthy Teens Surveys, 2013 and 2017.

Adult use

Lane County (21.0%) continues to have a slightly higher tobacco use prevalence among adults than the State (19.8%) Lane County also has a slightly higher prevalence of cigarette smoking and smokeless tobacco use among males.

Current tobacco use and related topics among Oregon adults in Lane County, 2012-2015

Tobacco use (%) Cigarette smoking (%) Smokeless tobacco use(males; %)

Lane County 21.0 17.9 7.6State of Oregon 19.8 17.0 7.2

Source: Oregon Behavioral Risk Factors Surveillance System, 2012 2015 combined years percentages are unadjusted.‐

Pregnant Women Tobacco Use

Among the population of pregnant women in Lane County, about 25% of pregnant women on Medicaid report using tobacco during pregnancy compared to only 5% of pregnant women who are not on Medicaid. This provides strong evidence about how lower income populations have a higher prevalence of tobacco use. Tobacco use among this population is concerning due to pregnancy complications that can result from tobacco use, as well as the short and long term health risks for the baby, such low birthweight, pre-term birth, cleft lip/palate, stillbirth, infant death, and Sudden Infant Death Syndrome (SIDS).8

5

Year 2012 Year 2013 Year 2014 Year 2015 Year 2016 (prelim)*

0

5

10

15

20

25

30

Percent of Lane County pregnant women report -ing tobacco use during pregnancy, 2012-2016

Lane Medicaid Lane Non-Medicaid

Perc

ent (

%)

Source: Lane County Vital Statistics, 2012, 2013, 2014, 2015, 2016 preliminary data.

Tobacco Use by Race and Ethnicity

Smoking affects some communities more than others. In Oregon, the highest prevalence of tobacco use is among American Indians and African Americans at 35.3% and 33.3%, respectively.

Tobacco use and related topics among adults by race and ethnicity, Oregon 2010-2011

White, Non-

Latino

African American, Non-Latino

Asian or Pacific

Islander, Non-Latino

American Indian or

Alaska Native, Non-Latino

Latino

CigarettesCurrent smoker (female) 20.2 24.3 11.3 ^ 33.9 14.5Current smoker (male) 22.8 40.7 18.0 ^ 36.9 26.5Current smoker (total) 21.4 33.3 14.1 35.3 20.8Secondhand smokeSmoking is never allowed in the home 91.1 80.0 92.5 84.5 89.0Smoking inside the home in last 30 days 6.7 14.0 2.6 ^ 14.1 4.6 ^One or more hours per week in same room with smoking

22.1 27.3 15.9 40.1 18.7

Smoking is never allowed in the car 77.9 65.4 90.6 68.8 90.5^ This number may be statistically unreliable and should be interpreted with caution.-- This number is suppressed because it is statistically unreliable.Source: Oregon Behavioral Risk Factors Surveillance System Race Oversample Dataset 2010 2011; age adjusted to the 2000 ‐ ‐standard population.

Adult Smoking by Lane County Jurisdiction

The adult smoking prevalence across cities in Lane County varies. Cities that are more rural like Florence and Oakridge have a higher percentage of adults who smoke, compared to more urban cities like Eugene and Springfield. In efforts to reduce tobacco use, it is important to consider factors that influence

6

behaviors, attitudes, trends, tastes and lifestyles of individuals. In this case, the city where a person lives can influence health behaviors such as smoking.

Smoking During Pregnancy by Lane County Jurisdiction

As mentioned in the previous section, the city where a person lives can influence health behaviors such as smoking. Rural cities like Florence and Oakridge have a higher prevalence of smoking during pregnancy than more urban cities like Eugene and Springfield.

7

Lane

Cou

nty

Vene

ta

Euge

ne

Cobu

rg

Junc

tion

City

Cotta

ge G

rove

Cres

wel

l

Sprin

gfiel

d

Low

ell

Oak

ridge

Wes

tfir

Dune

s City

Flor

ence

Lane Veneta Eug Jctu Cty/Cob

Jct Cty/Cob

S. Lane S. Lane Spfld Willmt Willmt Willmt W. Lane W. Lane

0%

10%

20%

30%

40%

22%17%

19% 21% 21% 22% 22% 22%26% 26% 26%

32% 32%

Percent of Adults Who Smoke Cigarettes by City / Regional Area in Lane County, 2010-2013

% o

f Adu

lts

Note: The estimates provided for all cities are for the region in which the cities are located.Source: Oregon Behavioral Risk Factor Surveillance System (BRFSS), 2010-2013 combined years.

