Indicators of Nicotine Addiction Among Women -- United States, 1991-1992

An estimated 22 million U.S. women were current smokers in 1993; of these, 73% wanted to quit smoking (1). However, attempts to quit smoking and to remain abstinent are hindered by nicotine addiction and by the subsequent effects of nicotine withdrawal (2). To assess the prevalence of selected indicators of nicotine addiction among U.S. women, CDC analyzed data from the National Household Survey on Drug Abuse (NHSDA) in 1991 and 1992 (3). This report presents the findings of the analysis.

The NHSDA is a household survey of a nationally representative sample of the civilian, noninstitutionalized U.S. population. Combined data from the 1991 and 1992 surveys (n=7137) were used to estimate the prevalences of four indicators of nicotine addiction among women who smoke. Information about these indicators was based on responses to four questions; current smokers * were asked whether, during the 12 months preceding the survey, they 1) "felt {they} needed or were dependent on cigarettes," 2) "needed larger amounts {more cigarettes} to get the same effect," 3) "felt unable to cut down on {their} use even though {they} tried," and 4) "had withdrawal symptoms, that is, felt sick because {they} stopped or cut down on {their} use." The analysis of "unable to cut down" (n=4422) and "felt sick" (n=4646) was restricted to persons who reported trying to reduce their use of cigarettes during the preceding 12 months. In addition, for the indicator "unable to cut down," because of the question design, respondents who reported not trying to reduce any drug use during the preceding 12 months (n=224) also were excluded. Because the likelihood of daily smoking (4; CDC, unpublished data, 1991) and the intensity of smoking (i.e., number of cigarettes smoked per day) (4,5) varies directly with age, respondents were classified into two age groups -- 12- 24-year-olds and greater than or equal to 25-year-olds. Data were adjusted for nonresponse and weighted to provide national estimates. Standard errors were calculated by using SUDAAN (6).

Among female smokers in both age groups, 75% reported feeling dependent on cigarettes Table_1. The prevalence of feeling dependent varied directly with intensity of smoking; among those who smoked six to 15 cigarettes per day, 80.6% (95% confidence interval {CI}=77.1%-84.2%) of those aged 12-24 years and 76.1% (95% CI=72.3%-79.9%) of those aged greater than or equal to 25 years reported feeling dependent on cigarettes. Female smokers aged 12-24 years were more likely to report needing more cigarettes to attain the same effect than were those aged greater than or equal to 25 years (18.0% {95% CI=15.8%-20.2%} versus 13.2% {95% CI=11.3%- 15.0%}). Among those who had tried to reduce smoking during the preceding 12 months, 81.5% (95% CI=78.9%-84.1%) of 12-24-year-olds and 77.8% (95% CI=75.1%- 80.5%) of greater than or equal to 25-year-olds reported being unable to do so; even among those who smoked six to 15 cigarettes per day, inability to reduce smoking was reported by 82.6% (95% CI=78.7%-86.4%) of 12-24-year-olds and 73.8% (95% CI=68.4%-79.2%) of the greater than or equal to 25-year-olds. Of all female smokers aged greater than or equal to 12 years, 35.4% reported withdrawal symptoms (i.e., feeling sick) when they tried to reduce their smoking.

Females in both the younger and older age groups were equally likely to report at least one of the four indicators of nicotine addiction (81.2% {95% CI=78.6%-83.8%} and 79.4% {95% CI=77.3%- 81.5%}, respectively) Table_1. Even among females who smoked five or fewer cigarettes per day, 63.1% (95% CI=56.4%-69.8%) of those aged 12-24 years and 53.0% (95% CI=46.9%-59.1%) of those aged greater than or equal to 25 years reported one or more of these indicators. Reported by: J Gfroerer, Prevalence Br, Office of Applied Studies, Substance Abuse and Mental Health Svcs Administration. Office on Smoking and Health, and Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: In 1990, an estimated 61,000 U.S. women aged greater than or equal to 35 years died from cardiovascular diseases attributable to cigarette smoking (7). Because the risk for myocardial infarction can be reduced by 50% after 1 year of abstaining from smoking (8), interventions to encourage smoking cessation are an important strategy to reduce cardiovascular mortality. Although most women smokers want to quit smoking, only 2.5% of all smokers successfully quit each year (9). The finding in this report that approximately 80% of female smokers reported symptoms of nicotine addiction underscores the importance of measures to increase women's access to cessation interventions, including adjunctive nicotine-replacement therapy.

The findings in this report are subject to at least two limitations. First, the NHSDA indicators are not comprehensive measures of nicotine addiction and do not include all symptoms of nicotine withdrawal (e.g., anxiety, irritability, anger, difficulty concentrating, hunger, or cravings for cigarettes) (2); as a result, the NHDSA data may underestimate the proportion of smokers who report at least one indicator of nicotine addiction. Second, these findings are based on self-reported data, and perceptions of nicotine addiction were not validated. However, in previous studies, self-reported symptoms of nicotine addiction have been confirmed by observer rating (2).

Although manifestations of cardiovascular disease occur primarily during adulthood, related high-risk behaviors, such as tobacco use, often are initiated during adolescence; an estimated 87% of female daily smokers began smoking at less than or equal to 18 years of age (CDC, unpublished data, 1991). Young persons often try using tobacco with a belief that they can quit. However, of adolescent smokers who have intended to not be smoking in 5-6 years, 73% still smoked 5 years later (10). The 1991 and 1992 NHSDA data suggest that an important reason for young smokers' failure to quit smoking is a prevalence of addiction similar to that among older smokers. Because of the difficulty in achieving abstinence and the strength and early onset of nicotine addiction, interventions to prevent smoking initiation are important.

