State-Specific Prevalence Among Adults of Current Cigarette Smoking and Smokeless Tobacco Use and Per Capita Tax-Paid Sales of Cigarettes -- United States, 1997

In the United States each year, tobacco use causes approximately 400,000 deaths and is the single most preventable cause of death and disease (1,2). Consequently, state and local public health agencies closely monitor tobacco use and its correlates (3). In 1996, the prevalence of current cigarette smoking among adults was the first health behavior and the first noninfectious condition added by the Council of State and Territorial Epidemiologists (CSTE) to the list of nationally notifiable conditions reported to CDC (4). In 1998, per capita sales of cigarettes (along with prevalence among youth of current cigarette smoking and current smokeless tobacco use) was added by CSTE to the list of notifiable conditions reported by states to CDC. This report summarizes state-specific findings for current cigarette and current smokeless tobacco use by adults from the Behavioral Risk Factor Surveillance System (BRFSS) and number of packs of tax-paid cigarettes sold per capita in each state from data compiled annually by The Tobacco Institute. The findings indicate that current adult cigarette smoking prevalence by state ranged from 13.7% to 30.8%, annual per capita tax-paid cigarette sales ranged from 49.1 packs to 186.8 packs, and adult smokeless tobacco use prevalence ranged from 1.4% to 8.8%.

State- and sex-specific prevalences of current cigarette smoking and current smokeless tobacco use among adults are available from the 1997 BRFSS. The BRFSS is a state-specific, random-digit-dialed telephone survey of health behaviors of the civilian, noninstitutionalized U.S. population aged greater than or equal to 18 years (5) conducted by state health departments with assistance from CDC. In 1996 and 1997, respondents were asked, "Have you smoked at least 100 cigarettes in your entire life?" and "Do you now smoke cigarettes every day, some days, or not at all?" Current cigarette smokers were defined as persons who reported having smoked at least 100 cigarettes during their lifetime and who currently smoke every day or some days. To determine current smokeless tobacco use, respondents were asked, "Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff?" and "Do you currently use any smokeless tobacco products such as chewing tobacco or snuff?" Current smokeless tobacco users were defined as persons who reported having ever used or tried any smokeless tobacco product and who currently use a smokeless tobacco product. To estimate prevalence, responses for each state were weighted to the current age, race, and sex distribution of the state's population (i.e., crude prevalence). To allow comparison of findings across states that had different age distributions, age-adjusted prevalences for each state were estimated by using direct standardization to 10-year age groups of the U.S. population in 1997 derived from U.S. census estimates (6). The number of packs of tax-paid cigarettes sold per capita in each state is compiled yearly by The Tobacco Institute by using information on federal, state, and local excise taxes and total population estimates (7).

In 1997, the median state prevalence of current cigarette smoking by adults was 23.2%; prevalence was 25.5% for men and 21.3% for women (Table_1). The crude median prevalence of current cigarette smoking was similar in 1997 and in 1996 (25.5% for men, 22.0% for women, and 23.6% for both groups combined) (4). In 1997, for every state except Florida, the crude prevalence of current cigarette smoking was within 1% of the age-adjusted prevalence for that state.

Current adult cigarette smoking prevalence differed approximately twofold across the states (Table_1). In 1997, the current cigarette smoking prevalence was highest in Kentucky (30.8%), Missouri (28.7%), Arkansas (28.5%), Nevada (27.7%), and West Virginia (27.4%), and lowest in Utah (13.7%), California (18.4%), Hawaii (18.6%), the District of Columbia (18.8%), and Idaho (19.9%). The current cigarette smoking prevalence for men was highest in Kentucky (33.1%), and for women in Nevada (29.8%). For both men and women, current smoking prevalence was lowest in Utah.

Per capita tax-paid sales of cigarettes for July 1, 1996, through June 30, 1997, varied approximately fourfold across the states (Table_1). The state median tax-paid cigarette sales was 90 packs per person per year. Sales were highest in Kentucky (186.8 packs) and lowest in Hawaii (49.1 packs).

Questions about current adult smokeless tobacco use were included in the 1997 BRFSS in 17 states (Table_2). The difference in prevalence was more than sixfold (from 1.4% in Arizona to 8.8% in West Virginia). Among men, the prevalence of current smokeless tobacco use was highest in West Virginia (18.4%) and Wyoming (14.7%); five states (Alabama, Alaska, Kansas, Kentucky, and Montana) reported prevalences of 9%-12%, and 10 states reported prevalences of less than or equal to 8%. For women, the prevalence of current smokeless tobacco use was less than or equal to 1.7% in all 17 states.

