Vol. 65, No. 27
July 15, 2016
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Tobacco Product Use Among Adults — United States, 2013–2014
Weekly / July 15, 2016 / 65(27);685–691
S. Sean Hu, MD1; Linda Neff, PhD1; Israel T. Agaku, DMD1; Shanna Cox, MSPH1; Hannah R. Day, PhD2; Enver Holder-Hayes, MPH2; Brian A. King, PhD1 (View author affiliations)View suggested citation
SummaryWhat is already known about this topic?
Although significant declines in cigarette smoking have occurred among U.S. adults during the past 5 decades, the use of emerging tobacco products has increased in recent years.What is added by this report?
During 2013–2014, 21.3% of U.S. adults used a tobacco product every day or some days, and 25.5% of U.S. adults used a tobacco product every day, some days, or rarely. Cigarettes remained the most commonly used tobacco product. Young adults aged 18–24 years reported the highest prevalence of use of emerging tobacco products, including water pipes/hookahs and e-cigarettes. Differences in the use of any tobacco product were observed, with higher use reported among males; persons aged <45 years; non-Hispanic whites, non-Hispanic blacks, or non-Hispanics of other races; persons in the Midwest or South; persons with a General Educational Development certificate; persons who were single/never married/not living with a partner or divorced/separated/widowed; persons with annual household income <$20,000; and persons who were lesbian, gay, or bisexual.What are the implications for public health practice?
Continued implementation of proven population-based interventions focused on the diversity of tobacco product use could help reduce tobacco use and tobacco related disease and death. These interventions include increasing tobacco product prices, implementing and enforcing comprehensive smoke-free laws, warning about the dangers of tobacco use through high-impact public education media campaigns, and increasing access to resources to help people quit tobacco use.
While significant declines in cigarette smoking have occurred among U.S. adults during the past 5 decades, the use of emerging tobacco products* has increased in recent years (1–3). To estimate tobacco use among U.S. adults aged ≥18 years, CDC and the Food and Drug Administration (FDA) analyzed data from the 2013–2014 National Adult Tobacco Survey (NATS). During 2013–2014, 21.3% of U.S. adults used a tobacco product every day or some days, and 25.5% of U.S. adults used a tobacco product every day, some days, or rarely. Despite progress in reducing cigarette smoking, during 2013–2014, cigarettes remained the most commonly used tobacco product among adults. Young adults aged 18–24 years reported the highest prevalence of use of emerging tobacco products, including water pipes/hookahs and electronic cigarettes (e-cigarettes). Furthermore, racial/ethnic and sociodemographic differences in the use of any tobacco product were observed, with higher use reported among males; non-Hispanic whites, non-Hispanic blacks, and non-Hispanics of other races†; persons aged <45 years; persons living in the Midwest or South; persons with a General Educational Development (GED) certificate; persons who were single/never married/not living with a partner or divorced/separated/widowed; persons with annual household income <$20,000; and persons who were lesbian, gay, or bisexual (LGB). Population-level interventions that focus on all forms of tobacco product use, including tobacco price increases, high-impact anti-tobacco mass media campaigns, comprehensive smoke-free laws, and enhanced access to help quitting tobacco use, in conjunction with FDA regulation of tobacco products, are critical to reducing tobacco-related diseases and deaths in the United States.§
NATS is a stratified, random-digit–dialed landline and cellular telephone survey of noninstitutionalized U.S. adults aged ≥18 years. The 2013–2014 NATS included 75,233 respondents (70% landline, 30% cellular); the overall response rate was 36.1% (landline 47.6%, cellular 17.1%). Based on established conventions regarding patterns of tobacco product use (3), NATS questions used varying thresholds of lifetime use to separate established users from experimenters and nonusers. Four tobacco product types assessed in NATS had lifetime usage thresholds: cigarettes (≥100 cigarettes); cigars/cigarillos/filtered little cigars (≥50 times); regular pipes (≥50 times); and chewing tobacco/snuff/dip (≥20 times). Water pipes/hookahs, e-cigarettes, snus, and dissolvable tobacco products did not have usage thresholds. Respondents who met the respective thresholds for cigarettes, cigars/cigarillos/filtered little cigars, regular pipes, and chewing tobacco/snuff/dip or who reported ever using water pipes/hookahs, e-cigarettes, snus, and dissolvable tobacco products, were then asked if they used each respective product at the time of the survey. With the exception of cigarettes, response options for frequency of use at the time of survey were “every day,” “some days,” “rarely,” or “not at all”; “rarely” was not included as a response option for cigarettes.
