Tobacco Use in America:  Chapter 1 - Introduction

1.1 Overview

Tobacco use is considered to be the most important preventable cause of death and disease in the United States (Bartecchi, MacKenzie, & Schrier, 1994; Office on Smoking and Health, 1999; U.S. Department of Health and Human Services [DHHS], 2000). The health consequences of tobacco use have been documented extensively. In 2001, it is estimated that tobacco-related disease will cause 450,000 deaths, mostly from smoking-related lung cancer and heart disease (Centers for Disease Control [CDC], 1997; National Cancer Institute [NCI], 2001). More than 1 billion people smoke worldwide, and an estimated 3 million die each year from tobacco-related illness (NCI, 2001). Despite all of its documented consequences, tobacco use continues to play an important role in the morbidity and mortality of this country.

For many years, whether tobacco could be considered a drug had been a topic for debate. In August 1996, the Food and Drug Administration (FDA) published its first comprehensive regulations restricting the sale and distribution of cigarettes and smokeless tobacco to children and adolescents. These regulations were based on the FDA conclusions that cigarette and smokeless tobacco products are delivery systems for nicotine, an addictive drug (CDC, 1996a; FDA, 1996), and the finding that most people begin smoking cigarettes in their adolescent years (Ellickson, Hays, & Bell, 1992; Office of Applied Studies [OAS], 1999, 2000a). Beginning cigarette use at an early age increases the risk of becoming ill or dying from causes attributable to smoking.

Nicotine is the primary component in tobacco that acts on the brain. Nicotine is one of more than 4,000 chemicals found in the smoke from cigarettes, cigars, and pipes. Smokeless tobacco products (such as chewing tobacco and snuff) also contain many toxins as well as high levels of nicotine. Repeated exposure to nicotine can result in addiction. Nicotine is recognized as one of the most commonly used addictive drugs, and cigarette smoking is the most prevalent form for nicotine addiction in the United States. For smokeless tobacco or environmental tobacco exposure, the nicotine is absorbed through the mucosal lining of the mouth or nose or through the skin. Cigar and pipe smokers do not generally inhale the smoke, so the nicotine is also absorbed through the mucosal membranes of the mouth. Cigarette smoking allows nicotine to be inhaled through the lungs. When inhaling, an average cigarette smoker gets 1 to 2 milligrams of nicotine per cigarette. After inhalation or absorption, nicotine passes rapidly into the arterial bloodstream and then into the brain. Inhalation transports the nicotine fastest to the brain (Benowitz, 1996; National Institute on Drug Abuse [NIDA], 1998). Nicotine has been found to activate the brain circuitry that regulates feelings of pleasure (alsoknown as "reward pathways"). Dopamine, a neurotransmitter involved in mediating the desire to consume drugs, is affected by nicotine (Benowitz, 1996; NIDA, 1998).

The most deleterious effects of nicotine addiction are the result of tobacco use, which has been linked to cancer, coronary heart disease, and stroke (FDA, 1996; Office on Smoking and Health, 1989). Overwhelming evidence demonstrates the cardiovascular hazards of smoking. The relationship between cigarette smoking and coronary disease was first reported by researchers at the Mayo Clinic in 1940 (English, Willius, & Berkson, 1940). Since then, studies have clearly shown that smoking substantially increases the risk of cardiovascular diseases, including stroke, sudden death, heart attack, peripheral vascular diseases, and aortic aneurism (Bartecchi et al., 1994; U.S. Public Health Service, 1989). As many as 30 percent of all coronary heart disease (CHD) deaths in the United States each year are attributable to smoking, with the risk being strongly dose related. A dose-response relationship refers to an increased risk of disease as the exposure to smoking increases. Smoking also nearly doubles the risk of ischemic stroke, and it acts synergistically with other factors to substantially increase the risk of CHD (Anderson, Wilson, O'Dell, & Kannell, 1991; Shinton & Beevers, 1989; U.S. Public Health Service, 1989, 1990). This relationship has been found for both men and women. A study of British doctors revealed a strong dose-response relationship between duration and extent of smoking and the death rate from ischemic heart disease in men younger than 65 years of age (Doll & Peto, 1976). The Nurses' Health Study showed that women who smoked one to four cigarettes per day had a 2.5 increase in risk for fatal coronary heart disease and nonfatal myocardial infarction (Willett et al., 1987). Cigarette use has also been well documented to be connected to multiple negative reproductive outcomes, including sudden infant death syndrome (SIDS) and low birthweight (CDC, 2001).