Lane C

ountyVen

eta

Eugen

e

Coburg*

Junction City

Cottage G

rove

Creswell

Sprin

gfield

Lowell

Oakridge

Westfir*

Dunes City

*

Floren

ce0%

10%

20%

30%

40%

16% 17%12% 13%

22%16%

20%23%

31% 30%

Percent of Women Who Smoked Cigarettes While Pregnant by City in Lane County, Oregon, 2010-2014

% o

f Birt

hs

*Suppressed; statistically unreliable.Source: Oregon Birth Certificates, Center for Health Statistics, Center for Public Health Practice, Public Health Division, Oregon Health Authority, 2010-2014.

Tobacco Related Diseases and Death

Tobacco is the leading cause of preventable death. Each year in Lane County, tobacco use kills 720 people, which is about two people every day. About 1 in 4 deaths are caused by tobacco use. Tobacco claims more lives than motor vehicle crashes, suicide, HIV/AIDS, and murders combined. There are 14,068 people in the county who suffer from a serious illness caused by tobacco; that is about the same as the combined populations of the cities of Cottage Grove and Creswell. Lane County residents pay nearly $260 million every year on tobacco-related medical care and lost productivity due to early deaths from tobacco use, which equals nearly $1,800 per household every year.

Tobacco Related Death Rate by Lane County Jurisdiction

In 2014, 1,306 lives were lost due to tobacco related deaths in Lane County. The following graph breaks down the tobacco related death rates by ZIP code. The City of Cottage Grove experienced the highest amount of loss, followed by the City of Florence.

8

Florence (97439)

Cottage Grove

(97424)

Oakridge* (97463)

Lane County Eugene (97401-5;

97408)

Springfield (97477-8)

0

100

200

300

400

336360

224

162

224

Tobacco Related Deaths by City (ZIP Code)in Lane County, Oregon, 2014

Rate

per

100

,000

pop

ulati

on (u

nadj

uste

d)

* Suppressed; statistically unreliable. Source: Oregon Death Certificates, Center for Health Statistics, Center for Public Health Practice, Public Health Division, Oregon Health Authority, 2014.

Cost of Tobacco

Buying tobacco products is not only expensive for the individual (approximately $1,825 a year for one pack per day), tobacco affects our entire community. The real cost of tobacco includes factors such as children’s lives sacrificed to addiction, an unequal disease burden on vulnerable populations, the emotional burden from watching a loved one suffer and die from a tobacco-related disease, higher rates of mental illness and substance use disorders, the environmental harms from tobacco and cigarette butts, the medical expenses that fall on taxpayers, productivity losses affecting the economy, decreased military readiness, the increased challenges that tobacco users have in securing jobs and homes, and various other factors. Smoking related illness costs the United States more than $300 billion each year1, but the real cost of tobacco on communities is much higher.

The Health and Economic Burden of Tobacco in Lane County

In 2014, medical treatment for tobacco diseases in Lane County cost $143.5 million. About 720 people died from using tobacco, which equals two people every day. Approximately 5% of the adult population in Lane County smokes cigarettes and are at risk for tobacco-related illness and death.

Tobacco’s toll in one year in Lane County

Youth population

Adult population

Adult cigarette smokers

Tobacco illness

Tobacco deaths

Medical Costs ($ in Millions)

Productivity loss ($ in Millions)

Lane County 68,479 287,646 59,200 14,068 720 143.5 115.0Sources: Portland State University Population Research Center 2014; Oregon Behavioral Risk Factor Surveillance System 2013;CDC Smoking-Attributable Morbidity and Mortality Cost calculator 2013.

9

Quitting Tobacco

Quitting tobacco is the best thing a tobacco user can do for their health. Most people who smoke tobacco want to quit and attempted to quit during the previous year. This indicates that we need to do more in the community to support people in quitting, such as increasing the price of tobacco, increasing the number of tobacco-free places, reducing the Tobacco Industry influence in retail stores, and connecting people to resources to quit. Approximately half of Oregonians who smoke have heard of the Oregon Tobacco Quit Line.

Quitting among current cigarette smokers, Oregon, 2010-2016

2010 2011 2012 2013 2014 2015 2016

Wants to quit 74.6 80.3 74.3 77.6 68.2 63.9 66.0Attempted to quit during previous year

54.5 58.3 58.3 53.0 57.8 53.7 23.0

Heard of Oregon Tobacco Quit Line (all adults)

42.0 39.3 NA 52.4 49.9 57.4 60.8

Source: Oregon Behavioral Risk Factors Surveillance System, 2010-2016; age-adjusted to the 2000 standard population.

Health Care Providers

Health care providers are an important resource for treating and preventing tobacco use. Health care providers can assist people who smoke with their quit attempts. Providers can also give medication to support smoking cessation.

