Chronic Obstructive Pulmonary Disease and Smoking Status — United States, 2017

Anne G. Wheaton, PhD; Yong Liu, MD; Janet B. Croft, PhD; Brenna VanFrank, MD; Thomas L. Croxton, PhD, MD; Antonello Punturieri, MD, PhD; Lisa Postow, PhD; Kurt J. Greenlund, PhD


Morbidity and Mortality Weekly Report. 2019;68(24):533-538. 

In This Article

Abstract and Introduction


Cigarette smoking is the leading cause of chronic obstructive pulmonary disease (COPD) in the United States; however, an estimated one fourth of adults with COPD have never smoked.[1] CDC analyzed state-specific Behavioral Risk Factor Surveillance System (BRFSS) data from 2017, which indicated that, overall among U.S. adults, 6.2% (age-adjusted) reported having been told by a health care professional that they had COPD. The age-adjusted prevalence of COPD was 15.2% among current cigarette smokers, 7.6% among former smokers, and 2.8% among adults who had never smoked. Higher prevalences of COPD were observed in southeastern and Appalachian states, regardless of smoking status of respondents. Whereas the strong positive correlation between state prevalence of COPD and state prevalence of current smoking was expected among current and former smokers, a similar relationship among adults who had never smoked suggests secondhand smoke exposure as a potential risk factor for COPD. Continued promotion of smoke-free environments might reduce COPD among both those who smoke and those who do not.

Data from 418,378 adult respondents to the 2017 BRFSS survey in the 50 states and the District of Columbia (DC) were analyzed. BRFSS is an annual state-based, random-digit–dialed cellular and landline telephone survey of the noninstitutionalized U.S. population aged ≥18 years and is conducted by state health departments in collaboration with CDC.* Response rates for BRFSS are calculated using standards set by the American Association for Public Opinion Research (AAPOR) Response Rate Formula #4. The response rate is the number of respondents who completed the survey as a proportion of all eligible and likely eligible persons. The median survey response rate for all states and DC in 2017 was 45.9% and ranged from 30.6% to 64.1%.§ COPD was defined by an affirmative response to the question "Has a doctor, nurse, or other health professional ever told you that you had chronic obstructive pulmonary disease or COPD, emphysema, or chronic bronchitis?" Persons were considered to have never smoked if they reported never smoking or smoked less than 100 cigarettes during their lifetime. Former smokers had smoked at least 100 cigarettes in their life, but were not current smokers. Current smokers had smoked at least 100 cigarettes and currently smoked some days or every day.

Age-specific and age-adjusted percentages and 95% confidence intervals (CIs) of adults with diagnosed COPD for all respondents and by smoking status were calculated for groups defined by selected sociodemographic characteristics, health characteristics, and state. Comparisons were made between these groups using t-tests with statistical significance set at p<0.05. State-specific age-adjusted current smoking prevalence was compared with state-specific age-adjusted COPD prevalence using Pearson correlation for all respondents and groups defined by smoking status. All analyses were conducted using SAS-callable SUDAAN (version 11.0.1; RTI International) to account for the stratified, complex cluster sampling design of the survey.

Overall age-adjusted prevalence of COPD was 6.2% in 2017 and was higher among women, older adults, and American Indians/Alaska Natives. Prevalence was also higher among those with less education, those who lived in more rural counties, those with a history of asthma, those who were underweight or obese, those who reported no leisure-time physical activity in the past 30 days, and those with additional chronic conditions (Table 1). Similar patterns were observed irrespective of smoking status. Among all adults, age-adjusted prevalence of COPD ranged from 3.4% in Hawaii to 13.8% in West Virginia (Table 2) (Figure). Among current smokers, overall age-adjusted COPD prevalence was 15.2% and ranged from 7.8% in Hawaii to 25.9% in West Virginia. Among former smokers, age-adjusted COPD prevalence was 7.6% and ranged from 4.7% in Hawaii to 15.1% in West Virginia. Among adults who never smoked, age-adjusted COPD prevalence was 2.8% and ranged from 1.6% in Minnesota to 6.0% in West Virginia. Among current smokers, COPD prevalence was highest in states in the Southeast and the Midwest. Among adults who never smoked, states with the highest COPD prevalence were concentrated in the Southeast. State-level prevalence of COPD among current smokers was strongly correlated with state-level current smoking prevalence (Pearson correlation coefficient = 0.69, p<0.001). State-level COPD prevalence among former smokers (Pearson correlation coefficient = 0.71, p<0.001) and among adults who had never smoked (Pearson correlation coefficient = 0.64, p<0.001) also were strongly correlated with state-level current smoking prevalence.


Age-adjusted* percentage of U.S. adults with chronic obstructive pulmonary disease (COPD), overall and by current or previous smoking status — Behavioral Risk Factor Surveillance System, 2017
Abbreviation: DC = District of Columbia.
* Age-adjusted to the 2000 U.S. standard population aged ≥18 years.