Cigarette smoking in the United States results in an estimated 443,000 premature deaths and $193 billion in direct health care expenditures and productivity losses each year.1 During 2007, an estimated 19.8% of adults in the United States were current smokers.2 To update 2006 state-specific estimates of cigarette smoking, CDC analyzed data from the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey and examined trends in cigarette smoking from 1998 to 2007. The results of these analyses indicated substantial variation in current cigarette smoking during 2007 (range of 8.7% to 31.1%) among the 50 states, the District of Columbia, Guam, Puerto Rico, and the US Virgin Islands. Trend analyses of 1998–2007 data indicated that smoking prevalence decreased in 44 states, the District of Columbia, and Puerto Rico, and six states had no substantial changes in prevalence after controlling for age, sex, and race/ethnicity. However, only Utah and the US Virgin Islands met the Healthy People 2010 target for reducing adult smoking prevalence to 12% (Objective 27-1a).3 The Institute of Medicine (IOM) calls for full implementation of comprehensive, evidence-based tobacco control programs at CDC-recommended funding levels to achieve substantial reductions in tobacco use in all states and areas.4 BRFSS conducts state-based, random-digit-dialed telephone surveys of the noninstitutionalized US civilian population over age 18 years, collecting data on health conditions and health risk behaviors. The 2007 survey was conducted in the 50 states, District of Columbia, Guam, Puerto Rico, and the Virgin Islands and included data from 430,912 respondents. Those respondents who answered “yes” to the question “Have you smoked at least 100 cigarettes in your entire life?” and answered “every day” or “some days” to the question “Do you now smoke cigarettes every day, some days, or not at all?” were classified as current cigarette smokers. These questions have been included in the survey each year since 1996; for this analysis, survey data from 1998 to 2007 were examined. For each year, estimates were weighted to the respondent's probability of being selected and the age-, race-, and sex-specific populations from the census for the state or area. These weights were used to calculate the state smoking prevalence estimates; 95% confidence intervals also were calculated. BRFSS uses a multistage sampling design primarily to generate state/area estimates. The median prevalence among all states and the District of Columbia is generally comparable to overall national estimates from other surveys.2 Response rates for BRFSS are calculated using Council of American Survey and Research Organizations (CASRO) guidelines. The median survey response rates were 59.1% (range of 32.5% to 76.7%) for 1998 and 50.6% (range of 26.9% to 65.4%) for 2007. Median cooperation rates were 63.0% for 1998 (range of 38.3% to 83.6%) and 72.1% (range of 49.6% to 84.6%) for 2007. For comparisons of smoking prevalence between males and females during 2007, statistical significance (p<0.05) was determined using a two-sided z-test. Logistic regression analysis was used to analyze temporal changes in current smoking during 1998 to 2007, controlling for changes in state and area distributions of sex, age, and race/ethnicity. Linear and quadratic trends over time were included in the models. Nonsignificant quadratic terms were dropped from the final models. Quadratic trends indicated a significant but nonlinear trend in smoking prevalence over time. Current Cigarette Smoking In 2007, the median prevalence of adult current smoking in the 50 states and District of Columbia was 19.8%. Among states, current smoking prevalence was highest in Kentucky (28.3%), West Virginia (27.0%), and Oklahoma (25.8%); and lowest in Utah (11.7%), California (14.3%), and Connecticut (15.5%). Smoking prevalence was 8.7% in the US Virgin Islands, 12.2% in Puerto Rico, and 31.1% in Guam. Median smoking prevalence among the 50 states and DC was 21.3% (range of 15.5% to 28.8%) for men and 18.4% (range of 8.0% to 27.8%) for women. Men had a significantly higher prevalence of smoking than women in 30 states, the District of Columbia, and all three territories. Trends in Cigarette Smoking During 1998–2007, linear decreases were observed in 28 states, the District of Columbia, and Puerto Rico. Nonlinear trends were detected in 19 other states. Trends in smoking prevalence varied among these states; however, all had reached a peak prevalence before 2004 and then began to decrease. Among 16 of these 18 states, logistic regression models indicated that the prevalence decreased during 1998 to 2007; in the other two states no change in prevalence occurred. No change over time in smoking prevalence (quadratic or linear) was observed in Alabama, Arizona, Tennessee, and West Virginia. Healthy People 2010 calls for reducing adult cigarette smoking prevalence to 12%.3 Utah and the Virgin Islands were the first state and territory to meet the Healthy People 2010 target in 2003 and 2001, respectively, and have continued to meet this target each year. The first demographic subgroup to meet the Healthy People 2010 target was women in Puerto Rico in 1997. In 2007, cigarette smoking prevalence among women in California, Puerto Rico, the US Virgin Islands, and Utah met the Healthy People 2010 target. Cigarette smoking prevalence among men has continued to exceed the less than 12% target, except among men in the Virgin Islands, whose prevalence declined from 12.1% in 2006 to 11.2% in 2007. Trends for 1998 to 2007 suggest that most states