Progress in Chronic Disease Prevention Cigarette Smoking in the United States, 1986

In August 1986, the Office on Smoking and Health, Center for Health Promotion and Education, CDC, initiated the Adult Use of Tobacco Survey to study the U.S. adult population's knowledge, attitudes, and practices regarding the use of tobacco. Data for this telephone survey, which was conducted primarily during the fourth quarter of 1986, were collected from a national probability sample of 13,031 respondents representing the noninstitutionalized, civilian adult population (greater than or equal to17 years of age) in the United States. The Mitofsky-Waksberg random-digit-dialing procedure (1) was used to generate a sample of households selected for screening. From the screening data, current and former cigarette smokers* were oversampled to ensure sufficient sample size for analysis within these two subgroups.

To compensate for nonresponse, for the oversampling of current and former smokers, and for the exclusion of nontelephone households, the sample estimates were weighted (ratio-adjusted) to 1986 Current Population Survey (CPS) counts of the U.S. adult population. This adjustment controlled for sex, age, race and ethnic (Hispanic) origin, education, and region of the country. Standard errors were computed to derive the 95% confidence intervals (CI) about the sample estimates by using software based on the procedure developed by Morganstein and Hanson (2).

The survey's overall response rate was 74.3%, which represents the product of the 85.5% response rate for the household screening sample and the 87.0% response rate for those individuals selected for an extended interview. The unadjusted racial composition of the respondents was 88.7% white, 8.4% black, and 2.9% all other racial groups combined.

Compared with the findings of other national surveys conducted during the past 40 years (Table 1), the results of the Adult Use of Tobacco Survey show the lowest prevalence of current cigarette smoking among adults ever recorded in the United States: 29.5% for men (95% CI, 28.4 to 30.6), 23.8% for women (95% CI, 22.7 to 24.9), and 26.5% overall (95% CI, 25.8 to 27.3). An estimated 24.6% of the U.S. adult population are former smokers, including 30.4% of men and 19.3% of women. The overall smoking rate by race was 28.4% for blacks (95% CI, 25.0 to 31.8) and 26.4% for whites (95% CI, 25.5 to 27.2).

The prevalence of smoking was higher among black men (32.5%) than among white men (29.3%) (Table 2). For men, the highest rate by age group was 37.1%, which occurred among men 35-44 years old. The highest age- and race-specific smoking rate occurred among black men 25-34 years old (45.9%), whereas the lowest rate occurred among black men 17-24 years old (14.3%). Among men who currently smoke, the mean number of cigarettes smoked per day was 22.8 (23.9 among white men, 14.8 among black men).

The prevalence of smoking was slightly higher among black women (25.1%) than among white women (23.7%) (Table 2). For women, the highest rates by age group were 29.2%, which occurred among women 25-34 years old, and 28.7%, which occurred among women 35-44 years old. The highest age- and race-specific smoking rate occurred among black women aged 35-44 years (36.4%), whereas the lowest rate (excluding those greater than or equal to 65 years old) occurred among black women aged 17-24 years (16.0%). Among women who currently smoke, the mean number of cigarettes smoked per day was 19.1 (19.8 among white women, 14.6 among black women). Reported by: Office on Smoking and Health, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: In 1979, the first Surgeon General's Report on Health Promotion and Disease Prevention was released (6). This report, entitled Healthy People, identified cigarette smoking as "the single most important preventable cause of death," responsible for an estimated 320,000 premature deaths a year in the United States and for debilitating chronic diseases in another 10 million Americans. These conclusions were based on extensive research summarized in the annual Surgeon General's reports on the health consequences of smoking, 18 of which have been issued since 1964. A year after publication of Healthy People, the Public Health Service established health objectives for the nation for the year 1990 (7,8). These objectives include 17 specific goals related to smoking and health.

The primary objective for 1990 is for the proportion of adults who smoke to be below 25%. The results of the Adult Use of Tobacco Survey show that this objective has almost been met. The overall prevalence of smoking in this survey (26.5%) is the lowest ever recorded in the United States (Table 1). In comparing these results with those of previous surveys, however, it must be noted that these surveys differ in sampling techniques, sample size, possible inclusion of proxy respondents, eligible respondent age, response rate, definition of "current regular smoker," and use of telephone versus personal interviews (3,9). These factors may affect measurements of smoking prevalence.

To evaluate the potential effect of the type of interview on measurements of smoking prevalence, state-specific smoking prevalence data for persons greater than or equal to18 years old from two surveys were compared: the supplement to the 1985 CPS (a personal- interview survey) and the 1985 Behavioral Risk Factor Surveillance System (BRFSS) (a telephone survey) (10). For the 22 jurisdictions included in the BRFSS (21 states and the District of Columbia), the median difference between the data on overall smoking prevalence from the CPS and the BRFSS was +2.5 percentage points (Office on Smoking and Health, CDC, unpublished data). The exclusion of households lacking telephones appears to account for an underestimate of about one percentage point in telephone surveys (sampling bias), because persons living in households where there are no telephones have a higher smoking prevalence than those in households with telephones (National Center for Health Statistics, CDC, unpublished data). In addition, there may be a greater response bias in telephone surveys than in personal-interview surveys, because the former usually have lower response rates. Although the differences between data from the CPS and the BRFSS suggest that smoking rates may vary slightly depending on the type of interview used in a survey, data on the prevalences of various health conditions obtained by telephone and personal interviews are generally similar (11-15).

Certain rates, such as the prevalence of smoking among all black men, young black men, and young black women, are markedly lower in the Adult Use of Tobacco Survey than the rates obtained by the National Health Interview Survey (16). Because of the smaller sample sizes for blacks overall and for specific age groups among blacks, the prevalence figures for blacks from the Adult Use of Tobacco Survey should be interpreted with caution. These results should be compared with those of future surveys using larger sample sizes to determine the extent to which the prevalence of smoking among blacks may have declined.

Despite the uncertainty in comparing data from surveys using different methodologies, longitudinal surveys using the same methodology show a steady decline in smoking prevalence. For instance, data from the National Health Interview Surveys from 1974 to 1985 show a consistent mean annual reduction in smoking prevalence of 0.6 percentage points (Table 1). These data parallel the per capita consumption of cigarettes (for persons greater than or equal to18 years of age) in the United States, which has declined each year since 1973 (17).

Although much progress has been achieved, the results of the Adult Use of Tobacco Survey show that an estimated 46.8 million Americans (greater than or equal to17 years old) still smoke cigarettes. To maintain momentum toward the goal of a smoke-free society, government agencies, private organizations, health-care providers, and others must work together to support programs and policies that encourage nonsmoking behavior. There should be an emphasis on reducing the prevalence of smoking among high-risk populations such as adolescents, minorities, blue-collar workers, and pregnant women. Smoking prevention and cessation programs should be offered in schools, worksites, health-care facilities, and other institutions. Public officials, state and local legislatures, employers, and insurance companies should support policies that discourage tobacco use and protect nonsmokers from exposure to environmental tobacco smoke. These policies include banning or restricting smoking in public places and worksites, prohibiting the sale of tobacco products to minors, prohibiting the distribution of free samples of tobacco products, providing reduced premiums for health and life insurance to nonsmokers, and providing third-party reimbursement for smoking-cessation programs.

References

1. Mitofsky W, Waksberg J. Sampling methods for random digit dialing. J Am Stat Assoc 1978; 73:40-46.

2. Morganstein DR, Hanson RH, Binzer G. Automation of sampling error computations for complex estimators. In: Proceedings of the American Statistical Association Section on Survey Research Methods. Washington, DC: American Statistical Association, 1982:127-32.

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