State-Specific Prevalence of Cigarette Smoking and Quitting Among Adults --- United States, 2004

After stagnating in the early 1990s, cigarette smoking prevalence among adults in the United States declined during the late 1990s and early 2000s (1). In 2002, for the first time, more than half of those who had ever smoked had quit smoking (1). To assess the prevalence of current and never cigarette smoking and the proportion of ever smokers who had quit smoking, CDC analyzed state/area data from the 2004 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis, which indicated substantial variation in current cigarette smoking prevalence among 49 states, the District of Columbia (DC), Puerto Rico (PR), and the U.S. Virgin Islands (USVI) (range: 9.5%--27.6%). In 44 states, DC, PR, and USVI, the majority of persons had never smoked. In 34 states, PR, and USVI, more than 50% of ever smokers had quit smoking. Effective, comprehensive tobacco-use prevention and control programs should be continued and expanded to further reduce initiation among young persons and to ensure that smokers have access to effective smoking-cessation services, including proactive telephone quitline counseling (2,3).

BRFSS is a state-based, random-digit--dialed, telephone health survey of the noninstitutionalized, civilian U.S. population aged >18 years. Estimates were weighted by age and sex distributions of each state/area population, and 95% confidence intervals were calculated using statistical analysis software. Because BRFSS data are state-specific, median prevalences are reported instead of national averages. The median response rate across 49 states and DC was 52.7% (range: 32.2% [New Jersey]--66.6% [Nebraska]).

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?" Ever smokers were defined as those who reported having smoked >100 cigarettes during their lifetime. Current smokers were defined as those who reported having smoked >100 cigarettes during their lifetime and who currently smoked every day or some days. Never smokers were defined as those who reported not having smoked >100 cigarettes during their lifetime. Former smokers were defined as those who reported having smoked >100 cigarettes during their lifetime and who currently did not smoke at all. The percentage of ever smokers who had quit smoking was calculated by dividing the number of former smokers by the number of ever smokers.

Current Cigarette Smoking Prevalence

In 2004, the median adult smoking prevalence among 49 states and DC was 20.9%, with a nearly three-fold difference between the lowest and highest prevalence (range: 10.5% [Utah]--27.6% [Kentucky]) (Table 1). Current smoking prevalence was highest in Kentucky (27.6%), West Virginia (26.9%), Oklahoma (26.1%), and Tennessee (26.1%), and was lowest in Utah (10.5%), California (14.8%), and Idaho (17.5%). Smoking prevalence was 9.5% in USVI and 12.7% in PR. Men generally had a higher smoking prevalence (median: 23.2% [range: 11.7%--29.3%]) than women (median: 19.2% [range: 9.4%--26.4%]) in 49 states and DC.

Never Cigarette Smoking Prevalence

In 2004, the median adult never smoking prevalence among 49 states and DC was 54.6% (Table 2). Never smoking prevalence was highest in Utah (73.7%) and California (61.1%) and lowest in Maine (47.7%) and West Virginia (48.0%). Never smoking prevalence was 72.2% in PR and 80.5% in USVI. Women had a higher never smoking prevalence (median: 59.5% [range: 52.1%--78.9%]) than men (median: 48.4% [range: 41.3%--68.4%]).

Percentage of Ever Smokers Who Have Quit Smoking

In 2004, the median percentage of adult ever smokers who had quit among 49 states and DC was 52.4% (Table 2). Among all states/areas surveyed, 36 had percentages of ever smokers who had quit at >50%. Four states had percentages of ever smokers who had quit at >60%: Connecticut (62.5%), California (62.0%), Vermont (60.5%), and Utah (60.1%). The five states with the lowest percentages of ever smokers who had quit were Kentucky (42.5%), Mississippi (44.0%), Alabama (45.6%), Louisiana (45.9%), and Tennessee (45.9%).

Reported by: N Kuiper, MPH, A Malarcher, PhD, J Bombard, MSPH, E Maurice, MS, K Jackson, MSPH, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

One of the Healthy People 2010 objectives (objective no. 27-1a) is to reduce cigarette smoking prevalence to <12% (4). As of 2004, Utah and USVI achieved this goal in the population overall and among both men and women; California women also achieved this goal. The findings in this report indicate that in the majority of states, most adults have never been smokers and, among those who have ever smoked, the majority have quit. However, the rate of decline in current smoking is not rapid enough for most states to achieve the 2010 objective. Comprehensive tobacco-control programs are effective in preventing and reducing tobacco use, and the more funds states spend on such programs, the greater the reduction in smoking (5). Many states have reduced funding in recent years, and only four states (Colorado, Delaware, Maine, and Mississippi) funded their programs in fiscal year 2005 at even the minimum levels recommended by CDC (3,6).

