Health Objectives for the Nation Cigarette Smoking Among Women of Reproductive Age -- United States, 1987-1992

Women who smoke cigarettes are at increased risk for lung cancer, chronic obstructive pulmonary disease, and complications of oral contraceptive use. During pregnancy, cigarette smoking increases the risks for a low birthweight infant and infant mortality. A national health objective for the year 2000 is to reduce cigarette smoking among women of reproductive age (i.e., 18- 44 years) to a prevalence of no more than 12% (objective 3.4h) (1). This goal is substantially lower than the estimated baseline prevalence of 29% measured by CDC's 1987 National Health Interview Survey (NHIS). To characterize recent trends in cigarette smoking and monitor progress toward the year 2000 objective, data from the NHIS for 1987 through 1992 were analyzed for women aged 18-44 years.

The NHIS is an ongoing household survey conducted annually among a nationally representative sample (n=120,000) of the civilian, noninstitutionalized U.S. population. Information about tobacco use was collected through personal interviews with an adult (aged greater than or equal to 18 years) randomly selected from each surveyed household (n=40,000). * Each year during 1987-1992, the sample sizes for the target study group that was asked tobacco-use questions (i.e., women aged 18-44 years) ranged from 3717 to 13,809. Respondents were asked if they ever smoked 100 cigarettes during their lifetimes and whether they currently smoked (2). Annual prevalence estimates and 95% confidence intervals (CIs) were calculated using SUDAAN (3). Data were weighted to provide national estimates.

During 1987-1992, the prevalence of cigarette smoking among reproductive-aged women in the United States declined 3.7%, from 29.6% in 1987 to 26.9% in 1992 Table_1. The prevalence declined substantially from 1987 (29.6%) to 1990 (25.6%) but increased slightly from 1991 (26.7%) to 1992 (26.9%). In 1992, an estimated 14.3 million U.S. women aged 18-44 years were smokers.

Smoking prevalence was inversely related to level of education and was consistently highest among women with less than a high school education Table_1. Among women with less than a high school education, smoking prevalence decreased from 46.5% in 1987 to 40.6% in 1990; in 1992, the rate (40.2%) remained unchanged. For women with 16 or more years of education, smoking prevalence declined from 14.2% in 1987 to 10.5% in 1990; however, in 1992, the rate increased to 12.5%.

During 1987-1992, smoking prevalence rates varied by race. During 1987-1990, race-specific declines in smoking prevalence occurred among both black and white women Table_1. For black women, the rate declined from 31.2% in 1987 to 22.8% in 1990, but increased significantly to 28.1% in 1991 before declining to 22.6% in 1992. For white women, the rate declined from 30.0% in 1987 to 26.5% in 1990, then increased to 27.1% in 1991 and 28.6% in 1992.

Among women aged 18-24 years, smoking prevalence among black women declined dramatically during 1987-1992, from 21.8% to 5.9%. In comparison, among white women, the prevalence was unchanged, 27.8% and 27.2% in 1987 and 1992, respectively. Reported by: Div of Health Interview Statistics, National Center for Health Statistics; Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: In 1965 (the first year the NHIS was used to monitor tobacco use), 33% of U.S. women were cigarette smokers (4). Since then, however, the health risks of cigarette smoking have been widely publicized, and the prevalence of cigarette smoking among women has declined gradually. During 1974-1985, smoking prevalence among women decreased at a rate of 0.3% per year, one third the rate for men (5). While smoking rates declined among women, death rates for lung cancer increased; in 1987, lung cancer surpassed breast cancer as the leading cause of cancer death among U.S. women. By 1990, 25.6% of women aged 18-44 years were current smokers.

Two important findings in this report regarding cigarette smoking by women during 1987-1992 are that 1) rates of cigarette smoking for young black women declined substantially during this period, and 2) after a 25-year decline, rates among women of other races and older women of reproductive age stopped declining in 1990. An important factor probably associated with the decline in smoking among younger black females was the decrease in rates of smoking reported by black female high school seniors during 1985- 1989 (6). In addition, cigarette smoking has been suggested to have less functional value for black women (i.e., they may be less likely to use smoking for weight control or social acceptability) (7). However, reasons for the increase in smoking among black women aged 18-44 years in 1991 only have not been determined. At least two factors have been suggested to account for the reduction or termination of declines in cigarette smoking among women of reproductive age: first, tobacco companies used advertising campaigns (8) and other approaches to target women, and second, the increase in rates of smoking initiation by young adolescent females during the early 1970s resulted in a greater number of adult women smokers (9).

