State Estimates of Adolescent Cigarette Use and Perceptions of Risk of Smoking: 2012 and 2013

National Survey on Drug Use and Health

Short Report

May 18, 2015

This artwork depicts the United States, counties, and small areas used in the National Survey on Drug Use and Health.

In Brief

Based on combined 2012 and 2013 data, rates of past month cigarette use among adolescents aged 12 to 17 was 6.1 percent nationally and ranged from 4.3 percent in California to 9.5 percent in Kentucky.

Rates of adolescent perceptions of great risk of smoking one or more packs of cigarettes per day ranged from 59.1 percent in Alaska to 70.4 percent in Florida.

Compared to combined 2002 and 2003 data, the 2012 and 2013 data show that 50 out of 51 states experienced a statistically significant decrease in the rate of adolescent past month cigarette use, and there were no states with a statistically significant increase in adolescent smoking.

State Estimates of Adolescent Cigarette Use and Perceptions of Risk of Smoking: 2012 and 2013

Authors

Rachel N. Lipari, Ph.D., and Arthur Hughes, M.S.

Introduction

Cigarette smoking and exposure to secondhand smoke causes more than 443,000 deaths every year, and another 8.6 million people suffer from a serious illness related to smoking.¹ According to the Surgeon General, if current trends continue, 5.6 million U.S. youths who are currently younger than 18 years of age will die prematurely during adulthood because of their smoking.² Thus, cigarette smoking imposes substantial health and financial costs on our nation and its states.³ Preventing adolescents from starting to smoke may be the most effective way to reduce the health and economic burden of tobacco-related disease in the future. Between 1991 and 2013, there was a significant linear decrease in the prevalence of cigarette use among high school students from 27.5 to 15.7 percent.⁴ It is useful to state policymakers and prevention specialists to assess whether the decline in smoking occurred across all states among adolescents aged 12 to 17.

States have been at the center of efforts to reduce adolescent smoking through cigarette taxation, enactment of laws that restrict smoking in public places, enforcement of laws that prohibit the sale and distribution of tobacco products to adolescents, and funding smoking prevention and cessation programs. As longitudinal research has shown, adolescents’ attitudes about the risks associated with cigarette smoking are often closely related to their use, with an inverse association between use and risk perceptions (i.e., the prevalence of use is lower among those who perceive high risk of harm from cigarette use).⁵ This corresponds to states with high prevalence of adolescent cigarette use typically having a low prevalence of adolescent perception that there is a great health risk from smoking. Therefore, many state and national prevention programs focus on teaching youths about the harm that smoking may do to their health and social life. State-level information about cigarette use and attitudes about smoking can provide states with vital data to monitor changes over time and to inform enforcement, educational, and prevention efforts.

This issue of The CBHSQ Report uses data from the combined 2012 and 2013 National Surveys on Drug Use and Health (NSDUHs) to present state (including the District of Columbia) estimates of past month cigarette use and perceptions of great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17.⁶ Findings in this report are annual averages based on combined 2012 and 2013 NSDUH data from approximately 45,000 respondents.⁷ These estimates are rank ordered from highest to lowest and divided into quintiles (fifths).⁸ Additionally, the combined 2012 and 2013 data are compared with combined 2002 and 2003 data to examine changes in these measures over time.

State Estimates of Adolescent Past Month Cigarette Use

The 2012 and 2013 data indicate that about 1 in 16 adolescents (6.1 percent) smoked cigarettes in the past month. Rates of adolescent past month cigarette use ranged from 4.3 percent in California to 9.5 percent in Kentucky (Figure 1).

Figure 1. Percentages of past month cigarette use among persons aged 12 to 17, by state: 2012 and 2013

This map of the United States shows the percentages of past month cigarette use among persons aged 12 to 17, by state, using combined 2012 and 2013 data. In 2012–2013, between 4.31 and 5.40 percent of youths used cigarettes in California, District of Columbia, Connecticut, Florida, Maryland, New York, New Jersey, Texas, Utah, and Hawaii. Between 5.46 and 6.25 percent of youths used cigarettes in Arizona, Massachusetts, Illinois, Nevada, Georgia, Virginia, Rhode Island, North Carolina, Oregon, and Alabama. Between 6.29 and 7.14 percent of youths used cigarettes in Kansas, Colorado, Alaska, Oklahoma, Washington, Idaho, Nebraska, Delaware, Minnesota, New Hampshire, and Michigan. Between 7.23 and 7.72 percent of youths used cigarettes in Maine, Iowa, South Carolina, Ohio, New Mexico, Wisconsin, Arkansas, Pennsylvania, Tennessee, and Indiana. Between 7.93 and 9.50 percent of youths used cigarettes in Montana, South Dakota, Louisiana, North Dakota, Mississippi, Vermont, Missouri, West Virginia, Wyoming, and Kentucky. If you would like someone from our staff to read the numbers on this graph or table image to you, please call 240-276-1250.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health (NSDUHs), 2012 and 2013.

