Tobacco Product Use Among Adults — United States, 2013–2014

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).

Acknowledgments

Kimberly Nguyen, Office on Smoking and Health, CDC; Benjamin Apelberg, Center for Tobacco Products, Food and Drug Administration.

Corresponding author: S. Sean Hu, shu@cdc.gov, 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.

References

1. US Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdfpdf iconexternal icon
2. King BA, Patel R, Nguyen KH, Dube SR. Trends in awareness and use of electronic cigarettes among US adults, 2010–2013. Nicotine Tob Res 2015;17:219–27. CrossRefexternal icon PubMedexternal icon
3. Agaku IT, King BA, Husten CG, et al. Tobacco product use among adults—United States, 2012–2013. MMWR Morb Mortal Wkly Rep 2014;63:542–7. PubMedexternal icon
4. Berg CJ, Stratton E, Schauer GL, et al. Perceived harm, addictiveness, and social acceptability of tobacco products and marijuana among young adults: marijuana, hookah, and electronic cigarettes win. Subst Use Misuse 2015;50:79–89. CrossRefexternal icon PubMedexternal icon
5. King BA, Dube SR, Tynan MA. Current tobacco use among adults in the United States: findings from the National Adult Tobacco Survey. Am J Public Health 2012;102:e93–100. CrossRefexternal icon PubMedexternal icon
6. Rosa JD, Aloise-Young P. A qualitative study of smoker identity among college student smokers. Subst Use Misuse 2015;50:1510–7. CrossRefexternal icon PubMedexternal icon
7. Harris JB, Schwartz SM, Thompson B. Characteristics associated with self-identification as a regular smoker and desire to quit among college students who smoke cigarettes. Nicotine Tob Res 2008;10:69–76. CrossRefexternal icon PubMedexternal icon
8. Dickinson DM, Johnson SE, Coleman BN, Tworek C, Tessman GK, Alexander J. The language of cigar use: focus group findings on cigar product terminology. Nicotine Tob Res 2016;18:850–6.
9. World Health Organization. WHO report on the global tobacco epidemic, 2008—the MPOWER package. Geneva, Switzerland: World Health Organization; 2008. http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdfpdf iconexternal icon
10. Caraballo RS, Giovino GA, Pechacek TF, Mowery PD. Factors associated with discrepancies between self-reports on cigarette smoking and measured serum cotinine levels among persons aged 17 years or older: Third National Health and Nutrition Examination Survey, 1988-1994. Am J Epidemiol 2001;153:807–14. CrossRefexternal icon PubMedexternal icon

TABLE 1. Percentage of persons aged ≥18 years who reported tobacco product use “every day” or “some days” and met established thresholds, by tobacco product and selected characteristics — National Adult Tobacco Survey, United States, 2013–2014

Abbreviations: CI = confidence interval; e-cigarettes = electronic cigarettes; GED = General Education Development certificate; LGB = lesbian, gay, or bisexual.
* Any tobacco use was defined as “every day” or “some days” use of cigarettes; cigars, cigarillos, or filtered little cigars; pipes; water pipes/hookahs; e-cigarettes; or smokeless tobacco (snus, dissolvable tobacco products, or snuff, chewing tobacco or dip). The survey assessed “every day” or “some days” use of the respective products only among persons who met specified lifetime usage thresholds: cigarettes (≥100 times); cigars/cigarillos/filtered little cigars (≥50 times); regular pipes (≥50 times); water pipes/hookahs (≥1 time); snus (≥1 time]; dissolvable tobacco products (≥1 time); chewing tobacco/snuff/dip (≥20 times); and e-cigarettes (≥1 time).
^† Any combustible tobacco users were defined as persons who met specified lifetime usage thresholds for at least one of four different tobacco product types (cigarettes [≥100 times]; cigars/cigarillos/filtered little cigars [≥50 times]; regular pipes [≥50 times]; water pipes/hookahs [≥1 time]), and who now (at the time of the survey) used the respective product(s) every day or some days.
^§ Current cigarette smokers were defined as persons who reported smoking ≥100 cigarettes during their lifetime and now smoked cigarettes every day or some days.
^¶ Current cigar/cigarillo/filtered little cigar smokers were defined as persons who reported smoking cigars, cigarillos, or little filtered cigars ≥50 times during their lifetime and now smoked cigars, cigarillos, or little filtered cigars every day or some days.
** Reported smoking a regular pipe filled with tobacco ≥50 times during their lifetime and now smoked a regular pipe filled with tobacco every day or some days.
^†† Reported smoking tobacco in a water pipe/hookah at least once during their lifetime and now smoked tobacco in a water pipe/hookah every day or some days.
^§§ Persons who reported using electronic cigarettes at least once during their lifetime and now used e-cigarettes every day or some days.
^¶¶ Smokeless tobacco users were defined as using at least one of the following three tobacco product types: 1) chewing tobacco, snuff, or dip; 2) snus; and 3) dissolvable tobacco products. Chewing tobacco, snuff, or dip users were respondents who reported using the product ≥20 times during their lifetime and now using chewing tobacco, snuff, or dip every day or some days. Snus or dissolvable tobacco product users were respondents who reported using each respective product at least once during their lifetime and now using each respective product every day or some days.
*** Estimate not presented because relative standard error ≥30%.
^††† Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

