Tobacco Product Use Among Adults — United States , 2013 – 2014

diseases and deaths in the United States.§ NATS is a stratified, random-digit–dialed landline and cellular telephone survey of noninstitutionalized U.S. adults aged ≥18 years. The 2013–2014 NATS included 75,233 respondents (70% landline, 30% cellular); the overall response rate was 36.1% (landline 47.6%, cellular 17.1%). Based on established conventions regarding patterns of tobacco product use (3), NATS questions used varying thresholds of lifetime use to separate established users from experimenters and nonusers. Four tobacco product types assessed in NATS had lifetime usage thresholds: cigarettes (≥100 cigarettes); cigars/cigarillos/ filtered little cigars (≥50 times); regular pipes (≥50 times); and chewing tobacco/snuff/dip (≥20 times). Water pipes/hookahs, e-cigarettes, snus, and dissolvable tobacco products did not have usage thresholds. Respondents who met the respective thresholds for cigarettes, cigars/cigarillos/filtered little cigars,

While significant declines in cigarette smoking have occurred among U.S. adults during the past 5 decades, the use of emerging tobacco products* has increased in recent years (1)(2)(3).To estimate tobacco use among U.S. adults aged ≥18 years, CDC and the Food and Drug Administration (FDA) analyzed data from the 2013-2014 National Adult Tobacco Survey (NATS).During 2013-2014, 21.3% of U.S. adults used a tobacco product every day or some days, and 25.5% of U.S. adults used a tobacco product every day, some days, or rarely.Despite progress in reducing cigarette smoking, during 2013-2014, cigarettes remained the most commonly used tobacco product among adults.Young adults aged 18-24 years reported the highest prevalence of use of emerging tobacco products, including water pipes/hookahs and electronic cigarettes (e-cigarettes).Furthermore, racial/ethnic and sociodemographic differences in the use of any tobacco product were observed, with higher use reported among males; non-Hispanic whites, non-Hispanic blacks, and non-Hispanics of other races † ; persons aged <45 years; persons living in the Midwest or South; persons with a General Educational Development (GED) certificate; persons who were single/never married/not living with a partner or divorced/separated/widowed; persons with annual household income <$20,000; and persons who were lesbian, gay, or bisexual (LGB).Population-level interventions that focus on all forms of tobacco product use, including tobacco price increases, high-impact anti-tobacco mass media campaigns, comprehensive smoke-free laws, and enhanced access to help quitting tobacco use, in conjunction with FDA regulation Tobacco Product Use Among Adults -United States, 2013-2014 S. Sean Hu, MD 1 ; Linda Neff, PhD 1 ; Israel T. Agaku, DMD 1 ; Shanna Cox, MSPH 1 ; Hannah R. Day, PhD 2 ; Enver Holder-Hayes, MPH 2 ; Brian A. King, PhD 1  regular pipes, and chewing tobacco/snuff/dip or who reported ever using water pipes/hookahs, e-cigarettes, snus, and dissolvable tobacco products, were then asked if they used each respective product at the time of the survey.With the exception of cigarettes, response options for frequency of use at the time of survey were "every day," "some days," "rarely," or "not at all"; "rarely" was not included as a response option for cigarettes.Data were weighted to provide nationally representative estimates of prevalence and number of users.To assess the effect of occasional tobacco use on estimates of current tobacco use, two definitions were used for all tobacco product types (except cigarettes): 1) use every day or some days; and 2) use every day, some days, or rarely.Any tobacco product use was defined as use of at least one tobacco product type.¶ Any combustible tobacco product use was defined as use of at least one of the following tobacco product types: cigarettes, cigars/cigarillos/ filtered little cigars, regular pipes, or water pipes/hookahs.All smokeless tobacco products (chewing tobacco/snuff/dip, snus, and dissolvable tobacco products) were aggregated into a single category.Prevalence estimates were calculated overall and by sex, age, race/ethnicity, U.S. Census region, education, marital status, annual household income, and sexual orientation.
Prevalence estimates with a relative standard error ≥30% are not presented.Differences between groups were assessed using chi-squared statistics; estimates with p<0.05 were considered to be statistically significant.
Overall, the reported prevalence of every day or some day use was as follows: any tobacco product use, 21  Differences in use of any tobacco product every day or some days were observed across population groups (Table 1).Prevalence was higher among males (26.3%) than females (16.7%), and among age groups, was highest among persons aged 25-44 years (26.1%) and lowest among persons aged ≥65 years (10.3%).Prevalence was highest among non-Hispanics of other races (i.e., American Indians/Alaska natives, Native Hawaiians/other Pacific Islanders, and persons of multiple race) (32.6%) and lowest among non-Hispanic Asians ¶ Participants who reported use of any product were considered any tobacco product users, but those who had a combination of "no" and missing responses to any of the assessed product type questions were excluded from the analysis.Participants who did not report use of any product "every day," "some days," or "rarely" who had missing responses for any of the assessed tobacco products (1.9% of respondents) were excluded.US Department of Health and Human Services/Centers for Disease Control and Prevention Abbreviations: CI = confidence interval; e-cigarettes = electronic cigarettes; GED = General Education Development certificate; LGB = lesbian, gay, or bisexual.* Any tobacco use was defined as "every day" or "some days" use of cigarettes; cigars, cigarillos, or filtered little cigars; pipes; water pipes/hookahs; e-cigarettes; or smokeless tobacco (snus, dissolvable tobacco products, or snuff, chewing tobacco or dip).The survey assessed "every day" or "some days" use of the respective products only among persons who met specified lifetime usage thresholds: cigarettes (≥100 times); cigars/cigarillos/filtered little cigars (≥50 times); regular pipes (≥50 times); water pipes/hookahs (≥1 time); snus (≥1 time]; dissolvable tobacco products (≥1 time); chewing tobacco/snuff/dip (≥20 times); and e-cigarettes (≥1 time).† Any combustible tobacco users were defined as persons who met specified lifetime usage thresholds for at least one of four different tobacco product types (cigarettes [≥100 times]; cigars/cigarillos/filtered little cigars [≥50 times]; regular pipes [≥50 times]; water pipes/hookahs [≥1 time]), and who now (at the time of the survey) used the respective product(s) every day or some days.§ Current cigarette smokers were defined as persons who reported smoking ≥100 cigarettes during their lifetime and now smoked cigarettes every day or some days.¶ Current cigar/cigarillo/filtered little cigar smokers were defined as persons who reported smoking cigars, cigarillos, or little filtered cigars ≥50 times during their lifetime and now smoked cigars, cigarillos, or little filtered cigars every day or some days.** Reported smoking a regular pipe filled with tobacco ≥50 times during their lifetime and now smoked a regular pipe filled with tobacco every day or some days.
† † Reported smoking tobacco in a water pipe/hookah at least once during their lifetime and now smoked tobacco in a water pipe/hookah every day or some days.§ § Persons who reported using electronic cigarettes at least once during their lifetime and now used e-cigarettes every day or some days.¶ ¶ Smokeless tobacco users were defined as using at least one of the following three tobacco product types: 1) chewing tobacco, snuff, or dip; 2) snus; and 3) dissolvable tobacco products.Chewing tobacco, snuff, or dip users were respondents who reported using the product ≥20 times during their lifetime and now using chewing tobacco, snuff, or dip every day or some days.Snus or dissolvable tobacco product users were respondents who reported using each respective product at least once during their lifetime and now using each respective product every day or some days.*** Estimate not presented because relative standard error ≥30%.).Prevalence patterns were generally similar when "rarely" was included in the definition of use (Table 2).Among every day, some days, or rarely users, younger adults aged 18-24 accounted for 55.8% of water pipe/hookah smokers, 24.3% of e-cigarettes users, 23.1% of regular pipe smokers, 21.6% of smokeless tobacco users, and 19.5% of cigar/ cigarillo/filtered little cigar smokers (Figure ).

Discussion
During 2013-2014, one in five U.S. adults (an estimated 49.2 million persons) used any tobacco product every day or some days, and one in four (58.8 million persons) used any tobacco product every day, some days, or rarely.Across population groups, differences were observed in tobacco use by sex, age, race/ethnicity, U.S. Census region, education, marital status, annual household income, and sexual orientation.The magnitude and patterns of tobacco product use generally were comparable to those from other national surveys of U.S. adults during the same period.**Use of any tobacco product every day or some days was nearly threefold higher among non-Hispanics of other races (i.e., American Indians/Alaska natives, Native Hawaiian/other Pacific Islanders, and persons of multiple race) than among Asian non-Hispanics.Adults with annual household incomes of <$20,000 also reported a higher prevalence of tobacco product use than did persons with higher annual household income and LGB adults reported higher prevalence of tobacco product use than did adults who identified as heterosexual/straight.
The use of e-cigarettes and water pipes/hookahs was particularly prevalent among certain populations.Most users of these two emerging tobacco products were not daily users.Moreover, young adults had the highest prevalence of use of e-cigarettes and water pipes, which might reflect that although most experimentation with tobacco products occurs during the teenage years, young adulthood increasingly is a time of initiation of tobacco products, including emerging tobacco products.† † The higher prevalence of use among younger adults might also be a consequence of targeted marketing of e-cigarette products and varying perceptions about the relative harm or social acceptability of these products compared with conventional cigarettes (1,4,5).When the definition of current users included participants who reported rarely using tobacco products, current use was disproportionately higher among younger adults.These users might not consider themselves to be tobacco product users, and thus, might not consider themselves to be at risk for tobacco-related disease or death (6,7).For example, one focus group study with adult cigar smokers found that some users would only use the term "smoker" or "cigar smoker" to describe someone who smoked cigars several times a week or daily (8).This finding underscores the importance of further research on the ascertainment of tobacco product use, as well as efforts to educate the public about the potential harms of all tobacco product use, including risks associated with occasional use.
Continued implementation of proven population-based interventions, including increasing tobacco product prices, implementing and enforcing comprehensive smoke-free laws, warning about the dangers of tobacco use through public education media campaigns, and increasing access to proven resources to help people quit tobacco use, can help reduce tobacco use and tobacco-related disease and death (1,9).In addition, regulatory authority over the manufacture, marketing, and sales of tobacco products is an important tool to further reduce tobacco-related disease and death in the United States.§ § In May 2016, FDA finalized a rule extending its authority to all products that meet the definition of a tobacco product, including e-cigarettes, cigars, pipes, and water pipes/hookahs.¶ ¶ This rule sets a national minimum age for sales; requires health warnings, tobacco product ingredient reporting, and reporting of harmful and potentially harmful constituents; and ensures FDA premarket review of new and changed tobacco products and premarket review of the marketing of products as reduced-risk (modified risk tobacco products).The rule also enables future rulemaking regarding tobacco product manufacturing, marketing, and sales.
The findings in this report are subject to at least four limitations.First, self-reported tobacco use might have resulted in misreporting; however, self-reported cigarette smoking correlates highly with serum cotinine levels (10) Abbreviation: e-cigarettes = electronic cigarettes.* Any tobacco use was defined as "every day" or "some days" use of cigarettes; and/or "every day, " "some days, " or "rarely" use of cigars, cigarillos, or filtered little cigars; pipes; water-pipes/hookahs; e-cigarettes; smokeless tobacco (snus, dissolvable tobacco products, or snuff, chewing tobacco or dip).Cigarettes not presented separately because the questionnaire only assessed "every day" or "some days" cigarette smoking (i.e., no "rarely" response option)."Every day" or "some days" use of cigarettes was assessed only among persons who reported smoking at least 100 cigarettes during their lifetime.For the other tobacco product types, the survey assessed "everyday, " "some days, " or "rarely" use among persons who met specified lifetime usage thresholds, which were different for the different tobacco product types assessed: cigars/cigarillos/filtered little cigars (≥50 times); regular pipes (≥50 times); water pipes/hookahs (≥1 time); snus (≥1 time); dissolvable tobacco products (≥1 time); chewing tobacco/snuff/dip (≥20 times); and e-cigarettes (≥1 time).† Respondents of unknown age (1.5%) were excluded from these calculations.§ Denominator for each product comprised respondents who had ever reached the threshold for the specified product, including current and former users. of $25.8 billion from settlement payments and tobacco taxes for all states combined, states will spend only 1.8% of this amount ($468 million) on comprehensive tobacco control programs (<15% of the CDC-recommended level of funding for all states combined).***Full implementation of comprehensive tobacco control programs at CDC-recommended funding levels, in conjunction with FDA regulation of tobacco products, could reduce tobacco use in the United States, thereby reducing morbidity and mortality caused by tobacco use (1).