State-Specific Prevalence and Trends in Adult Cigarette Smoking—United States, 1998-2007 FREE

MMWR. 2009;58:221-226

2 tables omitted

Cigarette smoking in the United States results in an estimated 443,000 premature deaths and $193 billion in direct health-care expenditures and productivity losses each year.¹ During 2007, an estimated 19.8% of adults in the United States were current smokers.² To update 2006 state-specific estimates of cigarette smoking, CDC analyzed data from the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey and examined trends in cigarette smoking from 1998-2007. Results of these analyses indicated substantial variation in current cigarette smoking during 2007 (range: 8.7%-31.1%) among the 50 states, the District of Columbia (DC), Guam, Puerto Rico (PR), and the U.S. Virgin Islands (USVI). Trend analyses of 1998-2007 data indicated that smoking prevalence decreased in 44 states, DC, and PR, and six states had no substantial changes in prevalence after controlling for age, sex, and race/ethnicity. However, only Utah and USVI met the Healthy People 2010 target for reducing adult smoking prevalence to 12% (objective 27-1a).³ The Institute of Medicine (IOM) calls for full implementation of comprehensive, evidence-based tobacco control programs at CDC-recommended funding levels to achieve substantial reductions in tobacco use in all states and areas.⁴

BRFSS conducts state-based, random-digit–dialed telephone surveys of the noninstitutionalized U.S. civilian population aged ≥18 years, collecting data on health conditions and health risk behaviors. The 2007 BRFSS survey was conducted in the 50 states, DC, Guam, PR, and USVI and included data from 430,912 respondents. Those respondents who answered “yes” to the question “Have you smoked at least 100 cigarettes in your entire life?” and answered “every day” or “some days” to the question “Do you now smoke cigarettes every day, some days, or not at all?” were classified as current cigarette smokers. These questions have been included in the survey each year since 1996; for this analysis, survey data from 1998-2007 were examined.

For each year, estimates were weighted to the respondent's probability of being selected and the age-, race-, and sex-specific populations from the census for the state or area. These weights were used to calculate the state smoking prevalence estimates; 95% confidence intervals also were calculated. BRFSS uses a multistage sampling design primarily to generate state/area estimates. The median prevalence among all states and DC is generally comparable to overall national estimates from other surveys.² Response rates for BRFSS are calculated using Council of American Survey and Research Organizations (CASRO) guidelines.* Median survey response rates were 59.1% (range: 32.5%-76.7%) for 1998 and 50.6% (range: 26.9%-65.4%) for 2007. Median cooperation rates were 63.0% for 1998 (range: 38.3%-83.6%) and 72.1% (range: 49.6%-84.6%) for 2007. For comparisons of smoking prevalence between males and females during 2007, statistical significance (p≤0.05) was determined using a two-sided z-test. Logistic regression analysis was used to analyze temporal changes in current smoking during 1998-2007, controlling for changes in state and area distributions of sex, age, and race/ethnicity. Linear and quadratic trends over time were included in the models. Nonsignificant quadratic terms were dropped from the final models. Quadratic trends indicated a significant but nonlinear trend in smoking prevalence over time.†

In 2007, the median prevalence of adult current smoking in the 50 states and DC was 19.8%. Among states, current smoking prevalence was highest in Kentucky (28.3%), West Virginia (27.0%), and Oklahoma (25.8%); and lowest in Utah (11.7%), California (14.3%), and Connecticut (15.5%). Smoking prevalence was 8.7% in USVI, 12.2% in PR, and 31.1% in Guam. Median smoking prevalence among the 50 states and DC was 21.3% (range: 15.5%-28.8%) for men and 18.4% (range: 8.0%-27.8%) for women. Men had a significantly higher prevalence of smoking than women in 30 states, DC, and all three territories.

During 1998-2007, linear decreases were observed in 28 states, DC, and PR. Nonlinear trends were detected in 19 other states. Trends in smoking prevalence varied among these states; however, all had reached a peak prevalence before 2004 and then began to decrease. Among 16 of these 18 states, logistic regression models indicated that the prevalence decreased during 1998-2007; in the other two states no change in prevalence occurred. No change over time in smoking prevalence (quadratic or linear) was observed in Alabama, Arizona, Tennessee, and West Virginia.

S Davis, PhD, A Malarcher, PhD, S Thorne, MPH, E Maurice, MS, A Trosclair, MS, P Mowery, MA, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Healthy People 2010 calls for reducing adult cigarette smoking prevalence to 12%.³ Utah and USVI were the first state and territory to meet the Healthy People 2010 target in 2003 and 2001, respectively, and have continued to meet this target each year. The first demographic subgroup to meet the Healthy People 2010 target was women in PR in 1997. In 2007, cigarette smoking prevalence among women in California, PR, USVI, and Utah met the Healthy People 2010 target. Cigarette smoking prevalence among men has continued to exceed the ≤12% target, except among men in USVI, whose prevalence declined from 12.1% in 2006 to 11.2% in 2007. Trends for 1998-2007 suggest that most states have shown declines in smoking prevalence; however, the present rate of decline likely will be too slow in nearly all states to reach the Healthy People target by 2010.

