Cigarette Smoking — United States, 2006-2008 and 2009-2010

Bridgette E. Garrett, PhD

Shanta R. Dube, PhD

Cherie Winder, MSPH

Ralph S. Caraballo, PhD

National Center for Chronic Disease Prevention and Health Promotion, CDC

Corresponding author: Bridgette E. Garrett, PhD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 770-488-5715; E-mail: bgarrett@cdc.gov.

Introduction

Cigarette smoking is the leading cause of preventable disease and death in the United States, resulting in approximately 443,000 deaths and $193 billion in direct health-care expenditures and productivity losses each year (1). Declines in smoking prevalence would significantly impact the health-care and economic costs of smoking. Efforts to accelerate the decline in cigarette smoking include reducing cigarette smoking disparities among specific population groups. Findings from the previous report on cigarette use in the first CDC Health Disparities and Inequalities Report (CHDIR) indicated that progress has been achieved in reducing disparities in cigarette smoking among certain racial/ethnic groups (2). However, little progress has been made in reducing disparities in cigarette smoking among persons of low socioeconomic status (SES) and low educational attainment.

This report on cigarette smoking and the analysis and discussion that follows is part of the second CHDIR. The 2011 CHDIR (3) was the first CDC report to take a broad view of disparities across a wide range of diseases, behavioral risk factors, environmental exposures, social determinants, and health-care access. The topic presented in this report is based on criteria that are described in the 2013 CHDIR Introduction (4). The report that follows provides more current information to what was presented in the 2011 CHDIR (2). The purposes of this report are to discuss and raise awareness of differences in the smoking prevalence of current smokers and to prompt actions to reduce disparities.

Methods

To assess the changes in disparities in smoking prevalence by selected sociodemographic characterisitcs during 2006-2008 and 2009-2010, CDC analyzed aggregated data from the National Survey on Drug Use and Health (NSDUH), which is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) and provides annual data on alcohol, tobacco, and illegal drug use among the noninstitutionalized U.S. household population aged ≥12 years (http://www.sahmhsa.gov/data/NSDUH.aspx). Smoking prevalence was determined for youths and adults (aged ≥12 years). Current smokers include persons who reported smoking at least one cigarette during the 30 days before the survey.

Aggregated data were analyzed for two survey cycles. The 2006–2008 survey cycle included 42,693 respondents with response rates of 74.0%, 73.9%, and 74.2%, respectively. The 2009–2010 survey cycle included 27,636 respondents with response rates of 75.7% and 74.4%, respectively. Demographic characteristics analyzed included race and ethnicity, sex, age, household income, employment status, and educational attainment. Geographic location was not analyzed because of limited data for this variable. Race and ethnicity were defined as non-Hispanic white, non-Hispanic black, Hispanic, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, Asian, and multirace. Household income was reported by poverty status, which is based on U.S. Census Bureau thresholds for federal poverty levels (FPL) (http://www.census.gov/hhes/www/poverty/html). Employment status was defined as fulltime, parttime, unemployed, and other. Educational attainment was defined as less than high school, high school diploma or equivalent, some college, and college graduate. For adults, low-SES was defined as those persons with less than a high school diploma unemployed or living at, near, or below the U.S. FPL. Disparities were measured as the absolute difference between rates. Population-weighted prevalence estimates and 95% confidence intervals (CIs) were calculated using statistical software to account for the multistage probability designs of NSDUH. No statistical testing was done for this analysis. In this approach, CIs were used as measure of variability and nonoverlapping CIs were considered statistically different. Using CIs in this way is a conservative evaluation of significance differences; infrequently, this might lead to a conclusion that estimates are similar when the point estimates do differ.

Results

Some progress in reducing smoking prevalence among certain racial/ethnic groups was observed; however, disparities among persons with low-SES persisted. For both youth and adults, little to no changes in smoking prevalence for those below FPL was observed from 2006–2008 to 2009–2010; however, decreases were observed for youth and adults who were above FPL (Tables 1 and 2). During 2009–2010, the prevalence of smoking was 46.4% among 12th-grade–aged youth who had dropped out of school compared with 21.9% among youth who were still in the 12th grade (Table 1). Among adults, smoking prevalence was 34.6% for those who did not graduate from high school compared with 13.2% among those with a college degree (Table 2). From 2006–2008 to 2009–2010, smoking declined from 44.7% to 40.9% among adults who were unemployed (Table 2). Among racial/ethnic groups, smoking prevalence was lowest among black and Asian youth aged 12–17 years during both survey cycles (Table 1). Although smoking prevalence remained highest among American Indian/Alaska Native youth and adults, smoking declined from 17.2% to 13.6% in youth and from 42.2% to 34.4% in adults (Table 1 and 2).

Discussion

Prevalence of smoking is highest for persons aged ≥18 years who do not have high school diploma. Assessing and reporting the prevalence of smoking among youth aged <18 years who drop out of school is critical because this is the period when problems with academic achievement occur. The findings in this report indicate that during 2009–2010, approximately half of youth who dropped out of school were smokers. These findings underscore the need to address tobacco use early in the life span, particularly among school-aged youth, who might be more vulnerable, to eliminate tobacco-related disparities. Implementing the key effective strategies known to prevent and reduce tobacco use among youth are needed, including reducing tobacco industry influences towards minors, particularly those in low SES communities (5).

