Tobacco use by age.

In 2010 approximately 27% of individuals age 12 and older and 19% of adults age 18 and older were current tobacco users, meaning they had used some form of tobacco at some point in the past month (CDC, 2012c; SAMHSA, 2011). In that same time, 23% of the population identified as current cigarette smokers, 5.2% identified as cigar smokers, 3.5% identified as smokeless tobacco users, and 0.8% identified as pipe smokers (SAMHSA). The highest rates of tobacco use in 2010 were among young adults, ages 18 to 25, 41% of whom were current tobacco users (SAMHSA). Adults aged 26 years or older were the next highest tobacco-using age group at 27%. Youths, ages 12 to 17, had the lowest prevalence, with approximately 10% being current tobacco users (SAMHSA). Cigarettes were the most commonly used tobacco product among all age groups, with 34% of young adults, 8% of youths, and approximately 9% of older adults age 65 and older smoking cigarettes within the past month (SAMHSA). Approximately 11% of young adults smoke cigars, 6% use smokeless tobacco, and nearly 2% smoke tobacco pipes (SAMHSA).

Tobacco use in middle and high school students has declined since the beginning of the 21st century. As of 2011, 7.1% used any form of tobacco (including cigarettes, cigars, smokeless tobacco, tobacco pipes, etc.) compared with a decade prior, when 14.9% used tobacco of some kind. Particularly, current cigarette use dropped from 10.7% in 2000 to 4.3% in 2011 (CDC, 2012a). The most commonly used forms of combustible tobacco in 2011 among middle school students were cigarettes (4.3%), cigars (3.5%), and pipes (2.2%) (CDC, 2012a). Additionally, up to 4% reported smoking a hookah (ALA, 2011).

Similar to use among middle school students, use of any tobacco product among high school students declined from 34.4% in 2000 to 23.2% in 2011 (CDC, 2012a). Particularly, current cigarette use dropped from 27.9% in 2000 to 15.8% in 2011 (CDC). The most commonly used forms of combustible tobacco in 2011 were cigarettes (15.8%), cigars (11.6%), and pipes (4%). Additionally, up to 11% reported smoking a hookah (ALA, 2011).

Tobacco use by gender.

Globally, cigarette usage is higher among men than among women, with 48% of men worldwide smoking compared with 12% of women (World Health Organization [WHO], 2013). In the same trend as that seen in the rest of the world, among individuals aged 12 and older in the United States, approximately 34% of males were tobacco users compared with approximately 22% of females in 2010 (SAMHSA, 2011). Males have higher rates of usage for all tobacco products. Over 25% of U.S. males smoke cigarettes compared with nearly 21% of females (SAMHSA). U.S. adults aged 18 and older had similar rates in 2010, with greater than 21% of adult males and greater than 17% of adult females smoking (CDC, 2012b). Similarly, greater than 8% of males smoke cigars, nearly 7% use smokeless tobacco, and greater than 1% smoke pipes compared with approximately 2% of females reporting smoking cigars and less than 1% reporting smokeless tobacco or pipe use (SAMHSA).

However, among youth, rates of smoking and use of other tobacco products such as chew and water pipes are nearly equivalent between the two genders (WHO, 2013). Similar to global tobacco rates, U.S. youth ages 12 to 17 report similar smoking rates among male and females, with nearly 9% of male and greater than 8% of female youth smoking cigarettes in 2010 (SAMHSA, 2011). In general, females tend to smoke less, use lower nicotine cigarettes, and inhale less deeply than males (National Institute on Drug Abuse [NIDA], 2012a). However, use of tobacco products may impact genders differently.

The lesbian, gay, bisexual, transgender, and queer (LGBTQ) population is a special population with disproportionately high rates of smoking and general tobacco use (National LGBT Tobacco Control Network, 2013). Smoking rates within the LGBTQ community range from 50% to 200% higher than that of the general heterosexual population (National LGBT Tobacco Control Network). A 2004 study found that compared with straight women, lesbian women are approximately 70% more likely to smoke and compared with straight men, gay men are greater than 55% more likely to smoke (Tang et al., 2004). LGBTQ youth follow similar tobacco use trends, with gay, lesbian, or bisexual adolescents smoking at much higher rates than their heterosexual peers (Easton, Jackson, Mowery, Comeau, & Sell, 2008). Compared with the heterosexual adolescent population, in which approximately 29% smoked cigarettes, up to 47% of lesbian or same sex–attracted adolescent females and 37% of gay or same sex–attracted adolescent males reported smoking (Easton et al., 2008). Smoking rates among those who identify as bisexual are high as well, around 39%, with bisexual males more than twice as likely to smoke as straight or gay males (ALA, 2010).

