State-Specific Prevalence of Cigarette Smoking -- United States, 1995

State-specific variation in the prevalence of cigarette smoking contributes to differences in the mortality patterns of smoking-related diseases, such as lung cancer, coronary heart disease, chronic bronchitis, and emphysema (1). In 1990, approximately 400,000 deaths were attributable to smoking: the median percentage of deaths attributable to smoking in all states was 19.2% (range: 13.4% in Utah to 24.0% in Nevada) (1). State-specific surveillance of the prevalence of cigarette smoking can be used to direct and evaluate public health interventions to reduce smoking and the burden of smoking-related diseases on society. In June 1996, the Council of State and Territorial Epidemiologists (CSTE) recommended that cigarette smoking be added to the list of conditions designated as reportable by states to CDC (2). This report responds to the CSTE recommendation and summarizes state-specific prevalences of cigarette smoking by U.S. adults in 1995. During 1995, the prevalence of smoking varied among states and ranged from 13.2% (Utah) to 27.8% (Kentucky).

The 1995 Behavioral Risk Factor Surveillance System (BRFSS) -- a state-based, random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged greater than or equal to 18 years -- was conducted in 50 states and was used to determine self-reported cigarette smoking among adults. Respondents were asked "Have you smoked at least 100 cigarettes in your entire life?" and "Do you smoke cigarettes now?" Current smokers were persons who reported having smoked greater than or equal to 100 cigarettes during their lifetimes and who smoke now. Every-day smoking was determined by asking current smokers "On how many of the past 30 days did you smoke cigarettes?" A quit attempt was determined by asking current every-day smokers "During the past 12 months, have you quit smoking for one day or longer?" Data from the 50 states were weighted to represent state populations and used to produce point estimates; 95% confidence intervals were calculated using SUDAAN.

During 1995, the median prevalence of current smoking was 22.4%; state-specific prevalences ranged from 13.2% (Utah) to 27.8% (Kentucky) (Table_1). Range endpoints were higher for men (16.4% to 31.6%) than for women (10.0% to 27.8%); however, state-specific prevalences were significantly higher for men than for women in only eight states (Alabama, Arizona, Georgia, Illinois, Missouri, North Carolina, Ohio, and Utah). Among current smokers, reported every-day smoking during the preceding 30 days ranged from 79.7% (New Jersey) to 92.9% (Oklahoma) (Table_2). The percentage of every-day smokers who reported having quit for greater than or equal to 1 day during the previous year ranged from 32.4% (Georgia) to 59.4% (Hawaii) (Table_2).

Reported by the following BRFSS coordinators: J Durham, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; J Cooper, MA, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; N Costello, MPA, Indiana; P Busick, Iowa; M Perry, Kansas; K Asher, Kentucky; R Meriwether, MD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; S Loyd, Mississippi; J Jackson-Thompson, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; W Honey, New Mexico; T Melnik, DrPH, New York; G Lengerich, VMD, North Carolina; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; J Ferguson, DrPh, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; R Diamond, MPH, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; J Stones, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; E Cautley, MS, Wisconsin; M Futa, MA, Wyoming. Council of State and Territorial Epidemiologists. Epidemiology Br, Office on Smoking and Health, and Behavioral Surveillance Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report are a milestone for public health surveillance in the United States: these findings document the first time surveillance for a behavior -- rather than a disease or illness -- has been nationally reportable (2). Although the wide state-specific variation in prevalence of cigarette smoking may reflect, in part, differences in sociodemographic characteristics (e.g., age, race, and educational level), previous reports indicated that variations persisted even after estimates were standardized to adjust for these differences (3). Despite some state-specific variations in prevalences, smoking patterns across most states were similar for men and women, indicating that the historically observed gap between men and women has decreased substantially.

