Cigarette Smoking Among Adults --- United States, 2000

One of the national health objectives for 2010 is to reduce the prevalence of cigarette smoking among adults to <12% (objective 27.1a) (1). To assess progress toward this objective, CDC analyzed self-reported data from the 2000 National Health Interview Survey (NHIS) sample Adult Core questionnaire and Cancer Control module. This report summarizes the findings of this analysis, which indicate that, in 2000, approximately 23.3% of adults were current smokers compared with 25.0% in 1993, reflecting a modest but statistically significant decrease in prevalence among U.S. adults. In 2000, an estimated 70% of smokers said they wanted to quit, and 41% had tried to quit during the preceding year; however, marked differences in successful quitting were observed among demographic groups. A comprehensive approach to cessation that comprises economic, clinical, regulatory, and educational strategies is required to further reduce the prevalence of smoking in the United States.

The 2000 NHIS Adult Core questionnaire was administered by personal interview to a nationally representative sample (n=32,374) of the U.S. noninstitutionalized civilian population aged >18 years; the survey response rate was 72.1%. Respondents were asked, "Have you smoked >100 cigarettes in your entire life?" and "Do you now smoke cigarettes every day, some days, or not at all?" Ever smokers were those who reported having smoked >100 cigarettes during their lifetime. Current smokers were ever smokers who reported smoki ng every day or some days. Former smokers were ever smokers who currently did not smoke. Interest in quitting smoking completely and attempts to quit were determined by asking current smokers, "Would you like to completely quit smoking cigarettes?" and "During the past 12 months, have you stopped smoking for 1 day or longer because you were trying to stop smoking?" Data were adjusted for nonresponses and weighted to provide national estimates. Confidence intervals were calculated by using SUDAAN.

In 2000, an estimated 46.5 million adults (23.3%) (95% confidence interval [CI]=+0.5) were current smokers. Overall, 19.1% (95% CI=+0.5) of adults were everyday smokers, and 4.1% (95% CI=+0.3) were some day smokers. The prevalence of smoking was higher among men (25.7% [95% CI=+0.8]) than women (21.0% [95% CI=+0.7]) (Table 1). Among racial/ethnic groups, Asians (14.4% [95% CI=+2.8]) and Hispanics (18.6% [95% CI=+1.3]) had the lowest prevalence of adult cigarette use; American Indians/Alaska Natives had the highest prevalence (36.0% [95% CI=+8.0]). By education level, adults who had earned a General Educational Development (GED) diploma had the highest prevalence (47.2% [95% CI=+4.3]) of smoking; persons with master's, professional, and doctoral degrees had the lowest prevalence (8.4% [95% CI=+1.2]) and met the 2010 objective. Current smoking prevalence was highest among persons aged 18--24 years and those aged 25--44 years and lowest among those aged >65 years. The prevalence of current smoking was higher among adults living below the poverty level* (31.7% [95% CI=+1.9]) than among those at or above the poverty level (22.9% [95% CI=+0.7]).

In 2000, an estimated 44.3 million adults (22.2% [95% CI=+0.5]) were former smokers, representing 24.7 million men and 19.7 million women. Among ever smokers, 48.8% (95% CI=+0.9) were former smokers (Table 2). Among current smokers, 70.0% (95% CI=+1.3) reported that they wanted to quit completely, and an estimated 15.7 million (41.0% [95% CI=+1.4]) had stopped smoking for >1 day during the preceding 12 months because they were trying to quit; 4.7%^† (95% CI=+0.5) of smokers who had smoked every day or some days during the preceding year quit and maintained abstinence for 3--12 months in 2000. Among all demographic groups, the majority of smokers were interested in quitting. However, the percentage of ever smokers who had quit varied sharply by demographic group. By level of education, the percentage of ever smokers who had quit ranged from 33.6% (95% CI=+4.7) to 74.4% (95% CI=+3.4), with the highest level of success among those with graduate degrees. By race/ethnicity, the percentage of ever smokers who had quit was highest for whites (51.0% [95% CI=+1.1]) and lowest for non-Hispanic blacks (37.3% [95% CI=+2.7]). Interest in quitting and attempts to quit decreased with age. In comparison, the percentage of ever smokers who had quit increased with age; however, because this measure is cumulative, older smokers have had more opportunities to quit, and continuing smokers are more likely to have died from the effects of long-term smoking.

During 1999--2000, significant changes in smoking prevalence did not occur (2). To assess temporal changes, CDC compared data from 1993 and 2000 (3). In addition to the modest decrease in the prevalence of current smoking, the prevalence of never smoking increased from 50.5% (95% CI=+0.9) in 1993 to 54.6% (95% CI=+0.6) in 2000. Preliminary data for 2001 indicate a continuing decline in current smoking among adults (22.8% [95% CI=+0.6]) (4).

