This chapter opens with a discussion of the number of new users of tobacco products from 1965 to 1998 based on data from the 1999 NHSDA. Subsequent sections focus on the age at first use of tobacco products; the ordering of initiation of cigarettes and cigars; the patterns of use for cigarettes, cigars, and smokeless tobacco; and the use of multiple tobacco products and other substances. Detailed tables are provided in Appendix D.
Estimates of incidence, or initiation (i.e., number of new users during a given year), provide another measure of the tobacco product use problem in the United States. Incidence rates can suggest emerging patterns of use, particularly among young people. Increases and decreases in incidence have usually been followed by corresponding changes in prevalence. Details of the methodology used to develop estimates of drug use incidence are given in the Summary of Findings from the 1999 National Household Survey on Drug Abuse (Office of Applied Studies [OAS], 2000b). The methodology for developing these 1999 estimates uses the NHSDA computer-assisted interviewing (CAI) data and is different from the methodology used from 1971 to 1998. The revised methodology has a significant impact on age-specific rates, so comparisons with previous incidence estimates should not be made.
Incidence estimates are based on NHSDA questions that focus on age at first use, year and month of first use for recent initiates, the respondent's date of birth, and the interview date. Using this information, along with editing and imputation when necessary, an exact date of first use is determined for each substance used by each respondent. For age-specific incidence rates, the period of exposure was defined for each respondent and age group for the time that the respondent was in the age group during the calendar year. Incidents of first use were also classified by year of occurrence and age at the date of first use. By applying sample weights to incidence of first use, estimates of the number of new users of each tobacco product for each year were made.
Because information on when people first used a tobacco product is collected on a retrospective basis, information on first-time use or incidence always lags 1 year behind information on current use. The 1999 incidence estimates are subject to several biases, including bias due to differentialmortality of users and nonusers of each tobacco product, bias due to memory errors (recall decay and telescoping), and underreporting bias due to social acceptability and fear of disclosure. (See Appendix A for a discussion of these data limitations.)
Tables 4.1 through 4.4 in Appendix D provide incidence data for any cigarette use, daily cigarette use, cigar use, and smokeless tobacco use. These estimates are presented for new users at any age, including those younger than 12 years, as well as for two specific age groups: youths aged 12 to 17 years and young adults aged 18 to 25 years. In addition, the average age of new users in each year and age-specific rates of first use are included. These rates are presented in these tables as the number of new users per 1,000 potential new users because they indicate that the rate of new use among persons who have not yet used the drug (i.e., potential new users). The rates are actually the number of new users per 1,000 person-years of exposure. The numerator of each rate is the number of persons in the age group who first used the tobacco product in the year, while the denominator is the person time exposure measured in thousands of years. Each person's exposure time ends on the date of first use. For age-specific estimates, exposure is limited to time during the year that the person was in the age group. Persons who first used the tobacco product in a prior year have zero exposure to first use in the current year, and persons who still have never used the tobacco product by the end of the current year had 1 full year of exposure to risk.
Approximately 3.2 million people tried their first cigarette in 1997 (1998 estimate not available; see Table 4.1 in Appendix D). Most of these new users were between the ages of 12 and 17 (2.3 million). Between 1990 and 1997, the rate of initiation among youths aged 12 to 17 increased from 108.9 to 157.6 per 1,000 potential new users. Among young adults aged 18 to 25, the rate of cigarette initiation increased from 46.8 per 1,000 potential new users in 1990 to 65.3 per 1,000 potential new users in 1997 (see Figure 4.1).
After increasing since the early 1990s, the number of 12 to 17 year olds initiating daily smoking dropped dramatically between 1997 and 1998 (see Table 4.2 in Appendix D). Initiation of daily cigarette use increased notably among adolescents between 1991 and 1997, rising steadily in this age group from 661,000 new daily smokers in 1990 to more than 1.1 million in 1997. Subsequently, there was a large decrease in 1998 to 864,000.