Tobacco use by race or ethnicity.

Smoking rates tend to differ among different racial and ethnic groups. In the United States, the American Indian (AI) or Alaskan Native (AN) population had the highest rates of both adult and youth smokers. More than 32% of the adult AI/AN population were current smokers in 2010 (CDC, 2012c). Additionally, more than 55% of AI/AN youth have ever used tobacco products, with cigarette smoking being the most common form of tobacco use (Yu, 2011). In rural areas, the rates are even higher, with AI smoking rates at greater than 45% (ALA, 2012). Overall, 19% of U.S. adults ages 18 or older were current smokers in 2010. Specifically, 32% of those who reported being AI/AN were current smokers, as were more than 27% of multiple-race, more than 20% of White, approximately 19% of Black, nearly 13% of Hispanic, and nearly 10% of Asian adults in 2010 (CDC, 2012c). Among individuals ages 12 and older, nearly 36% of AI/AN, 32% of individuals reporting multiple races, more than 29% of Whites, approximately 27% of Blacks, nearly 22% of Hispanics, and over 12% of Asians reported being current tobacco users in 2010 (SAMHSA, 2011).

Nearly 15% of AI/AN youths, ages 12 to 17, smoke compared with 10% of White youths, 8% of Hispanic youths, approximately 5% of Black youths, and greater than 4% of Asian youths (SAMHSA, 2011). Similar trends are seen among young adults, ages 18 to 25, with approximately 39% of White young adults smoking compared with approximately 27% of Hispanic young adults, 26% of Black young adults, and 21% of Asian young adults (SAMHSA).

Tobacco use by geographic location.

Tobacco use varies by geographic location as well as by population density. In 2010 the midwestern United States had the highest rates of smoking, at approximately 25%, compared with the South at 24%, the Northeast at 22%, and the West at 20% (SAMHSA, 2011). However, smokeless tobacco use was actually highest in the South at greater than 4% compared with the Midwest at approximately 4%, the West at 3%, and the Northeast at approximately 2% (SAMHSA).

Both cigarette and smokeless tobacco use were highest in nonmetropolitan areas, at 26% and greater than 6%, respectively (SAMHSA, 2011). Similarly, cigarette and smokeless tobacco use were both lowest in large metropolitan areas, at nearly 22% and approximately 2%, respectively (SAMHSA). These trends hold for both males and females up to age 64 (ALA, 2012). Although rural rates of tobacco use are higher in all areas, certain populations within metropolitan areas have higher smoking rates than their urban counterparts. Studies have indicated that lifetime smoking rates of African American adolescents living in large metropolitan public housing units are high, approximately 46%, and recent cigarette usage within the past year was approximately 20% (Yu et al., 2012). These smoking rates of African American youths living in urban public housing are more than double the national rates of smoking for adolescent African Americans, both for lifetime and for recent smoking rates (Yu et al.).

Yet, rural rates of tobacco use are the highest in the county. Rural youth are up to three times more likely to smoke than their urban or suburban peers (ALA, 2012). Young adults from rural areas, ages 18 to 34, have some of the highest smoking rates in the United States and are 27% more likely to smoke than urban young adults (ALA). At all ages, rural men are two times as likely to use smokeless tobacco as are men from urban areas (ALA). Those in rural areas have greater chances of being exposed to secondhand smoke but are also less likely to have access to smoking cessation programs (ALA). Not only do residents of rural areas have higher rates of cigarette and smokeless tobacco use, but also they typically start using tobacco at a young age and tend to use it more heavily than suburban or urban individuals (ALA). Dual use of both cigarettes and smokeless tobacco is twice as high in rural areas, at 2.5%, compared with national rates of dual usage of only 1.4% (ALA). Additionally, the rate of rural women who smoked during the duration of their pregnancy (greater than 27%) is similar to the smoking rate of nonpregnant urban women (ALA). Smoking and tobacco education and cessation programs implemented in culturally appropriate ways could have large impacts on improving the health of rural communities.

Tobacco use by education level and socioeconomic status.

In general, smoking and tobacco use are correlated negatively with education levels and SES. In 2010, more than 45% of adults with a general education development degree were current smokers compared with only approximately 24% of adults with a high school diploma, less than 10% of adults with an undergraduate college degree, and approximately 6% of adults with a postgraduate degree being current smokers (CDC, 2012b). Similarly, of adults who lived below the poverty line in 2010, nearly 29% were current smokers compared with approximately 18% of adults who lived at or above the poverty level (CDC).

