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Prevalence of Smoking by Area of Residence -- Missouri, 1989-1991

Variation in smoking prevalence by area of residence may be an important consideration in the development, implementation, and management of programs that promote nonsmoking. In general, the prevalence of cigarette smoking is highest among persons at economic, educational, and social disadvantage (1,2), and the proportion of persons who are disadvantaged is greater in urban and nonmetropolitan areas. Because smoking prevalence varies by area of residence and characterization of these differences can assist in directing efforts to promote nonsmoking, the Missouri Department of Health compared urban, suburban, and nonmetropolitan areas using data from two sources: the Behavioral Risk Factor Surveillance System (BRFSS) for Missouri from 1989 through 1991 (suburban and nonmetropolitan areas) and a survey specially commissioned in 1990 (Smoking Cessation in Black Americans {SCBA}) of persons living in low-income census tracts in north St. Louis and central Kansas City (urban areas). This report summarizes the results of this analysis.

BRFSS is a population-based, random-digit-dialed telephone survey of the civilian, noninstitutionalized population aged greater than or equal to 18 years (3). For this analysis, respondents' suburban or nonmetropolitan residence was determined by county of residence: respondents not living in counties composing a metropolitan statistical area (MSA) were categorized as residing in nonmetropolitan areas; respondents living in counties composing MSAs were categorized as residing in suburban areas. Persons living in the urban areas of St. Louis or Kansas City (Jackson County) were excluded from the BRFSS data. However, the SCBA survey was conducted in 60 low-income census tracts to determine smoking prevalence and attitudes among residents of these areas (4). To estimate prevalences, BRFSS data were weighted to reflect the total population in each area (based on the 1990 census) and for respondent probability of selection. Based on the 1990 census, 46% of persons resided in suburban areas, 34% in nonmetropolitan areas, and 20% in St. Louis and Kansas City. BRFSS data were aggregated for 3 survey years to increase the number of respondents in the demographic categories * for the suburban and nonmetropolitan areas, and SUDAAN was used to calculate the variance (5). For both the BRFSS and SCBA, current smokers were defined as persons who had smoked greater than or equal to 100 cigarettes and who reported being a smoker at the time of the interview. The prevalence of cessation was obtained by dividing the number of former smokers by the number of ever smokers (respondents who have ever smoked greater than or equal to 100 cigarettes during their lifetime) and multiplying by 100. Differences in group-specific prevalence rates in this report reflect nonoverlapping confidence intervals.

Overall, the prevalence of current smoking was higher among persons residing in the urban areas (32.4%) than in the suburban (24.8%) and nonmetropolitan areas (26.5%) Table_1. This pattern was consistent across all sex and education subgroups. The prevalence of current smoking also was higher in the urban areas for adults aged 35-54 years and greater than or equal to 55 years. For the 18-34-year age group, the prevalence of current smoking in the urban areas (31.3%) was comparable to that in the suburban (27.8%) and nonmetropolitan (33.5%) areas. For whites, the prevalence of current smoking was higher for those living in the urban areas (34.8%) than in suburban (24.9%) or nonmetropolitan (26.0%) areas. For blacks, the prevalence of current smoking was similar in urban areas (32.0%) and nonmetropolitan areas (32.1%) but higher than in suburban areas (24.0%).

Among current smokers, the mean number of cigarettes smoked per day was highest in the nonmetropolitan areas (22.8), lowest in the urban areas (15.0), and intermediate in suburban areas (19.9). The prevalence of cessation was lower in the urban areas (37.4%) than in the suburban (50.0%) or nonmetropolitan areas (47.6%). Reported by: CL Arfken, PhD, W Auslander, PhD, EB Fisher, Jr, PhD, Center for Health Behavior Research, Washington Univ School of Medicine, St. Louis; RC Brownson, PhD, School of Public Health, St. Louis Univ; J Jackson-Thompson, PhD, B Malone, MPA, Div of Chronic Disease Prevention and Health Promotion, Missouri Dept of Health. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: In Missouri during 1989-1991, the prevalence of smoking generally was highest in urban areas regardless of sex, education, age, and race. These findings are consistent with those of previous reports describing the relation between urban area of residence and smoking status (6,7). The persistence of the association between urban residence and smoking status, despite controlling for demographic characteristics, suggests that other factors contribute to the higher prevalence of smoking in urban areas. Such factors may include cultural norms, the burden and management of stress (8), relative effectiveness of risk-reduction messages (9), and exposure to tobacco advertisement and promotions. Differences in prevalences among racial/ethnic groups may be influenced by differences in educational levels, socioeconomic status, and social and cultural phenomena that require further explanation.