Overall, an estimated 1.7 million people began smoking on a daily basis in 1998. More than half of these new daily smokers were younger than 18 years of age. These 1.7 million daily smokers translate to more than 4,000 new daily smokers per day, of which more than 2,000 were youths. The annual number of new daily smokers increased from 1.4 million in 1990 to 2.0 million in 1997 (see Figure 4.1).Figure 4.1 Annual Numbers of New Tobacco Users: 1965-1998
Note: Information on when people first used a tobacco product is collected on a retrospective basis, so data on first use always lag 1 or 2 years behind information on current use.
Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1999.
Following a sharp increase in promotional activities by manufacturers, cigar sales in the United States increased by almost 50 percent between 1993 and 1998. The largest increase was in the sale of large cigars (DHHS, 1998b). A core element of cigar promotion was linking cigar smoking to a successful lifestyle and featuring highly visible women smoking cigars. Prior to the early 1990s, cigar usewas a behavior associated with older men, but these patterns have changed. These recent marketing efforts were successful in increasing cigar consumption among younger men and initiating cigar smoking among women (DHHS, 1998b).
This rise in cigar use was evident in the incidence data from the NHSDA (see Table 4.3 in Appendix D). Almost 5 million people tried cigars for the first time in 1998. This number translates to about 13,000 new cigar users per day. There was more than a threefold increase in cigar initiation since 1991, when there were only 1.5 million new cigar smokers (see Figure 4.1). The average age of cigar initiates changed little since the 1980s, and incidence rates increased among both youths (from 21.8 percent in 1991 to 99.5 percent in 1998) and young adults (from 30.4 percent in 1991 to 93.3 percent in 1998).
In the decades following the introduction of mass-produced and mass-marketed cigarettes, consumption and prevalence of smokeless tobacco had been on the decline. This decline stopped in the latter part of the 1970s and the early part of the 1980s subsequent to renewed and more aggressive advertising by the smokeless tobacco industry (DHHS, 1992).
The NHSDA indicates that an estimated 1 million people tried smokeless tobacco for the first time in 1998 (see Table 4.4 in Appendix D and Figure 4.1). Most new users were under the age of 18. The rate of initiation among youths aged 12 to 17 remained constant at approximately 30 per 1,000 potential new users since the 1980s.
Tables 4.1 through 4.4, discussed in the previous section, show the mean age of initiation of tobacco products, by year, as well as display the number of new users and the age-specific rates, by type of tobacco product. The mean ages refer to individuals who initiated use within a single time period (e.g., 1998). Each calendar year is analyzed separately using only the ages of the individuals who initiated use in that particular year. For example, in Table 4.1, the mean age for all people who started smoking in 1997 was 15.4. As discussed in greater detail in Section 4.2, an exact date of first use is determined for each tobacco product used by each respondent using data on (a) age at first use, (b) year and month of first use for recent initiates, (c) the respondent's date of birth, and (d) the interview date. Because information on when people first used a specific tobacco product is collected on a retrospective basis, information on first-time use always lags 1 year behind information on current use.Therefore, the mean ages for new users in Table 4.1 through 4.4 lag 1 year behind the 1999 survey year.
The average age at first use of a cigarette (Table 4.1) did not vary much between 1965 and 1997, and the mean age of new users ranged between 15 and 16 years. The average age for initiating daily cigarette use (Table 4.2) also did not change much. In general, smokers began daily use around age 18 between 1965 and 1997, and the average age of first daily use was 19 years for those who started this behavior in 1998. The mean age at first use for cigars (Table 4.3) seemed to be increasing somewhat over the 1965-to-1998 time period. From the mid-1960s through the end of the 1980s, the average age of first-time cigar users was around 19 years. In the 1990s, the mean age began to rise slowly, and the average age of people who initiated cigar use in 1998 was 23.0 years. As seen for the other tobacco products, there was not a consistent trend for average age of initiation of smokeless tobacco (Table 4.4). Although age at first use varied, first-time users of smokeless tobacco in the late 1990s seemed to be slightly older than new initiates in the 1960s (mean age of first smokeless tobacco use ranged from 14 to 16 years in the 1960s to 17.3 years in 1998).
