Tobacco smoking is the leading cause of preventable disease and death in the United States, resulting in approximately 480,000 premature deaths and more than $300 billion in direct health care expenditures and productivity losses each year.1 To assess progress toward achieving the Healthy People 2020 objective of reducing the percentage of U.S. adults who smoke cigarettes to no more than 12.0 percent,* the Centers for Disease Control and Prevention assessed the most recent national estimates of smoking prevalence among adults aged 18 years and older using data from the 2014 National Health Interview Survey (NHIS).
The percentage of U.S. adults who smoke cigarettes declined from 20.9 percent in 2005 to 16.8 percent in 2014, the most recent year for which data are available.
Among daily cigarette smokers, the declines were observed in the percen-tage who smoked 20 to 29 cigarettes per day (from 34.9% to 27.4%) or 30 or more cigarettes per day (from 12.7% to 6.9%).
In 2014, the prevalence of cigarette smoking was higher among males, adults age 25 to 44; multiracial persons and American Indian/Alaska Natives; persons who have a General Education Development certificate; live below the federal poverty level; live in the Midwest; are insured through Medicaid or are uninsured; have a disability or limitation; or are lesbian, gay, or bisexual.
Proven population-based interventions, including tobacco price increases, comprehensive smoke-free laws, high impact mass media campaigns, and barrier-free access to quitting assistance, are critical to reduce cigarette smoking and smoking-related disease and death among U.S. adults.
National Health Interview Survey
NHIS is an annual, nationally representative, in-person survey of the non-institutionalized U.S. civilian population. The NHIS core questionnaire is administered to a randomly selected adult in each sampled family.
The 2014 NHIS included 36,697 respondents age 18 and over; the response rate was 58.9 percent. Current cigarette smokers were respondents who reported smoking 100 or more cigarettes during their lifetimes and, at the time of the interview, reported smoking every day or some days. Former cigarette smokers were respondents who reported smoking 100 or more cigarettes during their lifetime but currently did not smoke.
Data were adjusted for differences in the probability of selection and nonresponse, and weighted to provide nationally representative estimates. Current smoking was assessed overall and by sex, age, race/ethnicity, education, poverty status, U.S. Census region, health insurance coverage, disability/limitation status, and sexual orientation.
The mean number of cigarettes smoked per day was calculated among daily smokers. Differences between groups were assessed using a Wald F-test, with statistical significance defined as p<0.05. Logistic regression was used to analyze trends using annual NHIS data from 2005 through 2014. Percentage changes in prevalence rates between 2005 and 2014 were calculated.
Almost 20% Decline
Current cigarette smoking among U.S. adults declined from 20.9% (45.1 million persons) in 2005 to 16.8% (40.0 million) in 2014, representing a 19.8% decrease (p<0.05 for trend).
Cigarette smoking was significantly lower in 2014 (16.8%) than in 2013 (17.8%). In 2014, prevalence was higher among males (18.8%) than females (14.8%), and was highest among adults age 25 to 44 (20.0%) and lowest among persons age 65 and over (8.5%).
Among racial and ethnic groups, smoking prevalence was highest among American Indian/Alaska Natives (29.2%) and multiracial adults (27.9%), and lowest among Asians (9.5%).
Among adults 25 and over, prevalence was highest among persons with a General Education Development certificate (43.0%) and lowest among those with a graduate degree (5.4%).
Persons living below the poverty level had a higher smoking prevalence (26.3%) than persons at or above this level (15.2%).
By U.S. Census region, prevalence was highest in the Midwest (20.7%) and lowest in the West (13.1%).
Adults reporting a disability or limitation had a higher smoking prevalence (21.9%) than persons reporting no disability or limitation (16.1%).
Prevalence also was higher among lesbian, gay, or bisexual adults (23.9%) than among straight adults (16.6%).
From 2005 to 2014, the percentage of adults who were former cigarette smokers did not change significantly (21.5% and 21.9%, respectively).
Overall in 2014, higher smoking prevalences were reported among persons insured by Medicaid only (29.1%; 5.5 million) and persons who were uninsured (27.9%; 8.8 million) than among persons insured by private health insurance (12.9%; 19.6 million) or Medicare only (12.5%; 2.3 million). Among those covered by Medicaid only, prevalences were higher among adults age 25 to 44 (35.6%) and those 45 to 64 (29.7%) than among those age 18 to 24 (18.2%).
Daily Smokers and 'Some-Days' Smokers
Among current smokers during 2005 to 2014, the number of daily smokers decreased from 36.4 million (80.8% of all smokers) to 30.7 million (76.8%), while the number of some-days smokers increased from 8.7 million (19.2%) to 9.3 million (23.2%).
