Tobacco Product Use Among Adults — United States, 2012–2013
Vol. 63, No. 25
June 27, 2014
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Tobacco Product Use Among Adults — United States, 2012–2013
On June 24, 2014, this report was posted as an MMWR Early Release on the MMWR website (http://www.cdc.gov/mmwr).
WeeklyJune 27, 2014 / 63(25);542-547
1,2, , PhD1, , MD3, , ScD1, , PhD3, , MD1, , MPH3, , PhD3 (Author affiliations at end of text), DMD
Despite significant declines in cigarette smoking among U.S. adults over the past five decades, progress has slowed in recent years, and the prevalence of use of other tobacco products such as cigars and smokeless tobacco has not changed (1,2). Additionally, the prevalence of use of emerging products, including electronic cigarettes (e-cigarettes), has rapidly increased (3). This report provides the most recent national estimates of tobacco use among adults aged ≥18 years, using data from the 2012–2013 National Adult Tobacco Survey (NATS). The findings indicate that 21.3% of U.S. adults used a tobacco product every day or some days, and 25.2% used a tobacco product every day, some days, or rarely. Population-level interventions focused on the diversity of tobacco product use, including tobacco price increases, high-impact antitobacco mass media campaigns, comprehensive smoke-free laws, and enhanced access to help quitting, in conjunction with Food and Drug Administration (FDA) regulation of tobacco products, are critical to reducing tobacco-related diseases and deaths in the United States (4).
The 2012–2013 NATS is a stratified, national random-digit–dialed landline and cellular telephone survey of 60,192 noninstitutionalized U.S. adults aged ≥18 years. The response rate to the survey was 44.9% (landline = 47.2%, cellular = 36.3%). The survey assessed use of the following tobacco product types: cigarettes, cigars/cigarillos/filtered little cigars, regular pipes, water pipes/hookah, e-cigarettes; chewing tobacco/snuff/dip, snus, and dissolvable tobacco products. Based on documented differences in the patterns of tobacco product use (1), NATS assessed varying thresholds of lifetime use to separate established users from experimenters and nonusers. Usage thresholds for the different tobacco product types were as follows: cigarettes (≥100 times), cigars/cigarillos/filtered little cigars (≥50 times), regular pipes (≥50 times), water pipes/hookahs (≥1 time), chewing tobacco/snuff/dip (≥20 times), e-cigarettes (≥1 time), snus (≥1 time), and dissolvable tobacco products (≥1 time). Respondents who met the respective thresholds were then asked if they now used the product "every day," "some days," or "not at all." A response option of "rarely" was also provided for all tobacco products other than cigarettes based on cognitive testing suggesting that some users of these other products did not consider "some days" or "not at all" to accurately reflect their use pattern. Because of limited sample size, all smokeless tobacco products (chewing tobacco/snuff/dip, snus, and dissolvable tobacco products) were aggregated into a single category.
Data were weighted to provide nationally representative estimates. Two definitions were used to assess the effect of occasional tobacco use on estimates of current tobacco use: 1) every day or some days, and 2) every day, some days, or rarely. Any tobacco product use was defined as use of at least one tobacco product type.* Any combustible tobacco product use was defined as use of at least one of the following tobacco product types: cigarettes, cigars/cigarillos/filtered little cigars, regular pipes, or water pipes/hookah. Tobacco use prevalence estimates were calculated overall and by sex, age, race/ethnicity, U.S. Census region,† education, annual household income, and sexual orientation. Prevalence estimates with a relative standard error ≥30% were omitted. Differences between groups were assessed using chi-squared statistics (p<0.05).
The percentages of all respondents who had ever met the threshold for each product type (i.e., current and former users), were as follows: cigarettes, 43.1%; cigars/cigarillos/filtered little cigars, 12.6%; regular pipes, 5.0%; water pipes/hookahs, 12.3%; e-cigarettes, 14.1%; chewing tobacco/snuff/dip, 9.6%; dissolvable tobacco products, 0.4%; and snus, 5.4%.
