Current Cigarette Smoking Among Adults — United States, 2011

Tobacco use remains the single largest preventable cause of death and disease in the United States. According to the 2010 U.S. Surgeon General's report, approximately 443,000 U.S. adults die from smoking-related illnesses each year (1). In addition, smoking has been estimated to cost the United States $96 billion in direct medical expenses and $97 billion in lost productivity annually (2). To assess progress toward the Healthy People 2020 (HP2020) objective to reduce cigarette smoking by adults (objective TU-1.1),* CDC's Office on Smoking and Health used data from the 2011 National Health Interview Survey (NHIS) to estimate current national cigarette smoking prevalence. The findings indicate that 19.0% of adults smoked cigarettes in 2011 and no statistically significant change in current adult smoking prevalence occurred from 2010 (19.3%) to 2011 (19.0%). Among daily smokers, the proportion who smoked ≥30 cigarettes per day (CPD) declined significantly, from 12.6% in 2005 to 9.1% in 2011, whereas the proportion of those who smoked 1–9 CPD increased significantly, from 16.4% to 22.0%. To help reduce the national prevalence of cigarette smoking among adults to the HP2020 target of 12%, population-based prevention strategies (e.g., increasing prices of tobacco products, antitobacco media campaigns featuring graphic personal stories on the adverse health impact of smoking, smoke-free laws for workplaces and public places, and barrier-free access to help quitting) will need to be implemented more extensively. Such evidence-based tobacco control interventions can help adults quit and prevent the initiation of tobacco use (3).

The NHIS adult core questionnaire is administered by in-person interviews to a nationally representative sample of the noninstitutionalized, U.S. civilian population aged ≥18 years. The 2011 NHIS adult core sample included 33,014 respondents, and the overall response rate was 66.3% (4). Current smokers were those who had smoked at least 100 cigarettes during their lifetimes and, at the time of interview, reported smoking every day or some days. Former smokers were those who reported smoking at least 100 cigarettes during their lifetimes but currently did not smoke. A quit attempt was defined as a report by a current smoker that they had stopped smoking for >1 day during the preceding year because they were trying to quit smoking, or a report by a former smoker that they had quit during the preceding year.† Overall and sex-specific estimates of current smoking were calculated by age, race/ethnicity, education level, poverty status,§ U.S. Census region,¶ and disability status.** The mean number of CPD was calculated for daily current smokers.

Data were adjusted for nonresponse and weighted to provide national estimates of smoking prevalence. A chi-square test was used to assess the statistical significance of changes in prevalence from 2010 to 2011 (p<0.05). Logistic regression was used to analyze overall temporal changes in prevalence and CPD during 2005–2011, controlling for sex, age, and race/ethnicity. The Wald test was used to determine statistical significance (p<0.05) of trends.

In 2011, an estimated 19.0% (43.8 million) of U.S. adults were current cigarette smokers. Of these, 77.8% (34.1 million) smoked every day, and 22.2% (9.7 million) smoked some days. Overall, among current smokers and those who had quit during the preceding year, 51.8% had made a quit attempt for >1 day during the preceding year.

Overall smoking prevalence did not change significantly from 2010 to 2011 (Table). Smoking prevalence in 2011 was 21.6% among males and 16.5% among females. By race/ethnicity, prevalence was lowest among non-Hispanic Asians (9.9%) and highest among non-Hispanic American Indians/Alaska Natives (31.5%). Prevalence was lowest among adults aged ≥65 years (7.9%) and highest among those aged 25–44 years (22.1%). Prevalence was higher among adults living below the federal poverty level (29.0%) compared with those living at or above this level (17.9%). Also, prevalence was higher among those reporting having a disability (25.4%) compared with those who reported no disability (17.3%).

During 2005–2011, a slight overall decline in current smoking prevalence was noted; the largest decline in current smoking prevalence occurred in adults aged 18–24 years (from 24.4% to 18.9%; p<0.05 for trend) (Figure 1). Among daily smokers, a significant decline in mean CPD was observed from 2005 (16.7) to 2011 (15.1) (p<0.05 for trend). The proportion of daily smokers who smoked ≥30 CPD declined significantly from 2005 (12.6%) to 2011 (9.1%). Meanwhile, a significant increase was observed in the proportion of daily smokers who smoked 1–9 CPD (from 16.4% to 22.0%; p<0.05 for trend) (Figure 2).

Reported by

Israel Agaku, DMD, Brian King, PhD, Shanta R. Dube, PhD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Israel Agaku, [email protected], 770-488-5138.

Editorial Note

Current smoking prevalence declined most markedly from 2005 to 2011 among adults aged 18–24 years (from 24.4% to 18.9%), and this age group, which had the highest prevalence in 2005, now has the lowest of any group aged <65 years. Although overall smoking prevalence declined slightly since 2005, it was 19.0% in 2011, higher than the HP2020 target of 12% for all U.S. adults. This underscores the need for more extensive implementation of evidence-based interventions, such as those outlined in the World Health Organization's MPOWER package.†† These include increasing the price of tobacco products, implementing smoke-free laws in workplaces and public places, warning about the dangers of tobacco use with antitobacco media campaigns, increasing access to help quitting, and enforcing restrictions on tobacco advertising, promotion, and sponsorship (3). Such population-based interventions have been shown to reduce population smoking prevalence as well as overall smoking intensity (i.e., CPD) (5).

Disparities in current smoking prevalence presented in this report are consistent with those in previous reports (6–8). The disparities in smoking prevalence by education level might result from differences in understanding of the health hazards of smoking and increased vulnerability to tobacco marketing (8).

In recent years, several advances in tobacco control have occurred in the United States. These include implementation of the 2009 Family Smoking Prevention and Tobacco Control Act, which granted the Food and Drug Administration the authority to regulate the manufacture, distribution, and marketing of tobacco products.§§ Although not affecting these 2011 findings, the federal mass media campaign conducted in early 2012, which included graphic personal stories on the adverse health impact of smoking, might contribute to future decreases in prevalence (9).

The findings in this report are subject to at least five limitations. First, the estimates of cigarette smoking were self-reported and were not validated by biochemical tests. However, research has indicated that self-reported smoking status correlates highly with measured serum cotinine levels (10). Second, questionnaires were administered only in English and Spanish, which might have resulted in nonresponse among persons who speak neither of those languages. Third, because NHIS does not include institutionalized populations and persons in the military, these results might not be generalizable to these groups. Fourth, the NHIS response rate of 66.3% might have resulted in nonresponse bias, even after adjustment for nonresponse. Finally, small samples sizes resulted in imprecise annual estimates for certain population groups (e.g., American Indians/Alaska Natives).

Although comprehensive tobacco control programs¶¶ have been effective in decreasing tobacco use in the United States, they remain underfunded. In fiscal year 2011, CDC recommended appropriate annual funding levels for each state comprehensive tobacco control program. However, only two states funded tobacco control programs at CDC-recommended levels, whereas 27 states funded at <25% of these levels (CDC, unpublished data, 2012). Despite increases in excise tax revenue, state funding for tobacco control programs has actually decreased during the past 5 years. Full implementation of comprehensive tobacco control programs at CDC-recommended funding levels might result in a substantial reduction in tobacco-related disease and death and billions of dollars in savings from averted medical costs and lost productivity (3).

Acknowledgments

National Center for Health Statistics; Public Health Surveillance Program Office, Office of Surveillance, Epidemiology, and Laboratory Services; Kat Asman, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

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