OBJECTIVE: Studies examining the use of smoking cessation treatment and related spending among enrollees with employer-sponsored health insurance are dated and limited in scope. We assessed changes in annual receipt of and spending on cessation medications approved by the US Food and Drug Administration (FDA) among tobacco users with employer-sponsored health insurance from 2010 to 2017. METHODS: We analyzed data on 439 865 adult tobacco users in 2010 and 344 567 adult tobacco users in 2017 from the IBM MarketScan Commercial Database. We used a negative binomial regression to estimate changes in receipt of cessation medication (number of fills and refills and days of supply). We used a generalized linear model to estimate spending (total, employers', and out of pocket). In both models, covariates included year, age, sex, residence, and type of health insurance plan. RESULTS: From 2010 to 2017, the percentage of adult tobacco users with employer-sponsored health insurance who received any cessation medication increased by 2.4%, from 15.7% to 16.1% (P < .001). Annual average number of fills and refills per user increased by 15.1%, from 2.5 to 2.9 (P < .001) and days of supply increased by 26.4%, from 81.9 to 103.5 (P < .001). The total annual average spending per user increased by 53.6%, from $286.40 to $440.00 (P < .001). Annual average out-of-pocket spending per user decreased by 70.9%, from $70.80 to $20.60 (P < .001). CONCLUSIONS: Use of smoking cessation medications is low among smokers covered by employer-sponsored health insurance. Opportunities exist to further increase the use of cessation medications by promoting the use of evidence-based cessation treatments and reducing barriers to coverage, including out-of-pocket costs.

Introduction: Asian immigrants to the U.S. smoke at higher rates than U.S.-born Asians. However, few programs exist to help these immigrants quit and little is known about their real-world effectiveness. The Centers for Disease Control and Prevention funded the Asian Smokers' Quitline to serve Chinese, Korean, and Vietnamese immigrants nationwide. This study examines service utilization and outcomes from the first 7 years of the program. Method(s): From August 2012 to July 2019, the Asian Smokers' Quitline enrolled 14,073 Chinese-, Korean-, and Vietnamese-speaking smokers. Service utilization rates and cessation outcomes were compared with those of an earlier trial (conducted 2004-2008) that demonstrated the efficacy of an Asian-language telephone counseling protocol. Data were analyzed in 2019. Result(s): Asian Smokers' Quitline participants came from all 50 states and the District of Columbia. The main referral sources were Asian-language newspapers (37.2%), family and friends (16.4%), healthcare providers (11.9%), and radio (11.9%). Overall, 37.6% were uninsured, 38.8% had chronic health conditions, and 15.4% had mental health conditions. Compared with participants in the earlier trial, Quitline participants received 1 fewer counseling session (3.8 vs 4.9, p<0.001) but were more likely to use pharmacotherapy (73.6% vs 20.9%, p<0.001). More than 90% were satisfied with the services they received. Six-month prolonged abstinence rates were higher in the Quitline than in the trial (complete case analysis: 28.6% vs 20.0%, p<0.001; intention-to-treat analysis: 20.5% vs 16.4%, p=0.005). Conclusion(s): The Asian Smokers' Quitline was utilized by >14,000 Asian-language-speaking smokers across the U.S. in its first 7 years. This quitline could serve as a model for delivering other behavioral services to geographically dispersed linguistic minority populations.

INTRODUCTION: Since 2012, the Centers for Disease Control and Prevention has conducted the national Tips From Former Smokers public education campaign, which motivates smokers to quit by featuring people living with the real-life health consequences of smoking. Cost effectiveness, from the healthcare sector perspective, of the Tips From Former Smokers campaign was compared over 2012-2018 with that of no campaign. METHODS: A combination of survey data from a nationally representative sample of U.S. adults that includes cigarette smokers and literature-based lifetime relapse rates were used to calculate the cumulative number of Tips From Former Smokers campaign‒associated lifetime quits during 2012-2018. Then, lifetime health benefits (premature deaths averted, life years saved, and quality-adjusted life years gained) and healthcare sector cost savings associated with these quits were assessed. All the costs were adjusted for inflation in 2018 U.S. dollars. The Tips From Former Smokers campaign was conducted and the survey data were collected during 2012-2018. Analyses were conducted in 2019. RESULTS: During 2012-2018, the Tips From Former Smokers campaign was associated with an estimated 129,100 premature deaths avoided, 803,800 life years gained, 1.38 million quality-adjusted life years gained, and $7.3 billion in healthcare sector cost savings on the basis of an estimated 642,200 campaign-associated lifetime quits. The Tips From Former Smokers campaign was associated with cost savings per lifetime quit of $11,400, per life year gained of $9,100, per premature deaths avoided of $56,800, and per quality-adjusted life year gained of $5,300. CONCLUSIONS: Mass-reach health education campaigns, such as Tips From Former Smokers, can help smokers quit, improve health outcomes, and potentially reduce healthcare sector costs.