Table 4.5 presents data on the average age at first use among all persons who ever used cigarettes, cigars, and smokeless tobacco in their lifetime, by gender and race/ethnicity. Age at first use data were not collected in the NHSDA for pipe smokers. Average age at first use data, as shown in Table 4.5, differ substantially from the mean ages at initiation discussed in Section 4.2 and shown in Tables 4.1 to 4.4. The average age at first use in Table 4.5 is not a single point in time (i.e., first-time use during a specific year), but instead reflects the mean age at first use for everyone who ever used a particular tobacco product. The average age at first use of tobacco products in 1999 among all persons who ever used in their lifteime was 15.4 years for cigarettes, 20.5 for cigars, and 16.7 for smokeless tobacco across all age groups.
For everyone who had ever smoked a cigarette, males initiated cigarette use at a younger age than females (14.8 vs.16.1 years, respectively). This same pattern was observed for age at first use of cigars (19.9 years for males vs. 22.3 years for females). Females reported first using smokeless tobacco at a younger age (15.9 years) than males (16.9 years).
By race/ethnicity, the average age at first cigarette use ranged from 14.5 years for American Indians/Alaska Natives to an average age of 16.7 years for first-time use of cigarettes among Asians. Average age for initiation of cigar use was more comparable among the different racial/ethnic groups. Average age at first use for smokeless tobacco ranged from 14.6 for blacks to 18.2 for Asians. In summary, first-time users of cigarettes were the youngest among first-time users of all tobaccoproducts, smokeless tobacco initiates were in the middle, and the average age for first use of cigars was older than that seen for the other two tobacco products.
The majority of cigar smokers first started smoking with cigarettes. As seen in Table 4.6 in Appendix D, 87.1 percent of all lifetime cigar and cigarette users initiated using tobacco products with cigarettes before using cigars. This ordering of tobacco products was particularly true for females, among whom 89.3 percent initiated cigarette use before cigar use. Among youths aged 12 to 17 years, 22.1 percent of males and 12.4 percent of females reported ever using cigars and cigarettes. Among these, 74.1 percent of males and 78.9 percent of females reported using cigarettes before cigars. Among 18 to 25 year olds in 1999, 52.5 percent of males and 28.4 percent of females had used cigars and cigarettes in their lives. Of these, 78.7 percent of males and 87.7 percent of females used cigarettes prior to using cigars. This ordering was even more pronounced among older cigar smokers. Among 26 to 34 year olds, 51.5 percent of males and 20.1 percent of females reported lifetime cigarette and cigar use. Among these respondents, 84.9 percent of the males and 93.5 percent of females used cigarettes prior to using cigars. The prevalence of lifetime cigarette and cigar use among survey respondents aged 35 years old or older was 57.4 for males and 12.7 percent for females. Approximately 89 percent of both the males and females in this age group reported initiating cigarettes before cigars.
Cigarette smoking pattern data are provided in Tables 4.7a and 4.7b in Appendix D. Table 4.7a presents past month intensity of cigarette use per day displayed by age group, gender, and race/ethnicity for current daily smokers in 1999. Frequency choices were 5 or fewer cigarettes per day, 6 to 15 per day, and a pack or more per day. For all current daily smokers aged 12 or older, the majority reported using 6 to 15 cigarettes per day (approximately half a pack) in the past month (70.6 percent of current smokers). However, distributions for the number of cigarettes used per day differed by race/ethnicity and gender, particularly for the youngest smokers. Table 4.7b presents the number of days on which cigarettes were smoked by current cigarette smokers displayed by age group, gender, and race/ethnicity. For all current smokers aged 12 or older, the majority reported smoking on more than 20 days in the past month (71.3 percent).
