Cigarette Smoking Among U.S. Adults Hits All-time Low

But With One in Seven Still Smoking, There's Room to Improve

November 20, 2019 08:49 am Chris Crawford –The good news: Cigarette smoking among U.S. adults reached an all-time low of 13.7% in 2018 -- down about two-thirds in the more than 50 years since U.S. Surgeon General Luther Terry, M.D., issued his landmark report on the health consequences of smoking.

Research Details

To obtain recent estimates of tobacco product use among U.S. adults 18 and older nationwide, researchers from the CDC, FDA and National Cancer Institute analyzed data from the 2018 National Health Interview Survey, an annual household survey of noninstitutionalized U.S. civilians.

The survey measured current cigarette smoking (defined as having smoked at least 100 cigarettes in a lifetime and smoking "every day" or "some days" at the time of the survey) and current (every day or some days) use of other tobacco products: cigars (i.e., cigars, cigarillos, filtered little cigars); pipes (i.e., regular pipes, water pipes, hookahs); e-cigarettes; and smokeless tobacco.

The MMWR researchers determined that in 2018, an estimated 49.1 million U.S. adults -- or 19.7% of the adult population -- currently used a tobacco product.

At 13.7%, cigarettes remained the most commonly used tobacco product, followed by cigars (3.9%), e-cigarettes (3.2%), smokeless tobacco (2.4%) and pipes (1%).

According to the CDC, most current tobacco product users (83.8%) reported using combustible products, and 18.8% reported using two or more tobacco products.

It's worth noting that between 2017 and 2018, e-cigarette use among adults rose from 2.8% to 3.2% -- a reversal from the decline observed among adults from 2014 to 2017. This increase was primarily driven by an uptick in e-cigarette use among young adults (ages 18-24) from 5.2% in 2017 to 7.6% in 2018. Smokeless tobacco use also increased from 2.1% to 2.4% among adults during the same time period; no significant changes occurred in the use of the other tobacco products included in the study.

"The sustained drop in adult smoking is encouraging as we work to reduce tobacco-related disease and death in the U.S. through science-driven policy, compliance and enforcement in addition to public education," said Adm. Brett Giroir, M.D., assistant secretary of health and acting FDA commissioner, in the release. "We remain dedicated to keeping pace with the evolving tobacco product landscape to ensure strong regulatory oversight in light of the increases in youth use of e-cigarette products in the U.S."

Family Physician Expert's Perspective

Thomas Houston, M.D., of Dublin, Ohio, former chair of the AAFP Commission on Health of the Public and Science, told AAFP News that the new report illustrates a great public health accomplishment.

"This decline (overall smoking prevalence in 1964 was 42%) has prevented millions of premature deaths," he said. "The lives saved, smoking-related chronic disease reductions and the years of life saved as people have stopped smoking have been our ultimate goal."

Yet, because one in seven Americans continues to smoke cigarettes, Houston said family physicians' admonition to "Ask and Act," like the AAFP's tobacco cessation program moniker, continues to be important.

"The Academy has great resources for family physicians to assist them in treating tobacco dependence," he said. "But there are subgroups of the population who continue to smoke at much higher rates, and our attention needs to focus even more strongly on these groups -- patients with low educational levels, those who are impoverished and those who have comorbid mental health/substance abuse disorders."

For example, patients with comorbid substance abuse conditions smoke in great numbers: About 65% of those in treatment for substance abuse disorders also smoke, as do those with heavy alcohol use, Houston said.

And although the CDC found e-cigarette use had increased in 2017-18, Houston said it was too early to tell if this year's outbreak of e-cigarette-associated lung injuries would dampen enthusiasm for nicotine e-cigarette use among young adults again.

"Youth users, as always, think themselves invincible," he said. "People who are vaping (tetrahydrocannabinol) products may have gotten the message, but since this is not legal in most states, it's hard to monitor and hard to extrapolate to nicotine e-cigarette use.

"Vaping nicotine is highest in the 18-24 age group, and this group appears to be the driver of the increase in adult e-cigarette use overall," Houston continued. "Age restrictions for sale of tobacco to only those over 21 may help, and the flavor bans that have been enacted in some areas may also slow the trajectory. But internet sales of pod-type e-cigarettes remain a largely unregulated source and are of concern."

How Can Family Physicians Help?

According to the CDC, cigarette smoking is the leading cause of preventable disease, disability and death in the United States -- responsible for more than 480,000 deaths per year, including more than 41,000 deaths resulting from secondhand smoke exposure.

Quitting smoking at any age is beneficial for health. Among current adult cigarette smokers, nearly 70% want to quit, and more than half made a quit attempt in the preceding year, the agency said.

"As always, we should support our patients as they make quit attempts, with counseling, pharmacotherapy, referral to telephone Quitlines and making sure they know that family physicians will continue to assist them for the long term," Houston said. "This is a chronic disease, and our approach must be one that recognizes the natural history of relapse and remission in tobacco dependence."

At the population level, he said there needs to be a continued push for what works in tobacco control policy: smoke-free indoor air laws, raising taxes on tobacco products and comprehensive tobacco control programs.

"Sustained campaigns like the CDC's Tips From Former Smokers ads are very important," Houston said. "We need to advocate for changes on the cigarette packs, such as the proposed graphic warnings, and eventually, plain packaging without brand logos. We have come a long way, but still have much to do."