We assessed characteristics and correlates of recent successful cessation (quitting smoking for 6 months or longer within the past year) among US adult cigarette smokers aged 18 years or older. Estimates came from the July 2018 fielding of the 2018-2019 Tobacco Use Supplement to the Current Population Survey (N = 26,759). In 2018, 7.1% of adult smokers reported recent successful cessation. Recent successful cessation varied by certain demographic characteristics, noncigarette tobacco product use, smoke-free home rules, and receipt of advice to quit from a medical doctor. To help more smokers quit, public health practitioners can ensure that evidence-based tobacco control interventions, including barrier-free access to evidence-based cessation treatments, are reaching all tobacco users, especially those who face greater barriers to quitting.

BACKGROUND: High-intensity antitobacco media campaigns are a proven strategy to reduce the harms of cigarette smoking. While buy-in from multiple stakeholders is needed to launch meaningful health policy, the budgetary impact of sustained media campaigns from multiple payer perspectives is unknown. METHODS: We estimated the budgetary impact and time to breakeven from societal, all-payer, Medicare, Medicaid and private insurer perspectives of national antitobacco media campaigns in the USA. Campaigns of 1, 5 and 10 years of durations were assessed in a microsimulation model to estimate the 10 and 20-year health and budgetary impact. Simulation model inputs were obtained from literature and both pubic use and proprietary data sets. RESULTS: The microsimulation predicts that a 10-year national smoking cessation campaign would produce net savings of $10.4, $5.1, $1.4, $3.6 and $0.2 billion from the societal, all-payer, Medicare, Medicaid and private insurer perspectives, respectively. National antitobacco media campaigns of 1, 5 and 10-year durations could produce net savings for Medicaid and Medicare within 2 years, and for private insurers within 6-9 years. A 10-year campaign would reduce adult cigarette smoking prevalence by 1.2 percentage points, prevent 23 500 smoking-attributable deaths over the first 10 years. In sensitivity analysis, media campaign costs would be offset by reductions in medical care spending of smoking among all payers combined within 6 years in all tested scenarios. CONCLUSIONS: 1, 5 and 10-year antitobacco media campaigns all yield net savings within 10 years from all perspectives. Multiyear campaigns yield substantially higher savings than a 1-year campaign.

Research shows that there is no risk-free level of exposure to secondhand smoke (SHS) and that eliminating smoking indoors fully protects nonsmokers from indoor SHS exposure. Casinos often allow smoking indoors and can be a source of involuntary SHS exposure for employees and visitors. We examined attitudes toward smoke-free casino policies among US adults. During June and July 2017, we used a web-based survey to ask a nationally representative sample of 4107 adults aged >/=18 about their attitudes toward smoke-free casinos. Among 4048 respondents aged >/=18, a weighted 75.0% favored smoke-free casino policies, including respondents who visited casinos about once per year (74.1%), several times per year (75.3%), and at least once per month (74.2%). Although the sociodemographic characteristics of respondents who favored smoke-free casino policies varied, the majority in each group, except current smokers (45.4%), supported smoke-free policies. Allowing smoking inside casinos involuntarily exposes casino employees and visitors to SHS, a known and preventable health risk. Further assessment of public knowledge and attitudes toward smoke-free casinos at state and local levels may help inform tobacco control policy, planning, and practice.

This study assessed state-specific smoking cessation behaviors among US adult cigarette smokers aged 18 years or older. Estimates came from the 2014-2015 Tobacco Use Supplement to the Current Population Survey (N = 163,920). Prevalence of interest in quitting ranged from 68.9% (Kentucky) to 85.7% (Connecticut); prevalence of making a quit attempt in the past year ranged from 42.7% (Delaware) to 62.1% (Alaska); prevalence of recently quitting smoking ranged from 3.9% (West Virginia) to 11.1% (District of Columbia); and prevalence of receiving quit advice from a medical doctor in the past year ranged from 59.4% (Nevada) to 81.7% (Wisconsin). These findings suggest that opportunities exist to encourage and help more smokers to quit.

The U.S. Surgeon General has concluded that the burden of death and disease from tobacco use in the United States is overwhelmingly caused by cigarettes and other combusted tobacco products (1). Cigarettes are the most commonly used tobacco product among U.S. adults, and about 480,000 U.S. deaths per year are caused by cigarette smoking and secondhand smoke exposure (1). To assess progress toward the Healthy People 2020 target of reducing the proportion of U.S. adults aged >/=18 years who smoke cigarettes to </=12.0% (objective TU-1.1),* CDC analyzed data from the 2016 National Health Interview Survey (NHIS). In 2016, the prevalence of current cigarette smoking among adults was 15.5%, which was a significant decline from 2005 (20.9%); however, no significant change has occurred since 2015 (15.1%). In 2016, the prevalence of cigarette smoking was higher among adults who were male, aged 25-64 years, American Indian/Alaska Native or multiracial, had a General Education Development (GED) certificate, lived below the federal poverty level, lived in the Midwest or South, were uninsured or insured through Medicaid, had a disability/limitation, were lesbian, gay, or bisexual (LGB), or had serious psychological distress. During 2005-2016, the percentage of ever smokers who quit smoking increased from 50.8% to 59.0%. Proven population-based interventions are critical to reducing the health and economic burden of smoking-related diseases among U.S. adults, particularly among subpopulations with the highest smoking prevalences (1,2).

