Estudio sobre consumo de cigarrillos en adultos de más de 18 años

8/8/2019 Estudio sobre consumo de cigarrillos en adultos de ms de 18 aos

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Morbidity and Mortality Weekly Report

Centers for Disease Control and Preventionwww.cdc.gov/mmwr

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Early Release / Vol. 59 September 7, 2010

care expenditures and productivity losses because o prematuremortality each year.*

Despite signicant declines during the past 30 years, ciga-rette smoking in the United States continues to be widespreadin 2008, one in ve U.S. adults (20.6%) were current smoker

ABSTRACT

Background: Cigarette smoking continues to be the leading cause o preventable morbidity and mortality inthe United States, causing approximately 443,000 premature deaths annually.Methods: Te 2009 National Health Interview Survey and the 2009 Behavioral Risk Factor SurveillanceSystem were used to estimate national and state adult smoking prevalence, respectively. Cigarette smokers

were dened as adults aged 18 years who reported having smoked 100 cigarettes in their lietime and nowsmoke every day or some days.

Results: In 2009, 20.6% o U.S. adults aged 18 years were current cigarette smokers. Men (23.5%) weremore likely than women (17.9%) to be current smokers. Te prevalence o smoking was 31.1% among personsbelow the ederal poverty level. For adults aged 25 years, the prevalence o smoking was 28.5% among personswith less than a high school diploma, compared with 5.6% among those with a graduate degree. Regionaldierences were observed, with the West having the lowest prevalence (16.4%) and higher prevalences beingobserved in the South (21.8%) and Midwest (23.1%). From 2005 to 2009, the proportion o U.S. adults whowere current cigarette smokers did not change (20.9% in 2005 and 20.6% in 2009).Conclusions: Previous declines in smoking prevalence in the United States have stalled during the past 5 years;the burden o cigarette smoking continues to be high, especially in persons living below the ederal poverty

level and with low educational attainment. Sustained, adequately unded, comprehensive tobacco controlprograms could reduce adult smoking.

Implications for Public Health Practice: o urther reduce disease and death rom cigarette smoking,declinesin cigarette smoking among adults must accelerate. Te Patient Protection and Aordable Care Act is expected toexpand access to evidence-based smoking-cessation services and treatments; this likely will result in additional useo these services and reductions o current smoking and its adverse eects among U.S. adults. Population-basedprevention strategies such as tobacco taxes, media campaigns, and smoke-ree policies, in concert with clinicalcessation interventions, can help adults quit and prevent the uptake o tobacco use, urthering the reduction inthe current prevalence o tobacco use in the United States across age groups.

Cigarette smoking continues to be the leading cause opreventable morbidity and mortality in the United States. Tenegative health consequences o cigarette smoking have beenwell-documented and include cardiovascular disease, multiplecancers, pulmonary disease, adverse reproductive outcomes, andexacerbation o other chronic health conditions (1). Cigarettesmoking causes approximately 443,000 premature deaths inthe United States annually and $193 billion in direct health-

* Additional inormation available at http://www.cdc.gov/tobacco/data_statistics/act_sheets/ast_acts/index.htm.

Vital Signs: Current Cigarette Smoking Among Adults Aged 18 Years United States, 2009
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htmhttp://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htmhttp://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htmhttp://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm


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MMWR Morbidity and Mortality Weekly Report

2 MMWR / September 7, 2010 / Vol. 59

(2). Year-to-year decreases in smoking prevalence havebeen observed only sporadically in recent years. Forexample, a slight decrease occurred rom 2006 to 2007but not rom 2007 to 2008 (2). Monitoring tobaccouse is essential in the eort to curb the epidemic otobacco use. o assess progress toward the HealthyPeople 2010objective o reducing the prevalence ocigarette smoking among adults to 12% (objective27-1a), this report provides the most recent nationalestimates o smoking prevalence among adults aged18 years, based on data rom the 2009 NationalHealth Interview Survey (NHIS), and provides state-level estimates based on data rom the 2009 BehavioralRisk Factor Surveillance System (BRFSS) survey.

Methods

Te 2009 NHIS adult core questionnaire collectsnational health inormation on illness and disability.Te questionnaire was administered by in-personinterview and included a random probability sampleo 27,731 noninstitutionalized civilian adults aged18 years; the overall response rate was 65.4%. Othe 27,731, a total o 128 were excluded because ounknown smoking status; thus, the nal sample sizeused in the analyses was 27,603. Te BRFSS survey isa state-based, random-digitdialed telephone surveyo the noninstitutionalized civilian adult populationand collects inormation on preventive health prac-tices, health-risk behaviors, and health-care access in

the United States. Te core questionnaire includesquestions on current cigarette smoking; the Councilo American Survey and Research Organizations(CASRO) median response rate was 52.5% (rom38.0% in Oregon to 66.9% in Nebraska), and themedian cooperation rate was 75.0% (55.5% inCaliornia to 88.0% in Kentucky).