Reported by the following BRFSS coordinators: J Cook, Alabama, MBA; P Owen, Alaska; B Bender, MBA, 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; S Hoecherl, Florida; L Martin, MS, Georgia; A Onaka, PhD, Hawaii; J Aydelotte, Idaho; B Steiner, MS, Illinois; K Horvath, Indiana; A Wineski, Iowa; M Perry, Kansas; K Asher, Kentucky; R Jiles, PhD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson, Mississippi; T Murayi, PhD, Missouri; P Feigley, PhD, Montana; M Metroka, Nebraska; E DeJan, MPH, Nevada; L Powers, MA, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; T Melnik, DrPH, New York; K Passaro, PhD, North Carolina; J Kaske, MPH, North Dakota; P Pullen, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; T Aldrich, PhD, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; C Roe, MS, Vermont; L Redman, MPH, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; P Imm, MS, Wisconsin; M Futa, MA, Wyoming. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: This report includes information about two CSTE-recommended indicators of tobacco use for all states (current cigarette smoking by adults and per capita tax-paid sales of cigarettes) and current smokeless tobacco use among adults for 17 states. Information on cigarette and smokeless tobacco use by youth in 1997 is available elsewhere (8). National surveys provide information about tobacco use and are useful for monitoring overall trends, but their effectiveness is limited for monitoring state-level year-to-year changes in tobacco consumption. National surveys also mask the twofold variation in current adult cigarette smoking prevalence among the states.

In the BRFSS, the crude and age-adjusted prevalences of current adult cigarette smoking were similar, indicating that differences in prevalence among states are related primarily to factors other than differences in adult age distributions. Although the median prevalence for current cigarette smoking among adults was nearly the same in 1996 and 1997, the twofold difference in prevalence among states, the wide variation in per capita tax-paid cigarette sales, and the wide variation in smokeless tobacco prevalence among adults suggest that further reductions in tobacco use are achievable.

The findings in this report are subject to at least three limitations. First, the BRFSS standardizes procedures among states, but the quality and completeness of the surveys can vary by state and year. Second, the changes in questions about current cigarette use in 1996 limit comparisons with previous years (9). Finally, estimates of per capita tax-paid cigarette sales provide populationwide rather than individual-based estimates of behaviors; because these estimates are based on tax revenues they may not accurately estimate actual consumption (10).

By monitoring tobacco-related health effects, policy changes, and public attitudes at state and local levels, tobacco-related activities can be evaluated and public health programs can be tailored to local populations. CDC and state health departments are working together to improve state-specific measures of tobacco-related health outcomes, policy interventions, and related activities to improve the prevention and control of tobacco use. In 1999, CDC will provide all states with funding for tobacco-use prevention and control programs. CDC also is collaborating with states that have other sources of funding for activities related to tobacco-use prevention to develop effective public health intervention, surveillance, and evaluation activities.

References

1. CDC. Smoking-attributable mortality and years of potential life lost -- United States, 1984. MMWR 1997;46:444-51.

2. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12.

3. CDC. State and national tobacco control highlights. World-Wide Web site http://www.cdc.gov/nccdphp/osh/statehi/statehi.htm. Accessed November 3, 1998.

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

5. CDC. State and sex-specific prevalence of selected characteristics, Behavioral Risk Factor Surveillance System, 1994 and 1995. MMWR 1997;46(no. SS-3).

6. Bureau of the Census, Economics and Statistics Administration, US Department of Commerce. Resident Population of the United States: estimates, by age and sex. World-Wide Web site http://www.census.gov/population/estimates/nation/intfile2-1.txt . Accessed November 3, 1998.

7. The Tobacco Institute. The tax burden on tobacco: historical compilation, vol 32. Washington, DC: The Tobacco Institute, 1997.

8. CDC. Youth Risk Behavior Surveillance -- United States, 1997. MMWR 1998;47(no. SS-3).

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

10. Clarke TM. A tax study: cigarette consumption in Washington state. Olympia, Washington: Washington State Department of Health, January 1997.