The findings in this report are subject to at least three limitations. First, BRFSS does not survey persons in households without telephones, a population that might be more likely to smoke (7). BRFSS estimates that 97.6% of the U.S. population had telephones in 2003; however, noncoverage ranged from 1.1% in Connecticut and New Hampshire to 6.6% in Mississippi and 23.8% in Puerto Rico (8). Second, estimates for cigarette smoking are based on self-reports and are not validated by biochemical tests. However, self-reported data on current smoking status have high validity (7). Third, the median response rate was 52.7% (range: 32.2%--66.6%); lower response rates indicate a potential for response bias. However, BRFSS estimates for current cigarette smoking are generally comparable with smoking estimates from other surveys with higher response rates (7). Moreover, evidence suggests that telephone surveys with low response rates might not contain differential response bias compared with those with higher response rates (9).

In more than half of states, the majority of ever smokers have quit smoking; however, for every smoker who successfully quits each year, many more make attempts but do not succeed (10). Tobacco dependence is a chronic condition that often requires repeated intervention (10). Patients who are willing to quit should be provided with effective interventions, including brief interventions by clinicians at every patient visit (i.e., the five "A"s: ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in the quit attempt, and arrange for follow-up) and pharmacotherapies for smoking cessation, including bupropion (sustained release), nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, and nicotine patch (10). Patients who are not ready to quit should be provided messages to increase the motivation to quit (10).

Although minimal clinical interventions (i.e., those lasting <3 minutes) increase overall tobacco cessation rates, a strong dose-response relation has been demonstrated between session length and successful cessation (10). Proactive telephone counseling is effective in increasing successful cessation and can reach substantial numbers of tobacco users. In November 2004, CDC, in partnership with the National Cancer Institute Cancer Information Service (NCI/CIS), created a new national network of quitlines. Through the network, states received funding as part of CDC's National Tobacco Control Program either to establish a quitline or to enhance existing quitline services, in addition to training and technical assistance from the North American Quitline Consortium. A national telephone number sponsored by NCI/CIS (800-QUIT-NOW) links callers to the free quitline serving the area where they live and is designed to ensure that proactive counseling services are available to all smokers who want to quit. These cessation interventions, combined with other elements of comprehensive programs, such as creating smoke-free worksites and public places, increasing tobacco excise taxes, implementing countermarketing campaigns, and increasing insurance coverage for tobacco-use treatment, all work to encourage cessation and prevent initiation (2,3). Implementing comprehensive state tobacco-control programs at CDC-recommended funding levels (3) should accelerate progress in reducing tobacco use.

References

1. CDC. Cigarette smoking among adults --- United States, 2003. MMWR 2005;54:509--13.
2. Task Force on Community Preventive Services. Guide to community preventive services: tobacco use prevention and control. Am J Prev Med 2001;20(2 Suppl 1):1--87. Available at http://www.thecommunityguide.org/tobacco.
3. CDC. Best practices for comprehensive tobacco control programs. Atlanta, GA: US Department of Health and Human Services, CDC; 1999.
4. US Department of Health and Human Services. Healthy people 2010: understanding and improving health. 2nd ed. Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov.
5. Farrelly MC, Pechacek TP, Chaloupka FJ. The impact of tobacco control program expenditures on aggregate cigarette sales: 1981--2000. Health Econ 2003;22:843--9.
6. Campaign for Tobacco-Free Kids. State tobacco settlement: status of funding, 2004. Available at http://tobaccofreekids.org/reports/settlements.
7. Nelson DE, Holtzman D, Bolen J, Stanwyck CA, Mack KA. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Social Prev Med 2001;46:S3--S42.
8. CDC. Behavioral Risk Factor Surveillance System. Notes for data users; 2003 data limitations. Available at http://www.cdc.gov/brfss/prevdata/usernote2003.htm.
9. Keeter S, Miller C, Kohut A, Groves RM, Presser S. Consequences of reducing nonresponse in a national telephone survey. Public Opin Q 2000;64:125--48.
10. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2000.

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Date last reviewed: 11/9/2005