Smoking status was dened identically or bothsurveillance systems by using two questions, Haveyou smoked at least 100 cigarettes in your entire lie?and Do you now smoke cigarettes every day, somedays, or not at all? Respondents who had smoked at

least 100 cigarettes during their lietime and, at thetime o interview, reported smoking every day or somedays were classied as current smokers. Smoking statuswas examined by race/ethnicity, age group, education(among persons aged 25 years), poverty status, andregion (overall and by sex). Starting in 2007, income

related ollow-up questions were added to NHISto reduce the number o responses with unknownvalues.** For this report, poverty status was denedusing 2008 poverty thresholds published by the U.SCensus Bureau in 2009; amily income was reportedby the amily respondent, who might or might nothave been the same as the sample adult respondentrom whom smoking inormation was collected.

Data rom the 2009 NHIS were adjusted or non-response and weighted to provide national estimateso cigarette smoking prevalence; 95% condenceintervals were calculated to account or the surveysmultistage probability sample design. Data rom the2009 BRFSS were weighted to adjust or dierencesin probability o selection and nonresponse, as welas noncoverage (e.g., households lacking landlines)and these sampling weights were used to calculateall estimates. Using NHIS data, the Wald test romlogistic regression analysis was used to analyze tem-poral changes in current smoking prevalence during20052009, overall and by region. For this 5-yeartrend analysis, results were adjusted or sex, age,and race/ethnicity; a p-value o


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MMWR / September 7, 2010 / Vol. 59 3

TABLE. Percentage of persons aged 18 years who were current cigarette smokers,* by selected characteristics National Health InterviewSurvey, United States, 2009

Total(N = 27,603)

Men(n = 12,193)

Women(n = 15,410)

Characteristic % (95% CI) % (95% CI) % (95% CI)

Age group (yrs)

1824 21.8 (19.424.2) 28.0 (24.531.5) 15.6 (12.918.3)2544 24.0 (22.825.1) 26.5 (24.728.2) 21.5 (20.122.9)

4564 21.9 (20.723.2) 24.5 (22.826.2) 19.5 (17.921.1)

65 9.5 (8.510.5) 9.5 (8.110.9) 9.5 (8.210.8)

Race/Ethnicity White, non-Hispanic 22.1 (21.223.1) 24.5 (23.225.9) 19.8 (18.820.8)

Black, non-Hispanic 21.3 (19.622.9) 23.9 (21.526.2) 19.2 (17.121.3)

Hispanic 14.5 (13.215.8) 19.0 (16.921.1) 9.8 (8.511.0)American Indian/Alaska Native 23.2 (12.933.5) 29.7 (15.444.0)

Asian, non-Hispanic** 12.0 (10.014.0) 16.9 (14.019.9) 7.5 (4.810.3)

Multiple race, non-Hispanic 29.5 (22.936.1) 33.7 (24.443.0) 24.8 (16.633.0)

Education

012 yrs (no diploma) 26.4 (24.528.3) 30.5 (27.633.5) 22.2 (19.924.5)8 yrs 17.1 (14.519.6) 22.2 (18.026.4) 11.9 (9.214.7)

911 yrs 33.6 (30.736.5) 36.5 (32.240.9) 30.5 (26.634.4)

12 yrs (no diploma) 28.5 (23.233.9) 34.1 (26.042.1) 23.3 (17.029.6)

GED

49.1 (44.553.8) 53.2 (46.659.8) 44.7 (38.251.2)High school graduate 25.1 (23.626.5) 29.0 (26.931.2) 21.5 (19.823.3)

Some college (no degree) 23.3 (21.724.9) 26.1 (23.428.8) 21.0 (19.022.9)Associate degree 19.7 (17.921.5) 20.6 (17.523.6) 19.1 (16.521.6)

Undergraduate degree 11.1 (10.012.3) 12.4 (10.714.2) 9.9 (8.311.4)

Graduate degree 5.6 (4.66.6) 4.9 (3.66.3) 6.3 (4.77.9)

Poverty status At or above poverty level 19.4 (18.620.2) 22.2 (21.123.3) 16.7 (15.717.6)

Below poverty level 31.1 (29.132.9) 34.2 (31.037.5) 28.7 (26.530.9)

Unspecifed 17.3 (15.319.3) 22.3 (18.626.1) 13.2 (11.015.4)

Region***Northeast 20.0 (18.022.0) 23.4 (20.526.3) 16.9 (14.819.0)

New England 19.4 (15.223.6) 21.5 (14.428.6) 17.5 (14.620.4)

Mid-Atlantic 20.2 (18.022.4) 24.1 (21.127.1) 16.7 (14.119.3)Midwest 23.1 (21.624.7) 25.7 (23.328.1) 20.8 (19.222.3)

East North Central 23.8 (22.125.5) 26.7 (23.829.6) 21.1 (19.522.6)

West North Central 21.8 (18.824.8) 23.6 (19.727.5) 20.1 (16.523.7)South 21.8 (20.722.9) 24.5 (22.826.2) 19.3 (18.120.5)

South Atlantic 20.1 (18.721.5) 22.3 (20.124.5) 18.0 (16.419.6)

East South Central 25.8 (22.728.9) 30.1 (25.035.2) 22.3 (20.024.6)

West South Central 22.5 (20.524.5) 25.5 (22.628.4) 19.8 (17.422.2)West 16.4 (14.917.9) 19.5 (17.621.4) 13.3 (11.315.2)

Mountain 18.8 (16.021.6) 21.7 (18.125.3) 16.0 (13.019.0)

Pacifc 15.3 (13.617.0) 18.6 (16.420.8) 12.1 (9.714.5)

Total 20.6 (19.921.3) 23.5 (22.424.5) 17.9 (17.118.7)

* Persons who reported smoking at least 100 cigarettes during their lietimes and who, at the time o interview, reported smoking every day or some days. Exclude128 respondents whose smoking status was unknown.

95% conidence interval. Excludes 53 respondents o unknown race. Data not reported because o unstable percentages; relative standard error 30%.

** Does not include Native Hawaiians or Other Paciic Islanders. Among persons aged 25 years. Excludes 137 persons whose educational level was unknown. General Educational Development certiicate. Family income is reported by the amily respondent who might or might not be the same as the sample adult respondent rom whom smoking inormation i

collected; 2009 estimates are based on reported amily income and 2008 poverty thresholds published by the U.S. Census Bureau.*** New England: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut. Mid-Atlantic: New York, Pennsylvania, and New Jersey. East North

Central: Wisconsin, Michigan, Illinois, Indiana, and Ohio. West North Central: Missouri, North Dakota, South Dakota, Nebraska, Kansas, Minnesota, and Iowa. SouthAtlantic: Delaware, Maryland, District o Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, and Florida. East South Central: Kentucky, Tennessee, Mississippi, and Alabama. West South Central: Oklahoma, Texas, Arkansas, and Louisiana. Mountain: Idaho, Montana, Wyoming, Nevada, Utah, ColoradoArizona, and New Mexico. Pacific: Alaska, Washington, Oregon, Caliornia, and Hawaii.


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prevalence was highest among adults who hadobtained a General Education Development cer-ticate (GED) (49.1%) and generally declined withincreasing education, being lowest among adults witha graduate degree (5.6%). Te prevalence o currensmoking was higher among adults living below the

ederal poverty level (31.1%) than among those ator above this level (19.4%). Smoking prevalence didnot vary signicantly or adults aged 1824 years(21.8%), 2544 years (24.0%), and 4564 years(21.9%); however, it was lowest or adults aged 65years (9.5%). Regionally, smoking prevalence washigher in the Midwest (23.1%) and South (21.8%)and lowest prevalence or adult current smoking wasobserved or the West (16.4%).

During 20052009, the proportion o U.S. adultswho were current cigarette smokers was 20.9% in2005 and 20.6% in 2009, with no signicant di-erence (Figure 1). No signicant changes in currentsmoking prevalence or U.S. adults were observedduring the 5-year period overall and or each o theour regions: Northeast, Midwest, South, or West(p0.05).

By state, the prevalence o current smoking rangedrom 9.8% (Utah) to 25.6% (Kentucky and WestVirginia) (Figure 2). States with the highest preva-lence o adult current smoking were clustered in theMidwest and Southeast regions.

Conclusions and CommentTe results o these analyses indicate that thenational estimates or the prevalence o currentcigarette smoking among adults aged 18 years didnot decline rom 2008 (20.6%) (2) to 2009, andduring the past 5 years (20052009) virtually nochange has been observed, even by region. In 2009certain population subgroups (e.g., Hispanic andAsian women, persons with higher levels o education, and older adults) continue to meet the HealthyPeople 2010target o 12% prevalence o smokingAlthough smoking prevalence was ound to be lowest

among Asian and Hispanic women, the ndings inthis report cannot assess specic Asian and Hispanicsubgroups. In a previous report, variations in smokingprevalence were observed within specic Asian andHispanic subgroups and between the sexes within

* Persons who reported smoking at least 100 cigarettes during their lietimes and who, at thetime o the survey, reported smoking every day or some days.

FIGURE 1. Percentage of adults aged 18 years who were current smokers,* bygeographic region National Health Interview Survey, United States, 20052009

Overall

North

Midwest

South

West

0

5

10

15

20

25

30

2005 2006 2007 2008 2009

Percentage

Year

Additional inormation available at http://www.cdc.gov/mmwrpreview/mmwrhtml/mm5542a1.htm.

Key Points

Smokingcausesapproximately443,000prema-ture deaths, accounts or up to 30% o cancerdeaths, and is the single most preventable cause

o disease and death in the United States. Despitetheadversehealtheectsof smoking

cigarettes, one in ve U.S. adults (46.6 millionmen and women) currently smoke.

Teprevalenceofadultsmokingisnotdecreas-ing. Eective population-based strategies toencourage cessation (e.g., tobacco taxes, smoke-ree policies, and media campaigns) are essentialto accelerate the reduction in tobacco use amongadults in the United States and prevent smokinginitiation in young persons.

Eectivecessationmethods shouldbemade

available to increase success rates when tobaccousers make quit attempts.

Additional information isavailableathttp://www.cdc.gov/tobacco and http://www.cdc.gov/vitalsigns.
http://www.cdc.gov/tobaccohttp://www.cdc.gov/tobaccohttp://www.cdc.gov/vitalsignshttp://www.cdc.gov/vitalsignshttp://www.cdc.gov/vitalsignshttp://www.cdc.gov/vitalsignshttp://www.cdc.gov/tobaccohttp://www.cdc.gov/tobacco


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these subgroups, suggesting that overall prevalenceor Asians and Hispanics do not accurately representthe wide variability across subgroups (3).

Dierences in understanding the health hazardso smoking and receptivity to antismoking mes-sages might be related to the prevalence variations

observed by education level (4). For example, personswith higher levels o education might have a betterunderstanding o the health hazards o smoking andmight be more receptive to health messaging about thedangers o smoking (4). Nonetheless, most popula-tion subgroups, particularly those with low educationand income levels, will not meet the Healthy People2010target.

Dierences also were noted by state and region.In 2009, the lowest prevalence was observed in theWest, with lowest prevalence in Utah, ollowed byCaliornia. Caliornia traditionally has been citedor its success in tobacco control because o its long-running comprehensive tobacco control program(5). Caliornias adult smoking prevalence declinedapproximately 40% during 19982006, and con-sequently lung cancer incidence in Caliornia hasbeen declining our times aster than in the rest othe nation (5). Similarly, Maine, New York, andWashington have seen 45%60% reductions in youthsmoking with sustained comprehensive statewideprograms (5).

Youth smoking is an important indicator to moni-

tor because most adult established smokers (>80%)begin beore the age o 18 years. In 2009, one inve U.S. high school students (19.5%) reportedsmoking cigarettes in the preceding 30 days (6).Moreover, declines in current smoking among highschool students have slowed, with an 11% declinerom 21.9% in 2003 to 19.5% in 2009 comparedwith a 40% decline observed rom 1997 (36.4%) to2003 (21.9%) (7).Te slowing in the decline observedor youth cigarette smoking indicates that cigarettesmoking among adults and the associated morbidityand mortality will continue to be important public

health issues or the oreseeable uture.Te ndings in this report are subject to at leastsix limitations. First, the estimates o cigarette smok-ing were sel-reported and were not validated bybiochemical tests. However, other studies using levels

o serum cotinine (a breakdown product o nicotine),yield similar prevalence estimates as those obtainedrom sel-reports (8). Second, questionnaires areadministered only in English and Spanish; thereore,smoking prevalence or certain racial/ethnic popula-tions might be overestimated or underestimated i

English and Spanish are not the primary languagesspoken. Tird, race/ethnicity was not adjusted orsocioeconomic status. Fourth, because NHIS andBRFSS do not include institutionalized populationsand persons in the military, the results are not general-izable to these groups. Fith, BRFSS does not currentlyinclude adults without telephone service (1.9%) orwith wireless-only service (13.6%). Because adultswith wireless-only service are more likely to smokecigarettes than the rest o the U.S. population and wireless-only service varies by state, state smokingprevalence might be underestimated.*** Finally, smallsamples sizes or certain population groups resulted insome imprecise estimates. Tis might explain why the2009 prevalence estimate or American Indian/Alaska

FIGURE 2. Percentage of persons aged 18 years who were current cigarettesmokers,* by state Behavioral Risk Factor Surveillance System, United States, 2009

9.8%12.9%

13.0%16.3%

16.4%19.0%

19.1%22.5%

22.6%25.6%

* Persons who reported smoking at least 100 cigarettes during their lietimes and who, at thetime o the survey, reported smoking every day or some days.

Additional inormation available at http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8results.cm.

Additional inormation available at http://www.cdc.gov/nchs/data/nhsr/nhsr014.pd.

*** Additional inormation available at http://www.cdc.gov/nchs/nhis.htm.
http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8results.cfmhttp://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8results.cfmhttp://www.cdc.gov/nchs/data/nhsr/nhsr014.pdfhttp://www.cdc.gov/nchs/data/nhsr/nhsr014.pdfhttp://www.cdc.gov/nchs/nhis.htmhttp://www.cdc.gov/nchs/nhis.htmhttp://www.cdc.gov/nchs/nhis.htmhttp://www.cdc.gov/nchs/nhis.htmhttp://www.cdc.gov/nchs/data/nhsr/nhsr014.pdfhttp://www.cdc.gov/nchs/data/nhsr/nhsr014.pdfhttp://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8results.cfmhttp://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8results.cfm


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Native women is lower than prevalence estimatesrom recent years.