Tobacco use is the leading cause of preventable disease and death in the United States, and cigarettes are the most commonly used tobacco product among U.S. adults. To assess progress toward achieving the Healthy People 2020 target of reducing the proportion of U.S. adults who smoke cigarettes to ≤12.0% (objective TU1.1), CDC assessed the most recent national estimates of cigarette smoking prevalence among adults aged ≥18 years using data from the 2015 National Health Interview Survey (NHIS). The proportion of U.S. adults who smoke cigarettes declined from 20.9% in 2005 to 15.1% in 2015, and the proportion of daily smokers declined from 16.9% to 11.4%. However, disparities in cigarette smoking persist. In 2015, prevalence of cigarette smoking was higher among adults who were male; were aged 25-44 years; were American Indian/Alaska Native; had a General Education Development certificate (GED); lived below the federal poverty level; lived in the Midwest; were insured through Medicaid or were uninsured; had a disability/limitation; were lesbian, gay, or bisexual; or who had serious psychological distress. Proven population-based interventions, including tobacco price increases, comprehensive smoke-free laws, anti-tobacco mass media campaigns, and barrier-free access to tobacco cessation counseling and medications, are critical to reducing cigarette smoking and smoking-related disease and death among U.S. adults, particularly among subpopulations with the highest smoking prevalences.

INTRODUCTION: Increasing tobacco excise taxes and implementing comprehensive smoke-free laws are two of the most effective population-level strategies to reduce tobacco use, prevent tobacco use initiation, and protect nonsmokers from secondhand smoke. We examined state laws related to smoke-free buildings and to cigarette excise taxes from 2000 through 2014 to see how implementation of these laws from 2000 through 2009 differs from implementation in more recent years (2010-2014). METHODS: We used legislative data from LexisNexis, an online legal research database, to examine changes in statewide smoke-free laws and cigarette excise taxes in effect from January 1, 2000, through December 31, 2014. A comprehensive smoke-free law was defined as a statewide law prohibiting smoking in all indoor areas of private work sites, restaurants, and bars. RESULTS: From 2000 through 2009, 21 states and the District of Columbia implemented comprehensive smoke-free laws prohibiting smoking in work sites, restaurants, and bars. In 2010, 4 states implemented comprehensive smoke-free laws. The last state to implement a comprehensive smoke-free law was North Dakota in 2012, bringing the total number to 26 states and the District of Columbia. From 2000 through 2009, 46 states and the District of Columbia implemented laws increasing their cigarette excise tax, which increased the national average state excise tax rate by $0.92. However, from 2010 through 2014, only 14 states and the District of Columbia increased their excise tax, which increased the national average state excise tax rate by $0.20. CONCLUSION: The recent stall in progress in enacting and implementing statewide comprehensive smoke-free laws and increasing cigarette excise taxes may undermine tobacco prevention and control efforts in the United States, undercutting efforts to reduce tobacco use, exposure to secondhand smoke, health disparities, and tobacco-related illness and death.

BACKGROUND: Helping tobacco smokers to quit during a medical visit is a clinical and public health priority. Research suggests that most health professionals engage their patients in at least some of the '5 A's' of the brief cessation intervention recommended in the U.S. Public Health Service Clinical Practice Guideline, but information on the extent to which patients act on this intervention is uncertain. We assessed current cigarette-only smokers' self-reported receipt of the 5 A's to determine the odds of using optimal cessation assisted treatments (a combination of counseling and medication). METHODS: Data came from the 2009-2010 National Adult Tobacco Survey (NATS), a nationally representative landline and mobile phone survey of adults aged ≥18 years. Among current cigarette-only smokers who visited a health professional in the past 12 months, we assessed patients' self-reported receipt of the 5 A's, use of the combination of counseling and medication for smoking cessation, and use of other cessation treatments. We used logistic regression to examine whether receipt of the 5 A's during a recent clinic visit was associated with use of cessation treatments (counseling, medication, or a combination of counseling and medication) among current cigarette-only smokers. RESULTS: In this large sample (N = 10,801) of current cigarette-only smokers who visited a health professional in the past 12 months, 6.3 % reported use of both counseling and medication for smoking cessation within the past year. Other assisted cessation treatments used to quit were: medication (19.6 %); class or program (3.8 %); one-on-one counseling (3.7 %); and telephone quitline (2.6 %). Current cigarette-only smokers who reported receiving all 5 A's during a recent clinic visit were more likely to use counseling (odds ratio [OR]: 11.2, 95 % confidence interval [CI]: 7.1-17.5), medication (OR: 6.2, 95 % CI: 4.3-9.0), or a combination of counseling and medication (OR: 14.6, 95 % CI: 9.3-23.0), compared to smokers who received one or none of the 5 A's components. CONCLUSIONS: Receipt of the '5 A's' intervention was associated with a significant increase in patients' use of recommended counseling and medication for cessation. It is important for health professionals to deliver all 5 A's when conducting brief cessation interventions with patients who smoke.

