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The Prevalence of Tobacco Use at Federally Qualified Health Centers in the United States, 2013

Susan A. Flocke, PhD1,2,3,4; Richard Hoffman, MD5; Jan M. Eberth, MSPH, PhD6; Hyunyong Park, PhD1,3; Genevieve Birkby, MPH1,2; Erika Trapl, PhD2,3,4; Steve Zeliadt, PhD7 (View author affiliations)

Suggested citation for this article: Flocke SA, Hoffman R, Eberth JM, Park H, Birkby G, Trapl E, et al. The Prevalence of Tobacco Use at Federally Qualified Health Centers in the United States, 2013. Prev Chronic Dis 2017;14:160510. DOI: http://dx.doi.org/10.5888/pcd14.160510.



We explored tobacco use across federally qualified health centers (FQHCs) and compared data on state-level tobacco use between FQHC patients and the general population. We used data from the Uniform Data System (UDS) and the Behavioral Risk Factor Surveillance System (BRFSS) to generate estimates of 2013 prevalence of tobacco use among adults aged 18 years or older. According to UDS data, the overall prevalence of tobacco use was 25.8% in FQHCs compared with 20.6% in the general population represented by BRFSS data, an average of 5.2 percentage points (range, −4.9 to 20.9) higher among FQHCs. Among FQHCs, the burden of tobacco use and the opportunity for offering cessation assistance is substantial.



Tobacco use contributes to substantial illness and death in the United States (1). Although prevalence of tobacco use has declined during the past decade among some demographic groups, rates have remained steady and even increased among some socially and economically disadvantaged populations (2).

Federally qualified health centers (FQHCs), which provide comprehensive health services to economically disadvantaged populations in rural and urban communities in the United States, are required to collect data on tobacco use screening and tobacco cessation counseling rates as Uniform Data System (UDS) measures. Understanding rates of tobacco use among FQHC clients can guide efforts to provide resources for tobacco cessation assistance where they are most needed (3–6).

Our study explores differences in tobacco use among FQHCs and compares state-level tobacco use between FQHC patients and the general population.



We used 2013 UDS FHQC data, which include quality-of-care indicators and patient demographics, to estimate tobacco use. We included only those FQHCs (967 of 1,202) that obtain tobacco use data from an electronic health record (EHR). Our denominator was the number of adults (≥18 y) having 1 or more medical visits to a FQHC in 2013. The numerator was the number of adults using any form of tobacco including cigarettes, cigars, and smokeless tobacco, as documented during routine patient care.

We estimated the prevalence of adult tobacco users in each state’s FQHC population by summing the total number of tobacco users across FQHCs and dividing by the total number of adult FQHC patients. We also estimated the prevalence of tobacco use for each FQHC and calculated the median and lowest and highest values for FQHCs in each state.

We then compared data on state-level estimates of FQHC tobacco use with data from the 2013 Behavioral Risk Factor Surveillance System (BRFSS), a random-digit–dial telephone survey that collects data on population-level prevalence of health risk behaviors among US adults aged 18 years or older. Three BRFSS items are used to indicate tobacco use: 1) “Have you smoked at least 100 cigarettes in your entire life?”, 2) “Do you now smoke cigarettes every day, some days, or not at all?”, and 3) “Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?” Survey participants that responded yes to question 1 and every day or some days to either question 2 or question 3 were identified as tobacco users (7). We applied BRFSS sampling weights to estimate state-specific prevalence of tobacco use (8).



In total, 1,202 FQHCs reported 2013 UDS data; 967 (80.4%) collected EHR-based tobacco use data. In this subset, the nearly 9 million adult patients seen were similar to the US population in percentage female (58.7%) and Hispanic (16.4%). FQHC patients were less likely than the US population to be older than 65 years (7.3% vs 14.1%) and more likely to be black (20.5% vs 13.0%) or other race (23.6% vs 8.6%). As expected, FQHC patients were more likely to be below the federal poverty level (71.7% vs 14.8%) and uninsured (34.8% vs 13.4%) or using government health insurance (50.8% vs 34.3%).

