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


The higher COPD prevalences observed among women, older adults, American Indians/Alaska Natives, adults with less education, those with a history of asthma, and those residing in rural areas were consistent with results from previous studies.[1–3] The geographic distribution also was consistent.[1] These patterns were similar among adults who had never smoked. Although smoking tobacco is the main contributor to COPD in the United States, other factors might play a role in the development of COPD among nonsmokers, including secondhand smoke exposure, occupational and environmental exposures, and chronic asthma.[4,5] Secondhand smoke exposure, in either childhood or as an adult, has been associated with an increased risk for COPD-associated mortality.[6] The 2006 Surgeon General's report on secondhand smoke concluded that although the evidence suggested a causal relationship between exposure to secondhand smoke and COPD risk, there was insufficient evidence to state definitively that the relationship is causal.[7]

In the current analysis, the geographic distribution of high COPD prevalence was similar for current smokers and adults who never smoked. There is also a strong correlation between state-level prevalences of COPD among adults who never smoked and state-level prevalence of current smoking. This could reflect that in certain regions adults who never smoked might be more likely to be exposed to secondhand smoke. Among the states in the highest quartile for COPD among adults who never smoked, only New Jersey had laws banning smoking in private worksites, restaurants, and bars as of December 31, 2017; the remainder of states in that quartile either had no smoke-free laws or laws banning smoking in only one or two venues.**

The findings in this report are subject to at least seven limitations. First, COPD status was based on self-report, not on medical records or diagnostic tests, and might be subject to recall and social desirability biases. Second, physicians might be more likely to diagnose COPD and other smoking-related diseases in states with high smoking rates, whereas COPD might be more likely to remain undiagnosed in states with lower smoking rates. Third, smoking status also was based on self-report and might be subject to social desirability bias. Fourth, because the data were cross-sectional, causality could not be examined. Fifth, e-cigarette use was not examined in this report. There were no other measures of exposure to secondhand smoke or other indoor or outdoor air pollutants or history of respiratory infections, all of which might contribute to COPD risk. Sixth, BRFSS surveys noninstitutionalized adults and does not include adults who live in long-term care facilities, prisons, and other facilities; therefore, findings are not generalizable to those populations. Finally, state BRFSS response rates were relatively low, which might lead to selection bias.

Population-based strategies for smoking prevention and control have the potential to decrease the prevalence of COPD in the United States. Such strategies include tobacco product price increases, mass media antismoking campaigns, comprehensive smoke-free laws, and barrier-free access to evidence-based cessation interventions.†† Comprehensive smoke-free laws not only help protect nonsmokers from secondhand smoke exposure, but they can also promote adoption of voluntary smoke-free rules in private settings (e.g., homes and automobiles) and reduce smoking prevalence through increased cessation and decreased initiation.§§ Clinicians can play a key role in increasing access to and use of cessation therapies, including counseling and Food and Drug Administration-approved cessation medications.¶¶ Current clinical guidelines recommend screening all patients for tobacco use at every visit;[8] however, clinicians should be mindful that not all COPD is necessarily caused by smoking and should use spirometry for diagnosis in patients with COPD symptoms,[9] regardless of their smoking history.