Lane County Community Health Centers Tobacco Use Prevalence by Clinic

The Community Health Centers of Lane County are Federally Qualified Health Centers that provide affordable health care services for the people of Lane County. There are six health clinics as well as a prenatal clinic. The following chart displays the tobacco use prevalence among six of the community health centers of Lane County. The Lane County Behavioral Health center has the highest prevalence at 72%. The Riverstone and Charnelton clinics hover at a 50% tobacco use prevalence. The Delta Oaks clinic has the lowest prevalence at 40%, which is still very high, as the general population in Lane County has a tobacco use prevalence of 21%.

10

Jul-Sep 16 Oct-Dec 16 Jan - Mar 17 Apr-Jun 17 Jul-Sep 170%

25%

50%

75%

100%

Lane County Community Health Centerstobacco use by clinic, 2017

LCBH Riverstone Charnelton Brookside SBHC Delta Oaks

% o

f pati

ents

with

a v

isit w

ho re

port

ed

usin

g to

bacc

o

Source: Community Health Clinics of Lane County Public Reporting Q3 Data, November 2017.

Trillium Members Who Use Tobacco

Trillium is the Community Care Organization that serves Lane County. Trillium provides health care providers for the Oregon Health Plan. In 2015, the tobacco use prevalence among people on the Trillium Health Plan was 32.4%. In 2016, the Trillium tobacco prevalence was 31.5%. Overall, the smoking prevalence among Trillium members seems to be on a downward trend.

11

Source: Oregon Health System Transformation: CCO Metrics 2016 Final Report.

Health Care Providers Asking About Tobacco Use

When interacting with a health care provider, it is important for the provider to screen for tobacco use. Most people want to quit tobacco and attempt to quit every year. Simply asking patients if they use tobacco, and as their health care provider, advising them to quit, doubles their chances of quitting in the next year. Research shows that patients view their providers more positively when the providers ask them about their tobacco use and advises them to quit. Tobacco users who receive effective treatment are two to three times more likely to quit and remain quit. The most effective treatment is medication combined with individual counseling. A provider can either integrate effective treatment in the clinic or refer to another tobacco dependence treatment resource.

Asking about tobacco use is the first step in assisting those who smoke with the quitting process and decreasing their preventable illness and death. The chart below indicates that about 80% of healthcare providers are asking about tobacco use which seems to be consistent for the years 2010-2016. Advising patients to quit and providing assistance with cessation is not as frequent as screening for use. Patients

12

are more likely to quit when their provider advises them to quit and connects them to cessation resources.

Tobacco Health Services, Oregon 2010-2016 2010 2011 2012 2013 2014 2015 2016HCP asked about tobacco use (all adults) 62.4 68.4 68.7 NA 69.6 76.5 69.0HCP asked about tobacco use (current cigarette smokers)

81.7 82.8 81.5 NA 83.0 82.3 81.8

HCP advised to quit tobacco use (current cigarette smokers)

59.2 60.3 64.2 NA 72.6 60.1 60.1

HCP offered assistance to quit tobacco use (current cigarette smokers)

39.8 39.1 51.8 NA 48.1 45.4 46.6

Source: Oregon Behavioral Risk Factors Surveillance System 2010-2016; age-adjusted to the 2000 standard population.

Retail Environment

Tobacco companies used to advertise tobacco products on TV, radio, and billboards, feature doctors to endorse products and use cartoons mascots to interest children. However, after the release of the U.S. Surgeon General’s report on smoking and health in 1964, pressure grew and lead to restrictions on how and where the Tobacco Industry could advertise. In 1971, cigarette ads were banned on TV and radio, but ads for smokeless tobacco products were allowed until they were banned in 1986. In 1998, the Master Tobacco Settlement Agreement, which was the result of civil litigation brought by 46 U.S. states, D.C., and five territories against major U.S. tobacco companies, imposed bans on transit billboard ads, paid brand product placement, cartoons, and tobacco brand sponsorships of sporting events and concerts.

In 2009, President Obama signed into law the Family Smoking Prevention and Tobacco Control Act, giving the U.S. Food and Drug Administration (FDA) comprehensive authority to regulate the manufacturing, marketing, and sale of tobacco products. This act banned the use of vending machines and product sampling (except in adult-only facilities), restricted the sale of tobacco in retail stores to face-to-face transactions between retailers and consumers, and expanded the existing limits on tobacco brand sponsorships and tobacco branding of non-tobacco items. Even though the FDA now has authority to regulate electronic cigarettes, no restrictions on electronic cigarette advertising have been passed. Due to the tobacco advertising restrictions, tobacco companies now spend over 90% of their marketing and promotion budget, most of which is dedicated to lowering the price of tobacco through price promotions, in retail stores.