The overall proportion of tobacco use in FHQCs was 25.8%, and median prevalence was 29.3%, ranging from 0.4% to 94.4% across states ( Table). BRFSS data from 2013 estimated US tobacco use at 20.6%, ranging from 12.1% to 30.8% across states.

Except for 5 states, state-level prevalence of tobacco use in FQHCs was higher than the BRFSS national average (Table). FQHC tobacco use prevalence and differences between FQHC and state-level estimates are displayed in the Figure

Federally qualified health center (FQHC) tobacco use prevalence and differences between FQHC and state-level estimates. Panel A shows the US prevalence of tobacco use among adult FQHC patients in 2013; panel B shows the differences in prevalence of tobacco use between FQHCs and the general population. Sources: Uniform Data System, 2013 (Panels A and B), and Behavioral Risk Factor Surveillance System, 2013 (Panel B).

Figure. Federally qualified health center (FQHC) tobacco use prevalence and differences between FQHC and state-level estimates. Panel A shows the US prevalence of tobacco use among adult FQHC patients in 2013; panel B shows the differences in prevalence of tobacco use between FQHCs and the general population. Sources: Uniform Data System, 2013 (Panels A and B), and Behavioral Risk Factor Surveillance System, 2013 (Panel B). [A text description of this figure is also available.]

Prevalence of tobacco use among individual FQHCs varied widely, even within states. Fifty-four percent of FQHCs had a tobacco prevalence greater than 30%; 63 FQHCs had tobacco use rates higher than 50%.



Our study is the first national assessment of the prevalence of tobacco use across FQHCs; previous reports focused on patient samples (9) or delivery of services among a subgroup of FQHCs (10). We found that in 2013 tobacco use among FQHC populations was considerably higher than for the general US population. Although the finding was not surprising, this report quantifies this difference for the first time. A second notable finding was the wide range of tobacco use and high prevalence of tobacco use in some FQHCs, particularly in sites where more than half of adult patients use tobacco. Caring for patients in an environment where the prevalence of tobacco use is high poses substantial challenges and may require additional investment of resources to successfully offer tobacco cessation.

Assessing tobacco use rates is an important first step to targeting opportunities for intervention and quality improvement (4). Implementing clinical interventions and decision support tools to effectively act on EHR-documented tobacco use to support delivery of tobacco treatment has emerged as a national priority, especially in low-income settings (3–6).

This study has 2 main limitations. First, UDS data are collected for administrative purposes rather than for research; we cannot verify outlier values or dictate how variables are documented. Conversely, BRFSS data collection procedures are standardized but rely on self-report. In an effort to report the most robust data possible, we limited analyses to FQHCs that generated UDS quality elements using an EHR so that estimates are based on the patient population rather than a random sample of manually abstracted records. To ensure data reliability, we examined 2 prior years of UDS reporting for the top and bottom 5% of FQHC tobacco use values; 2013 reporting prevalence was similar in all cases. Second, BRFSS is able to separate data on rates of combustible tobacco use and rates of smokeless tobacco use and in 2013 reported all tobacco use at 20.6%, combustible at 19.4%, and smokeless tobacco at 4% (7). However, UDS data combine all tobacco use (combustible and smokeless), limiting our ability to report tobacco use separately.

Recommendations by the US Preventive Services Task Force to offer annual lung cancer screening using low-dose computed tomography (LDCT) to long-term smokers older than 55 years will significantly affect FQHCs caring for older adults (11). Although the UDS cannot provide information on the number of individuals eligible for lung cancer screening (data on age and pack-year history are lacking), given tobacco user prevalence, the effort to implement the LDCT scans in FQHCs is substantial and will require an evaluation of costs and approaches to integrating smoking cessation (12). Understanding more about how FQHC clinicians, staff, and patients are addressing tobacco use — and how they plan to address lung cancer screening — is essential for guiding efforts to implement systems- and evidence-based practices to promote tobacco cessation and offer lung cancer screening to eligible patients.



