Health Objectives for the Nation Cigarette Smoking Among Adults -- United States, 1993

The annual prevalence of cigarette smoking among adults in the United States declined 40% during 1965-1990 (from 42.4% to 25.5%) (1) but was virtually unchanged during 1990-1992 (2). To determine the prevalence of smoking among adults, smoker interest in quitting, and the prevalence of cessation (i.e., quit ratio) among adults during 1993, the Year 2000 Health Objectives Supplementof the 1993 National Health Interview Survey (NHIS-2000) collected self-reported information about cigarette smoking from a random sample of civilian, noninstitutionalized adults aged greater than or equal to 18 years. This report presents the prevalence estimates for 1993 and compares them with estimates from the 1992 Cancer Epidemiology Supplement and presents 1993 estimates for smoker interest in quitting completely and the prevalence of cessation among ever smokers.

The overall response rate for the 1993 NHIS-2000 (n=20,860) was 81.2%. For 1993, current smoking status was determined through two questions: "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?" Ever smokers were persons who reported having smoked at least 100 cigarettes during their entire lives. Current smokers were defined as those who had smoked 100 cigarettes and now smoked either every day (i.e., daily smokers) or some days (i.e., some-day smokers). Former smokers had smoked at least 100 cigarettes in their lives but did not currently smoke. The prevalence of cessation was the percentage of former smokers among ever smokers. Interest in quitting smoking was assessed using answers to the question "Would you like to completely stop smoking cigarettes?" Data were adjusted for nonresponse and weighted to provide national estimates. Confidence intervals (CIs) were calculated using standard errors generated by the Software for Survey Data Analysis (SUDAAN) (3).

Prevalence estimates for 1992 were based on two definitions of current smoking and were calculated by averaging the estimates generated by each definition (2). One of the 1992 definitions of current smoking (smoking every day or some days) was identical to the definition used in 1993; these estimates are compared in this report.

In 1993, an estimated 46 million (25.0% {95% CI= plus or minus 0.7%}) adults in the United States were current smokers Table_1: 20.4% (95% CI= plus or minus 0.7%) were daily smokers, and 4.6% (95% CI= plus or minus 0.3%) were some-day smokers. Smoking prevalence was significantly higher among men (27.7% {95% CI= plus or minus 1.1%} {24 million men}) than among women (22.5% {95% CI= plus or minus 0.9%} {22 million women}) Table_1. The racial/ethnic group-specific prevalence was highest among American Indians/Alaskan Natives (38.7% {95% CI= plus or minus 8.7%}) and lowest among Asians/Pacific Islanders (18.2% {95% CI= plus or minus 4.1%}). The prevalence of smoking among persons with less than or equal to 8 years of education was significantly lower than that among persons with 9-15 years of education; however, among persons with greater than or equal to 9 years of education, prevalences varied inversely with education level. For all groups, the prevalence of smoking was highest among males who had dropped out of high school (42.1% {95% CI= plus or minus 4.4%}). Smoking prevalence was higher among persons living below the poverty level * (32.1% {95% CI= plus or minus 2.4%}) than among those living at or above the poverty level (23.8% {95% CI= plus or minus 0.8%}).

The prevalence of current smokers in 1993 was unchanged statistically from 1992 (25.0% and 26.3%, respectively). However, the prevalence of daily smoking in 1993 (20.4% {95% CI= plus or minus 0.7%}) was significantly lower than in 1992 (22.3% {95% CI= plus or minus 0.9%}). In addition, prevalence estimates for current smokers during 1993 were lower overall for women, persons with a college education or higher, total persons living at or above the poverty level, and women living at or above the poverty level Table_1.

Of current smokers, an estimated 32 million persons (69.7% {95% CI= plus or minus 1.6%}) reported they wanted to quit smoking completely. Women were more likely to report an interest in quitting (72.7% {95% CI= plus or minus 1.9%}) than men (67.1% {95% CI= plus or minus 2.2%}). Current smokers aged greater than or equal to 65 years (49.9% {95% CI=5.8%}) were the least likely to report that they wanted to completely stop smoking.