The findings in this report are subject to at least three limitations. First, because these estimates are based on self-reported data, prevalences may be underestimated (10). Second, a stratified analysis was conducted to control for each demographic variable individually because combining data from separate surveys with differing sampling designs precluded use of multivariate techniques to control for each variable simultaneously. Third, grouping areas at the urban, suburban, and nonmetropolitan levels may mask important community differences within each of these areas.

The findings in Missouri suggest that urban areas are an important target for nonsmoking promotion efforts. In general, local survey data can provide useful information to assist state and local health departments in identifying populations for risk-reduction programs. In Missouri, state and local health departments and community organizations are using these findings to develop programs and activities to reduce the prevalence of smoking among urban residents. For example, in Kansas City, intensive education efforts have been initiated to change social and community norms about smoking through activities such as rallies and town hall meetings and the promulgation of nonsmoking regulations. In St. Louis, activities have included counter-advertising, public service announcements, tobacco education in schools, and training of health-care providers about tobacco-use prevention.


  1. Fisher E Jr, Lichenstein E, Haire-Joshu D. Multiple determinants of tobacco use and cessation. In: Orleans C, Slade JD, eds. Nicotine addiction: principles and management. New York: Oxford, 1993.

  2. Novotny TE, Warner KE, Kendrick JS, Remington PL. Smoking by blacks and whites: socioeconomic and demographic differences. Am J Public Health 1988;78:1187-9.

  3. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-1987. Public Health Rep 1988;103:366-75.

  4. Brownson RC, Jackson-Thompson J, Wilkerson JC, Davis JR, Owens NW, Fisher EB Jr. Demographic and socioeconomic differences in beliefs about the health effects of smoking. Am J Public Health 1992;82:99-103.

  5. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.5 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

  6. Wechsler H, Gottlieb NH, Demone HW. Lifestyle, conditions of life, and health care in urban and suburban areas. Public Health Rep 1979;94:477-82.

  7. Ingram DD, Gillum RF. Regional and urbanization differentials in coronary heart disease mortality in the United States, 1968-85. J Clin Epidemiol 1989;42:857-8.

  8. Sclar ED. Community economic structure and individual well-being: a look behind the statistics. Int J Health Serv 1980;10:563-79.

  9. Wing S, Casper M, Riggan W, Hayes C, Tyroler HA. Socioenvironmental characteristics associated with the onset of decline of ischemic heart disease mortality in the United States. Am J Public Health 1988;78:923-6.

  10. Klesges L, Klesges R, Cigrang J. Discrepancies between self-reported smoking and carboxyhemoglobin: an analysis of the second National Health and Nutrition Survey. Am J Public Health 1992;82:1026-9.

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TABLE 1. Prevalence of current smoking among adults in urban * ,
suburban + and nonmetropolitan + areas  -- Missouri, 1989-1991.
                      Urban             Suburban       Nonmetropolitan
                   --------------    --------------    ---------------
Characteristic       %    (CI)         %      (CI)       %      (CI)
  Male             37.3  (+/-3.5)    25.5  (+/-3.1)    32.6  (+/- 4.2)
  Female           29.9  (+/-2.4)    24.1  (+/-2.5)    20.9  (+/- 2.9)

 <=12 years        35.1  (+/-2.6)    30.7  (+/-3.2)    29.7  (+/- 3.2)
 >12 years         27.9  (+/-3.2)    19.2  (+/-2.4)    19.0  (+/- 4.1)

Age group (yrs)
 18-34             31.3  (+/-3.3)    27.8  (+/-3.4)    33.5  (+/- 5.0)
 35-54             42.1  (+/-3.9)    28.7  (+/-3.4)    32.8  (+/- 4.9)
    >=55           25.2  (+/-3.3)    15.6  (+3.2)      14.3  (+/- 3.1)

Race @
 White             34.8  (+/-4.5)    24.9  (+/-2.1)    26.0  (+/- 2.6)
 Black             32.0  (+/-2.3)    24.0  (+/-7.8)    32.1  (+/-22.2)

Total              32.4  (+/-2.0)    24.8  (+/-2.0)    26.5  (+/- 2.6)
* Smoking Cessation in Black Americans Survey, 1990.
+ Missouri Behavioral Risk Factor Surveillance System, 1989-1991.
& +/-95% confidence interval.
@ Numbers for races other than black and white were too small for
  meaningful analysis.

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