Lung cancer accounts for nearly one third of the smoking-related deaths in the United States each year (CDC, 1997; Office on Smoking and Health, 1996). Men who smoke increase their risk of death from lung cancer 23 times, and women who smoke increase their risk by about 13 times. Nearly 87 percent of all lung cancer cases in this country are smoking related, and an estimated 150,000 Americans were diagnosed with lung cancer in 1999. Since the Surgeon General released the first U.S. report on smoking and health in 1964, more than 2 million Americans have died from smoking-related lung cancer. On average, 150,000 Americans die each year from smoking-related lung cancer (American Cancer Society, 1998; U.S. Public Health Service, 1989, 1990). In addition to lung cancer, tobacco use is associated with cancers of the mouth, pharynx, larynx, esophagus, stomach, pancreas, uterine cervix, kidney, ureter, and bladder. Overall, rates of death from cancer are twice as high among smokers as compared with nonsmokers, and heavier smokers have rates that are 4 times greater than those of nonsmokers. Although many studies examined only cigarettes, the health risks associated with smoking cigars, which include mouth, throat, and lung cancers, are also well documented (DHHS,1998b). In their review of the health effects of cigar use, NCI researchers concluded that regular cigar smokers are at an increased risk for coronary heart disease and chronic obstructive lung disease, especially if they inhale (DHHS, 1998b). Although many young people consider smokeless tobacco to be a safe alternative to cigarettes, it is time that smokeless tobacco takes its rightful place as a serious health risk (DHHS, 1992). The health risks associated with smokeless tobacco use include oral cancer and various diseases of the mouth, gums, and throat (DHHS, 1992).

There is increasing recognition of the contributions of passive smoking to consequences resulting from tobacco use (NCI, 1999). A 1992 report by the U.S. Environmental Protection Agency (EPA) documented that environmental tobacco smoke (ETS) is a major source of indoor air pollutants and that some unintentional inhalation by nonsmokers is unavoidable. The report indicated that environmental smoke is composed of mainstream smoke exhaled by the smoker and sidestream smoke emitted from the burning tobacco between puffs. Sidestream and mainstream smoke contain many of the same air contaminants. Because there is no evidence of a safe threshold level for tobacco exposure, nonsmokers exposed to ETS are at increased risk for the same health consequences recognized in smokers. ETS has been classified as a known human lung carcinogen, or a group "A" carcinogen, under EPA's system of carcinogen classification (EPA, 1993). Secondhand smoke is estimated to contribute to as many as 40,000 deaths related to cardiovascular disease and to cause approximately 3,000 lung cancer deaths per year among nonsmokers. The relationship of passive smoking to heart disease has also been well documented (Bartecchi et al., 1994; Glantz & Parmley, 1991).

Problems and complications related to tobacco use also include the fact that dropped cigarettes are a leading cause of residential fire fatalities (NIDA, 1998). Moreover, women who smoke during pregnancy are at greater risk than nonsmokers for premature delivery, and there is an increased risk of lower birthweight for babies carried to term by smoking mothers. Stillbirths and early neonatal deaths are also increased by smoking (Bartecchi et al., 1994). Cigarette smoking is a leading cause of pulmonary illness and death in the United States (Sherman, 1992). Tobacco use is related to such problems as pneumonia, influenza, bronchitis, emphysema, and chronic airway obstruction. ETS in homes is a risk factor for new cases of childhood asthma and it increases the severity of asthma for children.