States varied substantially in current levels of smoking and in trends in smoking during 1998-2007. These variations might be attributed to a number of factors, including differences in population demographics, differing levels of tobacco control programs and policies, and variations in tobacco industry marketing and promotion.⁵ As part of CDC's National Tobacco Control Program, all states work to implement comprehensive tobacco control programs that include effective strategies for preventing smoking initiation and increasing cessation.‡ These programs contribute to reductions in smoking prevalence through increases in the unit price of tobacco products, sustaining media campaigns (e.g., encouraging cessation and preventing initiation), implementation of smoke-free policies, support for quitlines, and reduced patient costs for tobacco use treatment.⁶ State per-capita tobacco control program expenditures are one measure of the state's ability to implement effective tobacco control program components⁶; during 1985-2003, states with higher expenditures had greater overall reductions in adult smoking prevalence.⁵

The findings in this report are subject to at least six limitations. First, smoking prevalence might be underestimated because BRFSS does not survey persons in households without any telephone service (2.5%) or with wireless-only telephones (17.5%), and adults with wireless-only service are more likely (30.2%) than the rest of the U.S. population to be current smokers.⁷ Second, estimates for cigarette smoking are based on self-report and are not validated by biochemical tests. However, self-reported data on current smoking status have high validity.⁸ Third, the median response rate was 59.1% (range: 32.5%-76.7%) in 1998 and 50.6% (range: 26.8%-65.4%) in 2007. Lower response rates increase the potential for response bias, which could have affected the assessment of trends over time; however, BRFSS aggregated state estimates previously have been shown to be comparable to smoking estimates from other surveys with higher response rates.⁸ The 2007 median smoking rate of 19.8% reported in this analysis is the same as the national estimate of cigarette smoking reported from the 2007 National Health Interview Survey (19.8%).² Fourth, trend analyses for Guam and USVI could not be reported because data were not available for the full time span. Fifth, modeling was limited to linear and quadratic trends. However, examination of plots of predicted versus observed prevalence estimates showed that the models fit the data well for the majority of states. For some states, prevalence estimates indicate declines in smoking prevalence might have leveled off since 2005; future trend modeling might need to account for this emerging pattern. Finally, only trends in overall current cigarette smoking prevalence were examined; trends might vary among demographic subpopulations within a state. For example, national trends in current smoking prevalence have varied between non-Hispanic white and black women; cigarette use among these two populations was comparable in the mid-1990s, but use declined more rapidly among non-Hispanic black women than non-Hispanic white women during 2000 and 2001.⁹ Assessing trends among subgroups is important for targeting interventions to those most at risk.

Despite declines in smoking prevalence during 1998-2007, cigarette smoking continues to cause large numbers of deaths each year across all states.¹ From 2002 to 2005, states cut funding for tobacco prevention and cessation programs by 28% (approximately $200 million).¹⁰ In fiscal year 2009, no state is funding comprehensive tobacco control programs at CDC-recommended funding levels, and only nine states are funding at least half of the recommended amount.^6,10 In contrast, tobacco industry marketing expenditures nearly doubled from 1998 ($6.9 billion) to 2005 ($13.4 billion).¹⁰ IOM concluded that substantial and enduring reductions in tobacco use depend on federal and state government steps to increase excise taxes, enact bans on smoking in public spaces, and increase health-care coverage for effective cessation interventions. IOM also called for full implementation of comprehensive tobacco control programs at CDC-recommended funding levels.⁴

On April 1, 2009, the single largest federal tobacco excise tax increase in history will go into effect, raising the excise tax for cigarettes to $1.01 from the current rate of $0.39. This increase likely will prompt some smokers to make a quit attempt.^4- 6 To assist smokers with their quit attempts, health-care providers should follow the recommendations in the 2008 update to the Public Health Service's Clinical Practice Guideline on Treating Tobacco Use and Dependence.§ Health-care providers should ask all patients about their use of tobacco, advise tobacco users to quit, assess their willingness to quit, assist in their quit attempt by offering medication and providing referrals to telephone-based quitlines or other counseling services and arrange for follow-up. Telephone-based quitlines are available in every state through a toll-free access number (800-QUIT-NOW [800-784-8669]).

*The response rate is the percentage of persons who completed interviews among all eligible persons, including those who were not successfully contacted. The cooperation rate is the percentage of persons who completed interviews among all eligible persons who were contacted.

†Quadratic trends indicate a significant but nonlinear trend in the data over time (e.g., whereas a linear trend is depicted with a straight line, a quadratic trend is depicted with a curve with one bend). Trends that include significant quadratic and linear components demonstrate nonlinear variation in addition to an overall increase or decrease over time.

‡CDC's Guide to Community Preventive Services reviews the effectiveness of interventions to reduce or prevent tobacco use and is available at http://www.thecommunityguide.org/tobacco/index.html.

§Available at http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf.