Blog & News
BRFSS Spotlight Series: Adult Smoking and E-Cigarette Use in the United States (Infographic)
February 10, 2020:
BRFSS SPOTLIGHT SERIES OVERVIEW |
Adult Smoking and E-Cigarette Use
In the first part of our BRFSS spotlight series, we analyzed newly available 2018 data for an existing measure, Adult Smoking, and a more complete set of existing data from 2017 (as data for 2018 was not available in a majority of states) for a brand new measure, Adult E-Cigarette Use.
According to the Centers for Disease Control and Prevention and the World Health Organization, smoking was the leading cause of preventable death in 2017, with cigarette smoking being responsible for approximately 480,000 deaths per year in the United States.1
Lately, however, concerns around growth in tobacco use have shifted away from cigarette smoking—which has declined across the nation from a rate of 20.1 percent in 2011 to 15.5 percent in 2018—in response to the rise of vaping and e-cigarette use in recent years, especially among youth.2
Though vaping/e-cigarette use is thought to be less harmful compared to regular cigarettes,3 mounting concerns about the short- and long-term effects of such use have led researchers to conduct studies such as a recent analysis conducted by scholars at the University of California, San Francisco and published in the American Journal of Preventive Medicine, which finds growing evidence linking e-cigarette use and respiratory diseases.
As researchers continue to monitor individual and population-level trends in health behaviors, such as tobacco use, data from surveys such as the BRFSS will have an important impact in increasing our understanding of the consequences of smoking and e-cigarettes.
Adult Smoking (2018)
Smoking is defined as adults (age 18 and older) who have smoked 100 or more cigarettes in their lifetime and who currently report smoking “some days” or “every day.” Nationally, 15.5 percent of adults smoked some days or every day in 2018, which decreased significantly from a reported rate of 16.4 percent the previous year. Across the states (and the District of Columbia), smoking rates varied from a low of 9.0 percent in Utah to a high of 25.2 percent in West Virginia.
Eight states (Arkansas, Indiana, Kentucky, Louisiana, Mississippi, Ohio, Tennessee, and West Virginia) reported that more than one in every five adults smoked in 2018. In better news, data from eight states (Arizona, Florida, Louisiana, Maryland, New Mexico, New York, Vermont, and Washington) showed significant declines in adult smoking rates from 2017 to 2018, and no states experienced significant increases.
Smoking Patterns by Race/Ethnicity*
When looking at 2018 data across the nation by race/ethnicity, Black adults were 6.7 percent more likely to smoke than White adults (17.4 percent vs. 16.3 percent). Correspondingly, rates of smoking were higher among Black adults than among White adults in seven states (Connecticut, Illinois, Michigan, Minnesota, Nebraska, Pennsylvania, and Texas) as well as in D.C., and were only lower than the rate of White adults in four states (Florida, Georgia, Louisiana, and Rhode Island). The gap between smoking rates of Black and White adults was highest in D.C., where Black adults were more than two times more likely than White adults to smoke (21.8 percent vs. 6.9 percent).
Nationally, Hispanic/Latino adults were 23.6 percent less likely to report smoking compared to White adults (12.4 percent vs. 16.3 percent). Rates of smoking were higher among Hispanic/Latino adults than White adults in only six states (Colorado, Connecticut, Hawaii, Michigan, Utah, and Wyoming) and were lower than White adult smoking rates in 15 states. Hawaii was highest among states with a statistically significant gap, with Hispanic/Latino adults who were 83.7 percent more likely to smoke than White adults (21.4 percent vs. 11.6 percent).
For the adult smoking measure, we also analyzed national-level data for adults of Other/Multiple races, a category that includes those who identify as American Indian or Alaska Native, Asian, Native Hawaiian/Pacific Islander, Other race, or Multiracial.+ The national data showed that, overall, Other/Multiracial adults were 16.4 percent less likely to smoke than White adults (13.6 percent vs. 16.3 percent). Of this group, American Indian or Alaska Natives were most likely to report smoking at 29.1 percent, followed by Multiracial adults (23.5 percent), Native Hawaiian/Pacific Islanders (21.8 percent), adults reporting as “Other” (16.9 percent), and Asian adults having the lowest smoking rate at 7.7 percent. A high-level state analysis also revealed that Other/Multiracial adults had the highest rates of smoking in 26 states over White adults, Black adults, and Hispanic/Latino adults.