To make progress toward reducing the persistent higher prevalence of smoking among low-SES populations, current tobacco-control interventions should be targeted toward these more vulnerable smokers. Educating the public about the harms of tobacco use through mass media campaigns is an effective strategy for raising awareness and decreasing smoking prevalence in the general population (6). Advertisements that are emotionally provocative and contain personal testimonies are especially effective in reaching low-SES populations (7). CDC recently implemented its first paid national media campaign to encourage smokers to quit (www.cdc.gov/quitting/tips). Mass media campaigns can be most effective in reaching all populations when they are part of a comprehensive tobacco-control program that includes comprehensive smoke-free policies that make all indoor public places 100% smoke-free, increase tobacco price, counter tobacco industry marketing activities, and increase the availability and accessibility of evidence-based cessation services (6,8).

Limitations

The findings in this report are subject to at least five limitations. First, data were based on self-reports and were not validated biochemically. However, studies have indicated that self-reported smoking status validated by measured serum cotinine levels yield similar prevalence estimates (9). Second, the NSDUH questionnaire is administered only in English and Spanish; therefore, estimates for certain racial/ethnic populations might be underestimated if neither English nor Spanish is the primary language spoken. Moreover, race/ethnicity was not adjusted by socioeconomic status. Third, because NSDUH does not include institutionalized populations and persons in the military, these results might not be generalizable to these groups. Fourth, although smoking prevalence was determined to be lowest among Asian and Hispanic women, variations in smoking prevalence have been observed with specific Asian and Hispanic groups (e.g., Korean and Vietnamese men and Puerto Rican men and women) (10). Finally, because of limited sample sizes for certain population groups (e.g., AI/AN), single-year estimates might have resulted in imprecise estimates.

Conclusion

Comprehensive tobacco-control strategies should be implemented in an equitable manner to be effective in addressing tobacco-related disparities. These strategies should ensure that all populations are covered by comprehensive smoke-free policies, including workplaces, restaurants, and bars; prices are increased on all tobacco products and coupled with access to evidence-based cessation services; exposure to industry advertising, promotions, and sponsorship are reduced among all populations; and the availability, accessibility, and effectiveness of tailored cessation services are increased for all populations (11).

The findings in this report underscore conclusions from the 2011 CHDIR that efforts to reduce future tobacco-related disparities associated with low SES should take a lifespan approach (2). Specifically, continuing population-based strategies that target youth, particularly among those with low academic achievement and drop-outs, will be critical in preventing future tobacco-related disparities. Coordinated, multicomponent interventions that combine mass media campaigns, price increases including those that result from tax increases, school-based policies and programs, and statewide or community-wide changes in smoke-free policies and norms are effective in reducing the initiation, prevalence, and intensity of smoking among youth and young adults (5,6). Finally, addressing the social determinants of health (e.g., socioeconomic status, cultural characteristics, acculturation, stress, targeted advertising, price of tobacco products, and varying capacities of communities to mount effective tobacco-control initiatives) will be necessary to disrupt the cycle of smoking among low-SES populations (2,12,13).

References

1. CDC. Smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 2000–2004. MMWR 2008;57:1226-8.
2. CDC. Cigarette smoking—United States, 1965-2008. In: CDC health disparities and inequalities report—United States, 2011. MMWR 2011;60(Suppl; January 14, 2011).
3. CDC. CDC health disparities and inequalities report—United States, 2011. MMWR 2011;60(Suppl; January 14, 2011).
4. CDC. Introduction: CDC Health Disparities and Inequalities Report—United States, 2013. In: CDC Health Disparities and Inequalities Report—United States, 2013. MMWR 2013;62(No. Suppl 3)
5. US Department of Health and Human Services, Office of the Surgeon General. Preventing tobacco use among youth and young adults; a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2012.
6. Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: Institute of Medicine, 2007.
7. Niederdeppe J, Kuang X, Crock B, Skelton A. Media campaigns to promote smoking cessation among socioeconomically disadvantaged populations; what do we know, what do we need to learn, and what should we do now? Social Science & Medicine 2008;67:1343-55.
8. National Cancer Institute. The role of media in promoting and reducing tobacco use. Tobacco Control Monograph No. 19. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, NIH Pub. No. 07-6242, June 2008.
9. Caraballo RS, Giovino GA, Pechacek TF, Mowery PD. Factors associated with discrepancies between self-reports on cigarette smoking and measured serum cotinine levels among persons aged 17 years or older: Third National Health and Nutrition Examination Survey, 1988-1994. Am J Epidemiol 2001;53:807-14.
10. Caraballo RS, Yee SL, Gfroerer J, Mirza SA. Adult tobacco use among racial and ethnic groups living in the United States, 2002–2005. Prev Chronic Dis 5. Available at http://www.cdc.gov/pcd/issues/2008/jul/07_0116.htm.
11. CDC. Best practices for comprehensive tobacco-control programs. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/tobacco/tobacco_control_program/stateandcommunity/best_practices.
12. Koh HK, Piotrowski JJ, Kumanyika S, Fielding JE. Healthy People a 2020 vision for the social determinants approach. Health Education and Behavior 2011;38:1207-12.
13. U.S. Department of Health and Human Services, Office of the Surgeon General. Tobacco use among U.S. racial/ethnic minority groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 1998.