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| MMWR Weekly Vol. 65, No. 52 January 06, 2017 |
| PDF of this issue |
Quitting Smoking Among Adults — United States, 2000–2015
Weekly / January 6, 2017 / 65(52);1457–1464
Stephen Babb, MPH1; Ann Malarcher, PhD1; Gillian Schauer, PhD1; Kat Asman, MSPH1; Ahmed Jamal, MBBS1 (View author affiliations)
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What is already known about this topic?
Quitting cigarette smoking benefits smokers at any age. Cessation counseling and medications each improve smokers’ chances of quitting, and have an even greater effect when combined. However, use of counseling and medications remains low.
What is added by this report?
Approximately two thirds of cigarette smokers are interested in quitting, and in 2015, approximately half of smokers reported receiving advice to quit from a health professional and making a quit attempt in the past year. However, fewer than one third of smokers who tried to quit used evidence-based cessation treatments, and fewer than one in 10 smokers overall successfully quit in the past year. As of 2015, approximately three in five adults who had ever smoked had quit.
What are the implications for public health practice?
Health care professionals can help smokers quit by consistently identifying patients who smoke, advising them to quit, and offering them cessation treatments. Health insurers can help smokers quit by covering proven cessation treatments with minimal barriers and promoting their use. States can help smokers quit by implementing population-based policy interventions and anti-tobacco mass media campaigns, and by funding comprehensive state tobacco control programs, including state quitlines, at CDC-recommended levels.
Stephen Babb, MPH1; Ann Malarcher, PhD1; Gillian Schauer, PhD1; Kat Asman, MSPH1; Ahmed Jamal, MBBS1 (View author affiliations)
View suggested citation
Quitting cigarette smoking benefits smokers at any age (1). Individual, group, and telephone counseling and seven Food and Drug Administration–approved medications increase quit rates (1–3). To assess progress toward the Healthy People 2020 objectives of increasing the proportion of U.S. adults who attempt to quit smoking cigarettes to ≥80.0% (TU-4.1), and increasing recent smoking cessation success to ≥8.0% (TU-5.1),* CDC assessed national estimates of cessation behaviors among adults aged ≥18 years using data from the 2000, 2005, 2010, and 2015 National Health Interview Surveys (NHIS). During 2015, 68.0% of adult smokers wanted to stop smoking, 55.4% made a past-year quit attempt, 7.4% recently quit smoking, 57.2% had been advised by a health professional to quit, and 31.2% used cessation counseling and/or medication when trying to quit. During 2000–2015, increases occurred in the proportion of smokers who reported a past-year quit attempt, recently quit smoking, were advised to quit by a health professional, and used cessation counseling and/or medication (p< 0.05). Throughout this period, fewer than one third of persons used evidence-based cessation methods when trying to quit smoking. As of 2015, 59.1% of adults who had ever smoked had quit. To further increase cessation, health care providers can consistently identify smokers, advise them to quit, and offer them cessation treatments (2–4). In addition, health insurers can increase cessation by covering and promoting evidence-based cessation treatments and removing barriers to treatment access (2,4–6).
NHIS is an annual, nationally representative, in-person survey of the noninstitutionalized U.S. civilian population. The NHIS Sample Adult core questionnaire is administered to a randomly selected adult (referred to as the sample adult) aged ≥18 years in each sampled family. NHIS sample sizes and final response rates for sample adults for 2000, 2005, 2010, and 2015 were 32,374 (response rate = 72.1%), 31,428 (69.0%), 27,157 (60.8%), and 33,672 (55.2%), respectively. Current and former smoking were defined according to Healthy People 2020 measures.† Persons attempting to quit included current smokers who stopped smoking for > 1 day during the 12 months before the interview because they were trying to quit and former smokers who had quit during the past year. Former smokers who last smoked 6–12 months ago were considered to have achieved recent cessation success. Every 5 years, a supplemental cancer-control questionnaire is administered to NHIS sample adult respondents; the questionnaire contains questions on interest in quitting smoking, receipt of a health professional's advice to quit, and use of cessation counseling and/or medication. Data were adjusted for differences in the probability of selection and nonresponse, and were weighted to provide nationally representative estimates. Logistic regression was conducted to analyze trends during 2000–2015. Both linear and quadratic terms were initially applied to all models. If the quadratic term was not significant, the linear model was used.
