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State-Specific Prevalence of Cigarette Smoking Among Adults, and Children's and Adolescents' Exposure to Environmental Tobacco Smoke -- United States, 1996

In 1996, the prevalence of cigarette smoking was added to the list of nationally notifiable health conditions reported by states to CDC (1). The addition of a health-related behavior to the list of diseases and illnesses reflected the recognized role of tobacco use as the leading preventable cause of death in the United States (2). This report summarizes the 1996 prevalence of current smoking among adults in 49 states and the District of Columbia and presents state-specific estimates of environmental tobacco smoke (ETS) exposure for children and adolescents residing in homes where adults smoke. The findings indicate that state-specific smoking prevalence among adults varied twofold and that approximately 15 million children and adolescents were exposed to ETS in their home.

State-specific data about adult smoking prevalence were obtained from the Behavioral Risk Factor Surveillance System (BRFSS), a state-based, random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged greater than or equal to 18 years. The 1996 BRFSS was conducted in 49 states and the District of Columbia. Respondents were asked "Have you smoked at least 100 cigarettes in your entire life?" and "Do you now smoke cigarettes every day, some days, or not at all?" Current smokers were defined as persons who reported having smoked greater than or equal to 100 cigarettes during their lifetimes and who currently smoked every day or on some days. Estimates were weighted to represent the populations of each state. For estimates of the percentage of homes with both current cigarette smokers and children and adolescents (persons aged less than 18 years) living at home, data were weighted to represent the number of households in each state.

Children's and adolescents' ETS exposure was calculated by applying the BRFSS-derived prevalence estimates to data from the 1992-1993 and 1996 Current Population surveys (CPSs), an annual survey of the civilian, noninstitutionalized U.S. population. Responses to questions included in the September 1992, January 1993, and May 1993 CPS were used to calculate the state-specific percentage of households that had an adult smoker and any children aged less than 18 years and that permitted smoking in all or some areas of the home (3). To estimate the percentage of households in which a child was exposed to ETS from an adult smoker residing in the home, the percentage of households in which smoking was allowed in the home (1992-1993 CPS) was applied to the percentage of households with an adult smoker and any children (1996 BRFSS). Finally, the resulting percentage was applied to the number of households and multiplied by the number of children in the home (1996 CPS) to calculate the number of children exposed to ETS in the home. Variances associated with these estimates were combined using a Taylor-Series approximation method.

During 1996, the median prevalence of current smoking was 23.6% (Table_1); state-specific prevalences ranged from 15.9% (Utah) to 31.6% (Kentucky). Range endpoints were higher for men (18.6%-33.9%) than for women (13.4%-29.5%). The percentage of households with an adult smoker and any children ranged from 7.0% (District of Columbia) to 14.9% (Alaska) (Table_2). The percentage of households with an adult smoker and children and in which smoking was allowed in some or all areas of the home ranged from 70.6% (Washington) to 95.6% (District of Columbia). The estimated number of children exposed to ETS in the home ranged from 32,105 (Delaware) to 1,120,051 (New York), and the estimated percentage of children ranged from 11.7% (Utah) to 34.2% (Kentucky) (Table_2).

Reported by the following BRFSS coordinators: J Cook, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, MS, Florida; E Pledger, MPA, Georgia; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; N Costello, MPA, Indiana; A Wineski, Iowa; M Perry, Kansas; K Asher, Kentucky; R Meriwether, MD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson, Mississippi; T Murayi, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; W Honey, New Mexico; T Melnik, DrPH, New York; K Passaro, PhD, North Carolina; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; J Ferguson, DrPH, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; L Redman, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; P Imm, MS, Wisconsin; M Futa, MA, Wyoming. Council of State and Territorial Epidemiologists. P Mowery, MA, Battelle Memorial Institute, Baltimore, Maryland. D Coole, MS, J Chrismon, TRW Inc, Fairfax, Virginia. Behavioral Surveillance Br, Div of Adult and Community Health, and Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report highlight the wide range of smoking prevalence and children's and adolescents' exposure to ETS across states and underscore the large population at risk for serious health effects of tobacco use (both smokers and nonsmokers). Compared with 1995 (4), the 1996 median prevalence of current smoking among adults increased approximately 1%; in 24 states, state-specific prevalences increased greater than or equal to 1%, and increases were statistically significant in 10 states. The increase from 1995 to 1996 may reflect, in part, the 1996 change in the definition used to assess self-reported smoking prevalence (in 1995, respondents were asked "Have you smoked at least 100 cigarettes in your entire lifetime?" and "Do you smoke cigarettes now?") (5). By including some-day smoking with every-day smoking in the definition of current smoking, prevalence estimates increase by approximately 1% (5).

The estimates in this report are subject to at least three limitations. First, because the proportion of restrictive smoking policies in the home may have increased since 1992-1993, the CPS data may have overestimated the percentage of households in which smoking in all or some areas was permitted. Second, total exposures for children may have been underestimated because of failure or inability to include other sources of exposure to ETS both inside the home (e.g., a household guest smoking a cigarette, cigar, or pipe) and outside the home. Finally, prevalence estimates may be underestimated because data were collected through telephone interviews; previous studies have documented substantial differences in the characteristics of persons who reside in households without a telephone compared with those who reside in households with a telephone.

In 1992, the Environmental Protection Agency classified ETS as a Group A carcinogen known to cause cancer in humans (6). The primary source of children's exposure to ETS is in the home (7); children exposed to ETS are at an increased risk for sudden infant death syndrome, acute lower respiratory tract infections, asthma induction and exacerbation, and middle-ear effusions (6,8). The findings in this report indicate that approximately one third to one half of adult current cigarette smokers have children residing in their homes, and in most (greater than 70%) of those homes smoking was permitted in some or all areas of the home. Therefore, during 1996, approximately 15 million (21.9%) children and adolescents aged less than 18 years were exposed to ETS in homes. One of the national health objectives for 2000 is to reduce to less than or equal to 20% the number of children aged less than or equal to 6 years exposed to ETS in the home (objective 3.8) (7). The findings in this report underscore the need for continued national and state-level public health initiatives to reduce cigarette smoking and children's exposure to ETS in the home.

In addition to addressing the smoking behaviors of adults and the related direct deleterious health effects for smokers, public health initiatives also must be directed toward the adverse effects on nonsmokers and on children exposed to ETS in the home. Strategies for reducing the prevalence of cigarette smoking and minimizing children's exposure to ETS include preventing young persons from initiating smoking, encouraging smokers to quit, and educating smokers about the hazards of ETS (9).

References

  1. CDC. Addition of prevalence of cigarette smoking as a nationally notifiable condition -- June 1996. MMWR 1996;45:537.

  2. CDC. Smoking-attributable mortality and years of potential life lost -- United States, 1984. MMWR 1997;46:444-51.

  3. Shopland DR, Hartman AM, Gibson JT, Mueller MD, Kessler LG, Lynn WR. Cigarette smoking among US adults by state and region: estimates from the Current Population Survey. J Natl Cancer Inst 1996;88:1748-58.

  4. CDC. State-specific prevalence of cigarette smoking -- United States, 1995. MMWR 1996;45: 962-6.

  5. CDC. Cigarette smoking among adults -- United States, 1992, and changes in the definition of current cigarette smoking. MMWR 1994;43:342-6.

  6. US Environmental Protection Agency. Respiratory health effects of passive smoking: lung cancer and other disorders. Washington, DC: US Environmental Protection Agency, 1992; publication no. EPA/600/6-90/006F.

  7. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

  8. California Environmental Protection Agency. Health effects of exposure to environmental tobacco smoke. Sacramento, California: California Environmental Protection Agency, Office of Environmental Health and Hazard Assessment, 1997.

  9. US Department of Health and Human Services. Preventing tobacco use among young people: report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.



