State-Specific Prevalence of Cigarette Smoking and Smokeless Tobacco Use Among Adults—United States, 2009

November 5, 2010 / Vol. 59 / No. 43

Among the 50 states and the District of Columbia (DC), smoking prevalence was highest in Oklahoma (25.5%), Kentucky (25.6%), and West Virginia (25.6%).
Among the 50 states and DC, smoking prevalence was lowest in Utah (9.8%), California (12.9%), and Washington (14.9%).
Among U.S. territories, smoking prevalence was 6.4% in the U.S. Virgin Islands, 10.6% in Puerto Rico, and 24.1% in Guam.
For 15 of the states, Puerto Rico, and Guam, smoking prevalence was significantly higher among men than women, and in no state or territory was smoking prevalence higher among women than men.

Among the 50 states and DC, smokeless tobacco use was highest in Wyoming (9.1%), West Virginia (8.5%), and Mississippi (7.5%).
Among the 50 states and DC, smokeless tobacco use was lowest in California (1.3%), DC (1.5%), Massachusetts (1.5%), and Rhode Island (1.5%).
Among U.S. territories, the prevalence of smokeless tobacco was 0.8% in the U.S. Virgin Islands, 1.4% in Puerto Rico, and 4.1% in Guam.
In all 50 states and DC, smokeless tobacco use was significantly higher among men than women; smokeless tobacco use among men ranged from 2.0% (DC) to 17.1% (West Virginia).
Data suggest that smokeless tobacco use is predominantly a public health problem among men, young adults (aged 18–24 years), and those with a high school education or less. It also is more prevalent in some states with higher smoking prevalence.

Among the 50 states and DC, between 2.9% (Delaware) and 13.7% (Wyoming) of smokers also reported using smokeless tobacco.
Smokeless tobacco use among smokers was more commonly reported by men than women in 40 states.
Nearly one-quarter of men who smoked in Wyoming (23.4%) and one-fifth of men who smoked in Arkansas (20.8%) reported also using smokeless tobacco.
Among the 25% of states in which cigarette smoking was greatest, seven also had the highest prevalence of smokeless tobacco use (Alabama, Alaska, Arkansas, Kentucky, Mississippi, Oklahoma, and West Virginia). In these states, at least one of every nine male smokers also reported using smokeless tobacco.

Research suggests that persons who use multiple tobacco products might have a more difficult time quitting, which might result in longer durations of product use and an increased likelihood of tobacco-related morbidity and mortality.
In order to promote cessation among all tobacco users, health care providers, including dentists and dental hygienists, should ask their patients about all forms of tobacco use; advise them to quit using all forms of tobacco; assess their willingness to quit; and assist them in quitting.
The World Health Organization recommends implementing this approach in combination with other measures, including raising excise taxes on all tobacco products and implementing smoke-free policies.
The report underscores the importance of anti-tobacco media messages, policies, and other interventions that prevent initiation and encourage cessation of both products, particularly in states with a high prevalence of smokeless tobacco use and cigarette smoking.

BRFSS is a state-based, landline telephone-administered survey of noninstitutionalized adults and is conducted annually in all 50 states, DC, Guam, Puerto Rico, and the U.S. Virgin Islands.
The 2009 BRFSS included data from 432,607 adults on current smoking prevalence and smokeless tobacco use.