Cigarette Smoking Among Adults -- United States, 1995

One of the national health objectives for 2000 is to reduce the prevalence of cigarette smoking among adults to no more than 15% (objective 3.4) (1). To assess progress toward meeting this objective, CDC analyzed self-reported information about cigarette smoking among U.S. adults from the Year 2000 Objectives Supplement of the 1995 National Health Interview Survey (NHIS). This report summarizes the findings of this analysis, which indicate that, in 1995, 24.7% (47.0 million) of adults were current smokers.

The 1995 NHIS was administered to a nationally representative sample (n=17,213) of the U.S. noninstitutionalized civilian population aged greater than or equal to 18 years; the overall response rate for the supplement was 80.9%. Participants 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 smokers were persons who reported having smoked greater than or equal to 100 cigarettes during their lifetimes and who smoked every day or some days at the time of interview. Former smokers were those who had smoked greater than or equal to 100 cigarettes during their lifetimes but who did not smoke currently. Interest in quitting was determined by asking current smokers, "Would you like to completely quit smoking cigarettes?" Attempts to quit were determined by asking current every-day smokers, "During the past 12 months, have you stopped smoking for one day or longer?" Data were adjusted for nonresponse and weighted to provide national estimates. Confidence intervals (CIs) were calculated using SUDAAN.

In 1995, an estimated 47.0 million adults (24.7% {95% CI=plus or minus 0.8 percentage points}), including 24.5 million men (27.0% of adult men {95% CI=plus or minus 1.2}), were current smokers (Table_1). Overall, 20.1% (95% CI=plus or minus 0.8) were every-day smokers, and 4.6% (95% CI=plus or minus 0.4) were some-day smokers (every-day smokers constituted 81.2% {95% CI=plus or minus 1.5} of all smokers). Prevalences of current smoking were higher among American Indians/ Alaskan Natives (36.2% {95% CI=plus or minus 10.6}), non-Hispanic blacks (25.8% {95% CI=plus or minus 2.6}, and non-Hispanic whites (25.6% {95% CI=plus or minus 1.0}) than among Hispanics (18.3% {95% CI=plus or minus 1.8}) and Asians/Pacific Islanders (16.6% {95% CI=plus or minus 4.6}). Current smoking prevalence was highest among persons with nine to 11 years of education (37.5% {95% CI=plus or minus 2.9}) and lowest among persons with greater than or equal to 16 years of education (14.0% {95% CI=plus or minus 1.4}) and was higher among persons living below the poverty level * (32.5% {95% CI=plus or minus 2.5}) than among those living at or above the poverty level (23.8% {95% CI=plus or minus 0.9}).

In 1995, an estimated 44.3 million adults (23.3% {95% CI=plus or minus 0.8}) were former smokers, including 25 million men and 19.3 million women. Former smokers constituted 48.6% (95% CI=plus or minus 1.4) of persons who had ever smoked at least 100 cigarettes. Among current smokers in 1995, an estimated 32 million (68.2% {95% CI=plus or minus 1.8}) wanted to quit smoking completely, and 17.3 million (45.8% {95% CI=plus or minus 2.0}) current every-day smokers had stopped smoking for at least 1 day during the preceding 12 months.

Reported by: Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The prevalence of smoking in 1995 (24.7% {95% CI=plus or minus 0.8}) was similar to that in 1994 (25.5% {95% CI=plus or minus 0.7}) (2). The findings in this report and previous trends (3) suggest that the goal of reducing the prevalence of cigarette smoking among adults to less than or equal to 15% by 2000 will not be attained. Smoking prevalence can be reduced by decreasing the rate of smoking initiation and by increasing the rate of smoking cessation. Methods for decreasing the rate of smoking initiation among adolescents include increases in prices of tobacco products, education, counter advertising campaigns, and efforts to restrict access to and limit the appeal of tobacco products (4).