Compared with previous years, prevalences of smoking decreased in some states while remaining relatively stable in others (4). For example, from 1984 to 1995, the prevalence declined from 26% to 16% in California, but remained consistently low in Utah (16% to 13%). Only Utah has achieved the national health objective for the year 2000 of reducing the prevalence of cigarette smoking among adults to no more than 15% (objective 3.4) (5); this objective has been nearly achieved in California. Successful state efforts may reflect a combination of factors including community-based tobacco-control programs, antitobacco use media campaigns, and enactment and enforcement of policies to restrict and prevent tobacco use (6).

Prevalences of reported every-day smoking and quitting smoking for greater than or equal to 1 day may be related to factors that influence current smoking prevalence, including physician advice to quit smoking, smoke-free indoor-air policies, the price of cigarettes, and counter-advertising campaigns. For example, prevalences of tobacco use and the amount of tobacco consumed may vary substantially in relation to the price of tobacco products (5) -- price increases may prompt current smokers to quit and deter young persons from starting, accounting for the prevention of premature deaths and resulting in savings of billions of dollars in health-care costs (1,5).

The findings in this report are subject to at least two limitations. First, prevalence estimates may be underestimated because data were collected through telephone interviews; previous studies indicate substantial differences in the characteristics of persons who reside in households without a telephone compared with those who reside in households with a telephone (7). Second, these estimates were only for adults and did not include persons aged less than 18 years. However, to adequately assess the impact of cigarette smoking, data about the prevalence of smoking among young persons also should be considered. Data about youth tobacco use during 1995 are available in 31 states; of these, 22 can produce generalizable state estimates (8).

The national health objectives for the year 2000 have established measurable goals for reducing the prevalence of cigarette smoking, preventing young persons from initiating smoking, encouraging smokers to quit, and developing public policies that are less supportive of tobacco use (5). Public health measures necessary to achieve the objective of reducing smoking in all states include individual-based interventions (e.g., services to help smokers quit), and population-based interventions (e.g., public health policies that prevent nicotine addiction and promote quitting smoking) (5,9).

References

1. Nelson DE, Kirkendall RS, Lawton RL, et al. Surveillance for smoking-attributable mortality and years of potential life lost, by state -- United States, 1990. In: CDC surveillance summaries (June). MMWR 1994;43(no. SS-1):1-8.

2. CDC. Addition of prevalence of cigarette smoking as a nationally notifiable condition -- June 1996. MMWR 1996;45:537.

3. CDC. Cigarette smoking among reproductive-aged women -- Behavioral Risk Factor Surveillance System, 1989. MMWR 1991;40:719-23.

4. Giovino GA, Schooley MW, Zhu BP, et al. Surveillance for selected tobacco-use behaviors -- United States, 1900-1994. In: CDC surveillance summaries (November). MMWR 1994;43(no. SS-3).

5. Public Health Service. Healthy people 2000: midcourse review and 1995 revisions. Washington, DC: US Department of Health and Human Services, Public Health Service, 1995.

6. Glantz SA. Changes in cigarette consumption, prices, and tobacco industry revenues associated with California's Proposition 99. Tobacco Control 1993;2:311-4.

7. Thornberry OT, Massey JT. Trends in United States telephone coverage across time and subgroups. In: Groves RM, Biemer PP, Lyberg LE, Massey JT, Nicholls WL, Waksberg J, eds. Telephone survey methodology. New York: John Wiley and Sons, 1989.

8. Kann L, Warren CW, Harris WA, et al. Youth risk behavior surveillance -- United States, 1995. In: CDC surveillance summaries (September). MMWR 1996;45(no. SS-4).

9. Shelton DM, Alciati MH, Chang MM, et al. State laws on tobacco control -- United States, 1995. In: CDC surveillance summaries (November). MMWR 1995;44(no. SS-6).