In 2015, 68.0% of all current smokers reported that they wanted to stop smoking completely. Smaller proportions of smokers aged ≥65 years (53.7%) and 18–24 years (62.3%) were interested in quitting than were smokers aged 25–44 years (72.7%) (Table 1). The prevalence of past-year quit attempts increased during 2000–2015 (p< 0.05 based on quadratic trend analysis), and was 55.4% in 2015, which was the time point when prevalence was highest (Figure). Past-year quit attempts decreased with increasing age. Higher prevalences of past-year quit attempts were reported by Asians (69.4%) and blacks (63.4%) than by whites (53.3%) (Table 1).
The prevalence of recent cessation increased during 2000–2015 (p< 0.05 based on linear trend analysis), and was 7.4% in 2015 (Figure). Recent cessation generally increased with increasing level of educational attainment, and smokers with private health insurance (9.4%) reported a higher prevalence of recent cessation than did smokers who were uninsured (5.2%) or enrolled in Medicaid (including persons with dual Medicaid/Medicare eligibility)§ (5.9%) (Table 1). As of 2015, among adults who had ever smoked, 59.1% (52.8 million) had quit.
During 2000–2015, increases were reported in receipt of advice from a health professional to quit: prevalence was 57.2% in 2015 (p< 0.05 based on quadratic trend analysis); prevalence was highest in 2005 and 2015, with a decrease observed in 2010 (Figure). Smokers aged 45–64 years (65.7%) and ≥65 years (65.7%) reported a higher prevalence of receiving advice to quit than did smokers aged 18–24 years (44.4%) and 25–44 years (49.8%) (Table 2). Lower prevalences of receiving advice to quit were reported by Asian (34.2%), American Indian/Alaska Native (38.1%), and Hispanic (42.2%) smokers than by white smokers (60.2%); and by uninsured smokers (44.1%) than by smokers with any type of insurance (range = 56.8%–69.2%). Smokers reporting a disability/limitation or serious psychological distress reported a higher prevalence of receiving advice to quit than did smokers without these conditions (71.8% and 70.2%, respectively, vs 53.6% and 55.7%).
Use of cessation counseling and/or medication among smokers who were trying to quit increased during 2000–2005 from 21.9% to 29.1%, with no change in 2010 (31.7%) or 2015 (31.2%) (p< 0.05 based on quadratic trend analysis) (Figure). The prevalence of use of counseling and/or medication increased with age through age 64 years (Table 2). Hispanics and Asians reported a lower prevalence of using counseling and/or medication (19.2% and 20.5%, respectively) than did whites (34.3%), as did uninsured smokers (21.4%) compared with smokers with any type of insurance other than Medicare and Medicare Advantage (range = 32.1%–36.0%). The prevalence of using counseling and/or medication was higher among smokers reporting a disability/limitation (39.0%) or serious psychological distress (41.6%) than among smokers without these conditions (28.5% and 30.1%, respectively). Gay, lesbian, or bisexual smokers reported a lower prevalence of counseling and/or medication use (14.5%) than did straight smokers (31.7%).
Among smokers who made quit attempts, 6.8% reported using counseling, 29.0% medication, and 4.7% both. Among smokers who used counseling, 4.1% used a telephone quitline, 2.8% used one-on-one counseling, and 2.4% used a stop smoking clinic, class, or support group. Among smokers who used medications, 16.6% used a nicotine patch, 12.5% used nicotine gum or lozenges, 7.9% used varenicline, 2.7% used bupropion, and 2.4% used nicotine spray or inhaler.
Discussion
In 2015, approximately two thirds of cigarette smokers were interested in quitting, and slightly more than half reported receiving advice to quit from a health professional and making a past-year quit attempt. However, fewer than one third of smokers who tried to quit used proven cessation treatments, and fewer than one in 10 smokers overall quit successfully in the past year. Approximately three in five adults who had ever smoked had quit. To enhance cessation rates, it is critical for health care providers to consistently identify smokers, advise them to quit, and offer evidence-based cessation treatments, and for insurers to cover and promote the use of these treatments and remove barriers to accessing them (2–6).