Effective efforts to assist smokers to quit permanently produce substantial and immediate health and economic benefits (5). Despite the desire of most smokers to stop smoking completely and the existence of proven interventions (6), most smokers may not have easy access to such interventions. One of the national health objectives for 2000 is to increase to 100% the proportion of health plans that offer treatment for nicotine addiction (objective 3.24) (1). Based on a survey of 105 large health-maintenance organizations in 1995, a substantial proportion (two thirds) reported offering some level of smoking-cessation program or product as a covered member service (7). However, coverage of cessation services and products was subject to restrictions; for example, only 23% of plans covered nicotine replacement therapy (NRT) as a standard drug benefit (7). Indemnity plans are less likely than managed-care plans to cover preventive services such as smoking cessation (8). In addition, more than half of corporations self-insure for their employees' health insurance benefits, and few corporations include coverage for smoking-cessation services in their benefit designs (8). As of March 1997, only five state Medicaid programs provided reimbursement for smoking-cessation counseling or group programs (L. Dixon, Health Policy Tracking Service, National Conference of State Legislatures, personal communication, 1997). Although Medicare pays for medically necessary services furnished by a physician or other Medicare provider, it does not pay for either special smoking-cessation programs or for over-the-counter drugs, including NRT (J. Stieber, Office of Legislation, Health Care Financing Administration, US Department of Health and Human Services, personal communication, 1997).

Advice from health-care providers to smokers to quit smoking increases cessation rates by 30% (6), and guidelines published by the Agency for Health Care Policy and Research state that all smokers should be advised by their health-care provider to quit (6). In addition, one of the national health objectives for 2000 is to increase to at least 75% the proportion of primary-care and oral health-care providers who routinely advise cessation and provide assistance and follow-up for tobacco-using patients (objective 3.16) (1). In 1996, for the first time, the Health Plan Employer Data Information Set (HEDIS), a managed-care "report card," included a measure of smokers' receipt of medical advice to quit. ** In 1996, the plan average for smokers reporting receipt of advise from health-care providers to quit was 61%; however, advice rates were as low as 30% for some plans (9).

Racial/ethnic variations in smoking prevalence are influenced by differences in educational level and cultural factors (e.g., the ceremonial use of tobacco among American Indians). Proven smoking-cessation treatments need to be culturally and language-appropriate (6).

Effective smoking-cessation interventions are less costly than other preventive medical interventions (e.g., treatment of hypercholesterolemia) (10). Although all proven types of cessation are cost-effective, those involving more intense counseling and the nicotine patch are most cost-effective (10). The prevalence of current smoking can be decreased by intensifying efforts to establish proven smoking cessation treatments (both pharmacotherapy and counseling) as a covered medical benefit and to reimburse clinicians for providing effective cessation interventions (6). Other priorities include the needs to train health-care providers and health-system administrators about the current cessation guideline recommendations, evaluate cessation interventions for children and adolescents, and better inform smokers about the availability and variety of proven smoking-cessation interventions.

References

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

2. CDC. Cigarette smoking among adults -- United States, 1994. MMWR 1996;45:588-90.

3. Giovino GA, Schooley MW, Zhu BP, et al. Trends and recent patterns in selected tobacco-use behaviors -- United States, 1900-1993. In: CDC surveillance summaries (November). MMWR 1994;43(no. SS-3).

4. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.

5. Lightwood JM, Glantz SA. Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke. Circulation 1997;96:1089-96.

6. US Department of Health and Human Services. Smoking cessation, clinical practice guideline {no. 18}. Washington, DC: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1996; DHHS publication no. (AHCPR)96-0692.

7. Pinney Associates. Smoking cessation and managed care. Bethesda, Maryland: Pinney Associates, 1995.

8. Schlauffler HH, Parkinson MD. Health insurance coverage for smoking cessation services. Health Educ Q 1993;20:185-206.

9. National Center for Quality Assurance. Quality Compass . Washington, DC: National Center for Quality Assurance, 1997.

10. Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. JAMA 1997;278:1759-66.