Table_1
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TABLE 1. Prevalence of current cigarette smoking among adults,* by state+ and sex -- United
States, Behavioral Risk Factor Surveillance System, 1996
==================================================================================================
                                   Men                    Women                    Total
                            ----------------        -----------------        ---------------------
State                          %   (95% CI&)            %    (95% CI)            %    (95% CI)
--------------------------------------------------------------------------------------------------
Alabama                     24.4   (+/-3.3%)         20.8   (+/-2.4%)         22.5   (+/-2.1%)
Alaska                      30.9   (+/-5.2%)         24.3   (+/-4.1%)         27.7   (+/-3.4%)
Arizona                     27.2   (+/-4.2%)         20.6   (+/-3.2%)         23.8   (+/-2.5%)
Arkansas                    27.7   (+/-4.2%)         23.3   (+/-2.7%)         25.4   (+/-2.4%)
California                  21.4   (+/-2.2%)         15.9   (+/-1.6%)         18.6   (+/-1.4%)
Colorado                    24.5   (+/-3.5%)         21.2   (+/-2.8%)         22.8   (+/-2.2%)
Connecticut                 22.7   (+/-3.5%)         21.2   (+/-2.9%)         21.9   (+/-2.2%)
Delaware                    25.0   (+/-3.3%)         23.5   (+/-2.7%)         24.2   (+/-2.2%)
District of Columbia        23.8   (+/-4.4%)         17.8   (+/-3.0%)         20.6   (+/-2.6%)
Florida                     23.3   (+/-2.3%)         20.4   (+/-1.9%)         21.8   (+/-1.5%)
Georgia                     24.7   (+/-3.2%)         16.3   (+/-2.2%)         20.3   (+/-1.9%)
Idaho                       21.3   (+/-2.6%)         21.1   (+/-2.2%)         21.2   (+/-1.7%)
Illinois                    26.3   (+/-2.8%)         23.5   (+/-2.3%)         24.8   (+/-1.8%)
Indiana                     31.6   (+/-3.2%)         26.0   (+/-2.6%)         28.7   (+/-2.1%)
Iowa                        26.3   (+/-2.5%)         21.2   (+/-1.9%)         23.6   (+/-1.6%)
Kansas                      26.1   (+/-3.3%)         18.3   (+/-2.4%)         22.1   (+/-2.0%)
Kentucky                    33.8   (+/-2.9%)         29.5   (+/-2.1%)         31.6   (+/-1.8%)
Louisiana                   31.6   (+/-3.9%)         20.8   (+/-2.8%)         25.9   (+/-2.4%)
Maine                       28.9   (+/-3.7%)         22.0   (+/-2.9%)         25.3   (+/-2.4%)
Maryland                    22.6   (+/-2.5%)         19.6   (+/-1.9%)         21.0   (+/-1.5%)
Massachusetts               23.9   (+/-3.6%)         22.9   (+/-2.9%)         23.4   (+/-2.3%)
Michigan                    26.5   (+/-2.9%)         24.8   (+/-2.4%)         25.6   (+/-1.9%)
Minnesota                   21.7   (+/-2.0%)         19.5   (+/-1.7%)         20.6   (+/-1.3%)
Mississippi                 28.6   (+/-4.2%)         18.5   (+/-2.6%)         23.2   (+/-2.4%)
Missouri                    29.0   (+/-4.0%)         26.7   (+/-3.1%)         27.8   (+/-2.5%)
Montana                     20.5   (+/-3.1%)         22.8   (+/-2.9%)         21.7   (+/-2.2%)
Nebraska                    25.4   (+/-4.5%)         18.9   (+/-2.5%)         22.0   (+/-2.6%)
Nevada                      28.5   (+/-4.5%)         28.0   (+/-4.0%)         28.2   (+/-3.0%)
New Hampshire               25.5   (+/-4.3%)         24.3   (+/-3.5%)         24.9   (+/-2.7%)
New Jersey                  25.0   (+/-2.9%)         20.9   (+/-2.2%)         22.8   (+/-1.8%)
New Mexico                  24.9   (+/-5.0%)         20.9   (+/-3.8%)         22.9   (+/-3.1%)
New York                    23.2   (+/-2.2%)         23.3   (+/-1.8%)         23.3   (+/-1.4%)
North Carolina              30.0   (+/-3.2%)         21.9   (+/-2.3%)         25.7   (+/-2.0%)
North Dakota                24.4   (+/-3.4%)         22.5   (+/-2.9%)         23.4   (+/-2.3%)
Ohio                        33.9   (+/-4.2%)         23.6   (+/-3.1%)         28.5   (+/-2.6%)
Oklahoma                    26.4   (+/-3.7%)         21.9   (+/-3.0%)         24.1   (+/-2.4%)
Oregon                      24.4   (+/-2.7%)         22.6   (+/-2.2%)         23.5   (+/-1.7%)
Pennsylvania                23.8   (+/-2.4%)         25.2   (+/-2.1%)         24.5   (+/-1.6%)
Rhode Island                25.7   (+/-3.5%)         19.8   (+/-2.6%)         22.5   (+/-2.2%)
South Carolina              25.3   (+/-4.2%)         23.8   (+/-3.0%)         24.5   (+/-2.5%)
South Dakota                22.3   (+/-2.9%)         19.2   (+/-2.4%)         20.7   (+/-1.9%)
Tennessee                   31.1   (+/-2.9%)         25.2   (+/-2.2%)         28.0   (+/-1.8%)
Texas                       27.5   (+/-3.7%)         18.5   (+/-2.6%)         22.9   (+/-2.2%)
Utah                        18.6   (+/-2.7%)         13.4   (+/-2.1%)         15.9   (+/-1.7%)
Vermont                     26.6   (+/-3.7%)         21.8   (+/-2.4%)         24.1   (+/-2.2%)
Virginia                    27.6   (+/-3.7%)         22.2   (+/-2.8%)         24.8   (+/-2.3%)
Washington                  24.6   (+/-2.4%)         22.4   (+/-2.1%)         23.5   (+/-1.6%)
West Virginia               28.0   (+/-3.2%)         25.5   (+/-2.5%)         26.7   (+/-2.0%)
Wisconsin                   27.6   (+/-3.6%)         22.4   (+/-2.9%)         24.9   (+/-2.3%)
Wyoming                     24.4   (+/-2.9%)         24.8   (+/-2.5%)         24.6   (+/-1.9%)
Range                  18.6-33.9                13.4-29.5               I15.9-31.6
Median                      25.5                     22.0                    I23.6
--------------------------------------------------------------------------------------------------
* Persons aged >=18 years who reported having smoked >=100 cigarettes and who reported
  smoking every day or some days.
+ No data were available for Hawaii.
& Confidence interval.
==================================================================================================