Frequency of Cigarette Smoking, by Age. Overall, the majority of current daily smokers reported smoking 6 to 15 cigarettes per day (about half a pack) (Table 4.7a). However, this frequency distribution differed by age group. A greater percentage of youths aged 12 to 17 than adult daily smokers aged 35 or older reported smoking 6 to 15 cigarettes per day (91.7 vs. 72.1 percent, respectively). Heavy smoking (one pack or more per day in the past month) was reported by 23.1 percent of daily smokers aged 35 or older, 14.3 percent of 26- to 34-year-old daily smokers, 9.4 percent of 18- to 25-year-old daily smokers, and 4.3 percent of 12- to 17-year-old daily smokers.
The majority of all current smokers reported smoking on more than 20 days in the past month (71.3 percent) (Table 4.7b). Smoking on more than 20 days in the past month was reported by 41.9 percent of current smokers aged 12 to 17, 60.6 percent of those aged 18 to 25, 69.0 percent of those aged 26 to 34, and 78.9 percent of those aged 35 or older. Current smokers aged 12 to 17 were more likely than those in other age groups to report having smoked on only 1 or 2 days in the past month (25.2 vs. 6.8 to 13.8 percent).
Frequency of Cigarette Smoking, by Gender. Among all male current daily smokers, 4.6 percent reported smoking 5 or fewer cigarettes per day, 73.3 percent smoked 6 to 15 cigarettes per day (about half a pack), and 22.1 percent smoked a pack or more a day (see Table 4.7a in Appendix D). For current daily smokers who were female, 3.4 percent reported smoking 5 or fewer cigarettes per day, 81.5 percent smoked 6 to 15 cigarettes per day, and 15.0 percent smoked a pack or more a day. Males were significantly more likely (as compared with females) to be heavier smokers for each age group except youths aged 12 to 17.
Male and female current smokers did not differ greatly in the number of days smoked in the past month, for all current smokers and each age group (Table 4.7b). More than 70 percent of all male and female current smokers reported smoking on 20 or more days in the past month.
Frequency of Cigarette Smoking, by Race/Ethnicity. Among all current daily smokers, whites were more likely than blacks and Hispanics to have smoked a pack or more per day (20.8 vs. 11.0 and 5.3 percent, respectively), and Asians were least likely to have smoked a pack or more per day (1.5 percent). Although these racial/ethnic patterns generally held for all smokers aged 18 or older, data for some of the age by race/ethnicity groups were suppressed because of low precision.
Among all current smokers, whites (75.3 percent) were more likely than blacks (63.1 percent) or Hispanics (52.5 percent) to have reported smoking on more than 20 days in the past month (Table4.7b). These differences generally held for the age groups, although some estimates were suppressed because of low precision.
The frequency of past month cigar use is provided in Table 4.8 by age, gender, and race/ethnicity. Cigar frequency categories were 1 to 2 days in the past month, 3 to 10 days, 11 to 20 days, and more than 20 days. For all ages, racial/ethnic groups, and genders, most cigar use was occasional (1 to 2 days a month), and very few cigar smokers lit up on more than 11 days per month. For all current cigar smokers, more than half (55.1 percent) reported cigar use on 1 to 2 days in the past month, 29.9 percent used on 3 to 10 days, 6.7 percent smoked on 11 to 20 days, and 8.2 percent smoked cigars on more than 20 days in the month prior to the 1999 survey.
Frequency of Cigar Use, by Age. Cigar use accounts for the largest share of noncigarette tobacco use. For young adults (18 to 25 year olds), 17.9 percent of males were current cigar users. Among young adult males who were current users, 55.5 percent smoked cigars on 1 or 2 days in the month prior to survey, 32.9 percent smoked on 3 to 10 days, 7.3 percent smoked on 11 to 20 days, and 4.4 percent reported the use of cigars on more than 20 days. About 5 percent of young adult females were current cigar smokers. Of these 18- to 25-year-old females who smoked at least once in the month prior to survey, 65.2 percent smoked cigars on 1 or 2 days, 24.1 percent smoked on 3 to 10 days, and 10.7 percent smoked cigars on more than 11 days. Frequent cigar use (i.e., use on more than 20 days in the past month) was most prevalent among the oldest cigar smokers. An estimated 14.1 percent of cigar users aged 35 years or older reported cigar use on 20 days or more in the past month compared with 3.3 percent of cigar users who were 26 to 34 year of age, 4.4 percent of those 18 to 25 years of age, and 2.6 percent of adolescent cigar users.