BACKGROUND: Exposure to secondhand smoke (SHS) causes significant disease and death. We assessed the prevalence and correlates of perceptions about the health harm of SHS among U.S. adults at the national and state level. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a national landline and cellular telephone survey. Perceptions about the health harms of SHS were assessed as follows: 'not at all harmful', 'somewhat harmful', and 'very harmful'. Descriptive statistics were used to assess the prevalence of SHS harm perceptions by tobacco use and sociodemographic factors, including sex, age, race/ethnicity, education, marital status, annual household income, region, sexual orientation, children in the household, and smoke-free law coverage. Logistic regression was used to assess odds of perceiving SHS to be "very harmful" (vs. "not at all harmful" or "somewhat harmful"), adjusting for the aforementioned factors. RESULTS: Nationally, 64.5 % of adults perceived SHS as 'very harmful' (state range: 73.5 % [Utah] to 53.7 % [Kentucky]). By tobacco use, the perception that SHS is 'very harmful' was: 76.5 % among nonusers of tobacco; 62.1 % among noncombustible only users; 47.9 % among combustible only users; and 40.8 % among dual combustible and noncombustible users. Following adjustment, the perception that SHS was 'very harmful' was higher among females, non-Hispanic minorities and Hispanics, respondents living with children, and states with 100 % smoke-free law coverage. Among current tobacco users the odds of perceiving SHS to be 'very harmful' was lower in the Midwest than the West. CONCLUSIONS: Almost two-thirds of American adults perceive SHS as 'very harmful'; however, currently only half of all Americans are protected by comprehensive state or local smoke-free laws. These findings underscore the importance of public education campaigns to increase awareness of SHS exposure harm and the benefits of smoke-free environments. Expanding comprehensive smoke-free laws could protect all Americans from SHS.

OBJECTIVE: The home is the primary source of secondhand smoke (SHS) exposure for children. We assessed national and state progress in smoke-free home (SFH) rule adoption in homes with and without children and adult smokers. METHODS: Data came from the 1992-1993 and 2010-2011 Tobacco Use Supplements to the Current Population Survey, a U.S. national probability household survey. Households were defined as having a SFH rule if all household respondents aged ≥18 indicated no one was allowed to smoke inside the home at any time. Households with children were those with occupants aged <18. Smokers were those who smoked ≥100 lifetime cigarettes and now smoked "everyday" or "some days". RESULTS: From 1992-1993 to 2010-2011, SFH rule prevalence increased from 43.0% to 83.0% (p<.05). Among households with children, SFH rules increased overall (44.9% to 88.6%), in households without smokers (59.7% to 95.0%), and households with ≥1 smokers (9.7% to 61.0%) (p<.05). Among households without children, SFH rules increased overall (40.8% to 81.1%), in households without smokers (53.4% to 90.1%), and households with ≥1 smokers (6.3% to 40.9%) (p<.05). Prevalence increased in all states, irrespective of smoker or child occupancy (p<.05). In 2010-2011, among homes with smokers and children, SFH rule prevalence ranged from 36.5% (West Virginia) to 86.8% (California). CONCLUSIONS: Considerable progress has been made adopting SFH rules, but many U.S. children continue to be exposed to SHS because their homes are not smoke-free. Further efforts to promote adoption of SFH rules are essential to protect all children from this health risk.

Tobacco smoking is the leading cause of preventable disease and death in the United States, resulting in approximately 480,000 premature deaths and more than $300 billion in direct health care expenditures and productivity losses each year (1). To assess progress toward achieving the Healthy People 2020 objective of reducing the percentage of U.S. adults who smoke cigarettes to </=12.0%,* CDC assessed the most recent national estimates of smoking prevalence among adults aged >/=18 years using data from the 2014 National Health Interview Survey (NHIS). The percentage of U.S. adults who smoke cigarettes declined from 20.9% in 2005 to 16.8% in 2014. Among daily cigarette smokers, declines were observed in the percentage who smoked 20-29 cigarettes per day (from 34.9% to 27.4%) or >/=30 cigarettes per day (from 12.7% to 6.9%). In 2014, prevalence of cigarette smoking was higher among males, adults aged 25-44 years, multiracial persons and American Indian/Alaska Natives, persons who have a General Education Development certificate, live below the federal poverty level, live in the Midwest, are insured through Medicaid or are uninsured, have a disability or limitation, or are lesbian, gay, or bisexual. Proven population-based interventions, including tobacco price increases, comprehensive smoke-free laws, high impact mass media campaigns, and barrier-free access to quitting assistance, are critical to reduce cigarette smoking and smoking-related disease and death among U.S. adults.

OBJECTIVES: We assessed sociodemographic disparities in local 100% smoke-free laws prohibiting smoking in all indoor areas of nonhospitality worksites, restaurants, and bars in 10 states. METHODS: We obtained data on local 100% smoke-free laws (US Tobacco Control Laws Database) and subcounty characteristics (2006-2010 American Community Survey) for Alabama, Alaska, Indiana, Kentucky, Mississippi, Missouri, North Dakota, South Carolina, Texas, and West Virginia. Outcomes included (1) 100% smoke-free law covering restaurants, bars, and workplaces; (2) 100% smoke-free law covering restaurants, bars, or workplaces; and (3) number of venue types covered by 100% smoke-free laws (0-3). Sociodemographics included total population, urban status, percentage racial/ethnic minority, per capita income, percentage with high-school diploma, percentage with blue-collar jobs, and percentage of workers who live and work in the same locality. RESULTS: Across states, localities with less-educated residents, smaller proportions of workers living and working in the same locality, or both generally had lower odds of being covered by 100% smoke-free laws. Coverage varied across states for other sociodemographics. CONCLUSIONS: Disparities exist in local smoke-free law coverage. Identifying patterns in coverage can inform state efforts to address related disparities.