This article is a product of a Prevention Research Center supported by cooperative agreement no. 1U48DP005013 SIP-14-011 from the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. This research was also supported by the Behavioral Measurement Shared Resource of the Case Comprehensive Cancer Center (no. P30CA043703). The authors thank the members of the Tobacco & Lung Cancer Screening CPCRN Workgroup for their feedback and encouragement on this project and Nelson Oliver for assistance in the preparation of this manuscript.


Author Information

Corresponding Author: Susan A. Flocke, PhD, Associate Professor of Family Medicine and Community Health, Case Western Reserve University, 11000 Cedar Ave, Suite 402, Cleveland, OH 44106-7136. Telephone: 216-368-3887. Email: susan.flocke@case.edu.

Author Affiliations: 1Department of Family Medicine & Community Health, Case Western Reserve University, Cleveland Ohio. 2Department of Epidemiology & Biostatistics, Case Western Reserve University, Cleveland Ohio. 3Prevention Research Center for Healthy Neighborhoods, Case Western Reserve University, Cleveland Ohio. 4Case Comprehensive Cancer Center, Cleveland, Ohio. 5Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, Iowa. 6South Carolina Rural Health Research Center, University of South Carolina, Columbia, South Carolina; Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina; Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina. 7University of Washington, School of Public Health, Seattle, Washington.