In 1993, an estimated 46 million adults were former smokers (49.6% {95% CI= plus or minus 1.2%} of ever smokers) Table_2. The prevalence of cessation was higher among men (51.9% {95% CI= plus or minus 1.5%}), whites (51.6% {95% CI= plus or minus 1.3%}), and persons living at or above the poverty level (52.4% {95% CI= plus or minus 1.2%}), and increased directly with age. Among education levels, the prevalence of cessation was lowest among persons with 9-11 years of education (38.2% {95% CI= plus or minus 3.3%}). Reported by: Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Although the overall prevalence of current smoking did not change from 1992 to 1993, the prevalence of daily smoking declined during 1993, possibly reflecting the proliferation of restrictive worksite and public smoking policies (4). In addition, the relatively greater decline among women is consistent with a previous report that, in workplace settings, women may be more likely to quit smoking because of worksite smoking bans (5).

Differences in prevalence among racial/ethnic groups may be influenced by differences in education levels and socioeconomic status, as well as by social and cultural phenomena. For example, in a recent report (6), the prevalence of behavioral risk factors, including cigarette smoking, was generally higher among persons with less than or equal to 12 years of education.

From 1992 to 1993, daily smoking prevalence increased among high school seniors from 17.2% to 19.0% (1). To be effective, school-based prevention programs should begin in kindergarten and continue through high school. This intervention should be especially intensive in middle school and should be reinforced in high school. CDC has published guidelines for incorporating tobacco-use prevention and cessation strategies in the early grades in schools (7). School-based programs should provide instruction about the short- and long-term physiologic and social consequences of tobacco use, social influences on tobacco use, peer norms regarding tobacco use, and refusal skills.

The findings in this report are subject to at least two limitations. First, because the 1992 and 1993 estimates are based on data collected during a 6-month period, these estimates may not be representative of annual prevalence. In particular, other data suggest that the restriction of the surveys to these periods may have minimized the true magnitude of declines in prevalence (National Household Survey on Drug Abuse, unpublished data, 1992 and 1993). Second, because these estimates are based on self-reported data, prevalences may be underestimated. However, underreporting is believed to be low in national prevalence surveys (8).

To sustain the decline in smoking prevalence, efforts must be intensified to discourage initiation and to promote cessation. Although 70% of smokers want to stop smoking and 34% attempt to quit each year, only 2.5% successfully stop smoking each year (9). The high rate of relapse is a consequence of the effect of nicotine dependence. Smokers who need assistance with stopping can receive self-help materials from local voluntary agencies, CDC (telephone {800} 232-1311 or {404} 488-5705), and the National Institutes of Health (telephone {800} 422-6237). Many smokers are addicted to nicotine and could potentially benefit from nicotine replacement therapy (NRT); NRT and other cessation assistance can be obtained from physicians and dentists. Information about formal cessation programs can be obtained from local voluntary agencies or health-care providers.

The health risks of cigarette smoking can be eliminated only by quitting; switching to lower "tar" and nicotine cigarettes is not a safe alternative (10). Comprehensive measures for promoting cessation and reducing the prevalence of smoking include increasing tobacco excise taxes, enforcing minors' access laws, restricting smoking in public places, restricting tobacco advertising and promotion, and conducting counter-advertising campaigns.

References

1. Giovino GA, Schooley MW, Zhu B-P, et al. Surveillance for selected tobacco-use behaviors -- United States, 1900-1994. MMWR 1994;43(no. SS-3).

2. CDC. Cigarette smoking among adults -- United States, 1992, and changes in the definition of current cigarette smoking. MMWR 1994;43:342-6.

3. Shah BV. Software for Survey Data Analysis (SUDAAN), version 5.50 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

4. Evans NJ, Gilpin E, Pierce JP, et al. Occasional smoking among adults: evidence from the California Tobacco Survey. Tobacco Control 1992;1:169-75.

5. Brenner H, Mielck A. Smoking prohibition in the workplace and smoking cessation in the Federal Republic of Germany. Prev Med 1992;21:252-61.

6. CDC. Prevalence of selected risk factors for chronic disease by education level in racial/ethnic populations -- United States, 1991- 1992. MMWR 1994;43:894-9.

7. CDC. Guidelines for school health programs to prevent tobacco use and addiction. MMWR 1994;43(no. RR-2).

8. CDC. The health benefits of smoking cessation: a report of the Surgeon General, 1990. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC)90-8416.

9. CDC. Smoking cessation during previous year among adults -- United States, 1990 and 1991. MMWR 1993;42:504-7.

10. US Department of Health and Human Services. The health consequences of smoking: the changing cigarette -- a report of the Surgeon General, 1981. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1981; DHHS publication no. (PHS)81-50156.