have shown declines in smoking prevalence; however, the present rate of decline likely will be too slow in nearly all states to reach the Healthy People target by 2010. Possible Factors for Variations States varied substantially in current levels of smoking and in trends in smoking during 1998 to 2007. These variations might be attributed to a number of factors, including differences in population demographics, differing levels of tobacco control programs and policies, and variations in tobacco industry marketing and promotion.5 As part of CDC's National Tobacco Control Program, all states work to implement comprehensive tobacco control programs that include effective strategies for preventing smoking initiation and increasing cessation. These programs contribute to reductions in smoking prevalence through increases in the unit price of tobacco products, sustaining media campaigns (e.g., encouraging cessation and preventing initiation), implementation of smoke-free policies, support for quitlines, and reduced patient costs for tobacco use treatment.6 State per-capita tobacco-control program expenditures are one measure of the state's ability to implement effective tobacco control program components;6 during 1985 to 2003, states with higher expenditures had greater overall reductions in adult smoking prevalence.5 Possible Limitations The findings in this report are subject to at least six limitations: First, smoking prevalence might be underestimated because BRFSS does not survey persons in households without any telephone service (2.5%) or with wireless-only telephones (17.5%), and adults with wireless-only service are more likely (30.2%) than the rest of the US population to be current smokers.7 Second, the estimates for cigarette smoking are based on self-report and are not validated by biochemical tests. However, self-reported data on current smoking status have high validity.8 Third, the median response rate was 59.1% (range of 32.5% to 76.7%) in 1998 and 50.6% (range of 26.8% to 65.4%) in 2007. Lower response rates increase the potential for response bias, which could have affected the assessment of trends over time; however, BRFSS aggregated state estimates previously have been shown to be comparable to smoking estimates from other surveys with higher response rates.8 The 2007 median smoking rate of 19.8% reported in this analysis is the same as the national estimate of cigarette smoking reported from the 2007 National Health Interview Survey (19.8%).2 Fourth, trend analyses for Guam and the US Virgin Islands could not be reported because data were not available for the full time span. Fifth, modeling was limited to linear and quadratic trends. However, examination of plots of predicted versus observed prevalence estimates showed that the models fit the data well for the majority of states. For some states, prevalence estimates indicate declines in smoking prevalence might have leveled off since 2005; future trend modeling might need to account for this emerging pattern. Finally, only trends in overall current cigarette smoking prevalence were examined; trends might vary among demographic subpopulations within a state. For example, national trends in current smoking prevalence have varied between non-Hispanic white and black women; cigarette use among these two populations was comparable in the mid-1990s, but use declined more rapidly among non-Hispanic black women than non-Hispanic white women during 2000 and 2001.9 Assessing trends among subgroups is important for targeting interventions to those most at risk. Despite declines in smoking prevalence during 1998 to 2007, cigarette smoking continues to cause large numbers of deaths each year across all states.1 From 2002 to 2005, states cut funding for tobacco prevention and cessation programs by 28% (approximately $200 million).10 In fiscal year 2009, no state is funding comprehensive tobacco control programs at CDC-recommended funding levels, and only nine states are funding at least half of the recommended amount.6.10 In contrast, tobacco industry marketing expenditures nearly doubled from 1998 ($6.9 billion) to 2005 ($13.4 billion).10 The Institute of Medicine concluded that substantial and enduring reductions in tobacco use depend on federal and state government steps to increase excise taxes, enact bans on smoking in public spaces, and increase health care coverage for effective cessation interventions. IOM also called for full implementation of comprehensive tobacco control programs at CDC-recommended funding levels.4 Single Largest Federal Tobacco Excise Tax Increase in History On April 1, 2009, the single largest federal tobacco excise tax increase in history [went] into effect, raising the excise tax for cigarettes to $1.01 from the current rate of $0.39. This increase likely will prompt some smokers to make a quit attempt.4-6 To assist smokers with their quit attempts, health care providers should follow the recommendations in the 2008 update to the Public Health Service's Clinical Practice Guideline on Treating Tobacco Use and Dependence. Health care providers should ask all patients about their use of tobacco, advise tobacco users to quit, assess their willingness to quit, assist in their quit attempt by offering medication and providing referrals to telephone-based quitlines or other counseling services and arrange for follow-up. Telephone-based quitlines are available in every state through a toll-free access number (800-QUIT-NOW—800-784-8669. Reprinted (slightly edited) from Morbidity and Mortality Weekly Report, 3/13/09, Vol. 58, No. 9, pp 221–226.