Adult E-Cigarette Use (2017)
E-Cigarette use is the newest measure that has been added to SHADAC’s State Health Compare web tool. The measure is defined as adults who currently report using e-cigarettes either “some days” or “every day.” Due to the fact that data are not available for all states in 2018, this analysis uses 2017 data in order to give a more complete picture of trends in e-cigarette use across the nation.
Nationally in 2017, 4.4 percent of adults used e-cigarettes—a rate that was statistically unchanged from 4.5 percent in 2016. Among the states, e-cigarette use ranged from a low of 2.5 percent in D.C. to a high of 7.1 percent in Oklahoma. Thirteen states (Arkansas, Arizona, Colorado, Indiana, Kentucky, Missouri, Nevada, Ohio, Oklahoma, Tennessee, Utah, West Virginia, and Wyoming) reported an e-cigarette use rate of more than one in every twenty adults in 2017. Just one state (Indiana) saw an increase in rates of e-cigarette use, while five states (Connecticut, Louisiana, Massachusetts, Nebraska, and Washington) saw decreases in rates of e-cigarette use.
Nationally, 3.2 percent of Black adults reported using e-cigarettes in 2017, a rate that was 36.5 percent less than White adults, who had an e-cigarette use rate of 5.0 percent. Hispanic/Latino adults reported e-cigarette use at 3.1 percent, a rate that was 38.2 percent less than White adults (5.0 percent), and Other/Multiracial adults’ reported e-cigarettes use that same year was 11.4 percent less than White adults (5.0 percent) at 4.4 percent.
As e-cigarette use becomes more of public health focus, and as more state and federal surveys field questions about this topic, SHADAC will continue to monitor available data for future analysis involving state-level trends in e-cigarette use.
A brief on Adult Smoking and E-cigarette Use at the national and state levels is currently planned for release some time later this year, and will include a deeper analysis of these data.
Notes
All data are from SHADAC analysis of the Behavioral Risk Factor Surveillance System (BRFSS). All differences described in the post are statistically significant at the 95% confidence level unless otherwise specified.
* Data breakdowns by race/ethnicity for smoking rates were not available in all states due to sample size limitations.
+ The “Other/Multiple race” category pools many different race/ethnic groups because of the small sample size for each individual category.
1 Centers for Disease Control and Prevention (CDC). (2019, November 15). Smoking and tobacco use: Fast facts. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm
World Health Organization (WHO). (2017, July 19). WHO report on the global tobacco epidemic, 2017. Available from https://www.who.int/tobacco/global_report/2017/en/
Blog & News
Affordability and Access to Care in 2018: Examining Racial and Educational Inequities across the United States (Infographic)
December 17, 2019:The Centers for Medicare and Medicaid Services (CMS) recently reported that the cost of health care spending in the United States increased by 4.6 percent last year to reach an all-time high of approximately $3.6 trillion.1 This report comes amidst a number of other concerning health care cost-related trends, such as the largest single-year increase for single-coverage premiums in 2018 from $6,368 to $6,715 (5.4 percent) for workers enrolled in employer-sponsored insurance (ESI) and an increase in average household spending on health care (out of pocket expenses, cost-sharing for ESI, and payroll taxes for Medicare, etc.) rising to a record $1.04 trillion.2
Rising expenses such as these have contributed to the record number of Americans (25 percent) who reported in 2019 that either themselves or a family member skipped or delayed needed medical care due to cost, according to the results from a new Gallup poll released earlier this month.3
This post examines Americans’ access and ability to afford medical care, focusing on inequities related to race/ethnicity and education, and using two recently updated measures from SHADAC’s State Health Compare: Adults Who Forgo Needed Medical Care and Adults with No Personal Doctor. These measures come from a SHADAC analysis of 2018 data from the CDC’s Behavioral Risk Factor Surveillance System (BRFSS).