During 2012–2013, an estimated 21.3% of U.S. adults used any tobacco product every day or some days (73.4% of these used ≥1 tobacco products daily), and 19.2% used any combustible tobacco product every day or some days (72.1% of these used ≥1 combustible tobacco products daily) (Table 1). Prevalence of every day or some days use of specific tobacco products was as follows: cigarettes, 18.0%; cigars/cigarillos/filtered little cigars, 2.0%; regular pipes, 0.3%; water pipes/hookah, 0.5%; e-cigarettes, 1.9%; smokeless tobacco, 2.6%. An estimated 25.2% of U.S. adults reported now using any tobacco product every day, some days, or rarely (62.7% of these used ≥1 tobacco products daily), and 22.9% used any combustible tobacco product every day, some days, or rarely (60.6% of these used ≥1 combustible tobacco products daily) (Table 2). Prevalence of every day, some days, or rarely use was as follows: cigars/cigarillos/filtered little cigars, 5.8%; regular pipes, 0.9%; water pipes/hookah, 3.9%; e-cigarettes, 4.2%; smokeless tobacco, 3.8%. Prevalence of every day, some days, or rarely use was significantly higher than every day or some day use for any tobacco product use, cigars/cigarillos/filtered little cigars, regular pipes, water pipes/hookah, e-cigarettes, and smokeless tobacco (p<0.05).
Among respondents who had ever met the threshold for each product type (i.e., current and former users), current everyday use was as follows: cigarettes, 30.9%; cigars/cigarillos/filtered little cigars, 5.8%; regular pipes, 2.2%; water pipes/hookahs, 0.4%; e-cigarettes, 5.3%; chewing tobacco/snuff/dip, 17.1%; dissolvable tobacco products, 3.1%; and snus, 1.8% (Figure). Among respondents who had ever met the threshold for each product type and who now used the product (i.e., current users only), current everyday use was as follows: cigarettes, 74.2%; cigars/cigarillos/filtered little cigars, 12.8%; regular pipes, 12.6%; water pipes/hookahs, 1.2%; e-cigarettes, 17.9%; chewing tobacco/snuff/dip, 48.1%; dissolvable tobacco products, 16.8%; and snus, 11.3%.
By sex, prevalence of any tobacco use every day or some days was higher among men (26.2%) than women (15.4%) (Table 1). By age, prevalence was highest among those aged 25–44 years (25.2%) and lowest among those aged ≥65 years (9.5%). By race/ethnicity, prevalence was highest among adults categorized as "other, non-Hispanic" (33.0%) and lowest among non-Hispanic Asians (8.8%). By region, prevalence was highest in the Midwest (23.9%) and lowest in the West (19.0%). Prevalence by education was highest among adults with a General Education Development certificate (43.8%) and lowest among those with a graduate degree (6.3%). Prevalence was highest among adults with annual household income of <$20,000 (29.8%) and lowest among those with income ≥$100,000 (12.8%). By sexual orientation, prevalence was higher among lesbian, gay, bisexual, or transgender (LGBT) adults (30.8%) than heterosexual/straight adults (20.5%).
During 2012–2013, an estimated one in five U.S. adults (50 million persons) currently used any tobacco product every day or some days, and an estimated one in four (60 million persons) used tobacco products every day, some days, or rarely. Any tobacco use was greater among men, younger adults, non-Hispanic other adults, those living in the Midwest and South, those with less education and income, and LGBT adults. Continued implementation of proven population-based interventions, including increasing tobacco product prices, implementing and enforcing comprehensive smoke-free laws, warning about the dangers of tobacco use through high-impact mass media campaigns, and increasing access to help quitting, can help reduce tobacco use (1,4,5). Additionally, regulatory authority over the manufacture, marketing, and sales of tobacco products are powerful tools to further reduce tobacco-related disease and deaths in the United States.§ In April 2014, FDA proposed to extend its authority to additional tobacco products, including e-cigarettes, cigars, pipes, and water pipes/hookahs.¶ This proposed rule would set a national minimum age for sales; require health warnings, tobacco ingredient reporting, and listing of harmful and potentially harmful constituents; ensure FDA premarket review of new and changed tobacco products and all marketing of reduced risk products; and enable future rulemaking regarding product manufacture, marketing, and sales.