Despite all of the documented consequences of smoking, tobacco remains one of the most widely used substances in the United States. The most common tobacco product used is cigarettes. Since the release of the first Surgeon General's report on smoking and health in 1964, the prevalence of cigarette smoking has declined dramatically among adults in the United States. However, the levels of tobacco use in our country remain unacceptably high. Data from the 1999 National Household Surveyon Drug Abuse (NHSDA) indicated that 30.2 percent of the civilian, noninstitutionalized population aged 12 or older were current tobacco users (66.8 million people) (OAS, 2000b). That is, they used cigarettes, smokeless tobacco (chewing tobacco or snuff), cigars, or pipe tobacco in the past month. The majority of these tobacco users are cigarette smokers. In 1999, there were almost 57 million past month cigarette smokers (this translates to 25.8 percent of the population aged 12 or older). The prevalence of both past year and past month smoking increases dramatically throughout adolescence and young adulthood, peaking when people are in their late teens or early 20s (OAS, 1999). Beyond that point, the prevalence of current smoking declines. The steepest gradient for lifetime smoking is observed in the teenage years. Fewer than 20 percent of 12 to 13 year olds had ever smoked a cigarette compared with 39 percent of 14 to 15 year olds. By ages 16 and 17, more than half had tried a cigarette at some point in their lifetime. Cigar use is also a particular concern. In the mid-1980s, when advertising was not required to mention any potential health risks related to products, cigar makers engineered an aggressive marketing campaign that resulted in a dramatic rise in cigar consumption in the United States between 1993 and 1998, both in the general population and among youths. This sharp increase reversed a 30-year decline in cigar use (U.S. Department of Agriculture, 1999; DHHS, 1998b).

This report presents national and State estimates from the 1999 NHSDA on the rates of tobacco use and other measures related to cigarettes. The use of other forms of tobacco (cigars, pipes, and smokeless tobacco) is also included. Trend data tables include data from NHSDAs prior to 1999. Some of the results in this report may be somewhat different from findings of other surveys that address similar issues. Such differences are almost inevitable given variations between surveys in such areas as sample design, questionnaires, and mode of administration.

The report is divided into seven chapters. The 1999 national prevalence estimates are discussed in Chapter 2, including data arranged by demographic characteristics. State-level estimates, including information on the Synar Amendment program, are provided in Chapter 3. Chapter 4 covers the initiation of smoking and patterns of use, and Chapter 5 includes information on the risk and protective factors related to smoking. Chapter 6 deals with tobacco use among special population groups, and Chapter 7 provides detailed information on the brands used for specific tobacco products. Appendices give technical details on the survey methodology, discuss other sources of data, and provide detailed tabulations of estimates discussed in each chapter.

1.2 Summary of NHSDA Methodology and Trend Estimates

The NHSDA is a primary source of statistical information on the use of illegal drugs by the U.S. population. Conducted by the Federal Government since 1971, the survey collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at their place of residence. The survey is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), and data collection is carried out by Research Triangle Institute (RTI), under a contract with SAMHSA's Office of Applied Studies (OAS). This section contains a brief description of the methodology. A more complete description is provided in other SAMHSA reports (see Appendix A).

The survey covers residents of households, noninstitutional group quarters (e.g., shelters, rooming houses, dormitories), and civilians living on military bases. Persons excluded from the survey include homeless people who do not use shelters, active military personnel, and residents of institutional group quarters, such as jails and hospitals. Appendix A also includes a description of surveys that cover populations not included in the NHSDA sampling frame.

Prior to 1999, the NHSDA was conducted using a paper-and-pencil interviewing (PAPI) methodology, and the interviews generally lasted about an hour. The NHSDA PAPI instrumentation consisted of a questionnaire booklet that was completed by the interviewer and a set of individual answer sheets that were completed by the respondent. All substance use questions, and other sensitive questions appeared on the answer sheets so that the interviewer was not aware of the respondent's answers. Less sensitive questions, such as demographics, occupational status, household size, and composition, were asked aloud by the interviewer and recorded in the questionnaire booklet.