INTRODUCTION: Until recently, in-language telephone quitline services for smokers who speak Asian languages were available only in California. In 2012, the Centers for Disease Control and Prevention (CDC) funded the national Asian Smokers' Quitline (ASQ) to expand this service to all states. The objective of this study was to examine characteristics of ASQ callers, how they heard about the quitline, and their use of the service. METHODS: Characteristics of callers from August 2012 through July 2014 were examined by using descriptive statistics. We examined demographics, cigarette smoking status, time to first cigarette, how callers heard about the quitline, and service use (receipt of counseling and medication) by using ASQ intake and administrative data. We analyzed these data by language and state. RESULTS: In 2 years, 5,771 callers from 48 states completed intake; 31% were Chinese (Cantonese or Mandarin), 38% were Korean, and 31% were Vietnamese. More than 95% of all callers who used tobacco were current daily cigarette smokers at intake. About 87% of ASQ callers were male, 57% were aged 45 to 64 years, 48% were uninsured, and educational attainment varied. Most callers (54%) were referred by newspapers or magazines. Nearly all eligible callers (99%) received nicotine patches. About 85% of smokers enrolled in counseling; counseled smokers completed an average of 4 sessions. CONCLUSION: ASQ reached Chinese, Korean, and Vietnamese speakers nationwide. Callers were referred by the promotional avenues employed by ASQ, and most received services (medication, counseling, or both). State quitlines and local organizations should consider transferring callers and promoting ASQ to increase access to cessation services.

OBJECTIVE: To assess the prevalence and characteristics of smoke-free home and vehicle rules by tobacco use. METHODS: Data came from the 2012-2013 National Adult Tobacco Survey, a telephone survey of adults aged ≥18. Respondents who reported smoking is 'never allowed' inside their home or any family vehicle were considered to have smoke-free home and vehicle rules, respectively. Prevalence and characteristics of smoke-free rules were assessed overall and by current tobacco use (combustible only, noncombustible only, combustible and noncombustible, no current tobacco use). Assessed characteristics included: sex, age, race/ethnicity, education, marital status, income, region, and sexual orientation. RESULTS: Nationally, 83.7% of adults (n=48,871) had smoke-free home rules and 78.1% (n=46,183) had smoke-free vehicle rules. By tobacco use, prevalence was highest among nonusers of tobacco (homes: 90.8%; vehicles: 88.9%) and lowest among combustible-only users (homes: 53.7%; vehicles: 34.2%). Prevalence of smoke-free home and vehicle rules was higher among males, adults with a graduate degree, and adults living in the West. CONCLUSIONS: Most adults have smoke-free home and vehicle rules, but differences exist by tobacco use. Opportunities exist to educate adults about the dangers of secondhand smoke and the benefits of smoke-free environments, particularly among combustible tobacco users.

BACKGROUND: Exposure to secondhand smoke (SHS) from burning tobacco causes disease and death in nonsmoking children and adults. No risk-free level of SHS exposure exists. METHODS: National Health and Nutrition Examination Survey (NHANES) data from 1999-2012 were used to examine SHS exposure among the nonsmoking population aged ≥3 years. SHS exposure among nonsmokers was defined as a serum cotinine level (a metabolite of nicotine) of 0.05-10 ng/mL. SHS exposure was assessed overall and by age, sex, race/ethnicity, poverty level, education, and whether the respondent owned or rented their housing. RESULTS: Prevalence of SHS exposure in nonsmokers declined from 52.5% during 1999-2000 to 25.3% during 2011-2012. During this period, declines were observed for all population subgroups, but disparities exist. During 2011-2012, SHS was highest among: children aged 3-11 years (40.6%), non-Hispanic blacks (46.8%), persons living below the poverty level (43.2%), and persons living in rental housing (36.8%). Among children aged 3-11 years, 67.9% of non-Hispanic blacks were exposed to SHS compared with 37.2% of non-Hispanic whites and 29.9% of Mexican Americans. CONCLUSION: Overall, SHS exposure in the United States has been reduced by half since 1999-2000. However, 58 million persons were still exposed to SHS during 2011-2012, and exposure remains higher among children, non-Hispanic blacks, those living in poverty, and those who rent their housing. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Eliminating smoking in indoor spaces fully protects nonsmokers from SHS exposure; separating smokers from nonsmokers, cleaning the air and ventilating buildings cannot completely eliminate exposure. Continued efforts to promote implementation of comprehensive statewide laws prohibiting smoking in workplaces and public places, smoke-free policies in multiunit housing, and voluntary smoke-free home and vehicle rules are critical to protect nonsmokers from this preventable health hazard in the places they live, work, and gather.

