Indicators of Nicotine Addiction Among Women-United States, 1991 to 1992

An estimated 22 million US women were current smokers in 1993;of these, 73% wanted to quit smoking [1]. However, attempts toquit smoking and to remain abstinent are hindered by nicotineaddiction and by the subsequent effects of nicotine withdrawal[2]. To assess the prevalence of selected indicators of nicotineaddiction among U.S. women, Centers for Disease Control (CDC)analyzed data from the National Household Survey on Drug Abuse(NHSDA) in 1991 and 1992 [3]. This report presents the findingsof the analysis.

The NHSDA is a household survey of a nationally representativesample of the civilian, noninstitutionalized U.S. population.Combined data from the 1991 and 1992 surveys (n = 7,137) wereused to estimate the prevalences of four indicators of nicotineaddiction among women who smoke. Information about these indicatorswas based on responses to four questions; current smokers (definedas persons who had ever smoked 100 cigarettes and had smoked duringthe 30 days preceding the survey) were asked whether, during the12 months preceding the survey, they:

1. Felt they needed or were dependent on cigarettes

2. Needed larger amounts (more cigarettes) to get the same effect

3. Felt unable to cut down on their use even though they tried

4. Had withdrawal symptoms, that is, felt sick because they stoppedor cut down on cigarette use.

The analysis of "unable to cut down" (n = 4,422) and"felt sick" (n = 4,646) was restricted to persons whoreported trying to reduce their use of cigarettes during the preceding12 months. In addition, for the indicator "unable to cutdown," because of the question design, respondents who reportednot trying to reduce any drug use during the preceding 12 months(n = 224) also were excluded. Because the likelihood of dailysmoking and the intensity of smoking (ie, number of cigarettessmoked per day) varies directly with age, respondents were classifiedinto two age groups: 12- to 24-year-olds and 25-year-olds andolder.

Among female smokers in both age groups, 75% reported feelingdependent on cigarettes. The prevalence of feeling dependent varieddirectly with intensity of smoking; among those who smoked 6 to15 cigarettes per day, 80.6% of those aged 12 to 24 years, and76.1% of those aged 25 years and older reported feeling dependenton cigarettes. Female smokers aged 12 to 24 years were more likelyto report needing more cigarettes to attain the same effect thanwere those aged 25 years and older (18.0% vs 13.2%). Among thosewho had tried to reduce smoking during the preceding 12 months,81.5% of 12- to 24-year-olds, and 77.8% of 25-year-olds and olderreported being unable to do so. Even among those who smoked 6to 15 cigarettes per day, inability to reduce smoking was reportedby 82.6% of 12- to 24-year-olds, and 73.8% of the 25-year-oldsand older. Of all female smokers aged 12 years and older, 35.4%reported withdrawal symptoms (ie, feeling sick) when they triedto reduce their smoking.

Females in both the younger and older age groups were equallylikely to report at least one of the four indicators of nicotineaddiction (81.2% and 79.4%, respectively). Even among femaleswho smoked five or fewer cigarettes per day, 63.1% of those aged12 to 24 years, and 53% of those aged 25 years and older reportedone or more of these indicators.

Editorial Note from the CDC: In 1990, an estimated 61,000U.S. women aged 35 years and older died from cardiovascular diseasesattributable to cigarette smoking [4]. Because the risk for myocardialinfarction can be reduced by 50% after 1 year of abstaining fromsmoking, [5] interventions to encourage smoking cessation arean important strategy to reduce cardiovascular mortality. Althoughmost women smokers want to quit smoking, only 2.5% of all smokerssuccessfully quit each year [6]. The finding in this report thatapproximately 80% of female smokers reported symptoms of nicotineaddiction underscores the importance of measures to increase women'saccess to cessation interventions, including adjunctive nicotine-replacementtherapy.

The findings in this report are subject to at least two limitations:

First, the NHSDA indicators are not comprehensive measures ofnicotine addiction, and do not include all symptoms of nicotinewithdrawal (eg, anxiety, irritability, anger, difficulty concentrating,hunger, or cravings for cigarettes)2; as a result, the NHSDA datamay underestimate the proportion of smokers who report at leastone indicator of nicotine addiction.

Second, these findings are based on self-reported data, and perceptionsof nicotine addiction were not validated. However, in previousstudies, self-reported symptoms of nicotine addiction have beenconfirmed by observer rating [2].

Although manifestations of cardiovascular disease occur primarilyduring adulthood, related high-risk behaviors, such as tobaccouse, often are initiated during adolescence; an estimated 87%of female daily smokers began smoking at 18 years or younger ofage (CDC, unpublished data, 1991). Young persons often try usingtobacco with a belief that they can quit. However, of adolescentsmokers who have intended to not be smoking in 5 to 6 years, 73%still smoked 5 years later [7]. The 1991 and 1992 NHSDA data suggestthat an important reason for young smokers' failure to quit smokingis a prevalence of addiction similar to that among older smokers.Because of the difficulty in achieving abstinence, and the strengthand early onset of nicotine addiction, interventions to preventsmoking initiation are important.

School-based programs, combined with community interventions,have been effective in preventing smoking initiation [7]. Othermeasures that can prevent smoking initiation, onset of nicotineaddiction, and subsequent morbidity and mortality associated withcardiovascular diseases include enforcement of laws that prohibitsales to minors, counteradvertising campaigns that "deglamorize"smoking to youth, and increases in the real price of cigarettes.

References:

1. CDC: Cigarette smoking among adults-United States, 1993. MMWR43:925-930, 1994.

2. CDC: The health consequences of smoking: Nicotine addiction-Areport of the Surgeon General. Rockville, Maryland, US Departmentof Health and Human Services, Public Health Service, CDC, DHHSpubl (CDC)88-8406, 1988.

3. Substance Abuse and Mental Health Services Administration:National household survey on drug abuse: Population estimates,1992. Rockville, Maryland, US Department of Health and Human Services,Public Health Service, Substance Abuse and Mental Health ServicesAdministration, DHHS publ (SMA)93-2053, 1993.

4. CDC: Cigarette smoking-Attributable mortality and years ofpotential life lost-United States, 1990. MMWR 42:645-649, 1993.

5. CDC: The health benefits of smoking cessation: A report ofthe Surgeon General, 1990. Rockville, Maryland, US Departmentof Health and Human Services, Public Health Service, DHHS publ(CDC)90-8416, 1990.

6. CDC: Smoking cessation during previous year among adults-UnitedStates, 1990 and 1991. MMWR 42:504-507, 1993.

7. US Department of Health and Human Services: Preventing tobaccouse among young people: A report of the Surgeon General. Atlanta,US Department of Health and Human Services, Public Health Service,CDC, National Center for Chronic Disease Prevention and Health