TABLE 1. Prevalence of current cigarette smoking* among adults, by state and sex,
and per capita tax-paid sales of cigarettes, by state+ -- United States, 1997
===============================================================================================================
                              Men                  Women               Total            Per capita tax-paid
                       -----------------     -----------------    -----------------     sales of cigarettes 
State                    %     (95% CI&)       %      (95% CI)      %      (95% CI)        (in packs)
------------------------------------------------------------------------------------------------------------
Alabama                 28.6    (+/-3.3)     21.3     (+/-2.5)    24.7     (+/-2.0)           104.9
Alaska                  27.4    (+/-4.9)     25.8     (+/-4.3)    26.7     (+/-3.3)            81.7
Arizona                 22.1    (+/-3.9)     20.2     (+/-3.6)    21.1     (+/-2.5)            64.6
Arkansas                32.1    (+/-4.4)     25.2     (+/-3.0)    28.5     (+/-2.6)           108.7
California              22.4    (+/-2.3)     14.5     (+/-1.6)    18.4     (+/-1.4)            53.8
Colorado                24.0    (+/-3.2)     21.2     (+/-3.0)    22.6     (+/-2.2)            81.3
Connecticut             21.4    (+/-3.2)     22.2     (+/-2.7)    21.8     (+/-2.1)            75.9
Delaware                29.3    (+/-3.5)     24.2     (+/-2.5)    26.6     (+/-2.1)           124.1
District of Columbia    22.7    (+/-4.0)     15.5     (+/-2.8)    18.8     (+/-2.4)            54.3
Florida                 26.0    (+/-2.6)     21.4     (+/-1.9)    23.6     (+/-1.6)            93.0
Georgia                 25.2    (+/-3.2)     19.9     (+/-2.7)    22.4     (+/-2.1)           100.6
Hawaii                  21.4    (+/-2.9)     15.8     (+/-2.5)    18.6     (+/-1.9)            49.1
Idaho                   21.8    (+/-2.2)     18.0     (+/-1.9)    19.9     (+/-1.4)            75.0
Illinois                25.0    (+/-2.7)     21.6     (+/-2.2)    23.2     (+/-1.7)            79.6
Indiana                 29.2    (+/-3.2)     23.7     (+/-2.7)    26.3     (+/-2.1)           135.3
Iowa                    25.5    (+/-2.4)     20.9     (+/-2.0)    23.1     (+/-1.6)            93.9
Kansas                  26.8    (+/-3.4)     18.9     (+/-2.3)    22.7     (+/-2.0)            89.2
Kentucky                33.1    (+/-2.9)     28.7     (+/-2.1)    30.8     (+/-1.8)           186.8
Louisiana               29.3    (+/-4.1)     20.4     (+/-2.7)    24.6     (+/-2.4)           105.3
Maine                   25.2    (+/-3.3)     20.4     (+/-2.8)    22.7     (+/-2.2)           101.1
Maryland                21.8    (+/-2.4)     19.4     (+/-2.0)    20.6     (+/-1.6)            72.7
Massachusetts           21.8    (+/-3.7)     19.2     (+/-2.6)    20.4     (+/-2.2)            66.7
Michigan                29.6    (+/-3.0)     22.8     (+/-2.2)    26.1     (+/-1.9)            75.6
Minnesota               24.1    (+/-2.0)     19.8     (+/-1.6)    21.8     (+/-1.3)            84.1
Mississippi             28.3    (+/-4.2)     18.6     (+/-2.8)    23.2     (+/-2.5)           106.3
Missouri                31.7    (+/-4.1)     26.0     (+/-2.9)    28.7     (+/-2.5)           120.6
Montana                 20.8    (+/-3.0)     20.2     (+/-2.6)    20.5     (+/-2.0)            88.9
Nebraska                24.4    (+/-3.1)     20.2     (+/-2.6)    22.2     (+/-2.0)            88.5
Nevada                  25.7    (+/-5.0)     29.8     (+/-4.6)    27.7     (+/-3.4)            95.6
New Hampshire           26.0    (+/-4.1)     23.7     (+/-3.0)    24.8     (+/-2.5)           174.4
New Jersey              23.3    (+/-3.0)     19.8     (+/-2.3)    21.5     (+/-1.9)            77.0
New Mexico              21.6    (+/-3.2)     22.6     (+/-2.7)    22.1     (+/-2.1)            61.8
New York                25.0    (+/-2.6)     21.5     (+/-2.0)    23.1     (+/-1.6)            64.5
North Carolina          29.7    (+/-2.7)     22.3     (+/-2.0)    25.8     (+/-1.7)           125.6
North Dakota            24.3    (+/-3.2)     20.3     (+/-2.7)    22.2     (+/-2.1)            77.5
Ohio                    26.3    (+/-3.2)     24.0     (+/-2.5)    25.1     (+/-2.0)           108.6
Oklahoma                25.2    (+/-3.7)     24.1     (+/-3.0)    24.6     (+/-2.4)           111.8
Oregon                  22.1    (+/-2.7)     19.4     (+/-2.1)    20.7     (+/-1.7)            89.5
Pennsylvania            26.2    (+/-2.6)     22.5     (+/-2.0)    24.3     (+/-1.6)            92.9
Rhode Island            25.6    (+/-3.6)     23.0     (+/-3.2)    24.2     (+/-2.4)            90.0
South Carolina          29.5    (+/-3.5)     17.8     (+/-2.3)    23.4     (+/-2.1)           124.5
South Dakota            28.1    (+/-3.3)     20.8     (+/-2.6)    24.3     (+/-2.1)            88.8
Tennessee               27.9    (+/-3.1)     26.0     (+/-2.2)    26.9     (+/-1.9)           118.9
Texas                   28.0    (+/-3.1)     17.5     (+/-2.2)    22.6     (+/-1.9)            72.6
Utah                    16.1    (+/-2.4)     11.5     (+/-2.0)    13.7     (+/-1.6)            57.0
Vermont                 25.1    (+/-2.9)     21.5     (+/-2.4)    23.2     (+/-1.9)            97.7
Virginia                26.2    (+/-3.4)     23.1     (+/-2.6)    24.6     (+/-2.1)           108.0
Washington              25.1    (+/-2.8)     22.7     (+/-2.2)    23.9     (+/-1.8)            55.6
West Virginia           27.1    (+/-3.1)     27.7     (+/-2.6)    27.4     (+/-2.0)           114.5
Wisconsin               25.6    (+/-3.4)     21.0     (+/-2.8)    23.2     (+/-2.2)            91.9
Wyoming                 24.0    (+/-3.8)     24.1     (+/-2.8)    24.0     (+/-2.4)           108.8
------------------------------------------------------------------------------------------------------------
* Percentage of persons aged >= 18 years who reported having smoked >= 100 cigarettes during their lifetime
  and who currently smoke every day or some days. Estimates are weighted to the age, race, and sex
  distribution of the state population (crude prevalence). Source: Behavioral Risk Factor Surveillance System.
+ Source: The Tobacco Institute. Data are for July 1, 1996, through June 30, 1997 ( 7 ).
& Confidence interval.
===============================================================================================================

