Agaku, Israel T. DMD; King, Brian A. PhD; Dube, Shanta R. PhD
By Israel T. Agaku, DMD; Brian A. King, PhD; and Shanta R. Dube, PhD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
Despite significant declines during the past 30 years, cigarette smoking among adults in the United States remains widespread, and year-to-year decreases in prevalence have been observed only intermittently in recent years.1,2 To assess the progress made toward the Healthy People 2020 (healthypeople.gov/2020/topicsobjectives2020) objective of reducing the proportion of U.S. adults who smoke cigarettes to 12 percent or less, this report provides the most recent national estimates of smoking prevalence among adults age 18 and over, based on data from the 2012 National Health Interview Survey (NHIS).
The findings indicate that the proportion of U.S. adults who smoke cigarettes fell to 18.1 percent in 2012. Moreover, during 2005–2012, the percentage of “ever-smokers” who quit increased significantly, from 50.7 to 55.0 percent, and the proportion of daily smokers who smoked 30 or more cigarettes per day declined significantly, from 12.6 to 7.0 percent.
Proven population-level interventions, including tobacco price increases, high-impact anti-tobacco mass media campaigns, comprehensive smoke-free laws, and barrier-free access to help quitting interventions, are critical to decreasing cigarette smoking and reducing the health and economic burden of tobacco-related diseases in the United States.3
NHIS is an annual, nationally representative, in-person survey of the non-institutionalized U.S. civilian population. Questions about cigarette smoking are directed to one randomly selected adult from each surveyed family.
In 2012, a total of 34,525 adults age 18 and over were selected and participated, yielding a response rate of 61.2 percent. Current smokers were respondents who reported smoking 100 or more cigarettes during their lifetime and, at the time of interview, reported smoking every day or some days. Former smokers were respondents who reported smoking at least 100 cigarettes during their lifetime but currently did not smoke.
The mean number of cigarettes per day was calculated among daily current smokers. A quit attempt was defined as a report by a current smoker that he/she stopped smoking for more than one day during the preceding year because they were trying to quit smoking, or a report by a former smoker that they quit smoking during the preceding year. Quit ratios were defined as the ratio of former smokers to ever smokers.
Data were adjusted for nonresponse and weighted to provide nationally representative estimates. Current smoking was assessed overall and by sex, age, race/ethnicity, education, poverty status, U.S. Census region, and disability/limitation status. Differences between groups were assessed using the chi-squared statistic and 95% confidence intervals. Quit ratios were calculated overall and by age group. Logistic regression was used to analyze overall trends in prevalence, cigarettes per day, and quit ratios during 2005–2012, controlling for sex, age, and race/ethnicity. The Wald test was used to determine statistical significance of trends from 2005 to 2012 (p<0.05).
In 2012, an estimated 18.1 percent (42.1 million) of U.S. adults were current cigarette smokers. Of these, 78.4 percent (33.0 million) smoked every day, and 21.6 percent (9.1 million) smoked some days. Overall smoking prevalence declined from about 21 percent in 2005 to 18 percent in 2012.
In 2012, prevalence was significantly higher among males (20.5%) than females (15.8%) and among persons age 18–24 (17.3%), 25–44 (21.6%), and 45–64 (19.5%) than among those 65 and over (8.9%). By race/ethnicity, prevalence was highest among respondents reporting multiple races (26.1%) and lowest among Asians (10.7%).
By education, prevalence was highest among persons with a graduate education development certificate (41.9%) and lowest among those with a graduate (5.9%) or undergraduate (9.1%) degree. Prevalence was significantly higher among people living below the poverty level (27.9%) than those living at or above this level (17.0%).
By U.S. Census region, prevalence was significantly higher in the South (19.7%) and Midwest (20.6%) than in the West (14.2%) and Northeast (16.5%). Respondents who reported having a disability/limitation with activities of daily living (disability/limitation) had a significantly higher prevalence (22.7%) than those with no disability/limitation (16.5%).
Among daily smokers, declines in mean cigarettes per day occurred from 16.7 in 2005 to 14.6 in 2012. During 2005–2012, increases occurred in the proportion of daily smokers who smoked one to nine cigarettes per day (16.4% to 20.8%) and 10 to 19 (36.0% to 41.2%), whereas declines occurred in those smoking 20 to 29 cigarettes per day (34.9% to 31.0%) and 30 or more (12.6% to 7.0%).
Among current smokers and former smokers who quit during the preceding year, 52.9 percent had made a quit attempt for more than one day. The overall quit ratio (i.e., the ratio of former to ever smokers) increased from 50.7 percent in 2005 to 55.0 percent in 2012. Quit ratios were lowest among adults age 18 to 24 and highest among those 65 and older in each survey year.
