The County Health Rankings show us that where we live matters to our health. The health of a community depends on many different factors - ranging from health behaviors, education and jobs, to quality of health care, to the environment.

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Tobacco Use

What Is It?

The County Health Rankings measure the percentage of the adult population who are current smokers to represent the extent of health risk in a community related to tobacco use. Measuring the prevalence of tobacco use in the population can alert communities to potential adverse health outcomes in the future and can be valuable for assessing the need for cessation programs or the effectiveness of existing programs.

Why Do We Measure It?

The relationship between tobacco use, particularly cigarette smoking, and adverse health outcomes has been well known for decades. The Rankings focus on cigarette smoking, the leading cause of preventable death. Each year approximately 443,000 premature deaths are primarily due to smoking.[1] Cigarette smoking is identified as a cause in multiple diseases including various cancers such as lung, bladder, esophageal, kidney, and pancreatic; cardiovascular diseases such as coronary heart disease and atherosclerosis; respiratory diseases (emphysema, chronic obstructive pulmonary disease, and pneumonia); adverse reproductive effects including fetal death, compromised fertility, and low birth weight; and other adverse health outcomes (e.g. increased morbidity, decreased bone density, and cataracts).[2]

Approximately 20% of the adult population in the United States currently smokes cigarettes.[3] Though smoking affects every community to some degree, smoking prevalence varies by gender, race and ethnicity, education level, and geography. Smoking prevalence is higher among men (22%) than women (17%).[3] Additionally, there are differences in smoking prevalence based on race; 36% of American Indians, 21% of whites, 20% of African Americans, 13% of Hispanics, and 10% of Asians are current smokers.[3] Disparities also exist based on education; 44% of adults who only obtained a GED diploma smoke compared with 6% of adults with a graduate-level degree.[3] Among U.S. states, smoking prevalence varies from a low of 9% in Utah to a high of 27% in West Virginia.[4]

Finally, because smoking cessation can lead to immediate health benefits at any age, smoking prevalence is an important measure to include when assessing health and planning interventions at a county level.[2]

Measurement Strategies

The prevalence of tobacco use is commonly measured with survey data on current cigarette smoking behavior. Though many surveys collect tobacco-related data, a major limitation of most is their relatively small sample sizes, which are not sufficient for county-level estimates. Two surveys that fall into this category are the Global Adult Tobacco Survey (GATS) and the National Health and Nutrition Examination Survey (NHANES). Data coverage is limited because both use in-person interviews to collect data. The GATS is only administered in 19 states, so it is not practical for a national analysis.[5] Similarly, the NHANES, while extensive in the diverse tobacco data collected, has a small sample size that makes analysis at the county level difficult.[5]

A third common survey-based data source is the Behavioral Risk Factor Surveillance System (BRFSS). Questions related to smoking behavior are included in the core questionnaire every year, and supplemental tobacco use questions are included in rotating modules. Conducted every year in all states, the BRFSS can be used to estimate smoking prevalence at the county level for most counties. The most common method of assessing tobacco use with BRFSS data, however, is measuring the percent of the population that are “current smokers,” meaning that a respondent has smoked at least 100 cigarettes in his or her lifetime and currently smokes “all or most days.” 

Some researchers argue that prevalence measures do not adequately represent smokers’ exposure to the harmful components of cigarette smoke and nonsmokers’ exposure to second-hand smoke. One study addressed this issue by using biomarkers as a mechanism to quantify the total exposure to cigarette smoke and its components in a population. The researchers found that there are significant differences among subpopulations: Young adult smokers had less exposure to cigarette smoke components than older adults; females had less exposure than males; and African American smokers had less exposure than white smokers.[6] Unfortunately, biological measures of smoking or tobacco use are not available through BRFSS or at the county level.

What Is the County Health Rankings Measurement Strategy?

The County Health Rankings uses county-level measures from the Behavioral Risk Factor Surveillance System (BRFSS) provided by the CDC to obtain the number of current adult smokers who have smoked at least 100 cigarettes in their lifetime. The BRFSS is a state-based, random-digit dial telephone survey of the adult population (ages 18 and older). In 2007, approximately 430,900 individuals were surveyed.[5] The response rates for this survey range from 27% to 65%.[5]

Measure Strengths & Limitations

Nelson et al. reviewed the reliability and validity of the BRFSS smoking measure by analyzing studies that used BRFSS data and studies that used different forms of data. They found high reliability and high validity for the “current smoker” responses.[7] This confirms that BRFSS survey data are a fairly accurate portrayal of the population’s smoking behavior.

The BRFSS faces challenges with collecting data and ensuring that the data is representative of the population. In recent years, increased use of cell phones as a home line, improved technology for screening of phone calls, greater concern over privacy with data, and a growing number of languages spoken throughout the U.S. could affect the reliability of the data and compromise its ability to accurately represent the population. However, BRFSS is making attempts to address these challenges.[8]

Because the BRFSS only surveys adults (ages 18 and older), another weakness of the County Health Rankings measure is the lack of data on adolescent smoking. The Youth Behavioral Risk Factor Survey attempts to fill this gap, but it currently does not provide enough data to estimate county-level smoking prevalence among youth.

Finally, new methods using biomarkers have shown that not all smokers are exposed to the same level of contaminants.[5] The simple “current smoker” status question that the survey data provides does not capture the thousands of chemical compounds in cigarettes and cigarette smoke nor take into account the effects of second-hand smoke, as can the biomarker assay.

Given the scope of the County Health Rankings and its data requirements, the BRFSS-based estimates of current smoking prevalence are both the most convenient and appropriate representation of individuals directly affected by tobacco use at the county level. 

 

References

[1] Centers for Disease Control and Prevention. State-specific prevalence and trends in adult cigarette smoking–United States, 1998-2007. MMWR Morb Mortal Wkly Rep. 2009;58:221-226.
[2] The Health Consequences Of Smoking: A Report Of The Surgeon General. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004.
[3] Cigarette smoking among adults–United States, 2007. MMWR Morb Mortal Wkly Rep. 2008;57:1221-1226.
[4] State-specific secondhand smoke exposure and current cigarette smoking among adults; United States, 2008. MMWR Morb Mortal Wkly Rep. 2009;58:1232-1235.
[5] Delnevo CD, Bauer UE. Monitoring the tobacco use epidemic III: The host: data sources and methodological challenges. Prev Med. 2009;48(suppl 1):S16-S23.
 [6] Roethig HJ, Munjal S, Feng SX, et al. Population estimates for biomarkers of exposure to cigarette smoke in adult US cigarette smokers. Nicotine Tob Res. 2009;11:1216-1225.
[7] Nelson DE, Holtzman D, Bolen J, Stanwyck CA, Mack KA. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Soz Praventivmed. 2001;46:S3-S42.
[8] Mokdad AH. The Behavioral Risk Factors Surveillance System: Past, present, and future. Annu Rev Public Health. 2009;30:43-54.