Te Healthy People 2010objective o reducing theoverall prevalence o cigarette smoking among U.S.adults to 12% (objective 27-1a) will not be met in2010. However, or some subpopulations and states,

this goal has been reached, demonstrating that thenational target is achievable. o meet this goal or theentire population in the uture, evidence-based strate-gies ocused on populations such as persons with lowereducation are needed (5). Eective strategies includingprice increases, comprehensive smoke-ree policies,and media campaigns to counter pro-tobacco industryinuences need to be implemented aggressively incoordination with providing access to aordable andeective cessation treatments and services (5,9). Ieach state sustained comprehensive tobacco controlprograms or 5 years with CDC-recommended levelso unding, an estimated 5 million ewer persons inthe country would smoke, resulting in prevention opremature tobacco-related deaths (5).

As this analysis shows, some populations have ahigher prevalence o cigarette use; thus, a ocus onreducing tobacco-related disparities also is neces-sary (5). Te Patient Protection and Aordable CareAct is expected to expand access to evidence-basedsmoking-cessation services and treatments. Given thedecline in smoking prevalence that was observed aterthe implementation o a mandated tobacco cessation

coverage or the Massachusetts Medicaid program(10), expanded access to cessation services and treat-ments might result in reductions in current smokingand its adverse eects among U.S. adults. For this tooccur, health proessionals need to better identiy,educate, and oer appropriate cessation services topersons who use tobacco.

he enactment o the 2009 Family SmokingPrevention and obacco Control Act has providednew opportunities or reductions in tobacco use (7,9).Te Act gives the Food and Drug Administrationauthority to regulate the manuacturing, marketing,

and distribution o tobacco products. Full implemen-tation o comprehensive tobacco control policies andprograms at CDC-recommended levels o unding (5)

would resume progress toward reducing the prevalence o smoking in the population.

Reported by

SR Dube, PhD, A McClave, MPH, C James, MSPH,R Caraballo, PhD, R Kaumann, PhD, T Pechacek,

PhD, Ofce on Smoking and Health, National Centeor Chronic Disease Prevention and Health Promotion,CDC.

Acknowledgments

his report is based, in part, on contributions byP Barnes, MA, and C Schoenborn, MPH, National Centeor Health Statistics, CDC.

References

1. US Department o Health and Human Services. Te healthconsequences o smoking: a report o the Surgeon General

Atlanta, GA: US Department o Health and Human ServicesCDC; 2004. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm.

2. CDC. Cigarette smoking among adults and trends insmoking cessationUnited States, 2008. MMWR 2009;58122732.

3. Caraballo RS, Yee SL, Groerer J, Mizra SA. Adult tobacco useamong racial and ethnic groups living in the United States20022005. Prev Chronic Dis 2008;5:19.

4. Siahpush M, McNeill A, Hammond D, Fong G. Socio-economic and country variations in knowledge o health riskso tobacco smoking and toxic constituents o smoke: resultsrom the 2002 International obacco Control (IC) FourCountry Survey. ob Control 2006;15(Suppl III):6570.

5. CDC. Best practices or comprehensive tobacco controprograms2007. Atlanta, GA: US Department o Health andHuman Services, CDC; 2007. Available at http://www.cdc.gov

tobacco/tobacco_control_programs/stateandcommunity/best_practices.

6. CDC. Youth Risk Behavior SurveillanceUnited States2009. MMWR 2010;59(No. SS-5).

7. CDC. Cigarette use among high school studentsUnitedStates, 19912009 MMWR 2010;59:797801.

8. Caraballo RS, Giovino GA, Pechacek F, Mowery PDFactors associated with discrepancies between sel-reports oncigarette smoking and measured serum cotinine levels amongperson aged 17 years or older: third National Health andNutrition Examination Survey, 19881994. Am J Epidemio2001;153:80714.

9. CDC. CDC Grand Rounds: current opportunities in tobaccocontrol. MMWR 2010;59:48792.

10. Land , Warner D, Paskowsky M, et al. Medicaid coverage

or tobacco dependence treatments in Massachusetts andassociated decreases in smoking prevalence. PLoS One2010;5:e9770.

Additional inormation available at http://www.dol.gov/ebsa/healthreorm.