* Poverty statistics are based on a definition originated by the Social Security Administration in 1964, 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.

TABLE 1. Percentage of adults aged >=18 years who were current cigarette smokers, * by sex, race/ethnicity, education level, age
group, and socioeconomic status -- National Health Interview Survey (NHIS), United States, 1992 and 1993 +
====================================================================================================================================
                                            1992 CES &                                         1993 NHIS-2000 @
                             Men               Women             Total             Men               Women            Total
                           (n=5,065)         (n=6,816)         (n=11,881)        (n=8,783)        (n=12,077)        (n=20,860)
Characteristic         %   (95% CI **)     %     (95% CI)     %    (95% CI)     %   (95% CI)      %   (95% CI)      %   (95% CI)
------------------------------------------------------------------------------------------------------------------------------------

Race/Ethnicity ++
 White                 28.3  (+/- 1.6)     26.3  (+/- 1.5)    27.3 (+/- 1.1)   27.0 (+/- 1.2)    24.0 (+/- 1.0)    25.4  (+/-0.8)
 Black                 30.1  (+/- 4.7)     24.9  (+/- 3.1)    27.3 (+/- 2.7)   32.4 (+/- 3.4)    21.0 (+/- 2.2)    26.0  (+/-2.0)
 Hispanic              22.3  (+/- 4.0)     15.6  (+/- 3.2)    18.7 (+/- 2.6)   28.3 (+/- 4.2)    12.7 (+/- 2.7)    20.4  (+/-2.6)
 American Indian/
  Alaskan Native &&    41.2  (+/-17.7)     42.5  (+/-14.5)    41.9 (+/-10.9)   35.9 (+/-13.6)    40.9 (+/-11.8)    38.7  (+/-8.7)
 Asian/Pacific
  Islander             19.3  (+/- 7.7)      4.9  (+/- 3.7)    12.2 (+/- 4.5)   27.4 (+/- 7.2)     9.5 (+/- 4.8)    18.2  (+/-4.1)

Education (yrs) @@
    <=8                27.8  (+/- 4.9)     17.7  (+/- 3.4)    22.4 (+/- 2.9)   28.5 (+/- 3.7)    13.6 (+/- 2.6)    20.5  (+/-2.3)
   9-11                40.3  (+/- 4.9)     31.9  (+/- 3.8)    35.6 (+/- 3.2)   42.1 (+/- 4.4)    32.3 (+/- 2.9)    36.8  (+/-2.7)
     12                33.5  (+/- 2.7)     29.2  (+/- 2.2)    31.1 (+/- 1.8)   32.0 (+/- 1.9)    26.9 (+/- 1.5)    29.2  (+/-1.2)
  13-15                26.4  (+/- 3.3)     23.8  (+/- 2.7)    25.0 (+/- 2.1)   28.4 (+/- 2.4)    22.1 (+/- 1.9)    25.0  (+/-1.5)
   >=16                17.6  (+/- 2.4)     15.0  (+/- 2.5)    16.5 (+/- 1.7)   14.8 (+/- 1.7)    11.9 (+/- 1.6)    13.5  (+/-1.2)

Age group (yrs)
  18-24                28.4  (+/- 4.1)     25.9  (+/- 3.7)    27.1 (+/- 2.8)   28.8 (+/- 3.3)    22.9 (+/- 2.7)    25.8  (+/-2.1)
  25-44                32.7  (+/- 2.1)     28.7  (+/- 2.0)    30.6 (+/- 1.5)   31.1 (+/- 1.6)    27.3 (+/- 1.3)    29.2  (+/-1.1)
  45-64                26.3  (+/- 2.7)     26.5  (+/- 2.4)    26.4 (+/- 1.8)   29.2 (+/- 2.0)    23.0 (+/- 1.7)    26.0  (+/-1.3)
   >=65                16.0  (+/- 2.8)     12.9  (+/- 2.0)    14.2 (+/- 1.6)   13.5 (+/- 2.2)    10.5 (+/- 1.3)    11.8  (+/-1.2)

