Cigarette Smoking Among Adults-United States, 1995

One of the national health objectives for the year 2000 is to reduce the prevalence of cigarette smoking among adults to no more than 15% (objective 3.4). To assess progress toward meeting this objective, the Centers for Disease Control (CDC) analyzed self-reported information about cigarette smoking among US adults from the Year 2000 Objectives Supplement of the 1995 National Health Interview Survey (NHIS). This report summarizes the findings of this analysis, which indicate that, in 1995, 24.7% (47.0 million) of adults were current smokers.

The 1995 NHIS was administered to a nationally representative sample (N = 17,213) of the US noninstitutionalized civilian population age ³ 18 years; the overall response rate for the supplement was 80.9%. Participants 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?” Current smokers were persons who reported having smoked ³ 100 cigarettes during their lifetimes and who smoked every day or some days at the time of interview. Former smokers were those who had smoked ³ 100 cigarettes during their lifetimes but who did not smoke currently.

Interest in quitting was determined by asking current smokers, “Would you like to completely quit smoking cigarettes?” Attempts to quit were determined by asking current every-day smokers, “During the past 12 months, have you stopped smoking for one day or longer?” Data were adjusted for nonresponse and weighted to provide national estimates. Confidence intervals (CIs) were calculated using SUDAAN.

Survey Results

In 1995, an estimated 47.0 million adults, including 24.5 million men (27.0% of adult men) were current smokers. Overall, 20.1% were every-day smokers, and 4.6% were some-day smokers (every-day smokers constituted 81.2% of all smokers). Prevalences of current smoking were higher among American Indians/Alaskan Natives (36.2%), non-Hispanic blacks (25.8%), and non-Hispanic whites (25.6%) than among Hispanics (18.3%) and Asians/Pacific Islanders (16.6%). Current smoking prevalence was highest among persons with 9 to 11 years of education (37.5%) and lowest among persons with ³ 16 years of education (14.0%), and was higher among persons living below the poverty level (32.5%) than among those living at or above the poverty level (23.8%).

In 1995, an estimated 44.3 million adults (23.3%) were former smokers, including 25 million men and 19.3 million women. Former smokers constituted 48.6% of persons who had ever smoked at least 100 cigarettes. Among current smokers in 1995, an estimated 32 million (68.2%) wanted to quit smoking completely, and 17.3 million (45.8%) current every-day smokers had stopped smoking for at least 1 day during the preceding 12 months.

Editorial Note from the CDC

The prevalence of smoking in 1995 (24.7%) was similar to that in 1994 (25.5%). The findings in this report and previous trends suggest that the goal of reducing the prevalence of cigarette smoking among adults to 15% by the year 2000 will not be attained. Smoking prevalence can be reduced by decreasing the rate of smoking initiation and by increasing the rate of smoking cessation. Methods for decreasing the rate of smoking initiation among adolescents include increases in the prices of tobacco products, education, counteradvertising campaigns, and efforts to restrict access to and limit the appeal of tobacco products.

Effective efforts to assist smokers to quit permanently produce substantial and immediate health and economic benefits. Despite the desire of most smokers to stop smoking completely and the existence of proven interventions, most smokers may not have easy access to such interventions. One of the national health objectives for 2000 is to increase to 100% the proportion of health plans that offer treatment for nicotine addiction (objective 3.24).

Based on a survey of 105 large health-maintenance organizations in 1995, a substantial proportion (two-thirds) reported offering some level of smoking cessation program or product as a covered member service. However, coverage of cessation services and products was subject to restrictions; for example, only 23% of plans covered nicotine replacement therapy (NRT) as a standard drug benefit. Indemnity plans are less likely than managed-care plans to cover preventive services, such as smoking cessation. In addition, more than half of corporations self-insure for their employees’ health insurance benefits, and few corporations include coverage for smoking-cessation services in their benefit designs.

As of March 1997, only five state Medicaid programs provided reimbursement for smoking cessation counseling or group programs. Although Medicare pays for medically necessary services furnished by a physician or other Medicare provider, it does not pay for either special smoking-cessation programs or over-the-counter drugs, including NRT.

Advice from health-care providers to smokers to quit smoking increases cessation rates by 30%, and guidelines published by the Agency for Health Care Policy and Research state that all smokers should be advised by their health-care provider to quit. In addition, one of the national health objectives for 2000 is to increase to at least 75% the proportion of primary-care and oral health-care providers who routinely advise cessation and provide assistance and follow-up for tobacco-using patients (objective 3.16). In 1996, for the first time, the Health Plan Employer Data Information Set (HEDIS), a managed-care “report card,” included a measure of smokers’ receipt of medical advice to quit. In 1996, the plan average for smokers reporting receipt of advice from health-care providers to quit was 61%; however, advice rates were as low as 30% for some plans.

Racial/ethnic variations in smoking prevalence are influenced by differences in educational level and cultural factors (eg, the ceremonial use of tobacco among American Indians). Proven smoking cessation treatments need to be culturally and language-appropriate.

Effective smoking cessation interventions are less costly than other preventive medical interventions (eg, treatment of hypercholesterolemia). Although all proven types of cessation are cost-effective, those involving more intense counseling and the nicotine patch are most cost-effective. The prevalence of current smoking can be decreased by intensifying efforts to establish proven smoking cessation treatments (both pharmacotherapy and counseling) as a covered medical benefit and to reimburse clinicians for providing effective cessation interventions. Other priorities include the needs to train health-care providers and health-system administrators about the current cessation guideline recommendations, evaluate cessation interventions for children and adolescents, and better inform smokers about the availability and variety of proven smoking cessation interventions.

Adapted from Morbidity and Mortality Weekly Report 46(51):1217-1220, 1997.