Biological and genetic factors.

There are a variety of different biological and genetic factors associated with tobacco use. The body’s biological response to nicotine can often lead to addiction and nicotine dependence over time. The nicotine from cigarettes and other tobacco products increases the levels of dopamine in the reward circuits of the brain, which is what leads to the pleasure and buzz so many tobacco users report experiencing (NIDA, 2012b). Over time, tobacco use will result in a neural sensitization, which makes each smoke or use of tobacco result in a stronger dopamine release (Lochbuehler, Otten, Voogd, & Engels, 2012). This continued use is capable of changing the user’s brain chemistry, resulting in nicotine addiction or dependence (NIDA, 2012b). All regular tobacco users, regardless of potential genetic factors, risk nicotine addiction simply by using tobacco products.

Various research has demonstrated, however, that there is in fact a genetic component to tobacco use. Genetics can impact all three stages of smoking and tobacco use: initiation, current usage, and cessation (Amos, Spitz, & Cinciripini, 2010). A longitudinal study, using a nationally representative sample of sibling pairs, reported that genes are an important etiological factor in nicotine dependence (Haberstick et al., 2007). The study has shown that genetic factors account for approximately 60% of the variance in smoking rates. Another study, using 32,359 California twins, reported that 32% of the variance in smoking initiation and 55% of the variance in smoking persistence are attributable to genetic factors (Hamilton et al., 2006). With genetics playing a large role in all aspects of nicotine dependence and tobacco use, genetics should also be considered when attempting to develop and implement tobacco prevention, education, and cessation programs.

Psychiatric factors.

Smoking and tobacco use are often comorbid with other psychiatric disorders, such as alcoholism, schizophrenia, depression, and anxiety disorders, among others (NIDA, 2012c). Although it is difficult to discern a direction concerning the link between psychiatric factors and tobacco use, studies have indicated that a psychiatric disorder may precede tobacco use (Griesler, Hu, Schaffran, & Kandel, 2008). Early onset of a psychiatric disorder has been found to increase the odds of adolescents becoming nicotine dependent (Griesler et al., 2008). Panic disorders such as panic attacks and panic-specific vulnerabilities have also been shown to influence tobacco use, with smoking and nicotine delivery as a potential means of coping with panic (Zvolensky & Bernstein, 2005). For many psychiatric disorders, tobacco use may serve as a self-medicated coping mechanism to help curb the symptoms of the illness.

Psychosocial factors.

Research has shown that low achievement motivation, rebelliousness, and thrill seeking are all psychological traits that influence smoking behaviors (Bricker et al., 2009). The presence of these traits and their level of intensity are shown to ultimately contribute to the likelihood that individuals will initially try smoking, as well as the probability of increasing smoking to a monthly or daily habit (Bricker et al.). Stress has been shown to be a factor in adolescent smoking, with personal and school-related stress linked to increased lifetime smoking and smoking intentions in multiethnic adolescents (Booker et al., 2008). Similar results concerning stress and smoking habits have been found in adults, with links existing between stressful life events and smoking status. Studies have found that stressful life events such as financial concerns or changes in residence may result in failure to quit smoking or relapse among women (McKee, Mciejewski, Falba, & Mazure, 2003). Individuals who have been trauma exposed and exhibit higher levels of posttraumatic stress symptoms are more likely to report smoking as a means to reduce symptoms, irrelevant of their actual smoking levels (Feldner et al., 2007). Smoking may be used as a means to relieve stress or symptoms of posttraumatic stress disorder and alleviate symptoms of stress and trauma. Low levels of self-worth, self-image, and self-esteem have also been shown to be factors that impact tobacco use, particularly in adolescent populations (CDC, 2012d). Perceived discrimination has been found to have different effects on adolescent males and females, with adolescent males increasing smoking rates and adolescent females decreasing smoking rates in discriminatory settings (Wiehe, Aalsma, Liu, & Fortenberry, 2010). Further research is needed to more fully understand the effects of stigma and discrimination on smoking habits so proper interventions and cessation treatments can be implemented. Historically marginalized and minority populations, such as the LGBTQ community, may be influenced by these factors. With the potential stigma and stress associated with being a minority, individuals may turn to smoking as a coping mechanism, which may help to explain high rates of smoking in minority populations (The DC Center for the LGBT Community, 2013).

Environmental and sociocultural factors.