Access to Tobacco vs. Fresh Fruits and Vegetables

As seen in the chart below, there are more tobacco retailers than stores that sell fresh produce. Some cities like Coburg and Westfir have no stores that sell fruits and vegetables, and people must go outside of the city to acquire nutritious foods. Although there are no stores that sell produce in these cities, there are places that sell tobacco products. In Cottage Grove, there are four times more tobacco retailers than fresh produce retailers. A similar situation exists in all cities throughout Lane County.

13

Coburg

Cottage G

rove

Creswell

Dunes City

*

Eugen

e

Floren

ce

Junction City

Lowell

Oakridge

Sprin

gfield

Veneta

Westfir*

0

1

2

3

4

5

6

7

8

Ratio of Availability of Tobacco Stores vs. Produce Stores in Lane County

TobaccoFruits and Vegetables

*City does not currently have any stores that sell tobacco.Source: Computed using Lane County Site Addresses (RLID, 2013), ACS 2008 to 2012 Household Size Estimates (US Census Bureau), Lane County Roads (RLID, 2013), Supermarkets, (Reference USA, 2013), Farmers Markets, Farm Stands (Willamette Farm and Food Coalition,2013).

Synar and Oregon State Police Enforcement Inspections

On August 9, 2017, Governor Kate Brown signed Senate Bill 754 into law. This law raised the required minimum age for a person to legally buy or obtain tobacco products, inhalant delivery systems, and tobacco product devices, from 18 to 21. Raising the age to purchase tobacco to age 21 is an evidence-based strategy that will help reduce youth initiation of tobacco, with the biggest impact expected to be a 25% reduction in initiation among 15 to 17 year olds.9 Most addiction to tobacco starts in adolescence, which means protecting kids is critical. Among adults who smoke, 96% report that they started smoking before they turned 21, and nearly 100% start before they turn 26.

The Federal Synar Amendment requires states to enact and enforce laws prohibiting the sale and distribution of tobacco products to individuals younger than 18. Now that Oregon is a Tobacco 21 state, the age requirement for enforcing the Synar Amendment is 21 years of age. Oregon must enforce youth tobacco access laws in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals younger than 21. Oregon must conduct random, unannounced inspections of youth-accessible tobacco outlets to assess tobacco retailer compliance with the state minimum legal sales age law. Oregon retailer violation rates must not surpass 20%.

14

Eugen

e

Sprin

gfield

Cottage G

rove

Coburg

Creswell

Floren

ce

Junction City

Oakridge

Veneta

Unincorporat

ed0%

5%

10%

15%

20%

25%

Sales to Minors Non-Compliance Rates by Lane County City, 2009-2018

Source: Oregon Tobacco Retail Synar Survey Results, 2009-2018; Oregon State Police Enforcement, 2009-2018; Oregon Health Authority Public Health Division, Health Promotion and Chronic Disease Prevention Section.

Lane County Tobacco Retailer Density

The Tobacco Industry is historically known to market their products to vulnerable populations such as minorities and children. The chart below displays the tobacco retailers that are in close proximity to places frequented by children in Lane County. Of the 290 tobacco retailers in Lane County in 2014, 174, or 60%, of the retailers are located in areas that are frequented by children.

Retailers within 1,000 foot of:

City Total RetailersPrivate and

Public SchoolsChildcare facilities Parks

Pools, museums,

libraries, or other

recreational areas

Any areas frequented by

childrenCoburg 3 0 0 1 0 1Cottage Grove 14 0 1 12 1 12Creswell 6 0 2 2 3 5Eugene 120 26 33 78 13 91Florence 10 0 2 5 4 8Junction City 7 0 3 6 4 7Lowell 2 2 0 2 0 2Oakridge 3 0 0 1 0 1Springfield 60 10 15 17 3 27Veneta 7 1 0 1 0 1Westfir 1 0 0 1 0 1Unincorporated 58 4 3 11 1 18Lane County 290 43 59 137 29 174

15

Cottage Grove Tobacco Retailer Density

The map below is a visual representation of tobacco retailers within 1,000 feet of places frequented by children in Cottage Grove. A majority of tobacco retailers in Cottage Grove are in close proximity to children. The density of tobacco retailers in Cottage Grove is 6 times the density of tobacco retailers in the county.

16

North Eugene Tobacco Retailer Density

Many schools in North Eugene have at least one tobacco retailer located within 1,000 feet, and several schools have multiple retailers located within 1,000 feet. Research indicates that the more tobacco retailers there are surrounding a school, the more likely underage smokers were to buy their own cigarettes and the less likely they are to get someone else to buy their cigarettes.

17

Eugene Tobacco Retailer Density

The City of Eugene is heavily concentrated with tobacco retailers that have easy access to children. Most tobacco retailers in the City of Eugene are located within 1,000 feet of a place, such as a school, library, pool, park, or child care facility, which is frequented by children.