During 2005–2012, the largest increase in quit ratios (22.7 to 26.5 percent) and decline in smoking prevalence (24.4 to 17.3 percent) occurred among those 18 to 24.
During 2005–2012, cigarette smoking prevalence declined among U.S. adults, and the quit ratio (i.e., the percentage of ever smokers who had quit) increased. During the same period, the proportion of daily smokers who smoked 30 or more cigarettes per day also declined.
Adults 18 to 24 had the greatest decrease in cigarette smoking prevalence; however, this decline might be attributable in part to the use of other tobacco products, such as flavored little cigars, which are especially popular with this age group.4
The decline in overall smoking prevalence from 20.9 percent in 2005 to 18.1 percent in 2012 is encouraging and likely reflects the success of tobacco control efforts across the country. However, given the slowing decline in adult smoking in recent years, continued implementation of evidence-based interventions outlined in the World Health Organization MPOWER package (who.int/tobacco/mpower/mpower_report_full_2008.pdf) is critical.
These include increasing the price of tobacco products, implementing and enforcing comprehensive smoke-free laws, warning about the dangers of tobacco use with antismoking media campaigns, and increasing access to help quitting. Such population-based interventions have been shown to reduce population smoking prevalence.3
In recent years, major advances have been made in tobacco control. These include the 2009 Family Smoking Prevention and Tobacco Control Act, which granted the Food and Drug Administration the authority to regulate the manufacture, distribution, and marketing of tobacco products.
Additionally, the 2009 Children's Health Insurance Program Reauthorization Act raised the federal tax rate for cigarettes from $0.39 to $1.01 per pack, and the 2010 Patient Protection and Affordable Care Act provided expanded coverage for evidence-based smoking-cessation treatments for many persons in the United States.
Finally, in 2012, CDC debuted Tips from Former Smokers (TIPS) (cdc.gov/tobacco/campaign/tips), the first federally funded, nationwide, paid-media tobacco education campaign in the United States. During the campaign, calls to the quitline portal 1–800-QUIT-NOW increased 132 percent, and the number of unique visitors to a smoking-cessation website (smokefree.gov) increased 428 percent.5 Additionally, an estimated 1.6 million quit attempts were attributable to the campaign.6
The disparities in smoking prevalence described in this report are consistent with previous studies.2 Variations across racial/ethnic groups might be attributable, in part, to targeted tobacco product marketing or differences in the social acceptability of smoking, whereas disparities by education might be related to differences in understanding of the health hazards of smoking and increased vulnerability to tobacco marketing.
Differences by disability/limitation status might be attributable, in part, to smoking-attributable disability in smokers and increased stress associated with disabilities.7 The high smoking prevalence observed among some population groups underscores the need for enhanced implementation and reach of proven strategies to prevent and reduce tobacco use among these groups.
The findings in this report are subject to at least six limitations.
First, smoking status was self-reported and not validated by biochemical testing. However, self-reported smoking status correlates highly with serum cotinine levels.8
Second, small sample sizes for certain population groups resulted in less precise estimates.
Third, data could not be disaggregated for specific racial/ethnic subgroups; although smoking prevalence was lowest among Hispanics and non-Hispanic Asians, variability in smoking prevalence exists among Hispanic and Asian subpopulations.9
Fourth, because NHIS does not include institutionalized populations and persons in the military, the results might not be generalizable to these groups.
Fifth, the NHIS response rate of 61.2 percent might have resulted in nonresponse bias, even after adjustment for nonresponse.
Finally, these estimates might differ from those derived from other surveillance systems. For example, the National Survey on Drug Use and Health consistently yields higher current smoking estimates than NHIS.10 These differences can be explained, in part, by the varying survey methodologies, the types of surveys administered, and the definitions of current smoking that are used. However, trends in prevalence are comparable across surveys.
Sustained, comprehensive state tobacco-control programs funded at CDC-recommended levels accelerate progress toward reducing the health burden and economic impact of tobacco-related diseases in the United States.3 However, during 2013, despite combined revenue of $25.7 billion from settlement payments and tobacco taxes for all states, only $459.5 million (1.8%) was spent on state comprehensive tobacco-control programs, representing only 12.4 percent of the CDC-recommended level of funding for all states combined; moreover, only two states (Alaska and North Dakota) currently fund tobacco control programs at CDC-recommended levels.
Implementation of comprehensive tobacco control policies and programs can result in a substantial reduction in tobacco-related morbidity and mortality and billions of dollars in savings from averted medical costs.3
Reprinted (slightly edited) from Morbidity and Mortality Weekly Report 2014; 63:29–34.
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