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Table_2
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TABLE 2. Percentage of households with an adult* current cigarette smoker and any children and adolescents+ in the home, rules& about smoking in the
home, and the estimated number of children exposed to environmental tobacco smoke (ETS) in the home, by state@ -- United States, Behavioral Risk
Factor Surveillance System, 1996
==================================================================================================================================================================
                                 Current cigarette smoker                 Smoking allowed in some or
                                and any children in the home              all areas of the home                      Children exposed to ETS in the home
                               -----------------------------             ------------------------------          -------------------------------------------------
State                             %               (95% CI**)               %                  (95% CI)            %                      No.           (95% CI)
------------------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama                         10.0               (+/-1.3%)              88.0               (+/-5.5%)           23.6                289,110       (+/- 45,817)
Alaska                          14.9               (+/-2.6%)              77.9               (+/-6.3%)           21.6                 47,493       (+/-  9,244)
Arizona                          9.8               (+/-1.8%)              76.9               (+/-7.3%)           18.5                227,316       (+/- 51,459)
Arkansas                        10.8               (+/-1.4%)              90.2               (+/-4.5%)           26.6                177,686       (+/- 28,902)
California                       7.3               (+/-0.8%)              72.3               (+/-3.3%)           12.3              1,114,865       (+/-154,535)
Colorado                         9.1               (+/-1.4%)              81.6               (+/-7.1%)           19.0                193,138       (+/- 34,746)
Connecticut                      9.7               (+/-1.5%)              84.4               (+/-6.8%)           20.8                186,859       (+/- 34,432)
Delaware                        10.0               (+/-1.3%)              86.2               (+/-6.4%)           17.7                 32,105       (+/-  5,663)
District of Columbia             7.0               (+/-1.6%)              95.6               (+/-5.1%)           31.8                 40,196       (+/-  9,985)
Florida                          8.1               (+/-0.9%)              79.8               (+/-3.3%)           19.6                692,720       (+/- 86,083)
Georgia                          8.8               (+/-1.2%)              91.0               (+/-4.8%)           21.0                423,332       (+/-108,547)
Idaho                            9.3               (+/-1.1%)              79.9               (+/-6.1%)           18.6                 61,811       (+/-  8,996)
Illinois                         9.7               (+/-1.1%)              87.6               (+/-2.8%)           24.1                773,657       (+/- 92,787)
Indiana                         11.6               (+/-1.3%)              85.4               (+/-5.1%)           27.5                420,257       (+/- 58,376)
Iowa                            11.4               (+/-1.1%)              91.7               (+/-4.1%)           27.2                231,575       (+/- 28,310)
Kansas                           8.9               (+/-1.3%)              88.9               (+/-4.6%)           22.8                161,255       (+/- 26,077)
Kentucky                        13.9               (+/-1.3%)              95.0               (+/-3.2%)           34.2                363,937       (+/- 40,646)
Louisiana                       10.7               (+/-1.5%)              85.4               (+/-5.8%)           23.0                294,892       (+/- 51,436)
Maine                           11.3               (+/-1.6%)              86.7               (+/-4.9%)           25.3                 79,530       (+/- 12,242)
Maryland                         8.8               (+/-0.9%)              89.3               (+/-6.1%)           20.1                270,018       (+/- 39,213)
Massachusetts                    7.4               (+/-1.2%)              84.3               (+/-3.4%)           19.7                297,469       (+/- 52,068)
Michigan                        10.9               (+/-1.2%)              91.2               (+/-2.3%)           26.8                716,003       (+/- 85,401)
Minnesota                        9.1               (+/-0.9%)              88.9               (+/-4.6%)           21.6                282,794       (+/- 33,276)
Mississippi                     11.2               (+/-1.7%)              86.2               (+/-5.7%)           23.6                192,720       (+/- 34,155)
Missouri                        10.2               (+/-1.5%)              88.9               (+/-5.1%)           26.9                352,936       (+/- 58,571)