18

Florence Tobacco Retailer Density

In Florence, the main highway US 101 and areas along the coast have a high concentration of tobacco retailers with access to children. Most tobacco retailers in Florence are located within 1,000 feet of places where children visit and spend time frequently.

19

Springfield Tobacco Retailer Density

About half of the tobacco retailers in Springfield are strategically placed near children-centered facilities, with 1 in 6 retailers being located near a school. Research indicates that density of tobacco retailers is associated with 11% increased odds of experimental smoking among high school-aged youth in urban areas.

Tobacco Retail Marketing Strategies

Every year, the Tobacco Industry spends billions on encouraging people who smoke to continue, persuade people who used to smoke to take it up again, and lure nonsmokers, particularly youth, to start smoking. Tobacco companies use most of their marketing budget – nearly $1 million every hour – at the point-of-sale, making it the primary venue for tobacco product marketing.1

20

Tobacco Product Placement

One of the marketing strategies used by the Tobacco Industry is to place products in a way that appeals to children. Product placement, such as displaying products or advertising tobacco products below 3 feet or within 12 inches of products sold to youth, is a tactic that is used by 61% of tobacco retailers in Lane County.10 The pictures below depict placement of tobacco products or ads near products that appeal to kids. These pictures were taken during the 2014 Lane County Retail Assessment.

Photo in a Lane County tobacco retailer where electronic cigarettes and e-liquids were placed next to candy.

21

Photo in a Lane County tobacco retailer where a smokeless tobacco ad was placed next to candy.

Photo in a Lane County tobacco retailer where e-cigarettes were placed near candy.

22

Photo in a Lane County tobacco retailer where Girl Scout Cookies were placed where accessing the cookies will put the Tobacco Powerwall in view.

Tobacco Product Discounts

Price discounts are another tactic used by the Tobacco Industry to make their products more affordable and easily accessible to their customers, especially youth. There are price discounts for all types of tobacco products. Cigarettes (menthol and non- menthol), smokeless tobacco, and flavored products are among the tobacco products with the most price discounts. These are also products that are popular among youth, low-income populations, and racial or ethnic minority populations.

23

Photo outside a tobacco retailer in another Oregon county displaying a price promotion ad that makes the cost to the consumer $0.

Cigarettes (non-m

enthol)

Menthol Cigarettes

Flavored little ci

gars or c

igarillos

Single little ci

gars or c

igarillos

E-cigarettes o

r refills

Flavored e-cigarettes o

r refills

Smokeless

tobacco (c

hew, snuff)

Flavored smoke

less tobacco

(chew, s

nuff)

Vape pen, e-hooka

d, e-ci

gars0%

10%

20%

30%

40%

50%

Percent of Lane County Tobacco Retailers that offer discounts by product type

Source: Lane County Retail Assessment Data Tobacco Summary, 2014.

24

Flavored Tobacco Products

Flavored tobacco products are popular product choices among youth. Flavored tobacco products are often cheap and packaged in a way similar to candy, using sweet flavors. Nearly 100% of Lane County tobacco retailers sell any flavored tobacco product, including menthol cigarettes. As mentioned previously, the 2017 OHT survey indicates that most 8th and 11th graders who use tobacco in Lane County use flavored tobacco or vaping products. It is also important to again note that most 8 th and 11th graders visit a convenience store one or more times in a week and saw a tobacco advertisement on a storefront or in a store, and that youth who see tobacco ads are more likely to experiment with and continue using tobacco. See the table on p. 4 of this report under the Youth Use section.

0%

25%

50%

75%

100%

Lane County Tobacco Retailer Flavored Tobacco Product Availability

Source: Lane County Retail Assessment Data Tobacco Summary, 2014.

Store Characteristics

Low-income populations tend to have higher rates of smoking. As you can see here, almost 80% of tobacco retailers in Lane County accept Supplemental Nutrition Assistance Program (SNAP), a federally-funded food benefits program for low-income individuals and families. It is important to note that tobacco retailers in the community are serving vulnerable populations, with low socioeconomic status, because when these populations enter a retailer to purchase food, they are being subjected to effective tobacco advertising.

25

SNAP WIC0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Percent of Lane County Tobacco Retailers that Accept SNAP/WIC

Source: Lane County Retail Assessment Data Tobacco Summary, 2014.

Oregon Indoor Clean Air Act

The Oregon Indoor Clean Air Act (ICAA) (also known as the Smokefree Workplace Law) protects workers and the public from secondhand smoke exposure in public, in the workplace, and within 10 feet of all entrances, exits, accessibility ramps that lead to and from an entrance or exit, windows that open and air-intake vents. The law also prohibits ash receptacles from being less than 10 feet from any windows that open, doors, air intake vents, and accessibility ramps.

