Current Cigarette Smoking Among Adults — United States, 2005–2014
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| MMWR Weekly Vol. 64, No. 44 November 13, 2015 |
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Current Cigarette Smoking Among Adults — United States, 2005–2014
Weekly
November 13, 2015 / 64(44);1233-1240, MBBS1; , PhD1; , MS1; , MPH1; , PhD1; , PhD1; , DrPH1;, PhD1
Tobacco smoking is the leading cause of preventable disease and death in the United States, resulting in approximately 480,000 premature deaths and more than $300 billion in direct health care expenditures and productivity losses each year (1). To assess progress toward achieving the Healthy People 2020 objective of reducing the percentage of U.S. adults who smoke cigarettes to ≤12.0%,* CDC assessed the most recent national estimates of smoking prevalence among adults aged ≥18 years using data from the 2014 National Health Interview Survey (NHIS). The percentage of U.S. adults who smoke cigarettes declined from 20.9% in 2005 to 16.8% in 2014. Among daily cigarette smokers, declines were observed in the percentage who smoked 20–29 cigarettes per day (from 34.9% to 27.4%) or ≥30 cigarettes per day (from 12.7% to 6.9%). In 2014, prevalence of cigarette smoking was higher among males, adults aged 25–44 years, multiracial persons and American Indian/Alaska Natives, persons who have a General Education Development certificate, live below the federal poverty level, live in the Midwest, are insured through Medicaid or are uninsured, have a disability or limitation, or are lesbian, gay, or bisexual. Proven population-based interventions, including tobacco price increases, comprehensive smoke-free laws, high impact mass media campaigns, and barrier-free access to quitting assistance, are critical to reduce cigarette smoking and smoking-related disease and death among U.S. adults.†
NHIS is an annual, nationally representative, in-person survey of the noninstitutionalized U.S. civilian population. The NHIS core questionnaire is administered to a randomly selected adult in each sampled family. The 2014 NHIS included 36,697 respondents aged ≥18 years; the response rate was 58.9%. Current cigarette smokers were respondents who reported smoking ≥100 cigarettes during their lifetimes and, at the time of interview, reported smoking every day or some days. Former cigarette smokers were respondents who reported smoking ≥100 cigarettes during their lifetime but currently did not smoke.
Data were adjusted for differences in the probability of selection and 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,¶ health insurance coverage,** disability/limitation status,††and sexual orientation.§§ The mean number of cigarettes smoked per day was calculated among daily smokers. Differences between groups were assessed using a Wald F-test, with statistical significance defined as p<0.05. Logistic regression was used to analyze trends using annual NHIS data from 2005 through 2014. Percentage changes in prevalence rates between 2005 and 2014 were calculated.
Current cigarette smoking among U.S. adults declined from 20.9% (45.1 million persons) in 2005 to 16.8% (40.0 million) in 2014, representing a 19.8% decrease (p<0.05 for trend) (Figure 1). Cigarette smoking was significantly lower in 2014 (16.8%) than in 2013 (17.8%) (p<0.05). In 2014, prevalence was higher among males (18.8%) than females (14.8%), and was highest among adults aged 25–44 years (20.0%) and lowest among persons aged ≥65 years (8.5%) (Table). Among racial and ethnic groups, smoking prevalence was highest among American Indian/Alaska Natives (29.2%) and multiracial adults (27.9%), and lowest among Asians (9.5%). Among adults aged ≥25 years, prevalence was highest among persons with a General Education Development certificate (43.0%) and lowest among those with a graduate degree (5.4%). Persons living below the poverty level had a higher smoking prevalence (26.3%) than persons at or above this level (15.2%). By U.S. Census region, prevalence was highest in the Midwest (20.7%) and lowest in the West (13.1%). Adults reporting a disability or limitation had a higher smoking prevalence (21.9%) than persons reporting no disability or limitation (16.1%). Prevalence also was higher among lesbian, gay, or bisexual adults (23.9%) than among straight adults (16.6%). From 2005 to 2014, the percentage of adults who were former cigarette smokers did not change significantly (21.5% and 21.9%, respectively).
Overall in 2014, higher smoking prevalences were reported among persons insured by Medicaid only (29.1%; 5.5 million) and persons who were uninsured (27.9%; 8.8 million) than among persons insured by private health insurance (12.9%; 19.6 million) or Medicare only (12.5%; 2.3 million). Among those covered by Medicaid only, prevalences were higher among adults aged 25–44 years (35.6%) and those aged 45–64 years (29.7%) than among those aged 18–24 years (18.2%) (Figure 2).