Frequency of Cigar Use, by Gender. Men were more likely than women to be current cigar smokers, and women who were cigar smokers were more likely than men to use them occasionally. For the two youngest age groups (12 to 17 and 18 to 25), females were significantly more likely than male cigar smokers to report use on only 1 or 2 days in the past month. Among the adolescents, 65.7 percent of female cigar users (compared with 54.6 percent of male cigar users) reported use on 1 or 2 days in the past month. For the young adults, 65.2 percent of females compared with 55.5 percent of male cigar users reported use on 1 or 2 days in the month prior to survey. The prevalence of cigar smoking among females in the older age groups was so low that estimates became unreliable for the category of cigar use on 1 or 2 days in the past month.
Frequency of Cigar Use, by Race/Ethnicity. Blacks were as likely to smoke cigars as whites. As shown in Figure 4.2 and Table 4.8 in Appendix D, blacks smoked cigars more frequently than their white counterparts, particularly among young adults. For cigar smokers of all ages, 20.5 percent of blacks used cigars on 11 or more days in the month prior to survey compared with 14.2 percent of white cigar users and 16.3 percent of Hispanic cigar smokers. Among adolescents, more than 22 percent of black current cigar smokers used cigars on 11 or more days in the past month compared with about 9 percent of white cigar smokers. For young adults (18 to 25 year olds), 6.3 percent of white current cigar users smoked them on 11 or more days compared with 33.7 percent of black current cigar smokers. The prevalence of cigar use was lower among the older age groups, making it unreliable to compare frequency of cigar use data by race/ethnicity for these two age groups.Figure 4.2 Frequency of Cigar Use among Males 18 to 25 Years of Age Who Smoked Cigars in the Past Month, by Race/Ethnicity: 1999
Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1999.
Table 4.9 in Appendix D provides frequency of use data for past month smokeless tobacco use in 1999. Frequency of use is shown by age, gender, and race/ethnicity. The frequency categories were 1 to 2 days, 3 to 5 days, and more than 5 days in the past month. Smokeless tobacco use was much less prevalent than cigarette or cigar use, so data on fewer racial/ethnic groups were statistically reliable enough to be displayed.
Frequency of Smokeless Tobacco Use, by Age. Among all smokeless tobacco users, 13.8 percent used it on 1 to 2 days in the past month, 11.3 percent used it on 3 or 5 days, and the majority (72.5 percent) used smokeless tobacco on more than 5 days in the past month. Frequency of use differed by age. Among 12 to 17 year olds, 39.1 percent used it on 1 to 2 days in the past month and 37.8 percent used it on more than 5 days in the past month. Older smokeless tobacco users were more likely to report using smokeless tobacco more than weekly (more than 5 days in the past month). Among males aged 26 or older who were current smokeless tobacco users in 1999, an estimated 80.9 percent used it on more than 5 days in the past month compared with 62.1 percent of young adult male smokeless tobacco users.
Frequency of Smokeless Tobacco Use, by Gender. Smokeless tobacco was used primarily by males. Prevalence among females was so low that even for the total age group (i.e., those aged 12 or older), frequency estimates for females were statistically unreliable except for the category of more than 5 days in the past month. For male smokeless tobacco users, 12.8 percent used it 1 or 2 days in the past month, 10.8 percent used it on 3 or 5 days, and 73.9 percent using it on more than 5 days in the month prior to the 1999 survey.