TABLE 1. Prevalence of current cigarette smoking among adults,* by state and sex -- United States, Behavioral Risk
Factor Surveillance System, 1995
=====================================================================================================================
                           Men                               Women                               Total
                    -----------------                   -------------------                ---------------------
State +                 % (95% CI &)                        %    (95% CI)                       %   (95% CI)
---------------------------------------------------------------------------------------------------------------------
Alabama              30.0  (+/-3.9%)                     19.7   (+/-2.6%)                    24.5  (+/-2.3%)
Alaska               26.5  (+/-4.7%)                     23.3   (+/-4.0%)                    25.0  (+/-3.1%)
Arizona              26.8  (+/-4.5%)                     19.1   (+/-3.1%)                    22.9  (+/-2.7%)
Arkansas             26.8  (+/-3.6%)                     23.8   (+/-2.7%)                    25.2  (+/-2.2%)
California           17.5  (+/-2.2%)                     13.6   (+/-2.3%)                    15.5  (+/-1.6%)
Colorado             22.2  (+/-3.2%)                     21.4   (+/-2.7%)                    21.8  (+/-2.1%)
Connecticut          21.0  (+/-3.3%)                     20.6   (+/-2.7%)                    20.8  (+/-2.1%)
Delaware             27.5  (+/-3.3%)                     23.6   (+/-2.7%)                    25.5  (+/-2.1%)
Florida              24.9  (+/-2.5%)                     21.6   (+/-2.0%)                    23.1  (+/-1.6%)
Georgia              24.3  (+/-3.0%)                     16.9   (+/-2.3%)                    20.5  (+/-1.9%)
Hawaii               18.8  (+/-3.0%)                     16.8   (+/-2.6%)                    17.8  (+/-2.0%)
Idaho                20.4  (+/-2.5%)                     19.2   (+/-2.1%)                    19.8  (+/-1.6%)
Illinois             26.6  (+/-2.9%)                     19.9   (+/-2.1%)                    23.1  (+/-1.8%)
Indiana              28.5  (+/-2.8%)                     26.0   (+/-2.6%)                    27.2  (+/-1.9%)
Iowa                 24.8  (+/-2.4%)                     21.7   (+/-1.9%)                    23.2  (+/-1.5%)
Kansas               24.0  (+/-3.0%)                     20.1   (+/-2.5%)                    22.0  (+/-2.0%)
Kentucky             28.8  (+/-3.2%)                     26.9   (+/-2.5%)                    27.8  (+/-2.0%)
Louisiana            26.3  (+/-3.8%)                     24.2   (+/-3.0%)                    25.2  (+/-2.5%)
Maine                26.9  (+/-4.1%)                     23.2   (+/-3.5%)                    25.0  (+/-2.6%)
Maryland             22.4  (+/-2.0%)                     20.1   (+/-1.6%)                    21.2  (+/-1.3%)
Massachusetts        22.5  (+/-3.3%)                     21.0   (+/-2.8%)                    21.7  (+/-2.2%)
Michigan             26.3  (+/-2.9%)                     25.2   (+/-2.4%)                    25.7  (+/-1.9%)