Family Smoking Prevention and obacco Control Act, Pub. L.111-31, 123 Stat1776 (2009). Additional inormation availableat http://www.gpo.gov/dsys/pkg/PLAW-111publ31/content-detail.html.
http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htmhttp://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htmhttp://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practiceshttp://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practiceshttp://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practiceshttp://www.dol.gov/ebsa/healthreformhttp://www.dol.gov/ebsa/healthreformhttp://www.gpo.gov/fdsys/pkg/PLAW-111publ31/content-detail.htmlhttp://www.gpo.gov/fdsys/pkg/PLAW-111publ31/content-detail.htmlhttp://www.gpo.gov/fdsys/pkg/PLAW-111publ31/content-detail.htmlhttp://www.gpo.gov/fdsys/pkg/PLAW-111publ31/content-detail.htmlhttp://www.dol.gov/ebsa/healthreformhttp://www.dol.gov/ebsa/healthreformhttp://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practiceshttp://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practiceshttp://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practiceshttp://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htmhttp://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm


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Using data rom the National Health and NutritionExamination Survey (NHANES) or 19992008, thisreport describes recent trends in secondhand smoke

exposure among nonsmokers by analyzing levels oserum cotinine, a metabolite o nicotine that reectsrecent exposure.

Methods

NHANES produces data or a nationally rep-resentative sample o the noninstitutionalized U.S.civilian population every 2 years. NHANES surveys

ABSTRACT

Background: Secondhand exposure to tobacco smoke causes heart disease and lung cancerin nonsmoking adults and sudden inant death syndrome, acute respiratory inections,middle ear disease, exacerbated asthma, respiratory symptoms, and decreased lung unc-tion in children.Methods: National Health and Nutrition Examination Survey data rom 19992008were analyzed to determine the proportion o the nonsmoking population with serumcotinine (the primary nicotine metabolite) levels 0.05 ng/mL, by age, sex, race/ethnicity,household income level, and to determine whether the household included a person whosmoked inside the home.

Results: During 20072008, approximately 88 million nonsmokers aged 3 years in theUnited States were exposed to secondhand smoke. Te prevalence o serum cotinine levels

0.05 ng/mL in the nonsmoking population declined signicantly rom 52.5% (95% CI =47.1%57.9%) during 19992000 to 40.1% (95% CI = 35.0%45.3%) during 20072008.Te decline was signicant or each sex, age, race/ethnicity, and income group studied exceptnon-Hispanic whites. Te change was greatest rom 19992000 to 20012002. For everyperiod throughout the study, prevalence was highest among males, non-Hispanic blacks,children (aged 311 years) and youths (aged 1219 years), and those in households belowthe ederal poverty level.

Conclusions: Secondhand smoke exposure has declined in the United States, but 88 mil-lion nonsmokers aged 3 years are still exposed, progress in reducing exposure has slowed,and disparities in exposure persist, with children being among the most exposed. Nearlyall nonsmokers who live with someone who smokes inside their home are exposed to

secondhand smoke.Implications for public health practice: Te only way to protect nonsmokers ully is toeliminate smoking in indoor spaces. Continued eorts at smoking cessation and compre-hensive statewide laws prohibiting smoking in workplaces and public places are neededto ensure that all nonsmokers are protected rom this serious health hazard. Health-careproviders should educate patients and parents about the dangers o secondhand smoke andollow clinical care guidelines to help smokers quit.

Secondhand exposure to tobacco smoke causesheart disease and lung cancer in nonsmoking adultsand sudden inant death syndrome, acute respiratory

inections, middle ear disease, exacerbated asthma,respiratory symptoms, and decreased lung unction inchildren (1). No risk-ree level o secondhand smokeexposure exists (1). Levels o secondhand smoke expo-sure among U.S. nonsmokers have allen substantiallyduring the past 20 years (2). However, millions ononsmokers remain exposed to secondhand smokein homes, workplaces, public places, and vehicles (1).

Vital Signs: Nonsmokers Exposure to Secondhand Smoke United States, 19992008


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include a home interview, physical examination at amobile examination center where biologic specimensare collected, and laboratory specimen testing, includ-ing serum cotinine analysis or participants aged 3years. Response rates exceeded 75% or all 2-yearstudy cycles.* From the 19992000, 20012002,

20032004, 20052006, and 20072008 NHANEScycles, 30,451 respondents were determined to benonsmokers (by cotinine level 10 ng/mL and sel-reported history or persons aged 12 years) and wereincluded in the analysis.

Serum cotinine was analyzed using an isotopedilution liquid chromatography tandem mass spec-trometry method (2). Cotinine concentrations belowa level known as the limit o detection (LOD) mightbe estimated inaccurately. Te cotinine LOD initiallywas 0.05 ng/mL and changed to 0.015 ng/mL aterimprovements to the method. Cotinine levels belowthe LOD were reported as LOD / 2; this valuerepresents the approximate midpoint o the intervalbetween zero and LOD on a log scale.

Serum cotinine levels >10 ng/mL are associatedwith active smoking within the past ew days (3).Tereore, children aged 311 years were assumed to benonsmokers i their serum cotinine concentration was10 ng/mL. Youths aged 1219 years were considerednonsmokers i their serum cotinine concentration was10 ng/mL and they did not report smoking withinthe preceding 30 days or use o any nicotine-containing

product within the preceding 5 days at their physicalexamination. Adults aged 20 years were considerednonsmokers i their serum cotinine concentration was10 ng/mL and they did not report being a currentsmoker during their home interview or report use oany nicotine-containing product within the preceding5 days at their physical examination.

