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Any Tobacco Use in 13 States --- Behavioral Risk Factor Surveillance System, 2008
Tobacco use is the leading cause of preventable death in the United States, and cigarette smoking, the predominant form of tobacco use in the United States, causes 443,000 deaths annually (1). In 2008, 20.6% of U.S. adults were current smokers (2); however, other tobacco products (e.g., smokeless tobacco, cigars, bidis, and kreteks) also were used by some adults and youths (3). Persons who use cigarettes in combination with other tobacco products (polytobacco use) might have an in increased risk for adverse health effects (3). To estimate the prevalence of any tobacco and polytobacco use, CDC analyzed data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) (the most recent data available) module on use of other tobacco products, which was implemented by 13 states. This analysis found that use of any tobacco product ranged from 18.4% (New Jersey) to 35.0% (West Virginia), cigarette use ranged from 14.6% (New Jersey) to 26.6% (West Virginia), and polytobacco use ranged from 1.0% (New Jersey) to 3.7% (West Virginia). Polytobacco use was more prevalent among men (4.4%), persons aged 18--24 years (5.7%), persons who were single (4.8%), persons with household incomes less than $35,000 (9.8%), and persons with less than a high school education (3.6%) or with a high school diploma or General Education Development (GED) certificate or diploma (3.6%). Because no form of tobacco is safe to use, prevention and cessation intervention programs need to address all forms of tobacco use to lower tobacco-related morbidity and mortality in the United States. Additionally, counter-marketing messages for tobacco products can be tailored for specific populations, such as young adults and males.
BRFSS is a state-based, telephone survey of noninstitutionalized, civilian adults aged ≥18 years in all 50 states, the District of Columbia (DC), and U.S. territories. In 2008, 13 states* collected information on the use of tobacco products other than cigarettes through an optional BRFSS module.† Responses to questions on this module and the core questionnaire were used to measure current use of cigarettes,§ smokeless tobacco,¶ and other tobacco products (cigars, pipes, bidis,** kreteks,†† and others).§§ Any tobacco users were considered respondents who currently used any of the following: cigarette, smokeless tobacco, or other tobacco products. Current polytobacco users were considered respondents who were current cigarette smokers and also current users of another form of tobacco (either smokeless tobacco or other tobacco products). BRFSS uses multistage probability sampling to obtain state-specific estimates of risk behaviors. Estimates weighted by probability of selection and post-stratified by age, sex, and race were calculated, as were 95% confidence intervals for each state and aggregated selected demographic subgroups. Response rates for the 2008 BRFSS survey were calculated using Council American Survey and Research Organizations (CASRO) guidelines,¶¶ and ranged from 43.4% to 65.5% (median: 55.3%) in the 13 states. Cooperation rates*** in 2008 ranged from 68.4% to 80.7% (median: 76.0%). Data were combined for the 13 states to examine how tobacco use measures were distributed among demographic groups in those states.††† For comparisons of prevalence by sex, race/ethnicity, income, education, and marital status, statistical significance (p<0.05) was determined using a two-sided z-test.
During 2008, the range of prevalence of any tobacco use in the 13 states was 18.4% (New Jersey) to 35.0% (West Virginia) (Table 1). Polytobacco use also was highest in West Virginia (3.7%) and lowest in New Jersey (1.0%). Among the 13 states, current use of any tobacco was more prevalent among men than women (p<0.001) and decreased with increasing age (Table 2). Any tobacco use was more prevalent among non-Hispanic whites (26.2%) and non-Hispanic blacks (24.4%) than among Hispanics (19.7%, p<0.001 and p=0.001, respectively). Any tobacco use also was most prevalent among persons who were a member of an unmarried couple (36.3%), single (30.3%), widowed or divorced (29.1%), or who had less than a high school education (33.1%). Any tobacco use decreased with increasing levels of annual income, 32.5% for those earning less than $15,000 and 19.2% for those earning $75,000 or more. Polytobacco use was most prevalent among men (4.4%), persons aged 18--24 years (5.7%), single adults (4.8%), persons with less than a high school education (3.6%) and high school diploma/GED (3.6%), and persons with incomes less than $35,000 (9.8%).
S Thorne, PhD, A McClave, MPH, V Rock, MPH, K Asman, MSPH, A Malarcher, PhD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
Tobacco control efforts have focused largely on decreasing the prevalence of cigarette smoking; however, other tobacco products also are being used singly or in combination by adults. The prevalence of cigarette smoking ranged from 14.6% to 26.6% in the 13 states in this analysis; however, when any tobacco use (including use of smokeless tobacco, cigars, pipes, bidis, kreteks, and other forms of tobacco) also is considered, an additional 5% of the adult population in these states would be considered tobacco users (range: 18.4%--35.0%). The findings in this report are similar to those of previous studies, which show that polytobacco use is higher among men and young adults than other demographic groups (3,4). Additionally, the findings show that the risk factors for polytobacco use mirror those for cigarette smoking (men, persons aged 18--24 years, persons who are single, persons whose household income is less than $35,000, and persons with no more than a high school education).
