Discussion
This study found that cigarette smoking persists among adults with chronic disease. Cigarette smoking is most prevalent among young and middle-aged adults and among adults with a history of COPD and 2 or more chronic diseases. Cigarette smoking prevalence among middle-aged adults with diabetes decreased during 2010 through 2019.
In 2019, among adults with COPD, at least 1 in 5 participants reported current cigarette smoking. Several characteristics might make it harder for people with COPD to quit smoking. Some studies have found that people with COPD who continue to smoke may have greater nicotine dependency and smoke more cigarettes per day; inhale a greater volume of smoke, allowing for increased amounts of substances into the lungs; or might not have the self-esteem and motivation to eventually achieve smoking cessation.[16,17] More than 1 in 3 young adults and almost 1 in 2 middle-aged adults with COPD reported cigarette smoking. This is an important finding because smoking cessation is the only established intervention that reduces loss of lung function among people with COPD, and the sooner a person quits smoking, the slower the rate of decline in lung function.[18] These results are comparable to previous findings and are not surprising given that smoking is the dominant cause of COPD.[16,19]
In our study we found that more than 1 in 4 adults aged 45 to 64 years with CHD currently smoked cigarettes. We did not find any significant temporal change in current cigarette smoking among adults with CHD. The association between smoking and cardiovascular disease is well established, with even low levels of cigarette exposure implicated in acute cardiovascular events, such as MI.[1] A study reported that 52.5% of patients (median age 45 years) hospitalized with acute MI were currently smoking cigarettes, and 62.0% of those who smoked at the time of their MI continued to smoke after the event.[20] Another study showed that adults who experienced a recent MI increased perception of the harm of smoking continuation and were more likely to report that they were attempting to reduce their smoking consumption or quit.[21] However, there was no association between recent MI and smoking cessation.[21] Results from earlier research using data from 2005 to 2013 reported increased prevalence of cigarette smoking among adults with heart disease and hypertension compared to adults without chronic disease.[7] Additionally, a study using a large US registry found that only 1 in 3 adults who smoke cigarettes and were seen for a cardiology visit received smoking cessation services.[22]
The prevalence of cigarette smoking among survivors of cancers associated with smoking reported in this study is higher than NHIS-based estimates of cigarette smoking among all cancer survivors reported by the National Cancer Institute.[23] One possible explanation for our higher estimates is our restriction of cancer types to those that are causally associated with cigarette smoking. Similar to our findings, the National Cancer Institute reported a decrease in cigarette smoking with increasing age among all cancer survivors.[23] Regardless of age and cancer type, it is important for all cancer survivors to quit smoking, because evidence suggests that smoking cessation has the potential to decrease all-cause mortality among all cancer survivors.[18]
Current cigarette smoking can complicate treatment of diabetes and lead to increased risk of cardiovascular disease, kidney disease, reduced circulation, and loss of sight.[1] Notably, we found a significant decrease in cigarette smoking among middle-aged adults with diabetes over time. A 2015 study reported that among people with type 2 diabetes, many did not realize that cigarette smoking was a causative risk factor for type 2 diabetes.[24] Our results reinforce the importance of knowledge and education with respect to smoking cessation. We did not see the significant changes in cigarette smoking among adults with diabetes in the young or older age groups, but this could be partially explained by more yearly type 2 diabetes incidence among middle-aged adults.[25]
More than 1 in 3 young and middle-aged adults with 2 or more chronic diseases report current cigarette smoking. People who smoke cigarettes and have multiple chronic diseases appear to seek health care services more frequently and are more likely to try to quit with the support of evidence-based cessation treatments such as nicotine replacement therapy,[26] yet the increased number of quit attempts and use of evidence-based cessation methods did not appear to equate to increased smoking cessation success.[26] Viewing cigarette smoking as a chronic disease and, therefore, using chronic disease management methods for smoking cessation might help adults achieve smoking cessation.[26] The use of these methods has been associated with both short-term and long-term smoking cessation versus usual care.[27]
Young and middle-aged adults with chronic disease consistently had a prevalence of current cigarette smoking that was higher than the prevalence among older adults. In many cases, estimates were more than double. These findings have several possible explanations. Overall, cigarette smoking prevalence tends to be higher among young age groups, regardless of chronic disease status.[2] Another possible explanation is a lower prevalence of traditional risk factors (eg, hypertension, hyperlipidemia) for chronic disease among young populations that typically lead to the development of chronic disease in older populations.[20] Therefore, because of the low prevalence of these risk factors among young populations, smoking is more likely to be a primary risk factor for chronic disease in young populations.[20] Additionally, the health effects of smoking are cumulative. Therefore, right censoring caused by increased likelihood of overall mortality among older populations may be a contributing factor in these findings. Additionally, age disparities in cigarette smoking may result from fewer visits to health care professionals, lack of tobacco use assessments, or low levels of tobacco cessation counseling among young adults who smoke cigarettes.[18] The prevalence of tobacco counseling during outpatient visits has been previously reported as 14.5% among adults aged 18 to 24 years, compared with 22.1% among adults aged 45 to 64 years.[18] Frequency of cessation advice provided by health care professionals has increased since 2000.[18] Yet almost 1 in 3 adults who smoke and have a chronic disease associated with smoking are not receiving advice to quit during their annual health care visits.[18] Further research examining cessation rates among adults with chronic disease may further contextualize the findings of this report.