TABLE 2. Percentage of persons aged ≥18 years who reported tobacco product use “every day,” “some days,” or “rarely” and met established thresholds, by tobacco product and selected characteristics — National Adult Tobacco Survey, United States, 2013–2014

Abbreviations: CI = confidence interval; e-cigarettes = electronic cigarettes; GED = General Education Development certificate; LGB = lesbian, gay, or bisexual.
* Any tobacco use was defined as “every day” or “some days” use of cigarettes; and/or “every day,” “some days,” or “rarely” use of cigars, cigarillos, or filtered little cigars; pipes; water pipes/hookahs; e-cigarettes; or smokeless tobacco (snus, dissolvable tobacco products, or snuff, chewing tobacco or dip). Cigarettes are not presented separately because the questionnaire only assessed “every day” or “some days” use (no “rarely” response option). “Every day” or “some days” use of cigarettes was assessed among those who reported smoking ≥100 cigarettes during their lifetime.
^† For the other tobacco product types, the survey assessed “every day,” “some days,” or “rarely” use among persons who met specified lifetime usage thresholds for the different tobacco product types: cigars/cigarillos/filtered little cigars (≥50 times); regular pipes (≥50 times); water pipes/hookahs (≥1 time); snus (≥1 time]; dissolvable tobacco products (≥1 time); chewing tobacco/snuff/dip (≥20 times); and e–cigarettes (≥1 time).
^§ Current cigar/cigarillo/filtered little cigar smokers were defined as persons who reported smoking cigars, cigarillos, or little filtered cigars ≥50 times during their lifetime and smoked a cigar, cigarillos, or filtered little cigars every day, some days, or rarely.
^¶ Reported smoking a regular pipe filled with tobacco ≥50 times during their lifetime and now smoked a regular pipe filled with tobacco every day, some days, or rarely.
** Reported smoking tobacco in a water pipe/hookah at least once during their lifetime and now smoked tobacco in a water pipe/hookah every day, some days, or rarely.
^†† Persons who reported using electronic cigarettes at least once during their lifetime and now using electronic cigarettes every day, some days, or rarely.
^§§ Smokeless tobacco users were defined using at least one of the following three tobacco product types: 1) chewing tobacco, snuff, or dip; 2) snus; and 3) dissolvable tobacco products. Chewing tobacco, snuff, or dip users were respondents who reported using the product at least 20 times during their lifetime and now used chewing tobacco, snuff, or dip every day, some days, or rarely. Snus or dissolvable tobacco product users were respondents who reported using each respective product at least once during their lifetime and now used each respective product every day, some days, or rarely.
^¶¶ Estimate not presented because relative standard error ≥30%.
*** Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

FIGURE. Distribution of persons aged =18 years who were “every day,” “some days,” or “rarely” tobacco users and met thresholds for established use,* by age group^† and type of tobacco product^§ — National Adult Tobacco Survey, United States, 2013–2014

Abbreviation: e-cigarettes = electronic cigarettes.

* Any tobacco use was defined as “every day” or “some days” use of cigarettes; and/or “every day,” “some days,” or “rarely” use of cigars, cigarillos, or filtered little cigars; pipes; water-pipes/hookahs; e-cigarettes; smokeless tobacco (snus, dissolvable tobacco products, or snuff, chewing tobacco or dip). Cigarettes not presented separately because the questionnaire only assessed “every day” or “some days” cigarette smoking (i.e., no “rarely” response option). “Every day” or “some days” use of cigarettes was assessed only among persons who reported smoking at least 100 cigarettes during their lifetime. For the other tobacco product types, the survey assessed “every day,” “some days,” or “rarely” use among persons who met specified lifetime usage thresholds, which were different for the different tobacco product types assessed: cigars/cigarillos/filtered little cigars (=50 times); regular pipes (=50 times); water pipes/hookahs (=1 time); snus (=1 time]; dissolvable tobacco products (=1 time); chewing tobacco/snuff/dip (=20 times); and e-cigarettes (=1 time).

^† Respondents of unknown age (1.5%) were excluded from these calculations.

^§ Denominator for each product comprised respondents who had ever reached the threshold for the specified product, including current and former users.