* Poverty statistics are based on definitions developed by the Social Security Administration in 1964 (which were subsequently modified by federal interagency committees in 1969 and 1980) and prescribed by the Office of Management and Budget as the standard to be used by federal agencies for statistical purposes.

** The source for data contained in this article is Quality Compass and is used with the permission of the National Committee for Quality Assurance (NCQA). Any analysis, interpretation, or conclusion based on these data is solely that of CDC, and NCQA specifically disclaims responsibility for any such analysis, interpretation, or conclusion.

TABLE 1. Percentage of persons aged >=18 years who were current cigarette smokers*, by selected characteristics -- United
States, Year 2000 Objectives Supplement of the National Health Interview Survey, 1995
==============================================================================================================================
                                            Men (n=7,423)                 Women (n=9,790)              Total (n=17,213)
                                        ----------------------       -----------------------        ---------------------
Characteristic                           %          (95% CI+)          %           (95% CI)          %           (95% CI)
------------------------------------------------------------------------------------------------------------------------------
Race/Ethnicity&
 White,non-Hispanic                     27.1        (+/- 1.5)         24.1        (+/- 1.3)         25.6        (+/- 1.0)
 Black,non-Hispanic                     28.8        (+/- 3.7)         23.5        (+/- 3.1)         25.8        (+/- 2.6)
 Hispanic                               21.7        (+/- 2.9)         14.9        (+/- 2.1)         18.3        (+/- 1.8)
 American Indian/ Alaskan               37.3        (+/-17.2)         35.4        (+/-13.9)         36.2        (+/-10.6)
Native@
 Asian/Pacific Islander                 29.4        (+/- 8.6)          4.3        (+/- 3.1)         16.6        (+/- 4.6)
Education (yrs)**
   <=8                                  28.4        (+/- 4.2)         17.8        (+/- 2.8)         22.6        (+/- 2.5)
  9-11                                  41.9        (+/- 4.4)         33.7        (+/- 3.5)         37.5        (+/- 2.9)
    12                                  33.7        (+/- 2.3)         26.2        (+/- 1.8)         29.5        (+/- 1.4)
 13-15                                  25.0        (+/- 2.6)         22.5        (+/- 2.2)         23.6        (+/- 1.6)
  >=16                                  14.3        (+/- 1.8)         13.7        (+/- 1.8)         14.0        (+/- 1.4)
Age group (yrs)
 18-24                                  27.8        (+/- 3.9)         21.8        (+/- 3.0)         24.8        (+/- 2.4)
 25-44                                  30.5        (+/- 1.8)         26.8        (+/- 1.6)         28.6        (+/- 1.2)
 45-64                                  27.1        (+/- 2.1)         24.0        (+/- 2.0)         25.5        (+/- 1.5)
  >=65                                  14.3        (+/- 2.1)         11.5        (+/- 1.5)         13.0        (+/- 1.3)
Poverty status++
 At or Above                            25.9        (+/- 1.3)         21.8        (+/- 1.1)         23.8        (+/- 0.9)
 Below                                  36.9        (+/- 4.3)         29.3        (+/- 2.9)         32.5        (+/- 2.5)
 Unknown                                26.9        (+/- 5.7)         21.0        (+/- 3.5)         23.5        (+/- 3.2)
Total                                   27.0        (+/- 1.2)         22.6        (+/- 1.1)         24.7        (+/- 0.8)
------------------------------------------------------------------------------------------------------------------------------
*  Persons who reported having smoked >=100 cigarattes and who reported now smoking every day or some days. Excludes 104
   respondents for whom smoking status was unknown.
+  Confidence interval.
&  Excludes 192 respondents in unknown, multiple, and other racial/ethnic categories.
@  Wide variances on estimates reflect the small sample sizes.
** Persons aged >=25 years. Excludes 60 persons with unknown years of education.
++ Poverty statistics are based on definitions developed by the Social Security Administration in 1964 (which were
   subsequently modified by federal interagency committees in 1969 and 1980) and prescribed by the Office of Management and
   Budget as the standard to be used by federal agencies for statistical purposes.
==============================================================================================================================

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