Among daily smokers, the mean number of cigarettes smoked per day declined from 16.7 in 2005 to 13.8 in 2014. During 2005 to 2014, increases occurred in the percentage of daily smokers who smoked one to nine (16.4% to 26.9%) or 10 to 19 cigarettes a day (36.0% to 38.8%), whereas declines occurred among those who smoked 20 to 29 (34.9% to 27.4%) or 30 or more cigarettes a day (12.7% to 6.9%) (Figure 3) (p<0.05 for trend).
'Indicates Marked Progress'
During 2005 to 2014, the prevalence of cigarette smoking among U.S. adults declined from 20.9 to 16.8 percent, including by a full percentage point during 2013 to 2014 alone, indicating marked progress toward achieving the Healthy People 2020 goal of reducing cigarette smoking prevalence to no more than 12.0 percent.
Adults age 18 to 24 had the greatest decrease in cigarette smoking prevalence; however, recent reports suggest that use of non-cigarette tobacco products, including e-cigarettes and hookahs, is common among youth and young adults.2,3
The extent to which emerging tobacco products, such as e-cigarettes, might have contributed to the observed decline in cigarette smoking in recent years is uncertain. E-cigarette use was first assessed in NHIS in 2014, so it is not possible to assess long-term patterns of e-cigarette use relative to cigarette use with this dataset; in 2014, 3.7 percent of adults currently used e-cigarettes every day or some days, with use differing by age, race/ethnicity, and cigarette smoking status.4
Although e-cigarettes have been promoted for smoking cessation, the U.S. Preventive Services Task Force has concluded that the current evidence is insufficient to recommend e-cigarettes for tobacco cessation in adults, including pregnant women.
No change occurred in the percen-tage of former cigarette smokers over time, suggesting that some of the decline in cigarette smoking might be driven by overall reductions in smoking initiation.
Disparities Consistent with Previous Studies
The observed disparities in smoking prevalence are consistent with previous studies.5 Differences by race/ethnicity might be partly explained by sociocultural influences and norms related to the acceptability of tobacco use.6
Differences in prevalence among persons with different types of health insurance coverage might be partly attributable to variations in tobacco-cessation treatment coverage and access to evidence-based cessation treatments across health insurance types.7
Higher prevalences among persons with disabilities and limitations might be related, in part, to smoking-attributable disability in smokers and possible higher stress associated with disabilities.8
These disparities underscore the importance of enhanced implementation of proven strategies to prevent and reduce tobacco use.
Ongoing changes in the U.S. health care system offer opportunities to improve the use of clinical preventive services among adults. The Patient Protection and Affordable Care Act of 2010 (ACA) is increasing the number of Americans with health insurance and is expected to improve tobacco-cessation coverage.7 The ACA requires most private insurers to cover tobacco cessation; a guidance document issued in May 2014 further clarified this ACA provision. However, neither private insurers nor state Medicaid programs consistently provide comprehensive coverage of evidence-based cessation treatments.7,9
In 2015, although all 50 state Medicaid programs covered some tobacco-cessation treatments for some Medicaid enrollees, only nine states covered individual and group counseling and all seven FDA-approved cessation medications for all Medicaid enrollees.9 Cessation coverage has the greatest impact when promoted to smokers and health care providers.7,9
Possible Limitations
The findings in this report are subject to at least five limitations:
* First, smoking status was self-reported and not validated by biochemical testing; however, self-reported smoking status correlates highly with serum cotinine levels;10
* Second, because NHIS does not include institutionalized populations and persons in the military, the results are not generalizable to these groups;
* Third, the NHIS response rate of 58.9 percent might have resulted in nonresponse bias;
* Fourth, the questionnaire did not assess gender identity, and including transgender persons might yield higher smoking estimates among sexual minorities; and
* Finally, these estimates might differ from other surveys on tobacco use. These differences in estimates can be partially explained by varying survey methodologies, types of surveys administered, and definitions of current smoking; however, trends in prevalence are comparable across surveys.
State Tobacco-Control Programs
Sustained comprehensive state tobacco control programs funded at CDC-recommended levels could accelerate progress toward reducing the health and economic burden of tobacco-related diseases in the United States.1
However, during 2015, states will spend only $490.4 million (1.9%) of combined revenues of $25.6 billion from settlement payments and tobacco taxes for all states on comprehensive tobacco control programs, representing less than 15 percent of the CDC-recommended level of funding for all states combined.
Moreover, only two states (Alaska and North Dakota) currently fund tobacco-control programs at CDC-recommended levels. Implementation of comprehensive tobacco-control interventions can result in substantial reductions in tobacco-related morbidity and mortality and billions of dollars in savings from averted medical costs.1
Additionally, states can work with health care systems, insurers, and purchasers of health insurance to improve coverage and utilization of tobacco-cessation treatments and implement health systems changes that make tobacco dependence treatment a standard of clinical care.7,9
Reprinted (slightly adapted) from Morbidity and Mortality Weekly Report 2015;64(44);1233-1240
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