The ICAA includes the use of "inhalant delivery systems." Inhalant delivery systems are devices that can be used to deliver nicotine, cannabinoids and other substances, in the form of a vapor or aerosol. These include e-cigarettes, vape pens, e-hookah and other devices. Under the law, Oregonians may not use e-cigarettes and other inhalant delivery systems in workplaces, restaurants, bars and other indoor public places in Oregon. There are no exemptions for electronic cigarette retail outlets, smoke shops, bars or other venues.

There is a delegation agreement between the Oregon Health Authority (OHA) and the Lane County Public Health (LCPH) Tobacco Prevention and Education Program (TPEP) that delegates the authority to conduct ICAA enforcement in Lane County to LCPH. This delegation agreement is a requirement of the TPEP grant. The agreement outlines the responsibilities of LCPH and OHA.

In 2000, long before the state ICAA, the City of Eugene was one of the first jurisdictions in Oregon to pass an Indoor Clean Air Law requiring workplaces to be smokefree. The City law is somewhat stricter then the State law. For instance, City Code expands the State law and prohibits smoking within 25 feet of publicly-funded buildings. Since the City law is stricter than the State law, the City conducts enforcement of the local and state Indoor Clean Air laws with businesses inside the City limits.

26

Lane County Indoor Clean Air Act Complaints

The Indoor Clean Air Act (ICAA) is enforced through a complaint-based system known as the Workplace Exposure Monitoring System. First-time complaints are verified within five business days of the complaint date. An initial response letter is sent to the business within ten days of the complaint date with the intent of educating the business on how to comply with the ICAA. According to a Memorandum of Understanding (MOU) between the County and the City of Eugene, all complaints within the City of Eugene are forwarded to Eugene code enforcement staff, who then conduct enforcement with businesses based on the enforcement protocols outlined in the MOU. Lane County Public Health Tobacco Prevention and Education Program staff work closely with the City of Eugene on enforcement in Eugene.

When a second complaint for a business is received through the Workplace Exposure Monitoring System, a site visit is conducted within 30 days of the complaint date. During the initial site visit, the Lane County Public Health Tobacco Prevention and Education Program staff inspect the business for indications of smoking both inside and outside the business. Lane County staff investigates for ash receptacles, cigarette butts, people smoking less than 10 feet from entrances, exits, air intake vents, and accessibility ramps, and ICAA signage on all entrances and exits. If violations are found, then Lane County staff develops a remediation plan with the business that must be completed within 15 days of the initial site visit.

Lane County staff completes a follow up site visit within 30 days of the remediation plan due date. During the follow up site visit, if the business is found to be non-compliant with the remediation plan or if additional violations are observed, then the case is referred to the Oregon Health Authority for potential citation. Lane County staff forwards all documentation to the Oregon Health Authority for review. The Oregon Health Authority determines whether the business receives a citation.

Over the past three years, Lane County has received a dramatic increase in the number of ICAA complaints. Between 2015 and 2016, there was a 157% increase in the number of complaints received. Most of the cases are inside the City of Eugene. Despite the high increase in complaints, the number of businesses cited by OHA remains relatively small. No businesses were cited in 2015, two businesses were cited in 2016, and five businesses were cited in 2017 (see chart below).Source: Oregon Workplace Exposure Monitoring System.

27

Lane

County Indoor Clean Air Act Complaint Types

The following chart displays the Indoor Clean Air Act complaints by type. Most of the complaints received inside Lane County are about smoking less than 10 feet from a door, window that opens, an accessibility ramp, or an air intake vent. The second most common complaint is smoking inside a business.

28

0

10

20

30

40

50

60

70

80

90

100

110

Lane County Indoor Clean Act Cases, 2015-2017

2015 2016 2017

Num

ber

0

10

20

30

40

50

60

70

Lane County Indoor Clean Air Act Complaints by Type, 2015-2017

2015 2016 2017

Num

ber

Source: Oregon Workplace Exposure Monitoring System.

Lane County Indoor Clean Air Act Complaints by City

Most of the Indoor Clean Air Act complaints are from the cities of Eugene and Springfield. Of the smaller cities in Lane County, Cottage Grove receives the next highest number of complaints.

29

Eugen

e

Sprin

gfield

Cottage G

rove

Floren

ce

Creswell

Oakridge

Junction City

Maplet

on

Mckenzie

Bridge

Crescen

t Lake

Elmira

Westlak

e05

101520253035404550556065

Indoor Clean Air Act Complaints by Lane County City, 2015-2017

2015 2016 2017

Num

ber

Source: Oregon Workplace Exposure Monitoring System.