During 2000–2015, modest but statistically significant increases occurred in the prevalence of past-year quit attempts (from 49.2% to 55.4%), recent smoking cessation (5.7% to 7.4%), receipt of health professional advice to quit smoking (52.4% to 57.2%), and use of cessation counseling and/or medication (21.9% to 31.2%). However, recent smoking cessation remains low, and little progress has been made since 2005 toward increasing receipt of advice to quit and use of counseling and/or medication. Use of cessation counseling and medication increases quit rates, especially when they are combined (2,3,7): combined behavioral and pharmacotherapy interventions increase cessation by 82%, compared with minimal intervention or usual care (7). Use of cessation medications is appropriate for most adult smokers, with the exception of pregnant women, light smokers (i.e., persons who smoke < 5-10 cigarettes daily), and persons with specific medical contraindications (2,3). The low prevalence of recent cessation likely is related in part to low use of evidence-based cessation treatments. Because approximately 70% of smokers see a physician annually, and even brief physician advice to quit increases quit rates (2), opportunities exist to increase cessation rates through health care system changes and other population-based strategies (2–4).
Observed disparities were consistent with those reported in previous studies (8). In 2015, smokers who were aged < 45 years, Hispanic, Asian, with an Associate’s or higher degree, lived in the Northeast, had private health insurance, or had no serious psychological distress met the Healthy People 2020 target for recent cessation (≥8.0%). Disparities in cessation behaviors by race/ethnicity might be partly explained by differences in tobacco use behaviors, health care utilization, access to cessation treatments, and knowledge about these treatments (1,2,4). Disparities by insurance status in receipt of advice to quit (44.1% for uninsured smokers versus 56.8% for smokers with private insurance), use of cessation counseling and/or medication (21.4% for uninsured smokers versus 32.1% for smokers with private insurance), and recent cessation (5.2% for uninsured smokers versus 9.4% for smokers with private insurance) are likely attributable, in part, to a lack of access to cessation treatments among the uninsured (2,4,5). Higher prevalence of receiving a health professional’s advice to quit and use of counseling and/or medication among smokers with serious psychological distress might be related to greater use of health care as well as greater tobacco dependence in this population (1,4).
Changes in the U.S. health care system could have contributed to this report’s findings. By increasing the number of adults with health insurance (9) and requiring improved cessation coverage by commercial insurance and Medicaid (5), the Patient Protection and Affordable Care Act¶ might have contributed to increases in the number of smokers who attempt to quit, use proven cessation treatments, and successfully quit (4,5). Improved cessation insurance coverage, together with new health care delivery and payment models and quality measures, might have contributed to increases in health professional advice to quit since 2010 (4,5).
The findings in this report are subject to at least three limitations. First, cigarette smoking and cessation-related measures were self-reported without validation by biochemical testing, and might be subject to social desirability bias. However, self-reported smoking status correlates with serum cotinine levels (10). Second, because NHIS does not include institutionalized populations and persons in the military, results are not generalizable to these groups. Finally, lower NHIS response rates might result in nonresponse bias. The extent to which nonresponse might have affected the results reported here is unknown.
Funding state tobacco control programs, including state quitlines, at CDC-recommended levels, increasing tobacco prices, implementing comprehensive smoke-free policies, conducting anti-tobacco mass media campaigns, and enhancing access to quitting assistance can increase tobacco cessation and reduce tobacco-related disease and death (1,4). Opportunities exist for insurers and employers to improve coverage and increase use of cessation treatments and for health systems to integrate cessation interventions into clinical care (1,4,5).
Acknowledgments
Brian King, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; Robin Cohen, National Center for Health Statistics, CDC; Jennifer Whitmill, Emory University.
Corresponding author: Stephen Babb, Sbabb@cdc.gov, 770-488-1172.
1Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
* Objectives TU-4.1 and TU-5.1. https://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use/objectives.
† To determine smoking status, respondents were asked, “Have you smoked at least 100 cigarettes in your entire life?” Those who answered “yes” were asked, “Do you now smoke cigarettes every day, some days, or not at all?” Current smokers were those who had smoked at least 100 cigarettes during their lifetime and, at the time of the interview, reported smoking every day or some days. Former smokers were those who reported smoking at least 100 cigarettes during their lifetime but currently did not smoke. http://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm.
§ A secondary analysis found that the prevalence of reported cessation behaviors for Medicaid enrollees did not change substantially when persons with dual Medicaid/Medicare eligibility were removed from the Medicaid coverage category.
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