In June 1996, the prevalence of cigarette smoking was added to the list of nationally notifiable health conditions reported by States to the Centers for Disease Control and Prevention (CDC, 1996a). Variation in the prevalence of cigarette smoking contributes to State differences in the mortality patterns of smoking-related diseases, such as lung cancer, coronary heart disease, chronic bronchitis, and emphysema (Nelson et al., 1994).
State-level data, stratified by age group, on the past month prevalence of any tobacco products, the past month use of cigarettes, and the perceived harm associated with cigarette use are provided in Tables 3.1 to 3.3 in Appendix C. These estimates were produced by combining the prevalence rate based on the State sample data and the prevalence rate based on a national regression model applied to local-area county and Census block group/tract-level estimates from the State. The parameters of the regression model are estimated from the entire national sample. Because the 42 less populous States and the District of Columbia (DC) have smaller samples than the 8 most populous States, estimates for the smaller States rely more heavily on the national model. The model for each substance use measure typically utilizes from 50 to100 independent variables in the estimation. These variables include basic demographic characteristics of respondents (e.g., age, race/ethnicity, and gender), demographic and socioeconomic characteristics of the Census tract or block group (e.g., average family income and percentage of single-mother households), and county-level substance abuse and other indicators (e.g., rate of substance abuse treatment, drug arrest rate, and drug- and alcohol-related mortality rate). For comparison purposes, tables and maps displaying estimates for all 50 States and DC utilize the modeled estimates for all 51 areas (see Appendix C and Figures 3.1 and 3.2 on the following pages).
Associated with each State estimate is a 95-percent prediction interval that indicates the precision of the estimate. For example, for past month use of any tobacco, the State with the highest estimated rate was West Virginia, with a rate of 39.2 percent. The 95-percent prediction interval on that estimate is between 35.2 and 43.3 percent. Therefore, the probability is .95 that the true prevalence for West Virginia will fall between 35.2 and 43.3 percent. The prediction interval indicates the uncertainty due to both sampling variability and model bias. For more information on the methodology used to generate State-level estimates of substance use, including tobacco use, please refer to the Summary of Findings from the 1999 National
Figure 3.1 Percentages of Persons Aged 12 or Older and Youths Aged 12 to 17 Reporting Past Month Use of Cigarettes: 1999
Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1999.
Figure 3.2 Percentages of Persons Aged 18 or Older Reporting Past Month Use of Cigarettes: 1999
Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1999.
Household Survey on Drug Abuse (Office of Applied Studies [OAS], 2000b). When comparing estimates of tobacco use among States, it is important to acknowledge that States show considerable variation in the distribution of demographic and socioeconomic variables often correlated with prevalence rates. The confidence intervals included with the prevalence estimates indicate that many of the State-level estimates overlap statistically.
The confidence intervals around the State-level estimates are fairly sizable, which means that estimates that appear to be different from each other may be similar when the statistical issues (e.g. design effects) are considered. Therefore, to compare States, we chose to discuss them in clusters of 10. The prevalence rates for any tobacco use, past month cigarette use, and perceived harm of smoking a pack or more of cigarettes per day were rank ordered and then divided into quintiles.
Data for State-level rates of past month use of any tobacco product (by age group) are in Table 3.1 in Appendix C. Overall, 30.3 percent of the people aged 12 or older in all States were current users of a tobacco product (i.e., cigarettes, cigars, pipe tobacco, or smokeless tobacco, such as chewing tobacco or snuff). The past month prevalence rate for the current use of any tobacco product by age was 17.5 percent of youths aged 12 to 17 years, 44.5 percent of young adults aged 18 to 25 years, and 29.7 percent of those who are 26 years old or older. Current tobacco use among youths ranged from a low of 10.8 percent for adolescents living in California to a high of 28.5 percent for youths in Kentucky, a State that grows and markets tobacco. In addition to Kentucky, the top 10 States for past month tobacco use among youths were West Virginia, North Dakota, Arkansas, Montana, Mississippi, South Dakota, Minnesota, Delaware, and Missouri (ranging from 28.5 to 21.7 percent). In addition to California, the lowest quintile for current tobacco use among youths consisted of Utah, Hawaii, the District of Columbia, New Jersey, Nebraska, New York, Florida, Idaho, and Texas (ranging from 10.8 to 16.1 percent).
Figure 3.1 in this chapter and Table 3.2 in Appendix C give the State-level estimates of current cigarette use by age group. Because cigarette use is a major contributor to statistics on any tobacco product use, the State rankings for adolescent current cigarette use looked very similar to those for past month tobacco use. The top quintile for adolescents ranged from 18.8 up to 23.9 and included both North and South Dakota, both North and South Carolina (both of which are major tobacco-producing States), Delaware, Montana, Arkansas, Minnesota, West Virginia, and Kentucky. The lowest clusterof States for teenage tobacco use ranged from 9.0 to 13.8 percent and was made up of California, Hawaii, Utah, the District of Columbia, Florida, New Jersey, New York, Idaho, Texas, and Maryland.