The 1999 NHSDA marked the first survey year in which the national sample was interviewed via computer-assisted interviewing (CAI; specifically, a combination of computer-assisted personal interview [CAPI] and audio computer-assisted self-interview [ACASI] techniques). For the most part, questions previously administered by the interviewer are now administered by the interviewer using CAPI. Questions previously administered using answer sheets are now administered using ACASI. CAI has many advantages over PAPI, including more efficient collection and processing of the data and improved data quality. Use of ACASI is designed to provide the respondent with a highly private and confidential means of responding so as to maximize honest reporting of illicit drug use and other sensitive behaviors.

To assess the impact of the change in data collection mode from PAPI to CAI and to measure trends in substance use, the 1999 survey utilized a dual-sample design. The main sample of 66,706 respondents was interviewed using the CAI methodology, while an additional 13,809 supplemental interviews were conducted via the PAPI methodology. The intent was to use the 1999 PAPI data to measure changes in use patterns because the methodology was the same as was used in prior years. The supplement was selected from a national subsample of 250 geographic strata. Both the main (CAI) and supplemental (PAPI) surveys were conducted from January through December 1999.

The 1999 NHSDA CAI sample employed a 50-State design with an independent, multistage area probability sample for each of the 50 States and the District of Columbia. Nationally, weight-adjusted response rates for household screening and for interviewing were 89.6 percent and 68.6 percent, respectively. Weighted response rates for the individual States for household screening ranged from 96.1 to 79.9 percent. For interviewing, the response rates for the States ranged from 82.8 to 58.4 percent.

The PAPI sample was designed to be the main basis for relating 1999 drug use estimates to estimates from 1998 and prior years. Even though it was implemented within the sampling frame for the 50-State sample designed for the CAI survey, an extra stage of sampling and a within-household screening procedure were added to allow coordinated oversampling of the Hispanic and black households in a manner comparable to the 1998 and prior years' surveys. Weighting, editing, and imputation procedures were also conducted in a manner comparable to prior years' surveys.

In spite of the efforts taken to maintain total methodological comparability, analyses have suggested that the 1999 PAPI data may not be comparable to earlier data. Investigations into possible technical problems related to data collection, response rates, Quarter 1 startup problems, weighting, and editing and imputation were conducted to see if any procedural changes or errors may underlie the problem. Although no technical problems or obvious causes associated with these factors have been discovered, one line of inquiry within this general investigation was to investigate possible interviewer experience effects. It was discovered that respondents were more likely to report substance use in interviews conducted by inexperienced interviewers than with experienced interviewers. This was exhibited in a small difference in predicted prevalence rates based on prior NHSDA experience and a continuing small, but often statistically significant, decline in predicted prevalence rates as interviewers accumulated experience during the year. Under continuing operations with about the same level of effort from year to year, the experience of interviewers would be approximately matched for two succeeding years causing both years' estimates to be influenced in comparable ways. Because of the expansion of the sample in 1999, the interviewers in 1999 were generally less experienced than in prior years.Analytical studies that took account of the differences in interviewer experience distributions showed that under comparable conditions, the 1999 estimates would be lower than shown by the direct estimates.

Initial analysis of the CAI sample indicates much smaller interviewer experience effects. This tends to validate the decision to move to the CAI technology as a means of reducing survey errors associated with the interviewing environment.

Selected estimates presented in this report for 1999 may differ from those released earlier by SAMHSA. An error was detected in the computer programs that assigned imputed values for drug use variables that had missing information in the 1999 NHSDA file. Based on an analysis of the impact of this error on 1999 prevalence estimates, imputation of all drug use data was redone using corrected programs. In addition, revisions were made to age at first use data that use month of first use. In this report, the following types of tables present estimates that may differ somewhat from previously released data: incidence, timing of initiation of cigar and cigarette use, and illicit drug and alcohol use by cigarette use.