In addition to genetic and psychosocial factors, environment and sociocultural factors can play a large part in tobacco use initiation and habits. As shown previously, low SES has been shown to impact smoking rates, with those with lower SES having higher rates of tobacco use than those with higher SES and education (CDC, 2012b). Additionally, the use and approval of tobacco by peers, parents, guardians, siblings, or the community can impact tobacco use and acceptance, as can exposure to smoking in movies or advertisements and the accessibility and cost of tobacco products (CDC, 2012d).

Various studies have demonstrated that children of smoking parents tend to view smoking more favorably and are more likely to indicate a desire to smoke than their peers whose parents do not smoke (Kobus, 2003; Lochbuehler et al., 2012). One study found that children whose parents smoked were more innately attuned to smoking cues than their peers whose parents did not smoke (Lochbuehler et al.). This finding could indicate that children of smoking parents may unconsciously be more aware and focused on smoking behaviors, even prior to their understanding of tobacco use, including smoking (Lochbuehler et al.). The impact of peers on smoking has also been well documented. Many studies have shown that youth who have smoking friends are more likely to smoke than their peers who have nonsmoking friends (Kobus). Social relationships, such as friends, romantic interests or partners, and social groups, can all impact smoking behavior in adolescents and youth; they can promote or discourage smoking, depending on the perspective of the influence (Kobus). Adolescents whose parents or peers smoke are more likely to try smoking compared with adolescents whose peers and parents do not smoke or view smoking negatively, who may be less likely to smoke or use tobacco (Kobus). Last, one study found that schools that incorporated tobacco education and prevention into their curriculum and schools that had policies that prohibited tobacco use on campus had lower rates of smoking then schools that did not incorporate tobacco education or policies (Lovato et al., 2010). The same study also found that the local price of cigarettes was inversely related to student smoking; the higher the cost of cigarettes in the community, the fewer students smoked.

Interplays among multiple factors.

Although genetics, psychiatry, psychosociology, and environment all are related to tobacco use, there are interplays among these factors for tobacco use. For example, psychosocial factors such as novelty seeking predict tobacco use through social environmental factors such as tobacco advertising and media (Audrain-McGovern et al., 2006). In the study, novelty-seeking personalities have been shown to have a significant indirect effect on smoking habits; with novelty seekers being more likely to be receptive to tobacco advertising and therefore more likely to either start or continue smoking. The researchers found that individuals who are receptive to tobacco advertising are up to three times more likely to smoke.

Associations between tobacco use and other risk behaviors.

Adolescent tobacco use has been shown to be related to a variety of other risk behaviors, such as alcohol consumption and drug usage, delinquent behaviors (for example, carrying weapons and fighting), dropping out of school, early sexual intercourse, not using seat belts, failure to exercise, and eating fewer than five daily servings of fruits and vegetables (Brener & Collins, 1998; CDC, 2012d; Escobedo, Reddy, & DuRant, 1997).

Cessation desire, treatment, and success.

With the most common form of chemical dependence in the United States being tobacco use disorder, treatment is often required for successful tobacco cessation (CDC, 2013). Although 69% of smoking U.S. adults wish to quit entirely, only 52% of adult cigarette users attempted to quit in 2010 (CDC, 2012c). Approximately 50% of youth ages 14 to 17 wish to quit smoking, with approximately 62% of young adults ages 18 to 24, 57% of adults ages 25 to 44, and up to 46% of older adults ages 45 and older wishing to quit cigarettes as well (CDC, 2013). However, fewer than one third (31%) of smokers who attempted to quit received cessation treatment (Malarcher, Dube, Shaw, Babb, & Kaufmann, 2011). Nearly 75% of adult smokers seeking cessation treatment are highly nicotine dependent (Zoler, 2008). Perhaps because of the lack of treatment among tobacco users who wish to quit, the overall rate of successful tobacco cessation among the smoking population is currently only approximately 6.2%, despite much higher percentages wishing to quit (Malarcher et al., 2011). In fact, more than 85% of smokers who attempt cessation without assistance end up relapsing, with many relapsing within a week of attempting to quit (NIDA, 2012b).

Tobacco use disorder and comorbid psychiatric disorders.

Nicotine is highly addictive, which leads to most tobacco users being nicotine dependent (CDC, 2013). Tobacco use disorder has been found to be comorbid with other psychiatric disorders in both adults and youths. Studies have indicated that adolescents with a depressive disorder were nearly five times as likely to have nicotine dependence compared with their nondepressive disorder peers (Fergusson, Lynskey, & Horwood, 1996). Other studies have identified that psychiatric disorders tend to precede nicotine dependence, as opposed to nicotine dependence triggering psychiatric illnesses (Griesler et al., 2008). An early onset of a psychiatric disorder was found to increase the risks of developing nicotine dependence in adolescents.

