• MMWR: One in Five U.S. Adults Uses Tobacco Products

    Evidence Suggests E-cigarette Use Is Increasing

    November 25, 2020, 10:17 am News Staff -- New research published in the Nov. 20 issue of the CDC’s Morbidity and Mortality Weekly Report has provided the latest information on use of tobacco products by adults in the United States. The findings, based on an analysis of National Health Information Survey data, indicated that just over 20% of all American adults use one or more tobacco products. The analysis also revealed notable discrepancies in the types of tobacco products adults use based on age and other factors – findings that could benefit family physicians when counseling different patient populations.

    physician showing x-ray to patient

    Tobacco use is the leading cause of preventable disease, disability and death in the United States. The CDC estimates that each year, about 480,000 people die from cigarette smoking, and that smoking-related illness costs more than $300 billion, including almost $170 billion in direct medical care for adults.


    The researchers analyzed data from the 2019 Sample Adult component of the NHIS to estimate the prevalence of tobacco use in American adults.

    In the survey, participants were asked about tobacco product use. They were considered current users if they reported using tobacco products every day or some days at the time of the survey. Current cigarette smokers, in addition to the previous criteria, also reported having smoked 100 or more cigarettes in their lifetime.

    The Sample Adult component included more than 31,000 adults aged 18 and older. The survey data were weighted to provide national representative estimates of tobacco product use. Prevalence estimates were calculated overall as well as by sex, age, race, geographic location and other variables.

    Analysis Suggests Increase in E-cigarette Use

    Overall, about 21% of American adults, or nearly 51 million, used some type of tobacco product, with traditional cigarettes being the most common. An estimated 34.1 million adults used traditional cigarettes, followed by e-cigarettes (10.9 million), cigars, cigarillos or filtered little cigars (8.7 million), smokeless tobacco (5.9 million) and pipes, water pipes or hookahs (2.4 million).

    Story Highlights

    The 10.9 million adults who reported using e-cigarettes in 2019 equated to about 4.5% of the adult population – an increase from 3.2% in 2018 and 2.8% in 2017. However, the researchers noted that changes in the survey methodology made it difficult to directly compare estimates from 2019 with previous years.

    Most current users of tobacco products (80.5%) used combustible tobacco products. Just under 19% of current tobacco users reported using two or more tobacco products.

    Prevalence of current tobacco use differed by age group. More than 25% of adults aged 25-44, and 23% of adults 45-64, were characterized as current users of tobacco products. In comparison, only 11.4% of adults 65 and older currently used tobacco products.

    There also was a marked difference in the use of specific tobacco products by age group. From a percentage standpoint, use of traditional cigarettes was highest in adults 45-64 and 65 and older, while use of e-cigarettes was highest in adults aged 18-24 and 25-44.

    Among adults who currently used e-cigarettes, almost 37% reported that they also smoked traditional cigarettes and 39.5% reported that they used to smoke traditional cigarettes. The authors noted that while there is some evidence that use of certain types of e-cigarettes may lead to increased smoking cessation, in order to achieve “meaningful health benefits” smokers must completely stop smoking cigarettes and stop using any other tobacco product.


    Based on their findings, the authors called for “comprehensive, evidence-based, population-level interventions in coordination with regulation of tobacco products” to decrease use and reduce the incidence of tobacco-related death and disease in the United States.

    Several interventions were suggested, including increasing the prices of tobacco products, creating comprehensive smoke-free policies and anti-tobacco campaigns, and eliminating barriers to coverage for smoking cessation programs and resources.

    Finally, as part of a comprehensive approach, they also recommended using targeted interventions to reach certain groups with the highest prevalence of tobacco product use.

    AAFP Perspective

    Kevin Kovach, Dr.P.H., M.Sc., senior manager of population and community health in the Academy’s Health of the Public and Science division, told AAFP News that although the findings did not surprise him, “there is some cause for concern.”

    Kovach said that while the reduction of tobacco use has been an important public health achievement, the increased use of e-cigarettes is concerning, and he said previous research has shown that youth and young adults who use e-cigarettes are at greater risk of smoking traditional cigarettes later in adulthood.

    The U.S. Preventive Services Task Force has provided evidence-based recommendation statements on primary care interventions for prevention and cessation of tobacco use in children and adolescents, and on interventions for tobacco smoking cessation in adults, including pregnant women, to help FPs address tobacco and nicotine use with their patients. These recommendations have been supported by the AAFP.

    It should be noted that an update to the task force’s recommendation on interventions for tobacco smoking cessation in adults is in progress, with a draft recommendation statement posted on the USPSTF website in June.

    Kovach added that while several FDA-approved therapies have been shown to be successful as tobacco cessation aids, e-cigarettes are not among those therapies.

    In terms of prevention, Kovach considered policy a key component.

    “The most important way to help curb the tobacco epidemic is prevention,” said Kovach. “Evidence-based policies are effective at preventing tobacco use. This includes taxing tobacco products, smoke-free policies, and comprehensive tobacco control programs. These types of programs have been recommended by the CDC’s Community Preventive Services Task Force based on strong evidence of effectiveness. However, these policies are enacted at the state and local levels and not all communities have the same level of protection. It is worth checking to see if your community is fully protected, and if not, raising awareness of this.”

    Education is also key, and communications programs like the CDC’s Tips From Former Smokers and The Real Cost Campaign from the FDA are helpful in giving context to smoking issues using stories from real patients.

    For AAFP members, Kovach recommended the Ask and Act program page, which serves as the Academy’s primary resource to assist FPs and their health care teams in incorporating tobacco cessation processes in their practices.

    Another resource for members to consider, the Tobacco Cessation Telehealth Guide, was developed by the AAFP in collaboration with Pfizer Inc. earlier this year and could prove especially valuable in light of the COVID-19 pandemic and the hesitancy of some patients to return to the clinic setting for care.

    Finally, Kovach told AAFP News that the Academy is in the process of completing Reimagining Ask and Act for the 21st Century, a project that will, among other things, “identify and operationalize opportunities to improve how to address e-cigarettes in primary care.” According to Kovach, the project will combine the experiences of 18 family medicine clinics with expert opinion and up-to-date medical literature to provide members with the latest information and resources on tobacco cessation. The project is expected to be completed early next year.