Racial and educational inequities persist in adults’ reported ability to afford needed medical care
Significant inequities in adults’ ability to afford medical care by race/ethnicity emerged when we examined the updated data for 2018. At the national level, our analysis showed that Hispanic/Latino adults were nearly twice as likely as White adults to forgo needed medical care due to cost (20.2 percent versus 10.5 percent), and African Americans/Black adults were 1.5 times as likely to report forgoing care compared to White adults (16.0 percent versus 10.5 percent). Hispanic/Latino adults were also significantly more likely to report forgoing medical care than White adults in 35 states and D.C., and this gap was greater than 20 percentage points in Maryland (31.4 percent versus 7.4 percent) and Missouri (34.4 percent versus 11.1 percent). Black adults were significantly more likely to report going without care than White adults in 24 states and D.C., and this gap was greater than 10 percentage points in four states: Iowa (16.2 percentage points), North Dakota (15.5 percentage points), Utah (11.5 percentage points), and Minnesota (10.2 percentage points).
Nationwide, Americans with less than a high school degree were almost three times as likely to report going without needed medical care due to cost as compared to those with a bachelor’s degree (21.1 percent versus 7.4 percent) in 2018. Adults with less than a high school education were significantly more likely to report forgone care due to cost compared to adults with college degrees in 2018 in all but two states—Montana and Vermont—and in the District of Columbia (D.C.). For four states this gap was greater than 20 percentage points in 2018—Georgia (21.1 percentage points), Maryland (20.9 percentage points), Oklahoma (21.2 percentage points), and Virginia (21.2 percentage points).*
Racial/ethnic minorities and adults without a high school diploma less likely to have a personal doctor
Nationally, Hispanic/Latino and Black adults were both significantly more likely to report not having a regular doctor as compared to their White counterparts. Our analysis revealed that Hispanic/Latino adults were more than twice as likely as White adults to report not having a personal doctor (38.8 percent versus 18.4 percent), and Black adults were nearly 25 percent more likely to report not having a personal doctor compared with White adults (22.8 percent versus 18.4 percent).*
These inequities in access to care by race/ethnicity were present in a large majority of states. A significant gap between Hispanic/Latino and White adults with no personal doctor was present in 43 states, and Hispanic adults were more than three times as likely to report not having a personal doctor in five states (Connecticut, Maryland, Nebraska, New Jersey, and North Carolina). This significant gap also persisted between Black and White adults in 20 states, as we found that Black adults were more than twice as likely to not have a personal doctor in three states—Connecticut (22.8 percent versus 10.8 percent), Iowa (31.2 percent versus 15.1 percent), and Rhode Island (21.2 percent versus 9.9 percent).*
Nationally, adults with less than a high school degree were more than twice as likely to not have a regular doctor as those with an undergraduate degree or greater (32.4 percent versus 15.7 percent). This pattern was consistent across nearly the entire nation, as adults with less than a high school education were significantly more likely than college graduates to report not having a personal doctor in 46 states. The gap between less than high school graduates and college graduates was larger than 20 percentage points in eight states (California, Colorado, Georgia, Maryland, Nebraska, Nevada, New Jersey, and Utah).
Note
* Data were not available or were suppressed for some states because the number of sample cases was too small, so this number could be higher if data were available in all states. For education breakdowns, adults are defined as 25 years of age and above. For race/ethnicity breakdowns, adults are defined as 18 years of age and above. All differences are statistically significant at the 95% level.
Explore Additional BRFSS Data at State Health Compare
Visit State Health Compare to explore national and state-level estimates for the following measures that also come from the BRFSS:
Income Inequality
Sales of Opioid Painkillers
Adult Cancer Screenings
Chronic Disease Prevalence
Activities Limited due to Health Difficulty
Adult Obesity
Adult Binge Drinking
Adult Smoking
Adult E-Cigarette Use (New Measure)
State Health Compare also features a number of other indicator categories, including: health insurance coverage, cost of care, access to and utilization of care, care quality, health behaviors, health outcomes, and social determinants of health.