During 1993--2000, substantial decreases in current smoking prevalence were reported for all age groups, except those aged 18--24 years. Persons aged 18--24 years and those aged 25--44 years continued to have the highest smoking prevalence; these age groups made little progress toward achieving the national health objectives (1). Current smoking prevalence increased among persons aged 20--24 years with >13 years of education, from 17.9% (95% CI=+2.2) during 1992--1993 to 22.7% (95% CI=+2.0) during 1999--2000.

Reported by: A Trosclair, MS, C Husten, MD, L Pederson, PhD, I Dhillon, MSPH, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

Although current smoking prevalence is declining among adults in the United States, the decline is not occurring at a rate sufficient to meet national health objectives for 2010. However, full implementation of comprehensive tobacco-control programs could help meet these objectives (5). Effective interventions include increasing the unit price of tobacco products, conducting sustained mass media campaigns, and increasing access to proven cessation treatments (6).

The findings in this report indicate that current smoking prevalence has remained stable among persons aged 18--24 years. This might reflect the aging of a cohort of persons with high smoking levels as adolescents in the mid-1990s (7) and/or the possible targeting of young adults by the tobacco industry. Increased efforts should be made to prevent tobacco use among youth and to provide cessation interventions to young adults who smoke.

The findings in this report are subject to at least three limitations. First, questionnaires and data-collection procedures for NHIS have changed since 1993. In 1995, the sample was redesigned. In 1997, questions on tobacco use were moved from supplementary questionnaires to the Adult Core questionnaire; therefore, trend analyses or comparisons with data from years preceding 1997 should be approached with caution. In addition, in 2000, the Office of Management and Budget changed its tabulation guidelines to require that data on Asians and Native Hawaiians and Other Pacific Islanders (NHOPI) be collected separately; this change made it impossible to perform comparisons with the formerly combined category of Asians/Pacific Islanders. Second, estimates for NHOPI are not included in this report; because of small sample sizes, those data were suppressed in the 2000 public use data files to protect respondents from being identified. Third, because the NHIS sample sizes for some racial/ethnic populations (e.g., American Indians/Alaska Natives) were limited, data for a single year might be unstable, as reflected in the wide CIs. Combining data from several years would produce more reliable estimates for these groups. All the estimates in this report, except those for persons wanting to quit (a question asked in 2000 only), could be produced from combined years of data.

Smoking cessation has major and immediate health benefits for smokers of all ages (8). Despite a high interest in quitting among all demographic groups, the percentage of ever smokers who have quit is low among some populations. Factors that might account for this include lack of access to proven treatments (e.g., brief advice from a health-care provider to quit or more intensive counseling that includes social support and a discussion of practical strategies to help smokers deal with nicotine withdrawal and situations that put them at high risk for relapse) and the cost of medications that are approved by the Food and Drug Administration for cessation (i.e., nicotine replacement therapy and bupropion sustained--release) (5,9). To increase the number of persons who quit smoking, health-care providers should integrate treatment into routine care by assessing patients' smoking behavior during every visit. Access to treatment should be increased by reducing out-of-pocket costs for cessation counseling and treatment and by expanding access to telephone counseling services (e.g., quitlines). Media campaigns and other population-based measures that increase interest in quitting and provide information on effective treatments also are needed (6,9). Preliminary estimates for 2002 indicate that six states were funding comprehensive programs at the minimum levels recommended by CDC (10). Implementation at the state and federal levels of comprehensive tobacco-control programs comprising educational, economic, clinical, and regulatory strategies will be required to meet the 2010 national objectives.

References

1. U.S. Department of Health and Human Services. Healthy people 2010, 2nd ed. With understanding and improving health and objectives for improving health (2 vols). Washington, DC: U.S. Department of Health and Human Services, 2000.
2. CDC. Cigarette smoking among adults---United States, 1999. MMWR 2001;50:869--73.
3. CDC. Cigarette smoking among adults---United States, 1993. MMWR 1994;43:925--9.
4. CDC. Early release of selected estimates from the National Health Interview Survey (NHIS). Available at http://www.cdc.gov/nchs/about/major/nhis/released200207/about.htm.
5. U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000.
6. Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prevent Med 2001;20:16--52.
7. CDC. Trends in cigarette smoking among high school students---United States, 1999--2001. MMWR 2002;51:409--12.
8. U.S. Department of Health and Human Services. The health benefits of smoking cessation. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990.
9. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: a clinical practice guideline. Rockville, Maryland: U.S. Department of Health and Human Services, Public Health Service, 2000.
10. CDC. Tobacco control state highlights 2002: impact and opportunity. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2002.

* Poverty thresholds for 1999 from the Bureau of the Census, Economics and Statistics Administration, U.S. Department of Commerce.

^† This estimate was calculated by using the following equation: Percentage successfully quit during the previous year = [(3 months < FS <1 year)/(3 months < FS <1 year) + (CS)] where FS = number of former smokers and CS = number of current smokers.

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