Minnesota            22.5  (+/-2.2%)                     18.6   (+/-1.7%)                    20.5  (+/-1.4%)
Mississippi          27.6  (+/-4.0%)                     20.9   (+/-2.9%)                    24.0  (+/-2.5%)
Missouri             28.0  (+/-4.0%)                     20.9   (+/-2.9%)                    24.3  (+/-2.5%)
Montana              22.5  (+/-3.8%)                     19.8   (+/-3.1%)                    21.1  (+/-2.5%)
Nebraska             24.8  (+/-3.4%)                     19.3   (+/-2.5%)                    21.9  (+/-2.1%)
Nevada               24.8  (+/-3.6%)                     27.8   (+/-3.2%)                    26.3  (+/-2.4%)
New Hampshire        21.9  (+/-3.8%)                     21.0   (+/-3.0%)                    21.4  (+/-2.4%)
New Jersey           21.6  (+/-4.5%)                     17.0   (+/-2.8%)                    19.2  (+/-2.6%)
New Mexico           22.7  (+/-4.4%)                     19.7   (+/-3.2%)                    21.2  (+/-2.7%)
New York             23.6  (+/-3.1%)                     19.6   (+/-2.3%)                    21.5  (+/-1.9%)
North Carolina       30.2  (+/-2.8%)                     21.8   (+/-2.1%)                    25.8  (+/-1.7%)
North Dakota         24.9  (+/-3.2%)                     20.5   (+/-2.9%)                    22.7  (+/-2.1%)
Ohio                 31.6  (+/-4.7%)                     21.0   (+/-3.2%)                    26.0  (+/-2.8%)
Oklahoma             21.6  (+/-3.3%)                     21.7   (+/-3.0%)                    21.7  (+/-2.2%)
Oregon               22.9  (+/-2.7%)                     20.8   (+/-2.3%)                    21.8  (+/-1.8%)
Pennsylvania         26.0  (+/-2.7%)                     22.5   (+/-2.5%)                    24.2  (+/-1.8%)
Rhode Island         24.0  (+/-3.4%)                     25.4   (+/-3.1%)                    24.7  (+/-2.3%)
South Carolina       24.6  (+/-3.2%)                     23.0   (+/-2.8%)                    23.7  (+/-2.1%)
South Dakota         22.8  (+/-3.0%)                     20.9   (+/-2.8%)                    21.8  (+/-2.1%)
Tennessee            27.9  (+/-3.4%)                     25.2   (+/-2.6%)                    26.5  (+/-2.1%)
Texas                27.1  (+/-3.9%)                     20.4   (+/-2.8%)                    23.7  (+/-2.4%)
Utah                 16.4  (+/-2.9%)                     10.0   (+/-1.8%)                    13.2  (+/-1.7%)
Vermont              24.9  (+/-3.0%)                     19.5   (+/-2.5%)                    22.1  (+/-1.9%)
Virginia             23.7  (+/-3.5%)                     20.5   (+/-2.7%)                    22.0  (+/-2.3%)
Washington           20.0  (+/-2.3%)                     20.3   (+/-2.0%)                    20.2  (+/-1.5%)
West Virginia        24.8  (+/-3.0%)                     26.5   (+/-2.5%)                    25.7  (+/-2.0%)
Wisconsin            24.5  (+/-3.5%)                     19.3   (+/-2.6%)                    21.8  (+/-2.2%)
Wyoming              22.1  (+/-2.8%)                     21.9   (+/-2.3%)                    22.0  (+/-1.8%)