Of the 10 states with the highest rates of past month cigarette use among adolescents, 4 were in the South (Louisiana, Kentucky, Mississippi, and West Virginia), 3 were in the Midwest (South Dakota, North Dakota, and Missouri), 2 were in the West (Montana and Wyoming), and 1 was in the Northeast (Vermont).⁹ Of the 10 states with the lowest rates of past month cigarette use among adolescents, 4 were in the South (District of Columbia, Florida, Maryland, and Texas), 3 were in the West (California, Utah, and Hawaii), and 3 were in the Northeast (Connecticut, New Jersey, and New York).

State Estimates of Adolescents’ Perception of Great Risk of Cigarette Use

The 2012 and 2013 data indicate that, nationwide, about two in three adolescents (65.0 percent) perceived great risk from smoking one or more packs of cigarettes per day. Among adolescents, perception of great risk from smoking one or more packs of cigarettes per day among this group ranged from 59.1 percent in Alaska to 70.4 percent in Florida (Figure 2).

Figure 2. Percentages of perceptions of great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17, by state: 2012 and 2013

This map of the United States shows percentages of perceptions of great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17, by state, using combined data from 2012 and 2013. In 2012–2013, between 59.08 and 61.69 percent of youths perceived great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17 in Alaska, Mississippi, Kentucky, Arkansas, District of Columbia, Oklahoma, Missouri, Arizona, Alabama, and West Virginia. Between 62.76 and 63.41 percent of youths perceived great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17 in Pennsylvania, New Mexico, Louisiana, South Carolina, North Carolina, Idaho, Tennessee, Montana, Rhode Island, and Oregon. Between 63.61 and 64.51 percent of youths perceived great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17 in Hawaii, Ohio, North Dakota, Wyoming, Michigan, Illinois, Texas, Minnesota, Georgia, Maine, and South Dakota. Between 64.59 and 65.93 percent of youths perceived great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17 in Nevada, Kansas, Indiana, Washington, New Jersey, Nebraska, Massachusetts, Wisconsin, Delaware, and Iowa. Between 66.03 and 70.43 percent of youths perceived great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17 in Maryland, New Hampshire, Virginia, Colorado, Vermont, California, New York, Connecticut, Utah, and Florida. If you would like someone from our staff to read the numbers on this graph or table image to you, please call 240-276-1250.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health (NSDUHs), 2012 and 2013

Of the 10 states with the highest rates of adolescent perception of great risk from smoking one or more packs a day, 4 were in the Northeast (New Hampshire, Vermont, New York, and Connecticut), 3 were in the West (Colorado, California, and Utah), and 3 were in the South (Maryland, Virginia, and Florida). Of the 10 states with the lowest rates of perception of great risk from smoking one or more packs of cigarettes per day, 7 were in the South (Alabama, Arkansas, District of Columbia, Kentucky, Mississippi, Oklahoma, and West Virginia), 2 were in the West (Alaska and Arizona), and 1 was in the Midwest (Missouri).

Changes Over Time

When 2002 and 2003 data are compared with 2012 and 2013 data, the nation as a whole experienced a statistically significant reduction in the rate of past month cigarette use among adolescents (from 12.6 to 6.1 percent; Table 1). On an individual state level, 50 states experienced a statistically significant decrease in the rate of adolescent past month cigarette use, and 1 state experienced no significant change.

Comparisons of the 2002 and 2003 data with the 2012 and 2013 data indicate that there was an increase at the national level in the rate of adolescent perception of great risk from smoking one or more packs of cigarettes per day (from 63.7 to 65.0 percent). On an individual state level, 4 states experienced a statistically significant increase in rate of adolescent perception of great risk from smoking, 1 state experienced a significant decline in rate of adolescent perceptions of great risk from smoking, and 46 experienced no change.

Table 1. Percentages of past month cigarette use and perceptions of great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17, by state: 2002–2003 and 2012–2013

This table shows the percentages of past month cigarette use and perceptions of great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17, by state: 2002–2003 and 2012–2013. If you would like someone from our staff to read the numbers on this graph or table image to you, please call 240-276-1250.

*Difference between 2012–2013 and 2002–2003 is statistically significant at .05 level.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health (NSDUHs), 2002, 2003, 2012, and 2013.