TABLE 2. Prevalence of current smokeless tobacco use* among adults, by state and
sex -- United States, 1997
============================================================================================
                          Men                 Women               Total
                  ------------------     ---------------     ----------------
State               %      (95% CI+)      %     (95% CI)      %     (95% CI)
-----------------------------------------------------------------------------
Alabama            9.9     (+/-2.2)      1.4    (+/-0.7)     5.4    (+/-1.1)
Alaska             9.2     (+/-3.2)      1.6    (+/-1.0)     5.5    (+/-1.7)
Arizona            2.6     (+/-1.3)      0.3    (+/-0.3)     1.4    (+/-0.7)
Georgia            6.4     (+/-1.8)      1.7    (+/-0.9)     4.0    (+/-1.0)
Indiana            6.8     (+/-1.7)      0.0    (+/-0.0)     3.2    (+/-0.8)
Kansas            10.3     (+/-2.5)      0.2    (+/-0.3)     5.1    (+/-1.2)
Kentucky          12.2     (+/-3.0)      0.6    (+/-0.5)     6.1    (+/-1.5)
Louisiana          7.6     (+/-2.1)      0.3    (+/-0.4)     3.7    (+/-1.1)
Montana           10.5     (+/-2.5)      0.2    (+/-0.3)     5.3    (+/-1.3)
Ohio               5.1     (+/-1.6)      0.0    (+/-0.1)     2.4    (+/-0.8)
Oklahoma           7.7     (+/-2.2)      0.3    (+/-0.3)     3.8    (+/-1.1)
Pennsylvania       7.4     (+/-1.7)      0.4    (+/-0.3)     3.8    (+/-0.9)
South Carolina     4.8     (+/-1.7)      1.0    (+/-0.6)     2.8    (+/-0.9)
Virginia           6.1     (+/-1.4)      0.1    (+/-0.1)     3.0    (+/-0.7)
Washington         5.6     (+/-1.4)      0.2    (+/-0.2)     2.9    (+/-0.7)
West Virginia     18.4     (+/-2.6)      0.2    (+/-0.2)     8.8    (+/-1.3)
Wyoming           14.7     (+/-2.3)      0.7    (+/-0.4)     7.6    (+/-1.2)
-----------------------------------------------------------------------------
* Percentage of persons aged >= 18 years who reported having ever used or tried smokeless
  tobacco products such as chewing tobacco or snuff and who currently use a smokeless tobacco
  product. Estimates are weighted to the age, race, and sex distribution of the state population
  (crude prevalence). Source: Behavioral Risk Factor Surveillance System.
+ Confidence interval.
=================================================================================================

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