Recommendations for improving Indoor Clean Air Act Compliance in Lane County

One of the ways to improve the Indoor Clean Air Act (ICAA) enforcement system is by increasing communication between Lane County and the City of Eugene. All Eugene ICAA complaints are forwarded to City of Eugene staff for enforcement. After cases are forwarded to Eugene, Eugene cases have remained open in the Workplace Exposure Monitoring System (WEMS) for long periods of time due to a lack of communication from City staff so County staff could update information in WEMS and close cases. This breakdown in communication happened after staff turnover and hiring of new staff. County staff identified this issue and are working with City staff to resolve any contributing issues.

County staff have developed a City/State law comparison chart and State ICAA checklist for City staff. County staff have also met with and trained City staff, City staff shadowed County staff during a county inspection, and County staff shadowed City staff during a City inspection. County and City staff have also begun collaborating more closely on shared cases and cases where they can each play their own, very different role, which includes, for County staff, educating and encouraging smoke- or tobacco-free properties as an option to assist with enforcement at certain types of properties.

Another way to decrease complaints received through WEMS is by educating local businesses. Two of the main ICAA complaints are: smoking less than 10 feet from a door, window that opens, accessibility ramp, or air intake vent; and smoking inside a business. It would be helpful to develop and send local

30

businesses educational materials about the ICAA and how to comply either in the mail or do targeted education in person. TPEP staff could also offer to conduct informational or educational ICAA inspections for businesses that want to know whether they comply and areas for improvement. This would be done without enforcement consequences because the purpose would be education to achieve compliance. However, due to lack of funding, both of these options might not be feasible.

Secondhand smoke

Secondhand smoke causes more than 7,300 lung cancer deaths among U.S. nonsmokers each year. Secondhand smoke also causes the deaths of 650 Oregonians each year.11 Secondhand smoke causes health problems in infants and children, including asthma attacks, respiratory infections, ear infections and sudden infant death syndrome (SIDS).

Perception of Harm of Secondhand Smoke

Over 90% of Lane County voters perceive secondhand smoke as harmful.

Very or Somewhat Harmful Not Very or Not Harmful DK/NA/REF0

10

20

30

40

50

60

70

80

90

10091

63

Perception of Harm of Secondhand Smoke

Perc

ent

Source: Lane County H&HS Community Survey, 2014.

Smoking in Homes

The following graph indicates how smoking is not allowed in most homes. From 1997-2015, there is a steady increase in Oregonians prohibiting smoking inside the home. This also raises the issue of the disparity of smoking and secondhand smoke exposure among people who are experiencing homelessness. Smoking is so pervasive in the community, it is hard for someone experiencing

31

homelessness to escape smoking and all the cues to smoke, which makes them more likely to smoke and less likely to quit.

Adults reporting no smoking allowed in the home, Oregon, 1997-2015

Source: Behavioral Risk Factor Surveillance System. Unpublished data. Note: Estimates are age-adjusted to the 2000 standard population. Data collection and weighting methods changed in 2010. Estimates beginning in 2010 should not be compared to those from earlier years.

Smoke Exposure at Work

Although over 90% of Lane County voters perceive secondhand smoke as harmful, over 10% of Oregonians still experience secondhand smoke exposure at work. This emphasizes the need for the Indoor Clean Air Act and protecting Oregonians from secondhand smoke exposure.

32

Adults reporting exposure to secondhand smoke at work, Oregon, 2001-2005

Source: Oregon Behavioral Risk Factor Surveillance System. Unpublished data. Note: Estimates are age-adjusted to the 2000 standard population. Data collection and weighting methods changed in 2010. Estimates beginning in 2010 should not be compared to those from earlier years.

33

References

1. Tsai J, Walton K, Coleman BN, et al. Reasons for Electronic Cigarette Use Among Middle and High School Students — National Youth Tobacco Survey, United States, 2016. MMWR Morb Mortal Wkly Rep 2018; 67:196–200.

2. Henriksen L, Feighery EC, Schleicher NC, Haladijan HH, et al. Reaching youth at the point of sale: Cigarette marketing is more prevalent in stores where adolescents shop frequently. Tob Control 2004; 3:315–8.

3. Centers for Disease Control and Prevention. 2012 Surgeon General’s Report – Preventing tobacco use among youth and young adults; Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General, Rockville, MD.

4. Slater SJ, Chaloupka FJ, Wakefield M, et al. The impact of retail cigarette marketing practices on youth smoking uptake; Arch Pediatr Adolesc Med 2007; 161:440–5.

5. Payntner J, Edwards R, The impact of tobacco promotion at the point of sale: A systematic review. Nicotine Tob Res 2009; 11;25–35.