1.3 Explanation of Terms Used in Report

Tables and text present prevalence measures for the U.S. general household population in terms of the rate and level of their use of tobacco products. Tables show prevalence estimates for tobacco use (any tobacco product, cigarettes, cigars, smokeless tobacco, and pipes) for lifetime, past year, past month, and daily use:

Lifetime Use. Lifetime prevalence refers to a respondent reporting use of a specific type of tobacco product at least once in their lifetime.

Past Year Use. Past year prevalence refers to using a specific type of tobacco product at least once during the 12 months preceding the interview date.

Past Month Use. Past month prevalence refers to using a type of tobacco product at least once during the 30 days preceding the interview date, this prevalence type is also referred to as "current use."

Data are presented for major racial/ethnic groups in several groupings, based on the level of detail the sample will allow. Because respondents were allowed to choose more than one racial group, a "more than one race" category is presented that includes persons who report more than one category among the seven basic groups listed in the survey question (white; black/African American; AmericanIndian or Alaska Native; Native Hawaiian; Other Pacific Islander; Asian; Other). It should be noted that the category "white" shown in this report includes only non-Hispanic whites; the category "black" includes only non-Hispanic blacks; and the category "Hispanic" includes Hispanics of any race. Also, more detailed categories are obtained in the survey for respondents who report Asian race or Hispanic ethnicity.

Data are also presented for four U.S. geographic regions and nine geographic divisions within these regions. These regions and divisions include the following groups of States:

Northeast Region. New England Division: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut; Middle Atlantic Division: New York, New Jersey, Pennsylvania.

Midwest Region. East North Central Division: Wisconsin, Illinois, Michigan, Indiana, Ohio; West North Central Division: North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri.

South Region. South Atlantic Division: West Virginia, Virginia, Maryland, Delaware, District of Columbia, North Carolina, South Carolina, Georgia, Florida; East South Central Division: Mississippi, Tennessee, Kentucky, Alabama; West South Central Division: Texas, Oklahoma, Arkansas, Louisiana.

West Region. Mountain Division: Idaho, Nevada, Arizona, New Mexico, Utah, Colorado, Wyoming, Montana; Pacific Division: California, Oregon, Washington, Hawaii, Alaska.

To examine population density, counties were grouped based on the "Rural-Urban Continuum Codes" developed by the U.S. Department of Agriculture (Butler & Beale, 1994). This variable differs from the "Population Density" presented in previous reports. Each county is either in a Metropolitan Statistical Area (MSA) or outside an MSA, as defined by the Federal Office of Management and Budget (OMB). For counties in New England, New England County Metropolitan Areas (NECMA) were used for defining codes. Large metropolitan areas have a population of 1 million or more. Small metropolitan areas have a population of fewer than 1 million. Nonmetropolitan areas are areas outside MSAs. For some tables, small metropolitan areas are further classified as having either fewer than or greater than 250,000 population. Counties in nonmetropolitan areas are classified based on the number of people in the county who live in an urbanized area, as defined by the Census Bureau at the subcounty level. "Urbanized" counties have 20,000 or more population in urbanized areas; "Less Urbanized" counties have at least 2,500 but fewer than 20,000 population in urbanized areas; and "Completely Rural" counties have fewer than 2,500 population in urbanized areas.

Other than presenting results by age group and other basic demographic characteristics, no attempt is made in this report to control for potentially confounding factors that might help to explain the observed differences. This point is particularly salient with respect to race/ethnicity, which tends to be highly associated with socioeconomic characteristics. The cross-sectional nature of the data limits the capability to infer causal relationships. Nevertheless, the data presented in this report are useful for indicating demographic subgroups with relatively high (or low) rates of tobacco use, regardless of underlying reasons for those differences.

1.4 Survey Sample Sizes

In 1999, a total of 66,706 respondents were interviewed using the NHSDA CAI survey methodology. Sample sizes for the total surveyed and for three age groups are presented in Table 1.1 by demographic characteristics and in Table 1.2 by geographic characteristics.

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