Although the mean education level ** of Hispanic women in this study was lower when compared with non-Hispanic women, the prevalence of cigarette smoking was significantly lower among Hispanic women, possibly reflecting the effect of potential cultural differences that decrease the social acceptability of smoking among Hispanic women. The findings in this report also indicate that, during 1987-1992, smoking rates were significantly higher for women living below the poverty level than those living at or above the poverty level. This inverse association between income and smoking prevalence also has been documented for men and reflects correlations with education level.

Comprehensive strategies to discourage tobacco use by women and to achieve the year 2000 national health objective should include four basic components: research, outreach, education, and advocacy. Research efforts should focus on the disparate race-specific trends in smoking by race and translation of successes in efforts to reduce smoking among other groups. Outreach should especially be directed toward providing interventions for the high proportion of women smokers with less than a high school education. Education campaigns that employ paid antismoking advertising have been implemented successfully in California and may be adapted for use in other locations in the United States (10). Examples of measures to strengthen advocacy of tobacco-control policies include increases in the excise taxes on tobacco products and enforcement of laws that restrict access to tobacco products by minors.

References

1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

2. CDC. Cigarette smoking among adults -- United States, 1992, and changes in the definition of current cigarette smoking. MMWR 1994;43:342-6.

3. Shah BV. Software for Survey Data and Analysis (SUDAAN) version 6.0 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

4. CDC. Reducing the health consequences of smoking: 25 years of progress -- a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (PHS)89-8411.

5. Fiore MC, Novotny TE, Pierce JP, Hatziandreu EJ, Patel KM, Davis RM. Trends in cigarette smoking in the United States: the changing influence of gender and race. JAMA 1989;261:49-55.

6. Bachman JG, Wallace JM, O'Malley PM, Johnston LD, Kurth CL, Neighbors HW. Racial/ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976-89. Am J Public Health 1991;81:372-7.

7. Camp DE, Klesges RC, Relyea G. The relationship between body weight concerns and adolescent smoking. Health Psychol 1982;12:24-8.

8. Ernster VL. How tobacco companies target women. In: American Cancer Society. World smoking and health. Atlanta: American Cancer Society, 1991:8-11.

9. Gilpin EA, Lee L, Evans M, Pierce J. Smoking initiation rates in adults and minors: United States, 1944-1988. Am J Epidemiol 1994;140:535-43.

10. Pierce JP, Evans N, Farkas AJ. Tobacco use in California: an evaluation of the tobacco control program, 1989-1993. La Jolla, California: University of California, San Diego, 1994.

* Health-topic supplements: Cancer Control and Epidemiology, 1987; Occupational Health, 1988; Diabetes Risk Factors, 1989; Health Promotion and Disease Prevention, 1990 and 1991; and Cancer Control, 1992. 

** In this study, the mean number of years of education completed by Hispanic women was 11.3 years and for non-Hispanic women, 13.1 years.

TABLE 1. Prevalence of current smoking * among women aged 18-44 years -- United States, National Health Interview Survey, + 1987-1992
===================================================================================================================================================
                                1987               1988               1989              1990              1991              1992
                            (n=13,809)         (n=13,746)         (n=6502)          (n=12,954)        (n=13,439)        (n=3717)
                           ---------------    --------------     --------------    --------------    --------------    --------------
Characteristic              %   (95% CI &)     %    (95% CI)      %    (95% CI)     %    (95% CI)     %    (95% CI)     %    (95% CI)
---------------------------------------------------------------------------------------------------------------------------------------------------
Race (Age group {yrs})
  White
    18-24                  27.8  (+/-2.2)     27.5  (+/-2.1)     26.0  (+/-3.0)    25.4  (+/-2.2)    25.2  (+/-2.1)    27.2  (+/-4.2)
    25-34                  31.8  (+/-1.5)     31.0  (+/-1.5)     30.9  (+/-2.3)    28.5  (+/-1.5)    28.4  (+/-1.5)    30.0  (+/-3.0)
    35-44                  29.2  (+/-1.5)     28.3  (+/-1.5)     26.2  (+/-2.3)    25.0  (+/-1.5)    26.8  (+/-1.5)    27.9  (+/-2.8)
    Total                  30.0  (+/-1.0)     29.2  (+/-1.0)     28.1  (+/-1.5)    26.5  (+/-1.0)    27.1  (+/-1.0)    28.6  (+/-1.9)