INTRODUCTION: Despite progress in implementing smoke-free laws in indoor public places and workplaces, millions of Americans remain exposed to secondhand smoke at home. The nation's 80 million multiunit housing residents, including the nearly 7 million who live in subsidized or public housing, are especially susceptible to secondhand smoke infiltration between units. METHODS: We calculated national and state costs that could have been averted in 2012 if smoking were prohibited in all US subsidized housing, including public housing: 1) secondhand smoke-related direct health care, 2) renovation of smoking-permitted units; and 3) smoking-attributable fires. Annual cost savings were calculated by using residency estimates from the Department of Housing and Urban Development and cost data reported elsewhere. Data were adjusted for inflation and variations in state costs. National and state estimates (excluding Alaska and the District of Columbia) were calculated by cost type. RESULTS: Prohibiting smoking in subsidized housing would yield annual cost savings of $496.82 million (range, $258.96-$843.50 million), including $310.48 million ($154.14-$552.34 million) in secondhand smoke-related health care, $133.77 million ($75.24-$209.01 million) in renovation expenses, and $52.57 million ($29.57-$82.15 million) in smoking-attributable fire losses. By state, cost savings ranged from $0.58 million ($0.31-$0.94 million) in Wyoming to $124.68 million ($63.45-$216.71 million) in New York. Prohibiting smoking in public housing alone would yield cost savings of $152.91 million ($79.81-$259.28 million); by state, total cost savings ranged from $0.13 million ($0.07-$0.22 million) in Wyoming to $57.77 million ($29.41-$100.36 million) in New York. CONCLUSION: Prohibiting smoking in all US subsidized housing, including public housing, would protect health and could generate substantial societal cost savings.

INTRODUCTION: Using nationally representative data, we assessed the prevalence and correlates of cigarette smokers who tried switching to smokeless tobacco (SLT) or to other combusted tobacco (OCT) products to quit. METHODS: Data came from 12,400 current or former adult smokers who made a quit attempt in the past year and responded to the 2010-2011 Tobacco Use Supplement to the Current Population Survey. Demographics and smoking characteristics were computed among those switching to SLT, switching to OCT, or trying to quit without using either strategy. Bivariate and multinomial logistic regression models identified correlates of using each strategy. RESULTS: Overall, 3.1% of smokers tried switching to SLT to quit, 2.2% tried switching to OCT, and 0.6% tried both strategies. Compared to those not using either switching strategy to try to quit, males were more likely than females to try switching to SLT or OCT; Blacks were less likely than Whites to try switching to SLT, but more likely to try switching to OCT; younger age groups were more likely to try switching to SLT or OCT; current someday smokers were more likely to have try switching to SLT (vs. everyday smokers), while recent former smokers were more likely to have tried switching to OCT. Both switching groups were more likely to have used cessation medication versus those not using switching strategies. CONCLUSION: Data suggest that switching to other tobacco products is a prevalent cessation approach; messages are needed to help clinicians encourage smokers who try to quit by switching to use evidence-based cessation approaches.

Tobacco use continues to be the leading cause of preventable disease and death in the United States. Cigarette smoking accounts for approximately 480,000 premature deaths annually and approximately $130 billion in direct medical expenses and $150 billion in lost productivity in the United States each year. Approximately 88% of adults who smoke daily began smoking by the age of 18 years. Although tobacco cessation is beneficial at any age, intervening as early as possible is important to maximize potential health benefits. After years of steady progress in decreasing smoking prevalence, decreases in smoking among youths and young adults have slowed in recent years. In 2011, a total of 18.1% of U.S. high school students in the United States were current cigarette smokers, and 49.9% of these smokers had tried to quit in the past 12 months. The proportion of youth cigarette smokers who tried to quit smoking in the past year decreased from 57.4% in 2001 to 49.9% in 2011.

Exposure to secondhand smoke (SHS) from cigarettes causes an estimated 41,000 deaths among nonsmoking U.S. adults each year and an estimated $5.6 billion annually in lost productivity caused by premature death. In a 2006 report, the Surgeon General concluded that there is no risk-free level of exposure to SHS. Although an increasing proportion of the population is covered by state or local comprehensive smokefree laws that prohibit tobacco smoking in all indoor public places and worksites, including restaurants and bars, millions of nonsmokers continue to be exposed to SHS in areas not covered by smokefree laws or policies, including homes. The home is the primary source of SHS exposure for children and a major source of exposure for nonsmoking adults. To assess progress toward increasing the proportion of households with smokefree home rules, CDC analyzed the most recent data from the Tobacco Use Supplement to the Current Population Survey. Households were considered to have a smokefree home rule if all adult respondents aged ≥18 years in the household reported that no one was allowed to smoke anywhere inside the home at any time. The analysis found that the national prevalence of smokefree home rules increased from 43.0% during 1992-1993 to 83.0% during 2010-2011. Over the same period, the national prevalence of smokefree home rules increased from 56.7% to 91.4% among households with no adult cigarette smokers and from 9.6% to 46.1% among households with at least one adult smoker. Enhanced implementation of evidence-based interventions (e.g., comprehensive smokefree laws, voluntary smokefree home rules, smokefree multiunit housing policies, and initiatives to educate the public about the health effects of SHS) is warranted to further reduce SHS exposure in the United States.

INTRODUCTION: Gradually reducing cigarette consumption is an approach used to quit smoking, but has not been widely studied at a population level. The purpose of this study was to assess the prevalence and demographic characteristics of U.S. adult smokers who tried to reduce to quit, and the relationship between reducing and successful quitting. METHODS: Data came from 12,571 adults in the 2010-2011 U.S. Tobacco Use Supplement to the Current Population Survey who tried to quit smoking in the past year. Frequencies and percentages were used to assess prevalence of reducing to quit; bivariate and multiple logistic regression models were used to assess correlates of reducing to quit and successful past year cessation. Analyses were conducted in SAS-callable SUDAAN. RESULTS: Among adults who tried to quit smoking in the past year, 43.0% (n=5,444) tried reducing to quit. Compared to those who tried to quit without reducing consumption, those reducing to quit had a significantly higher prevalence of using counseling or medication (40.2% vs. 25.0%). In adjusted multivariable models, females (vs. males), blacks (vs. whites), current some day smokers (vs. every day smokers), and those who used counseling had greater odds of trying to reduce to quit. Reducing to quit was negatively associated with successful past-year quitting (AOR=0.59, 95% CI: 0.48, 0.72). CONCLUSION: Reducing to quit is a common cessation strategy and, in these analyses, was associated with lower cessation success rates. More research on reducing to quit in a real-world setting is needed before widely recommending it as a cessation strategy.

INTRODUCTION: This study assessed the prevalence and correlates of secondhand smoke (SHS) exposure and attitudes toward smoke-free workplaces among employed U.S. adults. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a landline and cellular telephone survey of adults aged ≥18 years in the 50U.S. states and District of Columbia. National and state estimates of past 7-day workplace SHS exposure and attitudes toward indoor and outdoor smoke-free workplaces were assessed among employed adults. National estimates were calculated by sex, age, race/ethnicity, education, annual household income, sexual orientation, U.S. region, and smoking status. RESULTS: Among employed adults who did not smoke cigarettes, 20.4% reported past 7-day SHS exposure at their workplace (state range: 12.4% [Maine] to 30.8% [Nevada]). Nationally, prevalence of exposure was higher among males, those aged 18-44 years, non-Hispanic Blacks, Hispanics, and non-Hispanic American Indians/Alaska natives compared to non-Hispanic Whites, those with less education and income, those in the western United States, and those with no smoke-free workplace policy. Among all employed adults, 83.8% and 23.2% believed smoking should never be allowed in indoor and outdoor areas of workplaces, respectively. CONCLUSIONS: One-fifth of employed U.S. adult nonsmokers are exposed to SHS in the workplace and disparities in exposure exist across states and subpopulations. Most employed adults believe indoor areas of workplaces should be smoke free and nearly one-quarter believe outdoor areas should be smoke free. Efforts to protect employees from SHS exposure and to educate the public about the dangers of SHS and benefits of smoke-free workplaces could be beneficial.

OBJECTIVE: To determine the prevalence and characteristics of current cigarette smokers who report receiving health care provider interventions ('5A's': ask, advise, assess, assist, arrange) for smoking cessation. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a telephone survey of United States adults aged ≥18years. Among current cigarette smokers who reported visiting a health professional in the past year (n=16,542), estimates were calculated overall and by sex, age, race/ethnicity, education, income, health insurance coverage, and sexual orientation. RESULTS: Among smokers who visited a health professional (75.2%), 87.9% were asked if they used tobacco, 65.8% were advised to quit, and 42.6% were asked if they wanted to quit. Among those wanting to quit, 78.2% were offered assistance and 17.5% had follow-up arranged. Receipt of the 'ask' component was lower among males and uninsured individuals. Receipt of the 'advise' and 'assess' components was lower among those aged 18-24 and uninsured individuals. Receipt of the 'assist' component was lower among non-Hispanic blacks. No differences were observed for the 'arrange' component. CONCLUSIONS: Many current smokers report receiving health care provider interventions for smoking cessation. Continued efforts to educate, encourage, and support all health professionals to provide effective, comprehensive tobacco cessation interventions to their patients may be beneficial.

BACKGROUND: Increased knowledge of the harmful effects of SHS is an evidence-based key indicator for eliminating nonsmokers' exposure to SHS. This study assessed the prevalence and predictors of perceptions about the harm of secondhand smoke (SHS) exposure among U.S. middle and high school students. FINDINGS: Data were obtained from the 2012 National Youth Tobacco Survey, a nationally representative school-based survey of U.S. students in grades 6-12. Respondents who reported that they thought breathing smoke from other people's cigarettes or other tobacco products causes "some" or "a lot" of harm were considered to have the perception that SHS is harmful. Multivariate logistic regression was used to identify predictors of the perception that SHS is harmful. Predictors included sex, race/ethnicity, school grade level, current tobacco use, and whether the respondent currently lived with a tobacco user. Overall, 75.4% of students perceived SHS exposure as harmful. The adjusted odds of perceiving SHS exposure as harmful were higher among non-Hispanic Asians than among non-Hispanic whites, and among students in 10th-12th grades than among students in 8th grade. Adjusted odds were lower among boys than among girls, among non-Hispanic blacks than among non-Hispanic whites, among students living with a tobacco user than among those not, and among those who use combustible tobacco only or both combustible and non-combustible tobacco than among those who use no tobacco. CONCLUSIONS: Most middle and high school students perceive SHS exposure as harmful, but efforts are needed to increase the prevalence of this perception in certain subpopulations, particularly tobacco users.