Socioeconomic status ***
 At/Above poverty
  level                26.9  (+/- 1.4)     24.5  (+/- 1.4)    25.7 (+/- 1.0)   26.1 (+/- 1.2)    21.7 (+/- 0.9)    23.8  (+/-0.8)
 Below poverty level   35.1  (+/- 5.3)     28.9  (+/- 3.7)    31.4 (+/- 3.2)   38.1 (+/- 4.1)    28.2 (+/- 2.7)    32.1  (+/-2.4)
 Unknown               33.6  (+/- 5.7)     22.3  (+/- 3.7)    26.7 (+/- 3.2)   37.6 (+/- 4.9)    22.2 (+/- 3.0)    28.3  (+/-2.8)

Total                  28.0  (+/- 1.4)     24.8  (+/- 1.3)    26.3 (+/- 1.0)   27.7 (+/- 1.1)    22.5 (+/- 0.9)    25.0  (+/-0.7)
------------------------------------------------------------------------------------------------------------------------------------
  * Persons who reported having smoked at least 100 cigarettes and who reported now smoking every day or some days.
  + Excludes 168 respondents with unknown smoking status.
  & Cancer Epidemiology Supplement.
  @ Year 2000 Health Objectives Supplement.
 ** Confidence interval.
 ++ Excludes 257 respondents in unknown, multiple, and other race categories.
 && Estimates should be interpreted with caution because of the small number of cases.
 @@ Persons aged >=25 years.
*** Poverty statistics are based on definitions developed by the Social Security Administration in 1964, 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.
====================================================================================================================================

TABLE 2. Percentage of interest in quitting among current smokers aged >=18
years * and prevalence of cessation among ever smokers aged >=18 years, + by
sex, race/ethnicity, education level, age group, and socioeconomic status
-- National Health Interview Survey, United States, 1993 &
===============================================================================
                      Interest in quitting   Prevalence of cessation
                     among current smokers      among ever smokers
                           (n=5,261)                (n=10,370)
                    -----------------------  --------------------------
Characteristic         %        (95% CI @)      %           (95% CI)
-------------------------------------------------------------------------------
Sex
 Men                 67.1       (+/- 2.2)      51.9         (+/- 1.5)
 Women               72.7       (+/- 1.9)      46.7         (+/- 1.6)

Race/Ethnicity **
 White               70.0       (+/- 1.8)      51.6         (+/- 1.3)
 Black               71.4       (+/- 4.8)      37.8         (+/- 3.4)
 Hispanic            68.7       (+/- 5.8)      44.3         (+/- 5.0)
 American Indian/
  Alaskan Native ++  65.0       (+/-14.5)      35.1         (+/-16.6)
 Asian/Pacific
  Islander           60.2       (+/-12.2)      46.1         (+/- 8.7)

Education (yrs) &&
    <=8              62.6       (+/- 5.5)      56.2         (+/- 3.9)
   9-11              67.8       (+/- 4.4)      38.2         (+/- 3.3)
     12              71.5       (+/- 2.2)      45.3         (+/- 1.7)
  13-15              71.8       (+/- 3.6)      50.7         (+/- 2.3)
   >=16              67.5       (+/- 4.5)      65.4         (+/- 2.5)

Age group (yrs)
  18-24              68.6       (+/- 4.5)      21.7         (+/- 3.1)
  25-44              73.7       (+/- 2.0)      39.0         (+/- 1.5)
  45-64              68.5       (+/- 3.0)      56.6         (+/- 2.0)
   >=65              49.9       (+/- 5.8)      76.6         (+/- 2.1)

Socioeconomic status @@
 At/Above poverty
  level              70.7       (+/- 1.8)      52.4         (+/- 1.2)
 Below poverty level 69.7       (+/- 3.8)      30.4         (+/- 3.1)
 Unknown             59.0       (+/- 5.6)      41.6         (+/- 4.3)

Total                69.7       (+/- 1.6)      49.6         (+/- 1.2)
-------------------------------------------------------------------------------
 * Persons who reported having smoked at least 100 cigarettes and who reported
   now smoking every day or some days.
 + Persons who reported ever smoking 100 cigarettes in their lifetime.
 & Excludes 168 respondents with unknown smoking status.
 @ Confidence interval.
** Excludes 257 respondents in unknown, multiple, and other race categories.
++ Estimates should be interpreted with caution because of the small number of
   cases.
&& Persons aged >=25 years.
@@ Poverty statistics are based on definitions developed by the Social Security
   Administration in 1964, 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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