Use of multiple tobacco products is associated with higher nicotine addiction, inability to quit using tobacco, and adverse health effects (3). These health effects can lead to increased risks for tobacco-related morbidity and mortality (3). Because youths have higher polytobacco use than do adults (5), and among adults, young adults are the most likely to use multiple forms of tobacco concurrently (3,4), prevention programs and policy interventions need to address all forms of tobacco use, as recommended by CDC's Guide to Community Preventive Services.§§§
Healthy People 2010 objectives call for the reduction of cigarette smoking to 12.0% and the reduction of spit (smokeless) tobacco use to 0.4% (6). Although cigarette smoking has declined among adults in the United States during the past decade (2), use of smokeless tobacco has remained stable at approximately 3% among adults aged ≥26 years during 2004--2008 (4). However, from 2003 to 2008, smokeless tobacco use increased from 13.6% to 15.4% among non-Hispanic white men aged 18--25 years, and 1.9% to 3.4% among Hispanic men aged 18--25 years (4). Although women in all 13 states have met the Healthy People 2010 objective for smokeless tobacco use, no state in this report has met the objective for either current cigarette smoking or current smokeless tobacco use. Public Health Service guidelines suggest that clinicians use the five A's (ask, advise, assess, assist, and arrange) intervention method to help treat tobacco dependence, including polytobacco use (7). The guidelines also recommend that clinicians identify smokeless tobacco and other tobacco product users, urge them to quit, and provide cessation counseling interventions that are recommended for cigarette smokers (7).
The findings in this report are subject to at least four limitations. First, smoking prevalence might be underestimated because BRFSS does not survey persons in households without telephone service (2.5%) or wireless-only households (17.5%), and adults with wireless-only service are more likely (30.2%) than the rest of the U.S. population to be current smokers (8). Second, estimates for the current use of tobacco products are based on self-report and are not validated by biochemical tests. However, self-reported data on current smoking have high validity and this validity might translate to self-reported use of other tobacco products, such as smokeless tobacco, cigars, bidis, and kreteks (9). Third, the median response rate for the 13 states was 55.3% (range: 43.4%--65.5%) in 2008. Lower response rates increase the potential for response bias; however, BRFSS aggregated state estimates previously have been shown to be comparable to tobacco use estimates from other surveys with higher response rates (8). Fourth, these findings are not generalizable to other states. Those states that used the other tobacco product module most likely have an interest or concern about other tobacco use issues within their state.
The results in this report highlight the need to increase expenditures to incorporate strategies that address smoking and other tobacco use in state and national tobacco use prevention and cessation efforts. From 2005 to 2006, expenditures for smokeless tobacco product advertising increased from $250.8 million to $354.1 million (10). Additionally, smokeless tobacco use has increased among some population subgroups, especially young adults, non-Hispanic white men, and Hispanic men (4). The increase in advertising expenditures and increased use among subgroups both warrant continued surveillance and monitoring of smokeless tobacco use and use of other tobacco products.
The Family Smoking Prevention and Tobacco Control Act,¶¶¶ enacted in 2009, gives the Food and Drug Administration (FDA) authority to regulate the content, sales, and marketing of cigarettes, smokeless tobacco, and roll-your-own tobacco. Under this authority, new tobacco products cannot be introduced in the United States and existing products cannot be changed without FDA approval. The recent increased focus from the tobacco industry on smokeless tobacco products, combined with the unlikelihood of achieving Healthy People 2010 tobacco objectives, suggests the need for enhanced surveillance and implementation of comprehensive tobacco-control strategies (e.g., increased excise taxes on all tobacco products and counter-marketing messages) for other tobacco products, in addition to cigarettes.
This report is based, in part, on contributions by R Kaufmann, PhD, S Babb, MPH, R Caraballo, PhD, M Tynan, MPH, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, and C James, MSPH, Research Triangle Institute International.
- CDC. Smoking-attributable mortality, years of potential life lost, and productivity losses---United States, 2000--2004. MMWR 2008;57:1226--8.
- CDC. Cigarette smoking among adults and trends in cessation---United States, 2008. MMWR 2009;58:1227--32.
- Backinger CL, Fagan P, O'Connell ME, et al. Use of other tobacco products among U.S. adult cigarette smokers: prevalence, trends and correlates. Addict Behav 2008;33:472--89.