Frequency of Smokeless Tobacco Use, by Race/Ethnicity. Whites were most likely to be smokeless tobacco users. Because the prevalence of smokeless tobacco use was low, many estimatesfor the frequency of use categories were unreliable for the three racial/ethnic groups displayed in Table 4.9. The age differences observed for frequency or use among whites also held across the various racial/ethnic groups.
As seen in Table 4.10 in Appendix D, which is limited to past month tobacco users in 1999, many smokers reported using multiple tobacco products. The use of multiple tobacco products was particularly prevalent among the youngest smokers. The percentage of smokers reporting cigarette use only increased with age, going from 58.6 percent of smokers aged 12 to 17 to 75.2 percent of smokers 35 years of age or older. There was no age-related consistent pattern observed for the exclusive use of cigars, smokeless tobacco, or pipes. The use of cigars only was reported by 7.7 percent of youths, 5.9 percent of those aged 18 to 25, 7.1 percent of persons aged 26 to 34, and 5.9 percent of persons 35 or older. The exclusive use of smokeless tobacco ranged from 3.5 percent among 18 to 25 year olds to 8.7 percent of tobacco users who were 26 to 34 years of age. Pipe use was very rare; the use of pipes only was reported by a range from 0.3 percent of 18 to 25 year olds to 1.3 percent of the oldest age group.
For all age groups, past month use of both cigarettes and cigars was the most likely combination of tobacco products, particularly among the youngest smokers. Among tobacco users aged 12 to 17, an estimated 22.2 percent reported the current use of cigarettes and cigars. The use of cigars and cigarettes was reported by 18.6 percent of 18 to 25 year olds, 10.1 percent of 26 to 34 year olds, and 7.1 percent of persons 35 or older. Among youths and young adults, the current use of both cigars and smokeless tobacco was reported by 4.5 and 4.1 percent, respectively. Youths aged 12 to 17 years were more likely than other age groups to report past month use of both cigarettes and pipes, with 3.5 percent reporting this behavior in 1999.
Figure 4.3 Percentages of Persons Aged 12 or Older Reporting Past Month Use of Marijuana, by Level of Cigarette Use and by Age Group: 1999
Note: Estimates for use of "1 pack+ per day" among 12 to 17 year olds are not reported due to low precision.
Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1999.
Nonsmokers were significantly less likely to report the use of any illicit drugs, tobacco products other than cigarettes, or any of the alcohol-using behaviors. Among 12 to 17 year olds, only 4.7 percent of nonsmokers reported current use of any illicit drug compared with 26.0 percent of youth smokers reporting 5 or fewer cigarettes per day and 46.9 percent of youth smokers reporting about a half a pack of cigarettes per day. Smoking a half a pack of cigarettes per day was associated with a rate that was about 17 times higher for the current use of marijuana among youths (2.5 percent of nonsmokers vs. 42.8 percent of heavier smokers). Youth smokers of about a half a pack per day were almost 13 times more likely than their nonsmoking peers to report the use of tobacco products other than cigarettes (35.5 vs. 2.8 percent). Youths who smoked about a half pack per day were almost 10 times more likely than nonsmokers to report binge alcohol use (46.5 vs. 4.8 percent).Figure 4.4 Percentages of Persons Aged 12 or Older Reporting Past Month Binge Alcohol Use, by Level of Cigarette Use and by Age Group: 1999
Note: Estimates for use of "1 pack+ per day" among 12 to 17 year olds are not reported due to low precision.
Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1999.
Among older smokers, there was a very strong association between cigarette smoking and the use of other substances, but there was no consistent dose/response relationship between level of cigarette use and the likelihood of using other substances. In general, the level of cigarette use did not affect the association as strongly as that seen for the 12- to 17-year-old smokers. For current cigarette smokers aged 35 or older, an estimated 32.9 percent of those who smoked five or fewer cigarettesper day also reported binge drinking in the past month, and about 39 percent of heavy smokers (a pack or more per day) also reported binge drinking in the past month.