Approximately 1 in 4 young and middle-aged adults with COPD, CHD, stroke, diabetes, cancer associated with smoking, or people with 2 or more of these chronic diseases report current cigarette smoking. Smoking cessation can reduce morbidity and mortality risk in these populations. Using evidence-based cessation treatments, health care professionals can support the estimated 72.7% of adults aged 25 to 44 years and 68.7% of adults aged 45 to 64 years who report an interest in quitting.[9,28] By quitting smoking, individuals with CHD can reduce their overall risk of mortality and risk of a new cardiac event, and disease and symptom progression of COPD can be slowed.[18] Cancer survivors can improve their overall prognosis and might have the potential to decrease their mortality risk by quitting smoking.[1,18,29] The results of this study indicate a need to provide appropriate smoking cessation services at the right time and in the right setting to adults living with chronic diseases. In addition, public health can help work toward reducing smoking among adults with chronic disease by continuing outreach of representative campaigns, such as Tips from Former Smokers, a Centers for Disease Control and Prevention media campaign that has frequently included people with cancer, COPD, CHD, and diabetes.
Limitations
Several limitations apply to this study. First, cigarette smoking status and health outcomes were self-reported, resulting in potential recall and social desirability bias. Second, temporality of smoking initiation among those who currently smoke and quitting among those who formerly smoked cigarettes is unknown. Third, we were unable to distinguish type 1 and type 2 diabetes in the survey and could look at only those chronic diseases assessed in NHIS (eg, reason for exclusion of acute myeloid leukemia). Fourth, NHIS underwent changes to the nonresponse adjustment to sample weighting and a questionnaire redesign in 2019,[11] so comparisons using 2019 data must be interpreted with caution. Lastly, while this study provides evidence of an opportunity to improve clinical cessation services among adults with chronic disease, smoking is not always captured in clinical data (ie, electronic health records) and, therefore, might lead to a missed opportunity to provide cessation services. Even if smoking information is captured in clinical data, that information is not always used.
Conclusions
Our study provides updated estimates of current and former cigarette smoking among adults aged 18 years or older with chronic diseases associated with cigarette smoking. This study also provides new information on cigarette smoking trends among adults with chronic diseases over a 10-year period. Only one significant decrease in cigarette smoking was reported among age groups with chronic diseases over the past 10 years (middle-aged adults with diabetes), relative to the overall decrease in smoking prevalence seen among all US adults.[2] The results of this study indicate a consistent prevalence of cigarette smoking and a lack of progress over time in smoking reduction in these populations, who, in addition, are at risk of further complications by continuing to smoke. Cessation advice and services are not being provided to almost 1 in 3 people who have a chronic disease.[18] Greater access to cessation services, integration of cessation treatment into routine care in all clinical settings, recognition that people who smoke might benefit from a chronic disease–type management model, and long-term follow up and support may be important steps to take toward successful smoking cessation in this population.[29]
Acknowledgments
No financial disclosures or conflicts of interest were reported by the authors of this article. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. No copyrighted material, surveys, instruments, or tools were used in this article.
Prev Chronic Dis. 2022;19(9):E62 © 2022 Centers for Disease Control and Prevention (CDC)