Data were weighted to provide nationally representative estimates of prevalence and number of users. To assess the effect of occasional tobacco use on estimates of current tobacco use, two definitions were used for all tobacco product types (except cigarettes): 1) use every day or some days; and 2) use 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/hookahs. All smokeless tobacco products (chewing tobacco/snuff/dip, snus, and dissolvable tobacco products) were aggregated into a single category. Prevalence estimates were calculated overall and by sex, age, race/ethnicity, U.S. Census region, education, marital status, annual household income, and sexual orientation. Prevalence estimates with a relative standard error ≥30% are not presented. Differences between groups were assessed using chi-squared statistics; estimates with p<0.05 were considered to be statistically significant.
Overall, the reported prevalence of every day or some day use was as follows: any tobacco product use, 21.3% (estimated 49.2 million users); any combustible tobacco product use, 18.4% (42.8 million); cigarette use, 17.0% (39.8 million); cigar/cigarillo/filtered little cigar use, 1.8% (4.1 million); regular pipe use, 0.3% (0.7 million); water pipe/hookah use, 0.6% (1.4 million); e-cigarette use, 3.3% (7.8 million); and smokeless tobacco use, 2.5% (5.7 million) (Table 1). When “rarely” was added to the definition of use, prevalence of use was as follows: any tobacco product use, 25.5% (58.8 million users); any combustible tobacco product use, 22.2% (51.5 million); cigar/cigarillo/filtered little cigar use, 5.4% (12.6 million); regular pipe use, 0.8% (2.0 million); water pipe/hookah use, 4.3% (10.0 million); e-cigarette use, 6.6% (15.5 million); smokeless tobacco product use, 3.5% (8.2 million) (Table 2).
Differences in use of any tobacco product every day or some days were observed across population groups (Table 1). Prevalence was higher among males (26.3%) than females (16.7%), and among age groups, was highest among persons aged 25–44 years (26.1%) and lowest among persons aged ≥65 years (10.3%). Prevalence was highest among non-Hispanics of other races (i.e., American Indians/Alaska natives, Native Hawaiians/other Pacific Islanders, and persons of multiple race) (32.6%) and lowest among non-Hispanic Asians (11.2%); by region, prevalence was highest among persons living in the South (24.0%) and lowest among persons living in the West (17.6%). Prevalence was highest among adults with a GED certificate (50.0%) and lowest among persons with a graduate degree (6.4%). Prevalence was higher among adults who were single/never married/not living with a partner (26.1%) or divorced/separated/widowed (26.1%) than those married or living with a partner (18.0%). Prevalence was highest among adults with annual household income <$20,000 (32.2%) and lowest among those with annual household income ≥$100,000 (12.1%) and was higher among LGB adults (32.1%) than heterosexual/straight adults (20.7%). Prevalence patterns were generally similar when “rarely” was included in the definition of use (Table 2).
Among every day, some days, or rarely users, younger adults aged 18–24 accounted for 55.8% of water pipe/hookah smokers, 24.3% of e-cigarettes users, 23.1% of regular pipe smokers, 21.6% of smokeless tobacco users, and 19.5% of cigar/cigarillo/filtered little cigar smokers (Figure).
During 2013–2014, one in five U.S. adults (an estimated 49.2 million persons) used any tobacco product every day or some days, and one in four (58.8 million persons) used any tobacco product every day, some days, or rarely. Across population groups, differences were observed in tobacco use by sex, age, race/ethnicity, U.S. Census region, education, marital status, annual household income, and sexual orientation. The magnitude and patterns of tobacco product use generally were comparable to those from other national surveys of U.S. adults during the same period.** Use of any tobacco product every day or some days was nearly threefold higher among non-Hispanics of other races (i.e., American Indians/Alaska natives, Native Hawaiian/other Pacific Islanders, and persons of multiple race) than among Asian non-Hispanics. Adults with annual household incomes of <$20,000 also reported a higher prevalence of tobacco product use than did persons with higher annual household income and LGB adults reported higher prevalence of tobacco product use than did adults who identified as heterosexual/straight.