We examined characteristics associated with smoking cessation counseling among a national sample of 579 women pediatricians. Fifty-two percent of women pediatricians had received at least some training in cessation counseling and 41% counseled smoking patients at least once per year. Prevalence of counseling increased by amount of training; 20.7% of those with no training counseled at least once per year versus 62.0% of those with extensive training. Pediatricians 50-70 years of age were 1.8 times as likely as those 30-39 years of age to perform frequent counseling (p<0.01). Programs to promote smoking cessation training and counseling among pediatricians are needed.
This article examines the prevalence of current smoking and associated psychosocial correlates and whether these correlates differ by sex among adolescent students in Thailand. Data were analyzed from the Thailand Global Youth Tobacco Survey (GYTS), a school-based, cross-sectional survey conducted in 2005 and completed by Mathayom 1, 2, and 3 (U.S. seventh through ninth grades) students. Weighted prevalence estimates of the percentage of students who were current smokers (smoked on ≥ 1 day during the past 30 days) and noncurrent smokers were calculated for the sample and for each psychosocial variable. Separate logistic regression models were calculated for males and females to examine the independent association of the psychosocial correlates of current smoking. Significant correlates for both males and females included close peer smoking, secondhand smoke exposure, being offered a free cigarette by a tobacco industry representative, and belief that smoking is not harmful. These correlates are examined in the context of comprehensive tobacco control laws in Thailand.
To describe the formation of the Youth Tobacco Cessation Collaborative (YTCC), a voluntary collaborative of leading funders of youth tobacco cessation research and services.The long-term goal and specific short-term (2-year) goals, strategies, and accomplishments are briefly described with reference to its guiding action plan: National Blueprint for Action: Youth and Young Adult Tobacco-Use Cessation.Aiming to accelerate the pace of discovery and application, YTCC efforts have created a strategic vision for making progress toward filling key knowledge and intervention gaps.Lessons learned about effective partnership are reviewed, and future directions are described.
Background and Purpose —The relationship between alcohol consumption and cerebral infarction remains uncertain, and few studies have investigated whether the relationship varies by alcohol type or is present in young adults. We examined the relationship between alcohol consumption, beverage type, and ischemic stroke in the Stroke Prevention in Young Women Study. Methods —All 59 hospitals in the greater Baltimore-Washington area participated in a population-based case-control study of stroke in young women. Case patients (n=224) were aged 15 to 44 years with a first cerebral infarction, and control subjects (n=392), identified by random-digit dialing, were frequency matched by age and region of residence. The interview assessed lifetime alcohol consumption and consumption and beverage type in the previous year, week, and day. ORs were obtained from logistic regression models controlling for age, race, education, and smoking status, with never drinkers as the referent. Results —Alcohol consumption, up to 24 g/d, in the past year was associated with fewer ischemic strokes (<12 g/d: OR 0.57, 95% CI 0.38 to 0.86; 12 to 24 g/d: OR 0.38, 95% CI 0.17 to 0.86; >24 g/d: OR 0.95, 95% CI 0.43 to 2.10) in comparison to never drinking. Analyses of beverage type (beer, wine, liquor) indicated a protective effect for wine consumption in the previous year (<12 g/wk: OR 0.58, 95% CI 0.35 to 0.97; 12 g/wk to <12 g/d: OR 0.55, 95% CI 0.28 to 1.10; ≥12 g/d: OR 0.92, 95% CI 0.23 to 3.64). Conclusions —Light to moderate alcohol consumption appears to be associated with a reduced risk of ischemic stroke in young women.
Objectives: Information on the impact of health insurance on smoking and quit attempts at the state level is limited. We examined the state-specific prevalence of cigarette smoking and past-year quit attempts among adults aged 18-64 by health insurance and other individual- and state-level factors. Methods: We used data from 41 states, the District of Columbia, and Puerto Rico, the jurisdictions that administered the Health Care Access module of the 2014 Behavioral Risk Factor Surveillance System. Data on quit attempts included current smokers with a past-year quit attempt and former smokers who quit during the past year. Results: Overall, smoking prevalence ranged from 14.6% among those with private insurance to 34.7% among Medicaid enrollees, and past-year quit-attempt prevalence ranged from 66.4% among the uninsured to 71.5% among Medicaid enrollees. By insurance group, differences in the prevalence of state-specific past-year quit attempts ranged from 15 to 26 percentage points. Regardless of insurance type, people who were non-Hispanic white and had lower education levels were less likely to attempt quitting than were Hispanic people, non-Hispanic black people, and adults with more than a high school education. Conclusions: We found disparities in smoking and quit attempts by insurance status and state. Opportunities exist to increase access to cessation treatments through comprehensive state tobacco control programs and improved cessation insurance coverage, coupled with promotion of covered cessation treatments.