Among current smokers during 2005–2014, the number of daily smokers decreased from 36.4 million (80.8% of all smokers) to 30.7 million (76.8%), while the number of some-days smokers increased from 8.7 million (19.2%) to 9.3 million (23.2%) (p<0.05 for trends). Among daily smokers, the mean number of cigarettes smoked per day declined from 16.7 in 2005 to 13.8 in 2014 (p<0.05 for trend). During 2005–2014, increases occurred in the percentage of daily smokers who smoked 1–9 (16.4% to 26.9%) or 10–19 cigarettes per day (36.0% to 38.8%), whereas declines occurred among those who smoked 20–29 (34.9% to 27.4%) or ≥30 cigarettes per day (12.7% to 6.9%) (Figure 3) (p<0.05 for trend).
Discussion
During 2005–2014, the prevalence of cigarette smoking among U.S. adults declined from 20.9% to 16.8%, including by a full percentage point during 2013–2014 alone, indicating marked progress toward achieving the Healthy People 2020 goal of reducing cigarette smoking prevalence to ≤12.0%. Adults aged 18–24 years experienced the greatest decrease in cigarette smoking prevalence; however, recent reports suggest that use of noncigarette tobacco products, including e-cigarettes and hookahs, is common among youth and young adults (2,3). The extent to which emerging tobacco products, such as e-cigarettes, might have contributed to the observed decline in cigarette smoking in recent years is uncertain. E-cigarette use was first assessed in NHIS in 2014, so it is not possible to assess long term patterns of e-cigarette use relative to cigarette use with this dataset; in 2014, 3.7% of adults currently used e-cigarettes every day or some days, with use differing by age, race/ethnicity, and cigarette smoking status (4). E-cigarettes have been promoted for smoking cessation (1); however, the U.S. Preventive Services Task Force has concluded that the current evidence is insufficient to recommend e-cigarettes for tobacco cessation in adults, including pregnant women.¶¶ No change occurred in the percentage of former cigarette smokers over time, suggesting that some of the decline in cigarette smoking might be driven by overall reductions in smoking initiation.
Observed disparities in smoking prevalence are consistent with previous studies (5). Differences by race/ethnicity might be partly explained by sociocultural influences and norms related to the acceptability of tobacco use (6). Differences in prevalence among persons with different types of health insurance coverage might be partly attributable to variations in tobacco cessation treatment coverage and access to evidence-based cessation treatments across health insurance types (7). Higher prevalences among persons with disabilities and limitations might be related, in part, to smoking-attributable disability in smokers and possible higher stress associated with disabilities (8). These disparities underscore the importance of enhanced implementation of proven strategies to prevent and reduce tobacco use.
Ongoing changes in the U.S. health care system offer opportunities to improve the use of clinical preventive services among adults. The Patient Protection and Affordable Care Act of 2010 (ACA) is increasing the number of Americans with health insurance and is expected to improve tobacco cessation coverage (7). The ACA requires most private insurers to cover tobacco cessation (7); a guidance document issued in May 2014 further clarified this ACA provision.*** However, neither private insurers nor state Medicaid programs consistently provide comprehensive coverage of evidence-based cessation treatments (7,9). In 2015, although all 50 state Medicaid programs covered some tobacco cessation treatments for some Medicaid enrollees, only nine states covered individual and group counseling and all seven FDA-approved cessation medications for all Medicaid enrollees (9). Cessation coverage has the greatest impact when promoted to smokers and health care providers (7,9).
The findings in this report are subject to at least five limitations. First, smoking status was self-reported and not validated by biochemical testing; however, self-reported smoking status correlates highly with serum cotinine levels (10). Second, because NHIS does not include institutionalized populations and persons in the military, results are not generalizable to these groups. Third, the NHIS response rate of 58.9% might have resulted in nonresponse bias. Fourth, the questionnaire did not assess gender identity; including transgender persons might yield higher smoking estimates among sexual minorities. Finally, these estimates might differ from other surveys on tobacco use. These differences in estimates can be partially explained by varying survey methodologies, types of surveys administered, and definitions of current smoking; however, trends in prevalence are comparable across surveys.