The use of e-cigarettes and water pipes/hookahs was particularly prevalent among certain populations. Most users of these two emerging tobacco products were not daily users. Moreover, young adults had the highest prevalence of use of e-cigarettes and water pipes, which might reflect that although most experimentation with tobacco products occurs during the teenage years, young adulthood increasingly is a time of initiation of tobacco products, including emerging tobacco products.†† The higher prevalence of use among younger adults might also be a consequence of targeted marketing of e-cigarette products and varying perceptions about the relative harm or social acceptability of these products compared with conventional cigarettes (1,4,5). When the definition of current users included participants who reported rarely using tobacco products, current use was disproportionately higher among younger adults. These users might not consider themselves to be tobacco product users, and thus, might not consider themselves to be at risk for tobacco-related disease or death (6,7). For example, one focus group study with adult cigar smokers found that some users would only use the term “smoker” or “cigar smoker” to describe someone who smoked cigars several times a week or daily (8). This finding underscores the importance of further research on the ascertainment of tobacco product use, as well as efforts to educate the public about the potential harms of all tobacco product use, including risks associated with occasional use.
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 public education media campaigns, and increasing access to proven resources to help people quit tobacco use, can help reduce tobacco use and tobacco-related disease and death (1,9). In addition, regulatory authority over the manufacture, marketing, and sales of tobacco products is an important tool to further reduce tobacco-related disease and death in the United States.§§ In May 2016, FDA finalized a rule extending its authority to all products that meet the definition of a tobacco product, including e-cigarettes, cigars, pipes, and water pipes/hookahs.¶¶ This rule sets a national minimum age for sales; requires health warnings, tobacco product ingredient reporting, and reporting of harmful and potentially harmful constituents; and ensures FDA premarket review of new and changed tobacco products and premarket review of the marketing of products as reduced-risk (modified risk tobacco products). The rule also enables future rulemaking regarding tobacco product manufacturing, marketing, and sales.
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 (10). Second, small sample sizes among certain subgroups resulted in less precise estimates. Third, the overall response rate of 36.1% might have resulted in bias, even after adjustment for nonresponse. Finally, thresholds and current use measures varied by tobacco product type; for example, the absence of a response option of “rarely” for ascertaining cigarette smoking at the time of the survey might have resulted in underestimates for current cigarette smoking.
Sustained, comprehensive state tobacco control programs funded at CDC-recommended levels can accelerate progress toward reducing tobacco-related diseases and deaths (1). However, during fiscal year 2016, despite combined revenue of $25.8 billion from settlement payments and tobacco taxes for all states combined, states will spend only 1.8% of this amount ($468 million) on comprehensive tobacco control programs (<15% of the CDC-recommended level of funding for all states combined).*** Full implementation of comprehensive tobacco control programs at CDC-recommended funding levels, in conjunction with FDA regulation of tobacco products, could reduce tobacco use in the United States, thereby reducing morbidity and mortality caused by tobacco use (1).
Kimberly Nguyen, Office on Smoking and Health, CDC; Benjamin Apelberg, Center for Tobacco Products, Food and Drug Administration.
Corresponding author: S. Sean Hu, firstname.lastname@example.org, 770-488-5493.
1Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2Center for Tobacco Products, Food and Drug Administration.
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* Emerging tobacco products are non-cigarette tobacco products that have gained increasing popularity and use within the U.S. market over the past decade.
† Three race/ethnic groups (American Indians/Alaska natives, non-Hispanic; Native Hawaiians/other Pacific Islanders, non-Hispanic; and persons of multiple race, non-Hispanic) were combined into one category of “other, non-Hispanic” because sample sizes were too small to provide statistically reliable estimates for the individual groups. Data are presented separately for non-Hispanic white, non-Hispanic black, non-Hispanic Asian, and Hispanic adults.
¶ Participants who reported use of any product were considered any tobacco product users, but those who had a combination of “no” and missing responses to any of the assessed product type questions were excluded from the analysis. Participants who did not report use of any product “every day,” “some days,” or “rarely” who had missing responses for any of the assessed tobacco products (1.9% of respondents) were excluded.
** http://www.cdc.gov/nchs/nhis/SHS/tables.htm and http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf.