Cigarette smoking is the leading cause of preventable disease and death in the United States ( 1 ). The prevalence of adult cigarette smoking has declined in recent years to 14.0% in 2017 ( 2 ). However, an array of new tobacco products, including e-cigarettes, has entered the U.S. market ( 3 ). 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 30% that are not presented. ††† Hispanic persons could be of any race. All other racial/ethnic groups were non-Hispanic. §§§ Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. ¶¶¶ Based on income variables from the family file (n = 8,310 missing valid income data). Imputed income files were not used in this analysis. **** Private coverage: includes adults who have any comprehensive private insurance plan (including health maintenance organizations and preferred provider organizations). Medicaid: for adults aged 30%; neither daily use nor nondaily use is presented. The figure is a bar chart showing the prevalence of daily and nondaily use of selected tobacco products among adults aged ≥18 years who currently use each tobacco product, in the United States, during 2018. The 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 1 day during the past 12 months because they were trying to quit smoking and former smokers who quit during the past year. † Percentage of former cigarette smokers who quit smoking for ≥6 months during the past year, among current smokers who smoked for ≥2 years and former smokers who quit during the past year. § Percentage of persons who ever smoked (≥100 cigarettes during lifetime) who have quit smoking. The figure is a line chart showing the prevalence of past-year quit attempts and recent cessation and quit ratio among cigarette smokers aged ≥18 years, in the United States, during 2009–2018. Discussion The approximate two thirds decline in adult cigarette smoking prevalence that has occurred since 1965 represents a major public health success ( 1 ). 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 ( 6 ). Quitting smoking at any age is beneficial for health ( 1 , 4 ). 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. The 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% ( 7 ) 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 ( 2 ) to 7.6% in 2018. During 2014–2017 there had been a downward trajectory of adult e-cigarette use ( 2 , 8 ), 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 ( 9 ). 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). The 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 ( 10 ). 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. Coordinated 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 ( 1 , 4 ). Summary What is already known about this topic? Cigarette 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. What is added by this report? In 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. What are the implications for public health practice? Continued 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.