  Black
    18-24                  20.4  (+/-4.4)     21.8  (+/-4.1)     18.0  (+/-5.5)    10.0  (+/-2.8)    11.9  (+/-3.2)     5.9  (+/-4.2)
    25-34                  35.8  (+/-3.4)     37.2  (+/-3.6)     28.8  (+/-4.8)    29.1  (+/-3.3)    32.5  (+/-3.6)    29.0  (+/-6.9)
    35-44                  35.3  (+/-4.3)     27.6  (+/-3.8)     31.4  (+/-5.3)    25.5  (+/-3.6)    35.5  (+/-4.0)    27.9  (+/-7.3)
    Total                  31.2  (+/-2.5)     30.0  (+/-2.3)     26.6  (+/-3.3)    22.8  (+/-2.1)    28.1  (+/-2.4)    22.6  (+/-4.1)

Ethnicity
  Hispanic                 20.0  (+/-2.7)     20.4  (+/-2.5)     21.9  (+/-4.1)    16.9  (+/-2.6)    16.5  (+/-2.1)    18.9  (+/-4.2)
  Non-Hispanic             30.6  (+/-1.0)     29.7  (+/-0.9)     28.1  (+/-1.4)    26.6  (+/-1.0)    27.9  (+/-1.0)    27.8  (+/-1.8)

Education (yrs)
      <12                  46.5  (+/-2.7)     45.9  (+/-2.7)     42.7  (+/-3.9)    40.6  (+/-2.9)    40.5  (+/-2.7)    40.2  (+/-4.8)
       12                  33.7  (+/-1.4)     32.7  (+/-1.4)     31.2  (+/-2.1)    31.1  (+/-1.5)    32.0  (+/-1.5)    31.9  (+/-3.0)
    13-15                  24.7  (+/-1.6)     24.7  (+/-1.6)     25.9  (+/-2.5)    20.6  (+/-1.5)    22.8  (+/-1.7)    24.0  (+/-3.1)
     >=16                  14.2  (+/-1.5)     13.9  (+/-1.4)     12.0  (+/-2.0)    10.5  (+/-1.3)    12.0  (+/-1.4)    12.5  (+/-2.4)

Socioeconomic status @
  At/Above poverty level   28.3  (+/-1.0)     27.2  (+/-0.9)     26.4  (+/-1.4)    23.6  (+/-0.9)    25.3  (+/-0.9)    24.7  (+/-1.9)
  Below poverty level      37.0  (+/-3.1)     38.0  (+/-2.7)     34.9  (+/-3.9)    36.1  (+/-3.1)    32.7  (+/-3.0)    40.0  (+/-4.9)
  Unknown                  31.1  (+/-4.0)     31.9  (+/-4.2)     28.9  (+/-5.2)    30.4  (+/-3.8)    31.0  (+/-3.3)    24.7  (+/-5.6)

Total                      29.6  (+/-0.9)     28.8  (+/-0.9)     27.6  (+/-1.3)    25.6  (+/-0.9)    26.7  (+/-0.9)    26.9  (+/-1.7)
---------------------------------------------------------------------------------------------------------------------------------------------------
* Smoked at least 100 cigarettes and currently smoking.  This analysis excludes persons with unknown smoking status.
+ Health topic supplements: Cancer Control and Epidemiology, 1987; Occupational Health, 1988; Diabetes Risk Factors, 1989; Health Promotion and
  Disease Prevention, 1990 and 1991; and Cancer Control, 1992.
& Confidence interval.
@ Poverty statistics are based on a definition originated by the Social Security Administration in 1964, subsequently modified by federal
  interagency committees in 1969 and 1980, and prescribed by the Office of Management and Budget as the standard to be used by federal agencies for
  statistical purposes.
===================================================================================================================================================

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