Te percentage o the nonsmoking populationwith serum cotinine levels 0.05 ng/mL, the higherLOD, was calculated by survey cycle, sex, race/eth-nicity group, age group, household income level, andwhether households contained a person who smoked

inside the home; 95% condence intervals (CIs)were calculated using a log transormation or values>98% and the Wald method otherwise. Sample sizesare insufcient to allow separate reporting or race/ethnicity groups other than non-Hispanic whites,non-Hispanic blacks, and Mexican-Americans, but

all race/ethnicity groups are included in the reportedvalues or the total population and the values shownby sex, age group, and household income level. For20072008, the most recently completed NHANEScycle, the number o nonsmokers with serum coti-nine 0.05 ng/mL was calculated by age group using

the midpoint population as the denominator, andthe distribution o serum cotinine concentrationswas examined separately or nonsmokers who livedwith and without someone who smoked inside thehome.

wo-sided t-tests were used to assess dierencesbetween population group percentages within studycycles and dierences within population groups acrossstudy cycles; p


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decreased with age so that there were approximately2122 million exposed persons in each o the 2039year and 4059 year age groups and approximately 14million exposed persons in the 60 year age group.

Children and nonsmoking youths were morelikely than nonsmoking adults to live with someonewho smoked inside the home. During 20072008,18.2% (CI = 11.2%25.3%) o children aged 311years and 17.1% (CI = 12.7%21.4%) o youths aged

1219 years lived with someone who smoked insidethe home, compared with 5.4% (CI = 3.8%7.0%)o adults aged 20 years. Te majority (96.0%; CI= 93.3%98.6%) o nonsmokers who lived withsomeone who smoked inside the home had cotininelevels 0.05 ng/mL (Figure). Among nonsmokingchildren and youths living with someone who smokedinside the home, 98.3% (CI = 95.5%99.3%) had

serum cotinine 0.05 ng/mL, compared with 39.9%(CI = 34.3%45.4%) among those not living withsomeone who smoked inside the home (p


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the number o local and state laws prohibiting smok-ing in indoor workplaces and public places, increasesin voluntary smoking restrictions in workplaces andhomes, and changes in public attitudes regardingsocial acceptability o smoking near nonsmokers

and children (1). Although prevalence o exposurehas dropped or children and non-Hispanic blacks,groups that traditionally have had higher-than-averageexposure levels (14), disparities remain. Further,this report shows that millions o nonsmokers in theUnited States remain exposed to secondhand smoke,including nearly all o those who live with someonewho smokes inside the home.

Workplaces and homes usually are the mosimportant sources o secondhand smoke exposureamong adults because these are the settings wherethey typically spend the most time (1). Te numbero state, local, and voluntary smoke-ree policies hasgreatly increased in recent years and has helped toprotect nonsmokers rom the toxicants in second-hand smoke. Nonetheless, currently only 24 states

and the District o Columbia have comprehensivesmoke-ree laws covering workplaces, restaurantsand bars; complete statewide bans are needed in theremaining 26 states because only 47% o the nationapopulation is covered by comprehensive state or loca

FIGURE. Serum cotinine levels among nonsmoking persons aged 3 years National Health and Nutrition Examination Survey, United States, 20072008

Persons not living with a person who smokes inside the home

Persons living with a person who smokes inside the home

Millionsofpersons

Serum cotinine (ng/mL)

1

2

3

4

10

20

30

40

50

60

70

0.01 0.10.070.050.030.02 10.80.60.40.30.2 108765432

Millionsofpersons

Serum cotinine (ng/mL)

0.01 0.10.070.050.030.02 10.80.60.40.30.2 108765432

Key Points

Despiteprogressinprotectingnonsmokersfromsecondhand smoke, approximately 88 millionnonsmokers (including 32 million children and

youths) in the United States were exposed tosecondhand smoke during 20072008.

Children aremore likely than nonsmokingadults to live with someone who smokes insidethe home and more likely to be exposed tosecondhand smoke.

Tevastmajorityofnonsmokerswholivewithpersons who smoke inside the home are exposedto secondhand smoke.

Exposure to secondhandsmoke causesheartdisease and lung cancer in nonsmoking adultsand sudden inant death syndrome, acute respi-ratory inections, middle ear disease, exacerbatedasthma, respiratory symptoms, and decreasedlung unction in children.

Norisk-freelevelofsecondhandsmokeexposureexists.

Teonlyway toprotectnonsmokersfully isto eliminate smoking in indoor spaces, includ-ing workplaces, public places (e.g., restaurantsand bars), and private places (e.g., homes andvehicles) through smoke-ree laws and policiesand through decreased smoking prevalence.

Additional information isavailable athttp://www.cdc.gov/vitalsigns.

