Tobacco Product Use and Cessation Indicators Among Adults — United States, 2018

1Cigarette smoking is the leading cause of preventable disease and death in the United States. The prevalence of adult cigarette smoking has declined in recent years to 14.0% in 2017. However, an array of new tobacco products, including e-cigarettes, has entered the U.S. market. To assess recent national estimates of tobacco product use among U.S. adults aged ≥18 years, CDC, the Food and Drug Administration (FDA), and the National Cancer Institute analyzed data from the 2018 National Health Interview Survey (NHIS). In 2018, an estimated 49.1 million U.S. adults (19.7%) reported currently using any tobacco product, including cigarettes (13.7%), cigars (3.9%), e-cigarettes (3.2%), smokeless tobacco (2.4%), and pipes* (1.0%). Most tobacco product users (83.8%) reported using combustible products (cigarettes, cigars, or pipes), and 18.8% reported using two or more tobacco products. The prevalence of any current tobacco product use was higher in males; adults aged ≤65 years; non-Hispanic American Indian/Alaska Natives; those with a General Educational Development certificate (GED); those with an annual household income <$35,000; lesbian, gay, or bisexual adults; uninsured adults; those with a disability or limitation; and those with serious psychological distress. The prevalence of e-cigarette and smokeless tobacco use increased during 2017–2018. During 2009–2018, there were significant increases in all three cigarette cessation indicators (quit attempts, recent cessation, and quit ratio). Implementing comprehensive population-based interventions in coordination with regulation of the manufacturing, marketing, and distribution of all tobacco products can reduce tobacco-related disease and death in the United States.

2NHIS is an annual, nationally representative, household survey of the noninstitutionalized U.S. civilian population.† The 2018 NHIS Sample Adult component included 25,417 adults aged ≥18 years; the response rate was 53.1%. Data were weighted to provide nationally representative estimates, adjusting for differences in selection probability and nonresponse. Use of five tobacco products was assessed: cigarettes, cigars (cigars, cigarillos, or filtered little cigars), pipes (regular pipes, water pipes, or hookahs), e-cigarettes, and smokeless tobacco (chewing tobacco, snuff, dip, snus, or dissolvable tobacco). Current cigarette smokers reported having smoked ≥100 cigarettes during their lifetime and smoked every day or some days at the time of survey. Current users of all other tobacco products reported using these products every day or some days at the time of survey. Prevalence estimates for current use of any tobacco product, any combustible tobacco product, and ≥2 tobacco products§ were calculated. Estimates were calculated overall and separately by sex, age, race/ethnicity, U.S. Census region, education (for adults aged ≥25 years), marital status, annual household income, sexual orientation, health insurance coverage, disability, and presence of serious psychological distress. T-tests were performed to assess overall differences in tobacco product use from 2017 to 2018.¶ Daily and nondaily use of each product was assessed. Three cigarette smoking cessation indicators were assessed: past-year quit attempts,** recent successful cessation,†† and quit ratio.§§ Linear and nonlinear (quadratic) trends were assessed for each cigarette smoking cessation indicator during 2009–2018. Statistical significance was defined as p<0.05 for differences and trends. SAS-Callable SUDAAN software (version 11.0.3; Research Triangle Institute) was used to conduct all analyses; all analyses were weighted and accounted for the complex survey design.

3Among U.S. adults in 2018, 19.7% (estimated 49.1 million) currently used any tobacco product, 16.5% (41.2 million; 83.8% of current tobacco users) used any combustible tobacco product, and 3.7% (9.3 million; 18.8% of current tobacco users) used ≥2 tobacco products (Table). Cigarettes were the most commonly used tobacco product (13.7%; 34.2 million). Prevalence estimates of use of the other tobacco products in 2018 were as follows: cigars (3.9%; 9.6 million); e-cigarettes (3.2%; 8.1 million); smokeless tobacco (2.4%; 5.9 million); and pipes (1.0%; 2.6 million). During 2017–2018, the prevalence of e-cigarette use increased from 2.8% to 3.2% (p = 0.029), and the prevalence of smokeless tobacco use increased from 2.1% to 2.4% (p = 0.047). No significant changes occurred in the use of the other tobacco products included in this study. Among current tobacco product users, daily use was reported by 74.6% of cigarette smokers, 59.1% of smokeless tobacco users, 42.6% of e-cigarette users, and 15.8% of cigar smokers (Figure 1).¶¶

4The prevalence of any current tobacco product use was higher among males (25.8%) than among females (14.1%) and among persons aged 25–44 years (23.8%), 45–64 years (21.3%), and 18–24 years (17.1%) than among those aged ≥65 years (11.9%) (Table). Current tobacco product use was also higher among non-Hispanic American Indian/Alaska Native adults (32.3%), non-Hispanic multiracial adults (25.4%), non-Hispanic whites (21.9%), non-Hispanic blacks (19.3%), and Hispanic adults (13.8%) than among non-Hispanic Asian adults (10.0%), as well as among those who lived in the Midwest (23.6%) or the South U.S. Census regions (21.4%) than among those who lived in the West (15.3%) or the Northeast (17.5%). The prevalence of current tobacco product use was also higher among persons who had a GED (41.4%) than among those with other levels of education and among those who were divorced, separated, or widowed (22.6%) or single, never married, or not living with a partner (21.1%) than among those married or living with a partner (18.4%). Current tobacco product use was higher among persons with an annual household income <$35,000 (26.2%) than those in higher income groups, as well as among lesbian, gay, or bisexual adults (29.2%) than among those who were heterosexual (19.5%). Prevalence also was higher among adults who were uninsured (29.9%), insured by Medicaid (27.8%), or had some other public insurance (23.0%) than among those with private insurance (17.2%) or Medicare only (12.6%); among those who had a disability/limitation (24.3%); and those who had serious psychological distress (36.7%).

5Significant linear increases occurred for all three cigarette cessation indicators. Among adult cigarette smokers, the prevalence of making a quit attempt in the past 12 months increased from 52.8% in 2009 to 55.1% in 2018 (p<0.001) (Figure 2). Recent successful smoking cessation increased from 6.3% in 2009 to 7.5% in 2018 (p<0.001). The quit ratio for cigarette smoking increased from 51.7% in 2009 to 61.7% in 2018 (p<0.001).

6The approximate two thirds decline in adult cigarette smoking prevalence that has occurred since 1965 represents a major public health success. In 2018, 13.7% of U.S. adults aged ≥18 years currently smoked cigarettes, the lowest prevalence recorded since 1965. However, no significant change in cigarette smoking prevalence occurred during 2017–2018. Most cigarette smokers and smokeless tobacco users reported daily use, whereas most e-cigarette and cigar users reported nondaily use. Even nondaily use of cigarettes has been linked to increased mortality risk.

7Quitting smoking at any age is beneficial for health. During 2009–2018, significant linear increases occurred in quit attempts, recent successful cessation, and quit ratio. Population-based tobacco control interventions, including high-impact tobacco education campaigns like CDC’s Tips From Former Smokers (https://www.cdc.gov/tobacco/campaign/tips/index.html) campaign and FDA’s Every Try Counts campaign (https://www.fda.gov/tobacco-products/every-try-counts-campaign), combined with barrier-free access to evidence-based cessation treatments, can both motivate persons who use tobacco products to try to quit and help them succeed in quitting.

8The prevalence of adult e-cigarette use increased from 2.8% in 2017 to 3.2% in 2018 but was much lower than the 20.8% of U.S. high school students reporting past 30-day e-cigarette use in 2018. The prevalence of e-cigarette use among persons aged 18–24 years is higher than that among other adult age groups, and e-cigarette use in this age group increased from 5.2% in 2017 to 7.6% in 2018. During 2014–2017 there had been a downward trajectory of adult e-cigarette use, but during 2017–2018 a significant increase in adult e-cigarette use was detected for the first time. This increase might be related to the emergence of new types of e-cigarettes, especially “pod-mod” devices, which frequently use nicotine salts as opposed to the free-base nicotine used in other e-cigarettes and tobacco products. Sales of JUUL, a pod-mod device, increased by approximately 600% from 2016 to 2017, making it the dominant e-cigarette product in the United States by the end of 2017. Further research is needed to monitor patterns of e-cigarette use and the relationship between use of e-cigarettes and other tobacco products (e.g., cigarette smoking).

9The findings in this report are subject to at least three limitations. First, responses were self-reported and were not validated by biochemical testing. However, self-reported smoking status correlates highly with serum cotinine levels. Second, because NHIS is limited to the noninstitutionalized U.S. civilian population, the results are not generalizable to institutionalized populations and persons in the military. Finally, the NHIS Sample Adult response rate of 53.1% might have resulted in nonresponse bias.

10Coordinated efforts at the local, state, and national levels are needed to continue progress toward reducing tobacco-related disease and death in the United States. Proven strategies include implementation of tobacco price increases, comprehensive smoke-free policies, high-impact antitobacco media campaigns, barrier-free cessation coverage, and comprehensive state tobacco control programs, combined with regulation of the manufacturing, marketing, and distribution of all tobacco products.

11Cigarette smoking is the leading cause of preventable disease and death in the United States. Adult cigarette smoking prevalence has declined; however, new tobacco products, including e-cigarettes, have entered the U.S. market.

12In 2018, approximately 20% of U.S. adults currently used any tobacco product; cigarette smoking reached an all-time low (13.7%). During 2009–2018, significant increases in three cigarette cessation indicators occurred. During 2017–2018, e-cigarette and smokeless tobacco product use prevalence increased.

13Continued surveillance is critical to informing tobacco control efforts at the national, state, and local levels. Coordinated efforts and regulation of all tobacco products are needed to reduce tobacco-related disease and death in the United States.