The prevalence of U.S. cigarette smokers hit a historic low in 2007, falling to just under 20% of the adult population, according to data released in mid-March by the Centers for Disease Control and Prevention.
Physicians on the front line against tobacco use hailed this as a milestone in the ongoing effort to cut smoking by Americans. They also see the rise in the federal tobacco excise tax on April 1 that boosts the tax on a pack of cigarettes from $0.39 to $1.01 as an important escalation in the fight against tobacco that will likely send smoking rates down further.
Cutting the smoking prevalence rate among adults across the United States “is an extraordinary accomplishment,” said Dr. Michael C. Fiore, professor of medicine at the University of Wisconsin School of Medicine and Public Health in Madison and director of the Center for Tobacco Research and Intervention. In the mid-1960s, about 43% of all American adults smoked, so cutting the rate by more than half, to a median of 19.8% in 2007, “is one of the seminal public health achievements in our time,” he said. “If you look at the past 50 years there has been a remarkably straight line of decline of about 0.5% per year.”
Even over the decade covered by the new CDC report, smoking rates showed a meaningful drop from a median rate of 22.9% in 1998 to the 19.8% rate in 2007, a fall of about 3% (MMWR 2009;58:221–6). “Going from 23% to 20% for the whole U.S. population is very significant,” Dr. Fiore said.
“Every downward reduction is a positive achievement,” said Dr. Alan Blum, professor of family medicine at the University of Alabama, Tuscaloosa, and director of the Center for the Study of Tobacco and Society.
But physicians interviewed cautioned that the rate must be lowered even more. “We cannot be complacent,” Dr. Blum said. “Physicians need to be on the front lines working with every patient who smokes and their family.”
The new CDC statistics also highlighted the shortcomings of efforts against smoking. In 2000, the U.S. Department of Health and Human Services set American health goals for the upcoming decade in Healthy People 2010. One goal was to have a national smoking prevalence rate of 12%. The 2007 rate of 19.8% shows that the goal will not be met.
“The Healthy People 2010 goal was ambitious, and rightly so. The progress [on smoking rates] is encouraging, but slower than it should be. The fact that some states are approaching [the Healthy People 2010 goal] shows that the target was reasonable,” said Dr. Steven A. Schroeder, professor of health and health care at the University of California, San Francisco, and director of the UCSF Smoking Cessation Leadership Center.
In 2007, the only states or territories at or close to the 2010 goal were Utah (11.7%), Puerto Rico (12.2%), and the U.S. Virgin Islands (8.7%). But California, with a 2007 rate of 14.3% compared with a rate of 19.2% in 1998, showed a trend that may bring it close to the goal when the 2010 numbers are tallied.
The April rise in the federal excise tax will likely be a powerful boost toward maintaining the downward momentum. Cigarette smoking is very price-sensitive despite being addictive, Dr. Fiore noted. The added $0.62 in tax per pack may lead to quitting by more than 1.15 million adult smokers and may prevent about 1.45 million youths from starting to smoke, according to an estimate calculated by Frank J. Chaloupka, Ph.D., professor of economics at the University of Illinois at Chicago.
In addition to cost, four other factors have also helped drive smoking rates down, Dr. Fiore said:
▸ The increase in smoke-free ordinances that has led to a “de-normalization” of smoking;
▸ The increased recognition of the adverse health effects of smoking, including the danger from second-hand smoke;
▸ State-sponsored initiatives against smoking, although as the CDC report noted funding for these programs was cut by 28% during 2002–2005 (and yet smoking rates fell during this period despite reduced spending by states on tobacco prevention and cessation programs); and
▸ Development over the past 12 years of an evidence base for which medical treatments are effective in helping people quit.
Another finding of the CDC's report is additional documentation of the remarkable regional variation in smoking rates in the United States, from the lowest state rates in 2007 of 11.7% in Utah and 14.3% in California to the highest rates of 28.3% in Kentucky and 27.0% in West Virginia, a two-fold spread.
“Part of the regional differences reflect class differences; smoking is concentrated among those who are poor and have less education,” Dr. Schroeder said. Political factors also are at work, he added. States with high smoking rates also generally have governments that have maintained low tobacco taxes and have failed to pass laws mandating cleaner indoor air.
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