Although the prevalence of every day or some day cigarette smoking (18.0%) was significantly lower than the prevalence observed in the 2009–2010 NATS (19.5%) (6), cigarettes and other combustible products (e.g., cigars, pipes, and hookahs) remained the most prevalent forms of adult tobacco use. The 50th anniversary Surgeon General's report on the health consequences of smoking concluded that disease and deaths from tobacco use are overwhelmingly caused by cigarettes and other combusted products, and that rapid elimination of their use will dramatically reduce this burden (1). Additionally, the use of emerging tobacco products (e.g., e-cigarettes and water pipes/hookahs) was also evident and could be attributed to lower price relative to cigarettes; an increase in marketing, availability, and visibility; and the perception that they might be safer alternatives to cigarettes (1). Taken together, these findings underscore the importance of continued implementation of proven population-based interventions to address all forms of tobacco use, especially combustible products that currently account for the greatest public health burden.
Accounting for respondents who reported rarely using each respective tobacco product resulted in higher prevalence estimates among all population subgroups, especially young adults. A sensitivity analysis using NATS data showed that young adults were more likely to report using any tobacco products rarely. However, it cannot be determined from these data whether this represents early initiation that will escalate to established use. Furthermore, omitting the lifetime thresholds used to identify established users yielded higher estimates for certain products, including cigars/cigarillos/filtered little cigars. For example, overall use of cigars/cigarillos/filtered little cigars every day, some days, or rarely was 5.8% using the 50 lifetime cigar threshold and 7.4% without. Hence, intensified efforts are warranted to monitor occasional tobacco use in population-level surveys and to enhance the accuracy and sensitivity of tobacco use measures, particularly among young adults.
The findings in this report are subject to at least four limitations. First, self-reported tobacco use might have resulted in misreporting; however, self-reported cigarette smoking correlates highly with serum cotinine levels (7). Second, small sample sizes for certain subgroups resulted in less precise estimates. Third, the response rate of 44.9% might have resulted in nonresponse bias, even after adjustment for nonresponse. Fourth, the established thresholds and current use measures varied by tobacco product type. Although not a limitation, it is important to note that these estimates might differ from those derived from other surveillance systems. For example, although estimates of cigarette smoking from NATS were comparable with the National Health Interview Survey (NHIS) (8), the National Survey on Drug Use and Health (NSDUH) consistently yields higher estimates than NATS and NHIS (9). These differences might be explained, in part, by varying survey methodologies and tobacco use definitions. For example, NSDUH is conducted completely in-person, uses a self-administered survey mode, and provides incentives to participants (10).
Sustained, comprehensive state tobacco control programs funded at CDC-recommended levels can accelerate progress toward reducing tobacco-related diseases and deaths in the United States (4). However, during 2014, despite combined revenue of more than $25 billion from settlement payments and tobacco taxes for all states, states will spend only $481.2 million (1.9%) on comprehensive tobacco control programs,** representing <15% of the CDC-recommended level of funding for all states combined (4). Full implementation of comprehensive tobacco control programs at CDC-recommended funding levels, in conjunction with FDA regulation of tobacco products, could reduce tobacco use and change social norms regarding the acceptability of tobacco use in the United States (1,4,5).
Ralph S. Caraballo, PhD, Linda J. Neff, PhD, Kimberly Nguyen, MS, Office on Smoking and Health, CDC. Benjamin Apelberg, PhD, Center for Tobacco Products, Food and Drug Administration.
1Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2EIS officer, CDC; 3Center for Tobacco Products, Food and Drug Administration (Corresponding author: Brian King, email@example.com, 770-488-5107)
* Participants with missing responses for any of the assessed tobacco products (1.6% of respondents) were excluded.
† Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
§ Additional information available at http://www.fda.gov/tobaccoproducts/guidancecomplianceregulatoryinformation/ucm246129.htm.
¶ Additional information available at http://www.fda.gov/aboutfda/reportsmanualsforms/reports/economicanalyses/ucm394922.htm.
** Additional information available at http://www.tobaccofreekids.org/what_we_do/state_local/tobacco_settlement.