State-level estimates for the percentage of people who reported perceiving "great" risk of personal harm from smoking one or more packs of cigarettes per day are provided in Table 3.3 in Appendix C. It is well documented that perceived harm affects behavior (Duitsman & Colbry, 1995; Kelly, Swaim, & Wayman, 1996; Resnicow, Smith, Harrison, & Drucker, 1999). Therefore, it is not surprising that many of the States with the highest adolescent smoking rates also ranked lowest in perceived harm for heavy cigarette use. The percentage of youths citing great risk of harm for smoking one or more packs of cigarettes per day ranged from a low in Kentucky, with 52.7 percent, to a high of 70.3 percent for youths living in Utah. The cluster of States with the fewest youths perceiving a great risk of harm from heavy smoking ranged from 52.7 to 57.3 percent and consisted of, in addition to Kentucky, Tennessee, Kansas, Virginia, Nebraska, North Carolina, West Virginia, Nevada, South Dakota, and Ohio. In addition to Utah, the quintile where adolescents were most likely to perceive great harm from smoking a pack or more per day ranged from 70.3 to 62.7 percent and was made up of Florida, California, Maine, Massachusetts, the District of Columbia, New Jersey, Georgia, Connecticut, and Idaho.
In 1992, Congress enacted the Alcohol, Drug Abuse and Mental Health Administration Reorganization Act (P.L. 103-321), which includes an amendment (Section 1926) aimed at decreasing tobacco product use among individuals under the age of 18. This amendment, the Synar Regulation, was named for its sponsor, Congressman Mike Synar of Oklahoma. The Synar Amendment requires all States, as a condition of receiving Substance Abuse Prevention and Treatment (SAPT) Block Grant funding, to enact and enforce laws prohibiting any manufacturer, retailer, or distributer from selling or distributing tobacco products to minors.
A major component of the Federal requirement is that States must conduct an annual "compliance check" survey. At the risk of losing a portion of their SAPT Block Grant awards, they must perform random, unannounced inspections of a sample of tobacco vendors to measure retailer compliance with the State's laws and to meet annual retailer violation target rates. Each State must submit an annual report to the DHHS describing that year's enforcement activities, the extent to whichthe State reduced tobacco availability to minors, and a strategy and time frame for achieving an inspection failure rate of 20 percent or less of tobacco outlets accessible to persons under 18 years of age.
As noted above, a Synar-noncompliant State can lose a percentage of its Federal SAPT Block Grant funds. The Synar regulation does provide that in extraordinary circumstances a number of other factors may be considered, such as a scientifically sound survey indicating that the State is making significant progress toward reducing use of tobacco products by minors. Extraordinary circumstances include those that existed in the State that were beyond its control and prevented the State from meeting the negotiated target (e.g., a lawsuit that such inspections involve such issues as improper arrest or entrapment).
All States currently have laws making it illegal to sell or distribute tobacco to minors and all have developed methods for measuring statewide compliance with tobacco access laws. All States have conducted random, unannounced inspections of tobacco outlets. (Before the Synar Amendment, 46 States and DC had laws, but they were rarely enforced.) Table 3.4 in Appendix C lists violation rate data by State from 1997 through 2000. Average retailer sales rates to minors, as measured by the States annually, have been reduced. The Substance Abuse and Mental Health Services Administration (SAMHSA) expects all States to achieve the Synar Amendment's regulatory goal (an inspection failure rate of less than 20 percent of outlets accessible to youths) by September 30, 2002.
Findings from the FY2000 survey indicated that 23 States had a violation rate of 20 percent or less. This is not an improvement from FY1999 when 24 States had rates of 20 percent or less. In FY1998, there were 20 States with violation rates of 20 percent or less. FY2000 violation rates in excess of 20 percent ranged from 21.3 percent in Ohio to the high inspection failure rate of 55.8 percent in Wyoming. Among the States in compliance with the Synar Amendment regulations in FY2000, the range of violation rates went from a low of 6.4 percent in Maine to a high of 20.1 percent in Oklahoma. There was not much correlation between the prevalence of smoking and the inspection failure rates. States with low adolescent smoking prevalence rates did not necessarily have low inspection failure rates. For example, in 1999, Kentucky had the highest current smoking rate for adolescents (23.9 percent), but their FY2000 inspection failure rate was 19.7 percent, an acceptable level.