Range           16.4-31.6                           10.0-27.8                           13.2-27.8
Median               24.7                                20.9                                22.4
---------------------------------------------------------------------------------------------------------------------
* Persons aged >=18 who reported having smoked >=100 cigarettes and who reported smoking now.
+ No data were available for the District of Columbia.
& Confidence interval.
=====================================================================================================================

TABLE 2. Percentage of current adult smokers who smoked every day * and percentage
of every-day smokers who quit smoking for >=1 day +, by state  -- United States,
Behavioral Risk Factor Surveillance System, 1995
========================================================================================
                           Smoked every                    Quit smoking for
                                day                            >=1 day
                          ----------------               ---------------------
         State &              %  (95% CI @)                    %   (95% CI)
----------------------------------------------------------------------------------------
        Alabama            88.5  (+/-3.4%)                  42.5  (+/-5.9%)
         Alaska            88.8  (+/-3.8%)                  55.9  (+/-7.6%)
        Arizona            88.3  (+/-4.0%)                  48.7  (+/-6.9%)
       Arkansas            89.8  (+/-2.7%)                  46.0  (+/-5.5%)
     California            81.3  (+/-3.9%)                  52.3  (+/-6.4%)
       Colorado            81.9  (+/-4.2%)                  47.0  (+/-5.9%)
    Connecticut            88.8  (+/-3.3%)                  48.3  (+/-6.1%)
       Delaware            90.3  (+/-3.1%)                  50.5  (+/-5.1%)
        Florida            87.3  (+/-2.8%)                  46.4  (+/-4.1%)
        Georgia            89.8  (+/-3.1%)                  32.4  (+/-5.0%)
         Hawaii            84.5  (+/-4.4%)                  59.4  (+/-6.4%)
          Idaho            91.1  (+/-2.5%)                  42.1  (+/-4.8%)
       Illinois            86.1  (+/-3.2%)                  43.1  (+/-4.6%)
        Indiana            89.0  (+/-2.8%)                  41.2  (+/-4.2%)
           Iowa            87.0  (+/-2.6%)                  40.4  (+/-3.9%)
         Kansas            83.7  (+/-3.8%)                  38.1  (+/-5.3%)
       Kentucky            89.0  (+/-2.6%)                  38.8  (+/-4.4%)
      Louisiana            83.3  (+/-4.1%)                  50.7  (+/-6.0%)
          Maine            88.6  (+/-4.2%)                  34.6  (+/-5.7%)
       Maryland            84.6  (+/-2.6%)                  42.9  (+/-3.7%)
  Massachusetts            86.3  (+/-4.0%)                  56.5  (+/-5.9%)
       Michigan            83.2  (+/-3.3%)                  46.2  (+/-4.6%)
      Minnesota            84.5  (+/-2.7%)                  42.1  (+/-4.1%)
    Mississippi            84.2  (+/-4.5%)                  48.5  (+/-6.0%)
       Missouri            89.3  (+/-3.5%)                  45.2  (+/-6.4%)
        Montana            89.2  (+/-4.2%)                  41.5  (+/-6.8%)
       Nebraska            88.3  (+/-3.4%)                  41.5  (+/-5.8%)
         Nevada            88.0  (+/-3.3%)                  45.1  (+/-5.7%)
  New Hampshire            87.1  (+/-4.3%)                  44.6  (+/-6.9%)
     New Jersey            79.7  (+/-6.1%)                  43.2  (+/-8.4%)
     New Mexico            82.2  (+/-5.4%)                  47.4  (+/-7.6%)
       New York            88.5  (+/-3.0%)                  47.3  (+/-5.2%)
 North Carolina            88.7  (+/-2.5%)                  47.9  (+/-4.1%)
   North Dakota            88.1  (+/-3.3%)                  40.5  (+/-5.4%)
           Ohio            90.6  (+/-3.5%)                  45.2  (+/-6.8%)
       Oklahoma            92.9  (+/-3.3%)                  38.6  (+/-6.0%)
         Oregon            84.3  (+/-3.2%)                  37.0  (+/-4.7%)
   Pennsylvania            83.7  (+/-3.0%)                  42.0  (+/-4.8%)
   Rhode Island            86.0  (+/-3.9%)                  45.5  (+/-5.8%)
 South Carolina            87.6  (+/-3.1%)                  42.9  (+/-5.5%)
   South Dakota            90.7  (+/-3.0%)                  41.7  (+/-5.6%)
      Tennessee            91.1  (+/-2.6%)                  38.1  (+/-4.7%)
          Texas            83.8  (+/-4.0%)                  51.0  (+/-6.4%)
           Utah            85.2  (+/-5.2%)                  44.0  (+/-6.9%)
        Vermont            85.1  (+/-3.4%)                  37.5  (+/-5.2%)
       Virginia            83.9  (+/-4.2%)                  41.3  (+/-5.9%)
     Washington            86.1  (+/-2.8%)                  45.6  (+/-4.5%)
  West Virginia            91.8  (+/-2.3%)                  40.6  (+/-4.4%)
      Wisconsin            83.3  (+/-4.2%)                  49.3  (+/-6.1%)
        Wyoming            86.5  (+/-3.3%)                  40.1  (+/-4.8%)

          Range       79.7-92.9                        32.4-59.4
         Median            87.2                             43.6
----------------------------------------------------------------------------------------
* During the preceding 30 days.
+ During the preceding 12 months.
& No data were available for the District of Columbia.
@ Confidence interval.
========================================================================================

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