BACKGROUND: Tobacco smoking in multiunit housing can lead to secondhand-smoke (SHS) exposure among nonsmokers, increased maintenance costs for units where smoking is permitted, and fire risks. During 2009-2010, approximately 7.1 million individuals lived in subsidized housing in the U.S., a large proportion of which were children, elderly, or disabled. PURPOSE: This study calculated the annual economic costs to society that could be averted by prohibiting smoking in all U.S. subsidized housing. METHODS: Estimated annual cost savings associated with SHS-related health care, renovation of units that permit smoking, and smoking-attributable fires in U.S. subsidized housing were calculated using residency estimates from the U.S. Department of Housing and Urban Development and previously reported national and state cost estimates for these indicators. When state estimates were used, a price deflator was applied to account for differential costs of living or pricing across states. Estimates were calculated overall and by cost type for all U.S. subsidized housing, as well as for public housing only. Data were obtained and analyzed between January and March 2011. RESULTS: Prohibiting smoking in all U.S. subsidized housing would yield cost savings of approximately $521 million per year, including $341 million in SHS-related healthcare expenditures, $108 million in renovation expenses, and $72 million in smoking-attributable fire losses. Prohibiting smoking in U.S. public housing alone would yield cost savings of approximately $154 million per year. CONCLUSIONS: Efforts to prohibit smoking in all U.S. subsidized housing would protect health and generate substantial cost savings to society.

INTRODUCTION: Multiunit housing (MUH) residents are susceptible to secondhand smoke (SHS), which can infiltrate smoke-free living units from nearby units and shared areas where smoking is permitted. This study assessed the prevalence and characteristics of MUH residency in the United States, and the extent of SHS infiltration in this environment at both the national and state levels. METHODS: National and state estimates of MUH residency were obtained from the 2009 American Community Survey. Assessed MUH residency characteristics included sex, age, race/ethnicity, and poverty status. Estimates of smoke-free home rule prevalence were obtained from the 2006-2007 Tobacco Use Supplement to the Current Population Survey. The number of MUH residents who have experienced SHS infiltration was determined by multiplying the estimated number of MUH residents with smoke-free homes by the range of self-reported SHS infiltration (44%-46.2%) from peer-reviewed studies of MUH residents. RESULTS: One-quarter of U.S. residents (25.8%, 79.2 million) live in MUH (state range: 10.1% in West Virginia to 51.7% in New York). Nationally, 47.6% of MUH residents are male, 53.3% are aged 25-64 years, 48.0% are non-Hispanic White, and 24.4% live below the poverty level. Among MUH residents with smoke-free home rules (62.7 million), an estimated 27.6-28.9 million have experienced SHS infiltration (state range: 26,000-27,000 in Wyoming to 4.6-4.9 million in California). CONCLUSIONS: A considerable number of Americans reside in MUH and many of these individuals experience SHS infiltration in their homes. Prohibiting smoking in MUH would help protect MUH residents from involuntary SHS exposure.

OBJECTIVE: Exposure to secondhand smoke (SHS) from burning tobacco products causes disease and premature death among non-smoking adults and children. The objective of this study was to determine the nature, extent and demographic correlates of SHS exposure among adults in low- and middle-income countries with a high burden of tobacco use. METHODS: Data were obtained from the Global Adult Tobacco Survey (GATS), a nationally representative household survey of individuals 15 years of age or older. Interviews were conducted during 2008-2010 in Bangladesh, Brazil, China, Egypt, India, Mexico, the Philippines, Poland, Russia, Thailand, Turkey, Ukraine, Uruguay and Vietnam. Descriptive statistics were used to determine the prevalence and correlates of SHS exposure in homes, workplaces, government buildings, restaurants, public transportation and healthcare facilities. RESULTS: Exposure to SHS in the home ranged from 17.3% (Mexico) to 73.1% (Vietnam). Among those who work in an indoor area outside the home, SHS exposure in the workplace ranged from 16.5% (Uruguay) to 63.3% (China). Exposure to SHS ranged from 6.9% (Uruguay) to 72.7% (Egypt) in government buildings, 4.4% (Uruguay) to 88.5% (China) in restaurants, 5.4% (Uruguay) to 79.6% (Egypt) on public transportation, and 3.8% (Uruguay) to 49.2% (Egypt) in healthcare facilities. CONCLUSIONS: A large proportion of adults living in low- and middle-income countries are exposed to SHS in their homes, workplaces, and other public places. Countries can enact and enforce legislation requiring 100% smoke-free public places and workplaces, and can also conduct educational initiatives to reduce SHS exposure in homes.