- Substance Abuse and Mental Health Services Administration. Results from the 2008 national survey on drug use and health: national findings. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2009. Available at http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf. Accessed July 29, 2010.
- Bombard JM, Rock VJ, Pederson LL, Asman KJ. Monitoring polytobacco use among adolescents: do cigarette smokers use other forms of tobacco? Nictotine Tob Res 2008;10:1581--9.
- US Department of Health and Human Services. Tobacco use in population groups: reduce tobacco use in adults. Cigarette smoking (27-1a). In: Healthy people 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov/document/html/volume2/27tobacco.htm#_toc489766222. Accessed July 29, 2010.
- Fiore MC, Jean CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2008. Available at http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf. Accessed July 29, 2010.
- Blumberg SJ, Luke JV. Wireless substitution: early release of estimates on data from the National Health Interview Survey, July--December 2006. Hyattsville, MD: US Department of Health and Human Services, National Center for Health Statistics, CDC; 2007. Available at http://www.cdc.gov/nchs/data/nhis/earlyrelease/wireless200705.pdf. Accessed July 29, 2010.
- Nelson DE, Holtzman D, Bolen J, Stanwyck CA, Mack KA. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Soz Praventivmed 2001;46:S3--42.
- Federal Trade Commission. Smokeless tobacco report for the year 2006. Washington, DC: Federal Trade Commission; 2009. Available at http://www.ftc.gov/os/2009/08/090812smokelesstobaccoreport.pdf. Accessed July 29, 2010.
* The following 13 states used the 2008 BRFSS "other tobacco products" module: Delaware, Florida, Indiana, Kansas, Louisiana, Nebraska, New Jersey, North Carolina, Tennessee, Texas, West Virginia, Wisconsin, and Wyoming.
† Available at http://www.cdc.gov/brfss/questionnaires/pdf-ques/2008brfss.pdf.
§ Respondents who answered "yes" to the question, "Have you smoked at least 100 cigarettes in your entire life?" and answered "everyday" or "some days" to "Do you now smoke every day, some days, or not at all?" were classified as current cigarette users.
¶ Respondents who answered "yes" to the question, "Have you ever used or tried any smokeless tobacco products such as chewing tobacco, snuff, or snus?" and "everyday" or "some days" to "Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?" were classified as current smokeless tobacco users. (Snus is a small pouch of smokeless tobacco. Unlike traditional or other forms of smokeless tobacco, snus does not require those who use it to dip or spit the tobacco).
** Bidis are small, thin, hand-rolled cigarettes imported to the United States primarily from India and Southeast Asian countries. They consist of tobacco wrapped in a tendu or temburni leaf (plants native to Asia); some are secured with a colorful string at one or both ends. Bidis can be flavored (e.g., chocolate, cherry, and mango) or unflavored.
†† Kreteks, sometimes referred to as clove cigarettes, are imported from Indonesia and typically contain a mixture of tobacco, cloves, and other additives.
§§ Respondents who answered "yes" to the question, "Do you currently use cigars, pipes, bidis, kreteks, or other tobacco products?" were classified as current users of other tobacco products.
¶¶ The response rate is the percentage of persons who completed interviews among all eligible persons, including those who were not successfully contacted.
*** The cooperation rate is the percentage of persons who completed interviews among all eligible persons who were contacted.
††† After excluding surveys with missing data on the five tobacco questions for polytobacco use, data on 96% of the survey respondents were available. Only respondents who provided complete information for all five tobacco use questions (n = 98,637) were included in the estimates of polytobacco use; responses from 3,745 (3.8%) of those persons were excluded because of missing data.
§§§ CDC's Guide to Community Preventive Services reviews the effectiveness of interventions to reduce or prevent tobacco use and is available at http://www.thecommunityguide.org/tobacco/index.html.
¶¶¶ Pub. L. No. 111-31, 123 Stat. 1776 (June 22, 2009). Available at http://www.gpo.gov/fdsys/pkg/PLAW-111publ31/content-detail.html.
What is already known on this topic?
Cigarettes are the predominate form of tobacco used in the United States; however, other forms of tobacco also are used by adults and youths, and some persons use more than one form of tobacco (polytobacco use).
What is added by this report?
During 2008, polytobacco use was 2.5% among U.S. adults and most prevalent among men, persons aged 18--24 years, single adults, persons with no more than a high school education, and persons with annual incomes less than $35,000. The most common form of polytobacco use was current use of cigarettes and other tobacco products ( cigars, bidis, kreteks, or other tobacco products).
What are the implications for public health practice?
Surveillance, prevention, and cessation interventions need to address all forms of tobacco use to lower the public health burden of tobacco use throughout the United States. Clinicians should identify persons who use smokeless tobacco and other tobacco products, urge them to quit, and provide access to cessation counseling.
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