Additional inormation available at http://apps.nccd.cdc.govstatesystem.
http://www.cdc.gov/vitalsignshttp://www.cdc.gov/vitalsignshttp://apps.nccd.cdc.gov/statesystemhttp://apps.nccd.cdc.gov/statesystemhttp://apps.nccd.cdc.gov/statesystemhttp://apps.nccd.cdc.gov/statesystemhttp://www.cdc.gov/vitalsignshttp://www.cdc.gov/vitalsigns


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laws. Smoke-ree policies have been shown to greatlyreduce the probability and amount o exposure tosecondhand smoke in workplaces and public places,as well as adverse health events. Workplace smokingrestrictions lead to smoking reductions and cessationamong workers.** However, smoke-ree policies do

not eliminate secondhand smoke exposure rom allsources. As workplaces and public places increasinglyare made smoke-ree, private settings such as homesand vehicles are becoming relatively larger sources ooverall exposure (1).

Te home is the major source o secondhandsmoke exposure or children (1). During 19881994,ewer than 1% o children aged 416 years living withpersons who smoked inside the home had cotininelevels


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in 2009. Te U.S. Environmental Protection Agencyconducts a national campaign that educates andencourages parents to make their homes smoke-reeto protect their childrens health. Continued eortsto reduce secondhand smoke exposure in all settingsare needed to ensure that all nonsmokers are protected

rom this hazard.

Reported by

RB Kaumann, PhD, S Babb, MPH, A OHalloran,MSPH, K Asman, MSPH, E Bishop, MS, M Tynan,RS Caraballo, PhD, TF Pechacek, PhD, Ofce on Smok-ing and Health, National Center or Chronic DiseasePrevention and Health Promotion; JT Bernert, PhD,B Blount, PhD, Div o Laboratory Sciences, NationalCenter or Environmental Health, CDC.

Acknowledgments

his report is based, in part, on contributions byM Eischen, D Homa, PhD, A MacNeil, MPH, G Promo,MA, D Shelton, MPH, A rosclair, MS, Oice onSmoking and Health, National Center or Chronic DiseasePrevention and Health Promotion, CDC.

References

1. US Department o Health and Human Services. Te healthconsequences o involuntary exposure to tobacco smoke: areport o the Surgeon General. Atlanta, GA: US Departmeno Health and Human Services, CDC; 2006. Available athttp://www.surgeongeneral.gov/library/secondhandsmoke/report/ullreport.pd.

2. Pirkle JL, Bernert J, Caudill SP, Sosno CS, Pechacek Frends in the exposure o nonsmokers in the U.S. populationto secondhand smoke: 19882002. Environ Health Perspec2006;114:8538.

3. CDC. Fourth national report on human exposure to environmental chemicals. Atlanta, GA: US Department o Healthand Human Services, CDC; 2009. Available at http://wwwcdc.gov/exposurereport.

4. Max W, Sung H-Y, Shi Y. Who is exposed to secondhandsmoke? Sel-reported and serum cotinine measured exposurein the U.S., 19992006.

5. Mannino DM, Caraballo R, Benowitz N, Repace J. Predictoro cotinine levels in US children: data rom the hirdNational Health and Nutrition Examination Survey. Ches2001;120:71824.

6. Fiore MC, Jaen CR, Baker B, et al. Clinical practice guidelinereating tobacco use and dependence: 2008 update. RockvilleMD: US Department o Health and Human Services, PublicHealth Service; 2008. Available at http://www.surgeongeneralgov/tobacco/treating_tobacco_use08.pd.

7. Committee on Environmental Health, Committee on Substance Abuse, Committee on Adolescence, Committee onNative American Child Health. obacco use: a pediatricdisease. Pediatrics 2009;124:147484.

8. Benowitz NL, Bernert J, Caraballo RS, Holiday DB, WangJ. Optimal serum cotinine levels or distinguishing cigarettesmokers and nonsmokers within dierent racial/ethnic groupin the United States between 1999 and 2004. Am J Epidmio2009;169:23648.

9. Caraballo RS, Yee SL, Groerer J, Mizra SA. Adult tobacco useamong racial and ethnic groups living in the United States

20022005. Prev Chronic Dis 2008;5:19.10. CDC. Vital Signs: current cigarette smoking among adult

aged 18 yearsUnited States, 2009. MMWR 201059(35).

Additional inormation available at http://www.epa.gov/smokeree.
http://www.surgeongeneral.gov/library/secondhandsmoke/report/fullreport.pdfhttp://www.surgeongeneral.gov/library/secondhandsmoke/report/fullreport.pdfhttp://www.cdc.gov/exposurereporthttp://www.cdc.gov/exposurereporthttp://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdfhttp://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdfhttp://www.epa.gov/smokefreehttp://www.epa.gov/smokefreehttp://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdfhttp://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdfhttp://www.cdc.gov/exposurereporthttp://www.cdc.gov/exposurereporthttp://www.surgeongeneral.gov/library/secondhandsmoke/report/fullreport.pdfhttp://www.surgeongeneral.gov/library/secondhandsmoke/report/fullreport.pdf

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