Four states had a statistically significant decrease in adolescent cigarette use and an increase in rate of adolescent perception of great risk from smoking (Figure 3; Table 1); these states are Texas, New Hampshire, New York, and Florida.⁹ Alaska was the only state that had a significant decrease in adolescent cigarette use and a decrease in rate of adolescent perception of great risk from smoking. For 45 states, there was a statistically significant decrease in the rate of adolescent cigarette use but no change in the rate of adolescent perception of great risk from smoking. For 1 state (Utah), there was no statistically significant change for either measure.

Figure 3. Significant changes in percentages of past month cigarette use and perception of great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17, by state: 2002–2003 versus 2012–2013

This map of the United States shows states with significant change from 2002–2003 to 2012–2013 in past month cigarette use and perceptions of great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17. Between 2002–2003 and 2012–2013, most states experience a significant decrease in use and no change in perception of great risk. Four states (Texas, Florida, New York, and New Hampshire) experienced a significant decrease in use and an increase in perception of great risk. One state (Utah) experienced no change in use or perception of great risk, and one state (Alaska) experienced a significant decrease in use and a decrease in perception of great risk. If you would like someone from our staff to read the numbers on this graph or table image to you, please call 240-276-1250.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health (NSDUHs), 2002, 2003, 2012, and 2013.

Discussion

The prevalence of cigarette use initiation in childhood or adolescence has prompted the Surgeon General to declare tobacco use to be a “pediatric epidemic,” affirming the importance of tobacco use prevention and control measures that target youths.¹¹ Reducing smoking among adolescents will improve the nation's health both immediately and in the long term. Changing attitudes toward smoking can help to reduce smoking among youths.³ The percentages of youths reporting the use of cigarettes were lower among those who perceived great risk in smoking one or more packs of cigarettes per day than among those who did not perceive great risk in doing so.⁵

Findings in this report suggest that efforts to reduce smoking and change attitudes about smoking among adolescents have resulted in considerable progress, although this progress was not uniform across all states. Youths' perceptions of risk have not changed significantly in most states, although the rate of cigarette smoking among youths has declined in nearly every state. Highlighting the prevalence of adolescent cigarette use and attitudes toward use in each state, as well as monitoring changes, may help federal, state, and local policymakers continue to plan for and allocate resources to combat adolescent smoking, including efforts to reduce the availability of tobacco products to young people, raise awareness about smoking and its consequences, and improve prevention efforts. Even as states make progress in decreasing adolescent smoking, e-cigarette use poses a related health risk among youths. Youths who had never smoked conventional cigarettes but who had used e-cigarettes were almost twice as likely to have intentions to smoke conventional cigarettes as those who had never used e-cigarettes.¹¹ Current research indicates that cigarette use rates are much higher than e-cigarette use among high school students.¹² Future research on both cigarette use and e-cigarette use among youths is needed to continue monitoring these developments.

For more information on addressing cigarette use among youths, see the following Web sites: https://store.samhsa.gov/shin/content/PHD633/PHD633.pdf and https://www.samhsa.gov/building-blocks.

The combined 2012 to 2013 NSDUH state estimates for adolescent cigarette use and 24 additional behavioral health measures and the methodology that generated the state estimates are available online.⁶National maps and detailed tables showing state estimates for the 24 additional outcomes (e.g., substance use; substance use disorders; treatment; mental illness; depression; and suicidal thoughts) are provided at http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf

End Notes

Centers for Disease Control and Prevention. (2011). Tobacco use: Targeting the nation’s leading killer. Retrieved from http://www.cdc.gov/chronicdisease/resources/publications/aag/osh.htm
U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. (2014). The health consequences of smoking—50 years of progress: A report of the Surgeon General. Rockville, MD: Author. Retrieved from http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf
Adhikari, B., Kahende, J., Malarcher, A., Pechacek, T., & Tong, V. (2008). Smoking-attributable mortality, years potential life lost, and productivity losses—United States, 2000-2004. Morbidity and Mortality Weekly Report, 57(45), 1226–1228. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm
Kann, L., Kinchen, S., Shanklin, S. L., Flint, K. H., Kawkins, J., Harris, W. A., Lowry, R., Olsen, E. O., McManus, T., Chyen, D., Whittle, L., Taylor, E., Demissie, Z., Brener, N., Thornton, J., Moore J, Zaza, S.;, Centers for Disease Control and Prevention (CDC). (2014). Youth risk behavior surveillance—United States, 2013. Morbidity and Mortality Weekly Report: Surveillance Summaries, 63(Suppl. 4), 1–168. Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6304.pdf
Song, A. V., Morrell, H. E., Cornell, J. L., Ramos, M. E., Biehl, M., Kropp, R. Y., & Halpern-Felsher, B. L. (2009). Perceptions of smoking-related risks and benefits as predictors of adolescent smoking initiation. American Journal of Public Health, 99(3), 487–492.
Center for Behavioral Health Statistics and Quality. (2014). 2012–2013 NSDUH state estimates of substance use and mental disorders. Retrieved from https://www.samhsa.gov/data/population-data-nsduh/reports?tab=33
All estimates are based on a small area estimation (SAE) methodology in which state-level NSDUH data are combined with local-area county and census block group/tract-level data from the state. This methodology provides more precise estimates of state level outcomes than those based solely on the sample. The precision of the SAE estimates is improved by combining data across 2 years (i.e., 2012 and 2013).
Estimates were divided into quintiles for ease of presentation, but differences between states and quintiles were not tested for statistical significance. At times, more than 10 or fewer than 10 states were assigned to each quintile because of ties in the estimated prevalence rates.
The West has 13 states: AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, and WY. The South has 16 states plus the District of Columbia: AL, AR, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, and WV. The Northeast has 9 states: CT, MA, ME, NH, NJ, NY, PA, RI, and VT. The Midwest has 12 states: IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, and WI.
Tests of significance were conducted separately on the difference in the rates of cigarette use from combined 2002 to 2003 and combined 2012 to 2013 along with the difference in the percentage perceiving great risk for the same two time periods. However, no tests of significance were conducted jointly between the difference in cigarette use and the difference in the perceptions of great risk.
U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. (2012). Preventing tobacco use among youth and young adults: A report of the Surgeon General. Rockville, MD: Author. Retrieved from http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf
Centers for Disease Control and Prevention. (2014). More than a quarter-million youth who had never smoked a cigarette used e-cigarettes in 2013 [Press release]. Retrieved from http://www.cdc.gov/media/releases/2014/p0825-e-cigarettes.html

suggested citation

Lipari, R.N. and Hughes, A. State Estimates of Adolescent Cigarette Use and Perceptions of Risk of Smoking: 2012 and 2013. The CBHSQ Report: May 18, 2015. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Rockville, MD

Summary

Background: Adolescents’ attitudes about the risks associated with cigarette smoking are often closely related to their use. As States have been at the center of efforts to reduce adolescent smoking, examining adolescents’ attitudes about the risks associated with smoking provides needed prevention information. Method: Combined 2012 and 2013 National Surveys on Drug Use and Health (NSDUHs) state (including the District of Columbia) estimates of past month cigarette use and perceptions of great risk of smoking one or more packs of cigarettes per day among persons aged 12 to 17 were analyzed. Additionally, the combined 2012 and 2013 data are compared with combined 2002 and 2003 data to examine changes in these measures over time. Results: Findings in this report suggest that efforts to reduce smoking and change attitudes about smoking among adolescents have resulted in considerable progress, although this progress was not uniform across all states. Youths' perceptions of risk have not changed significantly in most states, although the rate of cigarette smoking among youths has declined in nearly every state. Conclusion: Highlighting the prevalence of adolescent cigarette use and attitudes toward use in each state, as well as monitoring changes, may helppolicymakers continue to combat adolescent smoking, including efforts to reduce the availability of tobacco products to young people, raise awareness about smoking and its consequences, and improve prevention efforts.

Keywords: cigarettes, National Survey on Drug Use and Health, NSDUH, risk

Author Information

cbhsqrequest@samhsa.hhs.gov

Keywords

2002, 2003, 2012, 2013, Adolescents as Population Group, All US States Only, Arizona, Arkansas, Awareness, California, Children as Audience, Colorado, Connecticut, Cultural Competence, Delaware, District of Columbia, Drug Use Trends, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Multi-Year Trend, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Parents and Caregivers, Pennsylvania, Policymakers, Population Data, Prevention, Prevention Professionals, Public Health Professionals, Public Officials, Research and Methodology, Researchers, Rhode Island, Risk & Protective Factors, Short Report, South Carolina, South Dakota, Substance Abuse, Tennessee, Texas, Tobacco, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

The National Survey on Drug Use and Health (NSDUH) is an annual survey sponsored by The Substance Abuse and Mental Health Services Administration (SAMHSA). The data used in this report are based on information obtained in 2002 through 2013 from 816,900 people aged 12 or older. The Survey collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at their place of residence. Computer-assisted interviewing methods are used to provide a private and confidential setting for respondents to complete the interview.

The NSDUH Report is prepared by The Center for Behavioral Health Statistics and Quality (CBHSQ), SAMHSA, and by RTI International in Research Triangle Park, North Carolina. (RTI International is a trade name of Research Triangle Institute.)

Information on the most recent NSDUH is available in the following publication:

Center for Behavior Health Statistics and Quality. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of national findings (HHS Publication No. SMA 14-4863, NSDUH Series H-48). Rockville, MD : Substance Abuse and Mental Health Services Administration.

Also available online: https://www.samhsa.gov/data/population-data-nsduh.