Similarly, adults with nicotine dependence have been shown to have increased chances of having other substance use disorders (for example, alcohol abuse), anxiety disorders, somatoform disorders, or affective disorder (Ulrich, Meyer, Rumpf, & Hapke, 2004). Estimates indicate that approximately 80% of alcoholics and as many as 90% of those with schizophrenia are regular smokers (NIDA, 2012c). In 2010, up to 23% of current smokers ages 12 and older reported using illicit drugs compared with fewer than 5% of their nonsmoking peers (SAMHSA, 2011). The report shows that rates of comorbidity are even higher among youths, with more than 50% of current smoking youth ages 12 to 17 using illicit drugs compared with only approximately 6% of their nonsmoking peers. Other comorbid factors may contribute to the relationship between nicotine dependence and psychiatric disorders. In some cases, smoking or tobacco use may serve as a form of self-medication for psychiatric illness, such as major depressive disorder or anxiety disorders. This may be brought on by a third variable, which could impact the relationship between psychiatric disorders and nicotine dependence (Ulrich et al., 2004). In total, approximately 44% of all cigarettes sold in the United States are purchased by people with psychiatric disorders (NIDA, 2012c).

Screening tools for tobacco use disorder.

Various assessment tools are used in tobacco cessation to screen for tobacco use disorder. The Hooked on Nicotine Checklist is used to assess nicotine dependence in youth (DiFranza et al., 2007). The checklist consists of 10 “yes” or “no” questions, such as “Have you ever tried to quit, but couldn’t?” or “Do you ever have strong cravings to smoke?” (DiFranza et al.). The score is calculated by summing the number of “yes” responses, with higher scores indicating higher nicotine dependence.

The Nicotine Dependence Syndrome Scale (NDSS) and the Fagerström Test for Nicotine Dependence (FTND) are assessments that can be used for both youth and adult screenings (Clark et al., 2005). The NDSS consists of 19 items, each of which has a 5-point Likert-type scale response option ranging from “not at all true” to “extremely true” (Shiffman, Waters, & Hickcox, 2004). Examples of the NDSS questions are “If I wake up during the night, I feel I need a cigarette” and “I smoke consistently and regularly throughout the day.” The FTND is a revision of the 1978 Fagerström Tolerance Questionnaire; it is a shorter assessment than the NDSS, consisting of only 6 items, such as “How soon after you wake up do you smoke your first cigarette?” and “How many cigarettes per day do you smoke?” (Heatherton, Kozlowski, Frecker, & Fagerström, 1991). Higher scores indicate higher nicotine dependence.

Screening tools for tobacco withdrawal.

Similar to assessing tobacco use disorder, various assessments are used to screen for tobacco withdrawal, especially in cessation programs or studies. The Nicotine Withdrawal Assessment for Youth (N-WAY) is used to assess adolescent and youth withdrawal (Goldfine, Branstetter, & Horn, 2012). The N-WAY screening is aimed at 13- to 19-year-old youths and uses 39 items to assess the frequency and significance of potential nicotine withdrawal symptoms experienced within the past week. Examples of items include restlessness, anger, headaches, and concentration problems. Each item has a 5-point Likert-type scale response option ranging from “not at all” to “almost always” or “extremely,” with higher scores indicating a higher severity of nicotine withdrawal.

The Minnesota Nicotine Withdrawal Scale (MNWS) is another screening tool for nicotine withdrawal (Hughes & Hatsukami, 1986). The revised version of the scale, the Minnesota Nictotine Withdrawal Scale–Revised (MNWS-R) is now used as well (Shiffman, West, & Gilbert, 2004). The MNWS-R is made up of 15 items that measure eight symptoms of withdrawal such as mood, appetite, and sleep disturbance using a 5-point Likert-type scale response option ranging from “0 or not present” to “4 or severe” (Shiffman, West, et al., 2004; Toll, O’Malley, McKee, Salovey, & Krishnan-Sarin, 2007). Similar to the N-WAY measure, the Wisconsin Smoking Withdrawal Scale (WSWS) is used to screen for nicotine withdrawal (Welsch et al., 1999). The WSWS consists of 28 items that use a 5-point Likert-type scale response ranging from “strongly disagree” to “strongly agree.” Questions range from “I have been impatient” to “I am satisfied with my sleep”; the questions are subdivided into various subscales, which combined measure different aspects of nicotine withdrawal, including anger, anxiety, sadness, concentration, hunger, somatic symptoms, sleep, and cravings (Welsch et al.).