Montana                          8.6               (+/-1.3%)              92.9               (+/-4.2%)           23.3                 52,487       (+/-  8,773)
Nebraska                         9.4               (+/-1.3%)              86.0               (+/-5.2%)           21.0                 96,897       (+/- 15,293)
Nevada                           8.7               (+/-1.6%)              86.0               (+/-5.8%)           20.8                 84,551       (+/- 16,847)
New Hampshire                   10.4               (+/-1.6%)              87.0               (+/-6.0%)           24.6                 70,576       (+/- 12,163)
New Jersey                       9.8               (+/-1.2%)              82.9               (+/-3.6%)           20.4                398,218       (+/- 49,758)
New Mexico                      10.0               (+/-2.0%)              81.9               (+/-6.0%)           19.1                103,431       (+/- 26,654)
New York                         9.6               (+/-0.9%)              88.9               (+/-2.2%)           23.2              1,120,051       (+/-111,384)
North Carolina                  10.1               (+/-1.2%)              87.5               (+/-2.7%)           26.1                416,544       (+/- 51,488)
North Dakota                    10.0               (+/-1.4%)              89.7               (+/-4.8%)           23.9                 42,729       (+/-  6,663)
Ohio                            11.8               (+/-1.6%)              91.0               (+/-2.2%)           29.8                919,290       (+/-128,696)
Oklahoma                         9.7               (+/-1.6%)              91.7               (+/-4.3%)           25.6                216,335       (+/- 36,983)
Oregon                           9.8               (+/-1.1%)              75.9               (+/-7.8%)           20.1                167,533       (+/- 26,977)
Pennsylvania                    11.0               (+/-1.1%)              87.6               (+/-2.7%)           27.9                858,229       (+/- 87,807)
Rhode Island                     9.3               (+/-1.4%)              92.4               (+/-4.9%)           23.9                 53,646       (+/-  8,179)
South Carolina                  11.3               (+/-1.7%)              86.2               (+/-4.7%)           22.2                240,315       (+/- 43,386)
South Dakota                     8.6               (+/-1.3%)              89.7               (+/-4.3%)           22.3                 45,027       (+/-  7,448)
Tennessee                       14.0               (+/-1.4%)              90.0               (+/-4.4%)           32.1                488,846       (+/- 64,578)
Texas                            9.6               (+/-1.4%)              82.0               (+/-3.4%)           18.4                995,462       (+/-158,639)
Utah                             8.0               (+/-1.2%)              73.5               (+/-8.4%)           11.7                 82,929       (+/- 16,503)
Vermont                         10.4               (+/-1.3%)              88.4               (+/-5.2%)           24.2                 42,340       (+/-  6,499)
Virginia                         8.6               (+/-1.3%)              87.5               (+/-4.8%)           22.5                336,794       (+/- 59,265)
Washington                       9.5               (+/-1.1%)              70.6               (+/-7.5%)           17.7                244,887       (+/- 39,191)
West Virginia                   10.8               (+/-1.2%)              93.6               (+/-3.5%)           30.4                128,665       (+/- 17,100)
Wisconsin                       11.4               (+/-1.6%)              90.9               (+/-4.1%)           28.5                428,302       (+/- 67,344)
Wyoming                         10.2               (+/-1.2%)              86.8               (+/-5.9%)           23.0                 33,950       (+/-  5,017)

Range                         7.0-14.9                                 70.6-95.6                           32,105-1,120,051
Median                           9.8                                      87.5                                 229,446
------------------------------------------------------------------------------------------------------------------------------------------------------------------
*  Persons aged >=18 years who reported having smoked >=100 cigarettes and who reported smoking every day or some days.
+  Persons aged >=18 years.
&  Based on the 1992-93 Current Population Survey Question, "Which statement best describes the rules about smoking in your home?" Allowing smoking is
   is defined as "Smoking is allowed in some places or at some times" and "Smoking is permitted anywhere." Restricted to adult smokers with children
   in the home.
@  No data were available for Hawaii.
** Confidence interval.
==================================================================================================================================================================

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