Sustained comprehensive state tobacco control programs funded at CDC-recommended levels could accelerate progress toward reducing the health and economic burden of tobacco-related diseases in the United States (1). However, during 2015, states will spend only $490.4 million (1.9%) of combined revenues of $25.6 billion from settlement payments and tobacco taxes for all states on comprehensive tobacco control programs,††† representing <15% 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 interventions can result in substantial reductions in tobacco-related morbidity and mortality and billions of dollars in savings from averted medical costs (1). Additionally, states can work with health care systems, insurers, and purchasers of health insurance to improve coverage and utilization of tobacco cessation treatments and to implement health systems changes that make tobacco dependence treatment a standard of clinical care (7,9).
1Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
Corresponding author: Ahmed Jamal, ajamal@cdc.gov, 770-488-5493.
References
* Objective TU-1.1. Additional information available at https://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use/objectives
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.† CDC. Best Practices for Comprehensive Tobacco Control Programs — 2014. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2014. Available athttp://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm.
§ Based on reported family income; 2005 estimates are based on reported family income and 2004 poverty thresholds published by the U.S. Census Bureau, and 2014 estimates are based on reported family income and 2013 poverty thresholds published by the U.S. Census Bureau.
¶ Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
** Medicaid only: Anyone reporting having Medicaid coverage, but no other insurance coverage, at the time of the interview. Persons reporting both Medicaid and "private insurance" were included in the "private insurance" category. Medicare only: Anyone reporting having Medicare coverage, but no other insurance coverage, at the time of the interview. Persons reporting both Medicare and "private insurance" were included in the "private insurance" category. Private insurance: Any comprehensive private insurance plan (including health maintenance and preferred provider organizations), obtained through an employer, purchased directly, or purchased through local or community programs, and excludes plans that pay for only one type of service, such as accidents or dental care. A small number of persons (132 respondents) were covered by both "other public insurance" and private plans and were included in both categories. For 2014, this group also included plans purchased through the Health Insurance Marketplace or a state-based exchange. Other public insurance: Includes Children's Health Insurance Program, state-sponsored or other government-sponsored health plan, and military plans. A small number of persons (132 respondents) were covered by both "other public insurance" and private plans and were included in both categories. This does not include anyone reporting any Medicare or Medicaid coverage. Uninsured: Having no private health insurance, Medicare, Medicaid, Children's Health Insurance Program, state-sponsored or other government-sponsored health plan, or military plan, or having only Indian Health Service coverage, or having only a private plan that paid for one type of service, such as accidents or dental care. Those who were dual eligible (enrolled in both Medicaid and Medicare) or reported Medicaid or Medicare and any other coverage were excluded unless they also had "private" insurance coverage.
†† Based on self–reported presence of selected impairments including vision, hearing, cognition, and movement. Limitations in performing activities of daily living defined based on response to the question, "Because of a physical, mental, or emotional problem, does [person] need the help of other persons with personal care needs, such as eating, bathing, dressing, or getting around inside this home?" Limitations in performing instrumental activities of daily living defined based on response to the question, "Because of a physical, mental, or emotional problem, does [person] need the help of other persons in handling routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?" Any disability/limitation was defined as a "yes" response pertaining to at least one of the disabilities/limitations listed (i.e., vision, hearing, cognition, movement, activities of daily living, or instrumental activities of daily living). In 2014, the American Community Survey questions were asked of a random half of the respondents from the 2014 Person File. For population estimates, the specific adult disability weight was doubled to account for the half of respondents who were not asked these questions.
§§ Starting in 2013, sexual orientation questions were added to NHIS. To determine sexual orientation, adult respondents were asked, "Which of the following best represents how you think of yourself?" with response options of gay ("lesbian or gay" for female respondents), straight, that is, "not gay" ("not lesbian or gay" for female respondents), bisexual, something else, and I don't know the answer.
¶¶ Additional information available at http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1.
.*** Additional information available at http://www.dol.gov/ebsa/faqs/faq-aca19.html.
.††† Robert Wood Johnson Foundation. Broken Promises to Our Children: a State-by-State Look at the 1998 State Tobacco Settlement 16 Years Later. A report on the states' allocation of the tobacco settlement dollars. Princeton, NJ: Robert Wood Johnson Foundation; December 2014. Available athttp://www.tobaccofreekids.org/microsites/statereport2015/.
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