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Return to your place in the textTable. Prevalence of Tobacco Use Among Patients at Federally Qualified Health Centers (N = 967) and a Comparison With Population Prevalence, by State, United States, 2013a
State No. of FQHCs No. of Adult FQHC Patients No. of FQHC Patients That Use Tobacco FQHC Tobacco Use, % Tobacco Use in Populationc, % Percentage Point Differenced
Totalb Median (Range)
All 967 8,762,429 2,258,335 25.8 29.3 (0.4–94.4) 20.6 5.2
Montana 16 53,930 24,611 45.6 40.2 (19.1–77.0) 24.7 20.9
Missouri 18 154,137 62,359 40.5 40.7 (17.2–60.3) 25.8 14.7
Nevada 3 26,250 10,565 40.2 33.0 (23.7–48.9) 21.5 18.7
Michigan 25 237,769 95,341 40.1 40.9 (18.7–63.9) 23.4 16.7
Arkansas 11 79,770 31,742 39.8 41.0 (21.3–82.3) 30.5 9.3
Iowa 11 58,802 23,342 39.7 35.5 (18.6–50.4) 22.9 16.8
South Dakota 6 26,570 10,446 39.3 36.5 (24.7–52.2) 24.3 15.0
Kansas 15 65,335 25,090 38.4 36.9 (16.1–47.7) 23.8 14.6
Indiana 18 157,991 60,588 38.3 36.6 (4.6–57.5) 25.0 13.3
Wyoming 3 8,585 3,088 36.0 36.9 (21.8–53.0) 26.8 9.2
Oklahoma 17 76,648 27,089 35.3 37.6 (14.8–58.4) 28.2 7.1
Ohio 30 209,899 72,597 34.6 38.4 (12.3–72.8) 26.0 8.6
North Dakota 4 15,363 5,293 34.5 33.8 (28.8–38.7) 26.4 8.1
Wisconsin 15 82,817 27,467 33.2 34.9 (9.0–55.5) 21.5 11.7
Tennessee 24 195,473 64,589 33.0 31.9 (9.1–60.1) 27.6 5.4
Louisiana 22 116,474 38,211 32.8 33.6 (13.2–45.6) 27.6 5.2
Alaska 21 43,399 13,873 32.0 33.7 (8.0–68.3) 27.3 4.7
Oregon 26 156,608 48,782 31.1 34.8 (11.4–67.5) 20.3 10.8
Connecticut 9 73,298 21,852 29.8 29.7 (15.2–38.9) 16.7 13.1
Colorado 12 155,570 46,297 29.8 31.7 (19.3–46.7) 20.5 9.3
West Virginia 22 186,695 55,185 29.6 31.1 (5.0–46.8) 34.3 −4.7
Kentucky 16 126,970 37,361 29.4 33.8 (12.7–66.1) 30.8 −1.4
Nebraska 5 26,101 7,675 29.4 34.2 (18.9–44.9) 22.0 7.4
Washington 21 377,869 109,186 28.9 30.2 (9.4–43.1) 18.3 10.6
New Mexico 13 107,381 30,974 28.8 30.5 (16.7–86.1) 21.7 7.1
Maine 15 106,992 30,777 28.8 29.8 (9.6–50.5) 21.5 7.3
South Carolina 14 132,501 38,054 28.7 30.7 (6.4–42.9) 25.0 3.7
New Hampshire 10 47,455 13,566 28.6 37.0 (18.2–73.0) 18.0 10.6
Idaho 8 47,127 13,250 28.1 27.4 (10.2–41.9) 20.5 7.6
Alabama 11 155,704 41,945 26.9 30.6 (10.6–54.0) 25.8 1.1
Minnesota 16 76,679 20,632 26.9 32.5 (9.2–71.9) 21.3 5.6
Maryland 12 130,809 35,102 26.8 29.5 (13.2–51.8) 17.9 8.9
District of Columbia 5 91,624 23,932 26.1 23.0 (5.6–46.0) 19.4 6.7
Mississippi 18 146,677 37,948 25.9 26.0 (11.7–48.7) 30.8 −4.9
Rhode Island 6 49,169 12,640 25.7 30.5 (17.1–40.6) 18.3 7.4
Virginia 23 166,179 41,099 24.7 29.9 (2.2–58.9) 21.6 3.1
Pennsylvania 29 204,291 49,920 24.4 30.4 (10.9–57.9) 23.7 0.7
Hawaii 12 52,740 12,843 24.4 21.3 (11.0–33.5) 14.4 10.0
Massachusetts 30 348,859 81,403 23.3 26.6 (5.4–85.5) 17.4 5.9
North Carolina 27 175,902 40,883 23.2 22.4 (0.4–41.0) 23.5 −0.3
Georgia 23 156,980 36,182 23.0 25.3 (6.0–48.8) 22.4 0.6
Delaware 3 23,055 5,301 23.0 23.1 (16.9–29.6) 20.6 2.4
Florida 38 385,604 88,308 22.9 26.0 (1.5–74.7) 18.5 4.4
Arizona 14 208,388 47,314 22.7 24.9 (13.3–70.9) 18.3 4.4
New York 51 759,384 165,743 21.8 29.3 (3.0–94.4) 17.9 3.9
New Jersey 18 186,291 39,153 21.0 26.5 (0.9–66.8) 16.7 4.3
Texas 61 516,650 104,219 20.2 21.2 (3.7–64.5) 18.8 1.4
Illinois 28 378,107 73,535 19.4 22.9 (4.5–53.0) 19.7 −0.3
Vermont 7 74,147 14,218 19.2 22.7 (8.4–41.5) 18.9 0.3
California 95 1,270,742 228,999 18.0 20.2 (4.3–78.8) 13.6 4.4
Utah 10 50,669 7,766 15.3 20.0 (2.9–48.9) 12.1 3.2

Abbreviations: BRFSS, Behavioral Risk Factor Surveillance System; FQHC, federally qualified health center.
a 967 FQHCs, which use the electronic health record to report clinical data, were included in the analysis.
b Number of patients that use tobacco divided by the number of total patients.
c Data from 2013 BRFSS.
d Difference in rate of tobacco use between patients at FQHCs and population.


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