Adult Smoking Cessation — United States, 2022

Abstract

Tobacco dependence is a chronic condition driven by nicotine addiction. Successful quitting can be increased by health care provider intervention and evidence-based treatment. CDC assessed national estimates of cigarette smoking cessation indicators among U.S. adults using 2022 National Health Interview Survey data. In 2022, approximately two thirds (67.7%) of the 28.8 million U.S. adults who smoked wanted to quit, and approximately one half (53.3%) made a quit attempt, but only 8.8% quit smoking. One half of adults who smoked and saw a health professional during the past year received health professional advice (50.5%) or assistance (49.2%) to quit smoking. Among those who tried to quit, 38.3% used treatment (i.e., counseling or medication). Adults who usually smoked menthol (versus nonmenthol) cigarettes had higher prevalences of quitting interest (72.2% versus 65.4%; p<0.05) and past-year quit attempts (57.3% versus 50.4%; p<0.05), lower prevalences of receiving quit advice (48.2% versus 53.8%; p<0.05) and using cessation treatment (35.2% versus 41.5%; p<0.05), but similar prevalence of quit success (9.5% versus 7.9%; p = 0.19). Opportunities exist for both public health and health care sectors to increase smoking cessation, including expanding access to and utilization of cessation services and supports. Incorporating equitable cessation strategies into all commercial tobacco prevention and control efforts can help advance and support smoking cessation for all population groups.

Introduction

Quitting smoking reduces the risk for premature death and smoking-related diseases (1). Tobacco dependence is a chronic, relapsing condition driven by nicotine addiction, and quitting can be difficult (1). Social and structural barriers to quitting exist differentially among population groups (2). For example, whereas comprehensive, barrier-free insurance coverage of cessation treatment is known to increase quitting success, only 20 state Medicaid programs provided such coverage in 2022 (1,3). In addition, commercial factors, such as marketing and product design, can influence quitting behaviors (1,4,5). Evidence suggests that persons who smoke menthol (versus nonmenthol) cigarettes could be less likely to successfully quit (5); previous studies have shown this finding is especially true of Black or African American (Black) adults who smoke, a high proportion of whom smoke menthol cigarettes in part because of aggressive, targeted marketing of menthol cigarettes to this population group (2,5).

Quitting success is increased by health care provider intervention and by use of behavioral counseling and Food and Drug Administration–approved medications, particularly when these treatments are used together (1). Understanding quitting intentions and behaviors can help identify gaps in treatment use and facilitate the development and implementation of efforts to increase access to and use of treatment. Healthy People 2030* includes four cessation-related objectives: 1) increasing quit attempts (TU-11), 2) increasing successful cessation (TU-14), 3) increasing receipt of health care provider advice to quit (TU-12), and 4) increasing treatment use (TU-13). This study expands on previous publications describing cessation-related indicators, including exploring differences in these indicators by sociodemographic and health-related factors as well as by cigarette type (menthol versus nonmenthol) (1).

Methods

Data Source

The National Health Interview Survey is an annual, nationally representative household survey of noninstitutionalized U.S. civilians. In 2022, a total of 27,651 adults aged ≥18 years were surveyed (response rate = 47.7%).^† Data were weighted to provide nationally representative estimates, adjusting for differences in selection probability and nonresponse. Consistent with previous studies, current smoking was defined as having ever smoked at least 100 cigarettes and currently smoking every day or some days (1). Former smoking was defined as having ever smoked at least 100 cigarettes and not currently smoking (1).

Smoking Cessation Indicators

Seven smoking cessation indicators were assessed: 1) interest in quitting, 2) past-year quit attempt (trying to quit smoking or successfully quitting in the past year), 3) recent successful cessation (former smoking and quit for ≥6 months in the past year), 4) receipt of health professional advice to quit tobacco use, 5) receipt of health professional assistance to quit (advice about ways to quit or prescription of cessation medication),^§ 6) use of counseling to quit,^¶ and 7) use of medication to quit.**

Data Analysis

Prevalence estimates were calculated for each cessation indicator overall and by sociodemographic and health characteristics. Differences in cessation indicators were assessed by usual type of cigarette smoked (menthol versus nonmenthol) both overall and among non-Hispanic White (White), non-Hispanic Black, and Hispanic or Latino (Hispanic) adults. Differences were assessed using Wald F chi-square tests with p-values <0.05 considered statistically significant. Analyses were conducted using SAS (version 9.4; SAS Institute) and SAS-callable SUDAAN (version 11.0.3; RTI International). This activity was reviewed by CDC, deemed not research, and conducted consistent with applicable federal law and CDC policy.^††

Results

Cessation Indicators

In 2022, 11.6% (95% CI = 11.1%–12.1%; estimated 28.8 million) of U.S. adults reported current cigarette smoking. Approximately two thirds of adults (67.7%) wanted to quit smoking, and approximately one half (53.3%) tried to quit in the past year, but fewer than one in 10 (8.8%) recently successfully quit (Table 1).

Among adults who currently smoked or who quit in the last year, 77.6% (95% CI = 75.7%–79.4%) and 83.1% (95% CI = 78.6%–87.1%), respectively, saw a health care provider in the past year. Among these adults, approximately one half received health professional advice (50.5%) or assistance (49.2%) to quit smoking (Table 2). Fewer than four in 10 (38.3%) adults who made a past-year quit attempt or quit smoking during the past 2 years used evidence-based treatment (counseling or medication) to help them quit. Medication^§§ was used more commonly than counseling^¶¶ (36.3% versus 7.3%). Very few used both medication and counseling (5.3%; 95% CI = 4.3%–6.4%).