6. Paynter J, Edwards R, Schluter PJ, McDuff I, et al. Point of sale tobacco displays and smoking among 14–15 year olds in New Zealand: A cross-sectional study. Tob Control 2009;18:268–74.

7. Henriksen L, Schleicher NC, Feighery EC, Fortmann SP. A longitudinal study of exposure to retail cigarette advertising and smoking initiation. Pediatrics 2010;126:232–8.

8. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Printed with corrections, January 2014.

9. Institute of Medicine. Public health implications of raising the minimum age of legal access to tobacco products. Washington, DC: The National Academies Press, 2015.

10. Lane County Retail Assessment, 2014.11. Oregon Health Authority. “Oregon Tobacco Facts 2013: Secondhand Smoke.” Available at:

https://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/tobacco_facts/secondhand_smoke.pdf.

12. Federal Trade Commission. Federal Trade Commission Cigarette Report for 2015.Washington: Federal Trade Commission, 2017.

13. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2017 Nov 6].

14. Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. Annual Healthcare Spending Attributable to Cigarette Smoking: An Update. American Journal of Preventive Medicine 2014;48(3):326–33 [accessed 2017 Nov 6].

15. Leatherdale ST, Strath JM. Tobacco retailer density surrounding schools and cigarette access behaviors among underage smoking students.

34

16. McCarthy WJ, Mistry R, Lu Y. Density of Tobacco Retailers Near Schools: Effects on Tobacco use Among Students. Am J Public Health. 2009;99(11):2006-13.

17. Lane County Public Health, PeaceHealth, Trillium Community Health Plan, & United Way of Lane County.

18. Lane County Community Health Improvement Plan (CHIP). April 2013. Available at http://www.preventionlane.org/chip

19. Centers for Disease Control and Prevention, Chronic Disease Prevention and Health Promotion. Tobacco Use:Targeting the Nation’s Leading Killer. 2011. Available at http://www.cdc.gov/chronicdisease/resources/publications/aag/osh.htm

20. U.S. Department of Health & Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health & Human Services, Centers for Disease Control & Prevention, National Center for Chronic Disease Prevention & Health Promotion, Office on Smoking and Health, 2012. Available at http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/index.html

21. Guide to Community Preventive Services. Community mobilization with additional interventions to restrict minors' access to tobacco products. Available at http://www.thecommunityguide.org/tobacco/communityinterventions.html. Last updated: June 2001.

22. Oregon Health Authority, Addictions and Mental Health Division. Student Wellness Survey, 2014.23. 7Oregon Health Authority, Public Health Division. Oregon Behavioral Risk Factor Surveillance System

(BRFSS) Survey, 2008-2012.24. Oregon Center for Health Statistics, Vital Records Office. Birth Certificates, 2009-2013.25. Extrapolated from Oregon Tobacco Facts by County: Lane County. Available at https://

public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/countyfacts/lanefac.pdf; Computations based upon Hyland A, Vena, C, Bauer, J et al Cigarette Attributable Morbidity-United States 2000, MMWR 2003, September 5, 52(35) 842-843.

26. Lane County Tobacco Prevention & Education Program. Retail Assessment, 2014.27. Computed using Lane County Site Addresses (RLID, 2013), ACS 2008 to 2012 Household Size

Estimates (US Census Bureau), Lane County Roads (RLID, 2013), Supermarkets, (Reference USA, 2013),Farmers Markets, Farm Stands (Willamette Farm and Food Coalition,2013).

28. Oregon Health Authority, Addictions & Mental Health Division. Synar Inspection Results: Lane County, 2012-2013.

29. Johnson S, McCaslin C. Lane County Health & Human Services 2014 Survey.30. Zhu SH et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product

regulation,Tob Control 2014;23(suppl 3):iii3-iii9. Available at http://tobaccocontrol.bmj.com/content/23/suppl_3/iii3.full

31. Oregon Health Authority, Public Health Division. E-Cigarette Primer. Available at http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/SmokefreeWorkplaceLaw/Documents/EcigFactSheet.pdf

32. Oregon Health Authority, Public Health Division. Oregon Healthy Teens Surveys, 2011 & 2013. Available at https://public.health.oregon.gov/BirthDeathCertificates/Surveys/OregonHealthyTeens/Pages/index.aspx

35

33. Chatham-Stephens, K et al. Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes— United States, September 2010–February 2014, MMWR, April 4, 2014/63(13);292-293. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm?s_cid=mm6313a4_w

34. FEMA, U.S. Fire Administration. Electronic Cigarette Fires and Explosions, October 2014. Available athttps://www.usfa.fema.gov/downloads/pdf/publications/electronic_cigarettes.pdf

36