School-based programs, combined with community interventions, have been effective in preventing smoking initiation (10). Other measures that can prevent smoking initiation, onset of nicotine addiction, and subsequent morbidity and mortality associated with cardiovascular diseases include enforcement of laws that prohibit sales to minors, counter-advertising campaigns that "deglamorize" smoking to youth, and increases in the real price of cigarettes.

References

1. CDC. Cigarette smoking among adults -- United States, 1993. MMWR 1994;43:925-30.

2. CDC. The health consequences of smoking: nicotine addiction -- a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1988; DHHS publication no. (CDC)88-8406.

3. Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse: population estimates, 1992. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, 1993; DHHS publication no. (SMA)93-2053.

4. Moss AJ, Allen KF, Giovino GA, et al. Recent trends in adolescent smoking, smoking-uptake correlates, and expectations about the future. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1992. (Advance data no. 221).

5. Giovino GA, Schooley MW, Zhu B-P, et al. Surveillance for selected tobacco-use behaviors -- United States, 1900-1994. MMWR 1994;43(no. SS-3).

6. Shah BV. Software for survey data analysis (SUDAAN), version 5.50 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

7. CDC. Cigarette smoking-attributable mortality and years of potential life lost -- United States, 1990. MMWR 1993;42:645-9.

8. CDC. The health benefits of smoking cessation: a report of the Surgeon General, 1990. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC)90-8416.

9. CDC. Smoking cessation during previous year among adults -- United States, 1990 and 1991. MMWR 1993;42:504-7.

10. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.

Defined as persons who had ever smoked 100 cigarettes and had smoked during the 30 days preceding the survey.

TABLE 1. Percentage of females who were current cigarette smokers * and who reported experiencing selected indicators of nicotine
addiction +, by age and intensity & of smoking -- National Household Survey on Drug Abuse, United States, 1991 and 1992 @
============================================================================================================================================
                      Felt dependent      Needed more cigarettes         Unable            Felt sick when cut        Any addiction
                       on cigarettes          for same effect         to cut down **         down on smoking **           indicator ++
Age group/          -------------------   ----------------------   -------------------    ---------------------    -------------------
 Smoking intensity    %    (95% CI &&)       %       (95% CI)        %      (95% CI)        %        (95% CI)        %      (95% CI)
--------------------------------------------------------------------------------------------------------------------------------------------
12-24 yrs                  (n=2138)                (n=2137)                (n=1376)               (n=1446)               (n=2138)
    <=5             52.4  (45.6%-59.3%)    12.8  ( 9.2%-16.4%)     67.4  (60.7%-74.1%)    21.6  (16.4%-26.9%)      63.1  (56.4%-69.8%)
   6-15             80.6  (77.1%-84.2%)    17.5  (14.2%-20.7%)     82.6  (78.7%-86.4%)    33.3  (28.0%-38.5%)      87.0  (83.9%-90.1%)
  16-25             86.2  (82.3%-90.0%)    18.8  (14.2%-23.3%)     92.3  (88.8%-95.9%)    48.3  (42.0%-54.6%)      90.4  (87.3%-93.6%)
   >=26             88.1  (80.1%-96.1%)    36.4  (26.9%-45.8%)     88.9  (78.7%-99.1%)    45.3  (30.5%-60.0%)      88.2  (80.1%-96.2%)

  Total             74.8  (71.8%-77.8%)    18.0  (15.8%-20.2%)     81.5  (78.9%-84.1%)    35.4  (32.5%-38.3%)      81.2  (78.6%-83.8%)

>=25 yrs                    (n=4996)               (n=4997)                (n=3046)               (n=3199)               (n=4999)
    <=5             42.7  (37.1%-48.3%)     6.8  ( 3.9%- 9.7%)     54.0  (46.3%-61.7%)    22.1  (15.5%-28.7%)      53.0  (46.9%-59.1%)
   6-15             76.1  (72.3%-79.9%)    12.9  ( 9.2%-16.7%)     73.8  (68.4%-79.2%)    33.8  (27.9%-39.6%)      82.1  (78.8%-85.4%)
  16-25             81.1  (77.7%-84.5%)    11.6  ( 9.1%-14.2%)     82.0  (77.4%-86.5%)    34.4  (28.8%-40.0%)      84.0  (81.0%-87.1%)
   >=26             85.9  (81.6%-90.1%)    21.1  (15.3%-27.0%)     93.7  (90.5%-97.0%)    48.6  (39.5%-57.7%)      88.7  (85.1%-92.3%)

  Total             74.6  (72.4%-76.9%)    13.2  (11.3%-15.0%)     77.8  (75.1%-80.5%)    34.8  (31.4%-38.2%)      79.4  (77.3%-81.5%)

 * Persons who reported smoking 100 cigarettes during their lifetime and who reported smoking cigarettes during the preceding 30 days.
 + The indicators were, during the 12 months preceding the survey, 1) "felt {they} needed or were dependent on cigarettes," 2) "needed
   larger amounts {more cigarettes} to get the same effect," 3) "felt unable to cut down on {their} use, even though they tried," and
   4) "had withdrawal symptoms, that is, felt sick because {they} stopped or cut down on cigarette use."
 & Number of cigarettes smoked per day.
 @ n=7137.
** The analysis of "unable to cut down" (n=4422) and "felt sick" (n=4646) was restricted to persons who reported trying to reduce their
   use of cigarettes during the preceding 12 months. In addition, for the indicator "unable to cut down," because of the question design,
   respondents who reported not trying to reduce any drug use during the preceding 12 months (n=224) also were excluded.
++ Current smokers who reported at least one of the four indicators of nicotine addiction.
&& Confidence interval.
============================================================================================================================================

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