U.S. smoking reduction trends may not meet 2010 Healthy People goal

Issue: May 2009

A new Morbidity and Mortality Weekly Report suggested that the decline in smoking rates may be slowing.

Utah was the only state that met projections for the 2010 Healthy People target for reducing the prevalence of adult smoking to 12%, according to the report.

States with the highest prevalence of smoking were Kentucky (28.3%), West Virginia (27.0%) and Oklahoma (25.8%). Utah (11.7%), California (14.3%) and Connecticut (15.5%) were among the states with the lowest smoking prevalence. Men were reported to have a significantly higher prevalence of smoking in 30 states. A trend analysis suggested that smoking decreased in 44 states, Washington, D.C. and Puerto Rico from 1998 to 2007. The report attributed the differences in smoking prevalence to factors such as population demographics, the varying degrees of effectiveness of tobacco control programs, and policies and variations in tobacco industry marketing.

“Despite declines in smoking prevalence during 1998-2007, cigarette smoking continues to cause large numbers of deaths each year across all states,” the researchers wrote. “Health care providers should ask all patients about their use of tobacco, advise tobacco users to quit, assess their willingness to quit, assist in their quit attempt by offering medication and providing referrals to telephone-based quitlines or other counseling services and arrange for follow-up.”

For more information:

CDC. MMWR. 2009;58:221-226.

There are several things in this document that are incredibly important. First of all, we continue to have a problem with tobacco use. Somewhere between 20% and 22% throughout the country, higher in some states, clustered in the south, lower in some states in the Midwest. What is of concern is that only one US territory and one US state, the Virgin Islands and Utah, have actually reached the Healthy People 2010 threshold, which is about 12%. So that means that the 49 states really have a big challenge in front of them to try to bring down the average of 20% to the target of 12%.

Click here to hear more perspective from Dr. Yancy.

The target is appropriate, because as was pointed out in the report, there continues to be an excessive number of preventable deaths due to tobacco use, and so we really have to engage a concerted thought process regarding the best way to promote smoking cessation.

The article mentions the extra taxes that will be levied in just a few short weeks. That will be onerous for some smokers and difficult for some to quit because as we know it is an addictive behavior and you cannot just stop because you decide to stop – there has to be some support. Practitioners may face patients coming in requesting help with smoking cessation because of the economic burden of continued tobacco use. There are references in that CDC document that speak to programs within the CDC that help facilitate smoking cessation, but practitioners will need to become more facile with these tools. We have all made a mistake up until now when we tell people “you need to stop smoking,” “this is not good for you,” and “this is not healthy for your heart,” but we leave the patients wanting with the unanswered question of “how do we stop?”

With those things in mind, the one thing about this article that raised my question mark was the statement that, if it is correct, is somewhat against what we have been led to believe, and that is smoking in the minority population is going down. Other data have suggested that it was the other circumstance; this does call into question the source of the information. The authors point out that these findings are based on a telephone survey. It does not use persons who only have wireless access, and that group may have a smoking incidence as high as 30% or greater; in addition, non-whites have a high use of wireless devices. It could be that there is a response bias which, as mentioned in this article, may result in some of the aggregate numbers being under-reported and some of the subgroup data not being entirely spot-on.

What is missing in this article is maybe the most important statistic, and that is the use of tobacco products in persons under the age of 18. This article is very specific; the investigators only accepted responses in persons over the age of 18. We are concerned that across the country, there are more and more adolescents and teenagers who begin smoking, and those numbers are unrecognizable based on these data, but may be our biggest public health challenge. Tobacco companies are continuing to market products that appeal to younger individuals, and we are concerned that those younger smokers become addicted quite quickly and have a very difficult time discontinuing this behavior.

This article is helpful because it tells us that smoking remains a big problem. It is sobering. It tells us that about half of the states have not made much progress. It is even more alarming by telling us that only one state has hit the true target threshold and that only one territory has done the same. It raises some questions, questions about data acquisition and data about subgroups, and misses what I believe is the most important subgroup - those under the age of 18. We cannot escape the overarching message. It is not a filtered story. It tells us that we still have a major problem.

– Clyde W. Yancy, MD

Medical Director, Baylor Heart and Vascular Institute, Dallas