Related Reading
Now Available on State Health Compare: Eleven Updated Measures and One Brand New Measure
Educational Attainment and Access to Health Care: 50-State Analysis
Fifty-State Analysis Finds Lower Access to Care among Adults with Less Education
[1] Hartman, M., Martin, A.B., Benson, J., & Catlin, A. (2019, December 5). National Health Care Spending in 2018: Growth Driven by Accelerations in Medicare and Private Insurance Spending. HealthAffairs. [E-published ahead of print.] https://doi.org/10.1377/hlthaff.2019.01451
[2] State Health Access Data Assistance Center (SHADAC). (2019, August 14). State-level Trends in Employer-Sponsored Health Insurance, 2014-2018. Retrieved from https://www.shadac.org/ESIReport2019
Murad, Y. (2019, December 5). U.S Health Spending Rose to $3.6 Trillion in 2018, Propelled by Health Insurance Tax. Morning Consult. Retrieved from https://morningconsult.com/2019/12/05/u-s-health-spending-rose-to-3-6-trillion-in-2018-propelled-by-health-insurance-tax/
[3] Saad, L. (2019, December 9, 2019). More Americans Delaying Medical Treatment Due to Cost. Retrieved from https://news.gallup.com/poll/269138/americans-delaying-medical-treatment-due-cost.aspx
Publication
State and County Coverage Estimates, 2013-2017 ACS
Use this clickable map to see health insurance coverage estimates for each state and all counties for the pooled years 2013-2017.
Counties are searchable by bookmark in each state file.
2013-2017 American Community Survey (ACS) 5-Year Estimates:
Percent Uninsured, Total Civilian Noninstitutionalized Population by County
Click here to view estimates for Puerto Rico by municipio.
Click here to view a 50-state table of estimates.
These estimates come from the 5-year American Community Survey (ACS) via the U.S. Census Bureau’s American FactFinder (AFF) tool. The 5-year ACS is created by pooling together five years of ACS data to produce estimates for areas and subgroups with smaller populations.
About the ACS
The ACS is a household survey that began in 2005 and produces annually updated data on a variety of population characteristics, including health insurance coverage. In total, the ACS surveys approximately three million US households each year. An important feature of the ACS is that it includes a large enough sample for state‐level and sub‐state estimates.
The Census Bureau publishes 1-year estimates for areas with populations of 65,000 or more and 5-year estimates (covering 60 months) for all statistical, legal, and administrative entities.
The ACS began asking survey respondents about health insurance coverage during the 2008 calendar year. Specifically, the survey asks respondents about current coverage for each person in the respondent’s household. A person is categorized as “insured” if he or she has coverage at the point in time at which the survey is administered.
How Are these Estimates Different from the Estimates that SHADAC Publishes Using Census Bureau Micro-Data Files?
Two definitions used by the Census Bureau to generate the tabulations above differ from those that SHADAC uses to generate tabulations for State Health Compare. The definitional differences are as follows:
Family
- The Census Bureau defines a family as all related people in a household.
- SHADAC defines a family using a measure called the “Health Insurance Unit” (HIU), which includes all individuals who would likely be considered a family unit in determining eligibility for either private or public coverage.
- To learn more about the HIU, see SHADAC Brief #27, “Defining Family for Studies of Health Insurance Coverage.”
Family Income
- The Census Bureau determines family income as a percentage of the Federal Poverty Level (FPL), which is a definition of poverty used primarily for statistical purposes. For example, FPL is used to estimate the number of Americans living in poverty each year.
- SHADAC determines family income as a percentage of the U.S. Department of Health and Human Services’ Federal Poverty Guidelines (FPG), which is a measure used for administrative purposes. For example, FPG is used to determine eligibility for federal programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP).
- To learn more about the difference between FPL and FPG, click here.