Cessation Indicators by Sociodemographic and Health Characteristics

Cessation indicators varied by sociodemographic and health characteristics. For example, prevalence of past-year quit attempts ranged from 74.4% among persons aged 18–24 years to 47.5% among those aged 45–64 years (Table 1). Recent successful quitting ranged from 15.3% among those aged 18–24 years to 5.6% among those aged 45–64 and ≥65 years. Recent successful quitting also varied by education (ranging from 16.8% among those with a graduate degree to 4.0% among those without a high school diploma) and income level (ranging from 11.9% among those with high income to 7.5% among those with low income). Treatment use varied by race and ethnicity. Prevalence was 42.7% among White adults, followed by non-Hispanic adults of another race (33.6%), Black adults (32.6%), Hispanic adults (28.8%), and non-Hispanic Asian adults (15.9%) (Table 2). When stratified by insurance coverage, prevalences of receiving advice, receiving assistance, and using any treatment were lowest among uninsured adults (31.2%, 27.4%, and 20.4%, respectively). Adults reporting a smoking-related chronic disease, anxiety disorder, depression, or disability had higher prevalences of receiving advice or assistance and of using treatment than did adults without these conditions.

Cessation Indicators by Cigarette Type Smoked (Menthol Versus Nonmenthol)

Adults who usually smoked menthol (versus nonmenthol) cigarettes had higher prevalences of interest in quitting (72.2% versus 65.4%; p<0.05) and quit attempts (57.3% versus 50.4%; p<0.05), but a similar prevalence of recent successful cessation (9.5% versus 7.9%; p = 0.19) (Figure). Adults who smoked menthol (versus nonmenthol) cigarettes had lower prevalences of receiving advice to quit (48.2% versus 53.8%; p<0.05) and using treatment (35.2% versus 41.5%; p<0.05).

Discussion

In 2022, most adults who smoked wanted to quit, and approximately one half tried to quit in the past year, but fewer than 10% quit successfully. Consistent with previous studies, this analysis identified a low prevalence of clinical cessation intervention (i.e., advice and assistance) and treatment use (1). Several barriers to treatment access might play a part in this finding. Medication recalls and shortages have contributed to declines in prescriptions for cessation medication (6). Gaps exist in both clinician knowledge of cessation treatment and availability of comprehensive cessation-related clinical practice guidelines (7,8). Provision of cessation treatment in behavioral health settings and hospital-affiliated cessation programs is limited (9,10). Access barriers to Medicaid treatment coverage, such as treatment duration limits, annual limits on the number of covered quit attempts, and requirements for prior authorization, are common (3). In addition, threats to maintenance of current access exist, including recent discontinuation of the nicotine oral inhaler*** as well as pending legal challenges to requirements in the Affordable Care Act for most private insurers to cover tobacco cessation treatments.^†††

The U.S. Department of Health and Human Services has identified opportunities to advance and support smoking cessation, including among population groups experiencing smoking- and cessation-related disparities.^§§§ Comprehensive commercial tobacco^¶¶¶ prevention and control strategies, such as retail strategies and smoke-free policies, can support and increase cessation at the population level (1). Equitable implementation of such strategies needs to include attention to ensuring equitable access to cessation treatments and supports. Leveraging and expanding the current infrastructure of evidence-based cessation supports, including quitlines,**** digital cessation services,^†††† and cessation-focused mass media campaigns can continue to advance smoking cessation (1). Expanding and promoting barrier-free, comprehensive cessation treatment coverage can increase availability and use of treatment (1). In addition, implementing systems-level changes in health care settings, including adoption of treatment protocols and standardized clinical workflows, can systematize clinical treatment delivery and might increase treatment access for the approximately three in four adults who smoke who see a health care provider in a given year^§§§§ (1). This analysis identified a lower prevalence of receiving clinician advice and assistance to quit smoking among adults without smoking-related disease. Systemization of treatment delivery could help ensure clinical intervention for all adults who smoke, thereby potentially increasing the prevention of smoking-related disease and death (1).

As efforts toward advancing cessation continue, awareness of tobacco-related disparities and attention to the unique needs of each population group (e.g., cultural and language preferences and treatment access barriers) remain critical to ensuring equitable progress. For example, in this study, adults who smoked menthol (versus nonmenthol) cigarettes had a similarly low prevalence of quit success despite higher prevalences of quitting interest and quit attempts. This finding might be due, in part, to lower use of treatment in this group, which suggests a need to enhance treatment awareness, access, and use among adults who smoke menthol cigarettes, particularly as jurisdictions enact restrictions on the sale of flavored tobacco products.^¶¶¶¶ Substantial evidence shows that adoption of policies that prohibit the sale of menthol cigarettes increases smoking cessation and could help reduce tobacco-related health disparities (5). Increasing and ensuring equitable awareness of and access to cessation services, including counseling and medication, (i.e., taking a cessation in all tobacco policies approach) is important to maximizing the impact of commercial tobacco control policies, including flavor prohibitions.

Limitations

The findings in this report are subject to at least two limitations. First, because the National Health Interview Survey does not sample institutionalized adults or adults in the military, results are not generalizable to these groups. Second, survey responses were self-reported and not biochemically validated and might be subject to social desirability and recall bias.

Implications for Public Health Practice

Substantial progress has been made in reducing cigarette smoking in the United States, but disparities in use and cessation remain (1). Continued progress in reducing tobacco use and related disparities requires efforts to increase smoking cessation. Opportunities exist across public health and health care sectors to increase smoking cessation, including expanding access to and use of cessation services and supports. Incorporating equitable cessation opportunities into all commercial tobacco prevention and control efforts (i.e., taking a cessation in all tobacco policies approach) can help advance and support smoking cessation for all population groups and has potential to reduce tobacco-related health disparities.