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. 2020 Nov 16;23(6):909–919. doi: 10.1093/ntr/ntaa231

Racial/Ethnic Disparities Across Indicators of Cigarette Smoking in the Era of Increased Tobacco Control, 1992–2019

Kari-Lyn K Sakuma 1,✉, John P Pierce 2, Pebbles Fagan 3, France T Nguyen-Grozavu 2, Eric C Leas 4, Karen Messer 2, Martha M White 2, Amanda S Tieu 2, Dennis R Trinidad 2
PMCID: PMC8522466  PMID: 33196799

Abstract

Introduction

This study compared tobacco use and cessation for African Americans (AA), Asians/Pacific Islanders (API), Hispanics/Latinos (H/L), American Indian/Alaskan Natives (AI/AN), and non-Hispanic Whites (NHW) in the United States to California (CA), the state with the longest continually funded tobacco control program. The purpose of this study was to identify tobacco use disparities across racial/ethnic groups across time.

Methods

Cigarette use prevalence (uptake and current use), consumption (mean number of cigarettes smoked per day [CPD]), and quit ratios were calculated across survey years, and trends were examined within each race/ethnic group and comparing between CA and the United States, utilizing the 1992–2019 Tobacco Use Supplements to the Current Population Survey.

Results

Prevalence decreased for all race/ethnic groups. Current use among CA NHW showed significant decline compared with US counterparts, whereas US H/L showed greater decline than CA counterparts. CPD decreased by approximately 30% across race/ethnic groups, with CA groups having lower numbers. The greatest decrease occurred among AA in CA (average 10.3 CPD [95% confidence interval (CI): 10.3, 12.6] in 1992/1993 to 3 CPD [95% CI: 2.4, 3.7] in 2018/2019). Quit ratios increased from 1992/1993 to 2018/2019 for CA H/L 52.4% (95% CI: 49.8, 53.0) to 59.3 (95% CI: 55.8, 62.5) and CA NHWs 61.5% (95% CI: 60.7, 61.9) to 63.8% (95% CI: 63.9, 66.9).

Conclusions

Although overall prevalence decreased over time for each racial/ethnic group, declines in CA outpaced the United States only for NHWs. Reductions in CPD were encouraging but the quit ratio points to the need to increase tobacco control efforts toward cessation.

Implications

The successes in reduced cigarette use uptake and prevalence across time for both California and the rest of the United States were observed largely among non-Hispanic White populations. Although reductions in the number of cigarettes smoked per day are a notable success, particularly among the Californian African Americans, efforts to support quitting across racial/ethnic groups, especially marginalized groups, need to be prioritized.

Introduction

Since the 1990s, the tobacco control landscape in the United States has become increasingly restrictive and overall cigarette smoking prevalence rates have decreased.1,2 Over this same period, California has been the only state in the nation to have a continuously funded, comprehensive Tobacco Control Program, which has cultivated a strong anti-tobacco climate.3,4 California restricted sales, increased taxes, utilized the Clean Air Act to restrict smoking indoors and in public locations, launched comprehensive education and media campaigns to prevent tobacco use initiation, and created quitlines.3–5 This level of investment has contributed to California, tied with Utah, as having the lowest current cigarette use prevalence in the nation at just 8% between 2014 and 2015.6

California is currently the most populous state in the United States, with an estimated 39.5 million individuals,7 and is home to the largest Latino population in the United States.8 As of 2018, no race or ethnic group constitutes the majority of California’s population.9 The demographic makeup of the United States is also showing increasing racial/ethnic diversity. As the population ages and the proportion of White residents decline across the United States, younger cohorts are demonstrating steady or increasing proportions of more racial/ethnic groups.10 Population-level cigarette smoking rates and tobacco-related morbidity and mortality may shift alongside these demographic changes in the United States.

Racial/ethnic minority populations suffer disproportionately from tobacco-related diseases compared with non-Hispanic White populations.1,11,12 African Americans and Hispanic/Latinos smoke fewer cigarettes13–15 and are more likely to be nondaily smokers,14,16 yet have greater risk of lung cancer morbidity and mortality.1,17–20 American Indian/Alaskan Native populations have the highest cigarette use prevalence21 and are more likely to suffer disproportionate rates of tobacco-related death.22 Some Asian subgroups, Native Hawaiians, and other Pacific Islanders also suffer from disproportionate rates of tobacco-related mortality.11,17,18 Collectively, the disparities in tobacco-related diseases observed among racial/ethnic populations require closer study. Comparing California to the rest of the United States affords an opportunity to examine how different cigarette use behaviors change over time within each racial/ethnic group. These differences may give public health and policy makers insight on how to best address tobacco-related health disparities.

Previous studies have shown marked differences in smoking behaviors between California and the rest of the United States, suggesting a positive impact of the state’s efforts on reducing prevalence,23–26 tobacco consumption,27 and tobacco-related diseases.23,28,29 For example, changes in smoking behaviors in the 1970s–1980s were more rapid in California compared with the rest of the United States as a result of early and aggressive tobacco control; these changes were reflected in reduced lung cancer rates nearly 20 years later.26,29 However, relatively few studies have specifically examined differences between California and the United States in reducing racial/ethnic disparities in smoking,30,31 and none have detailed trends over time in cigarette uptake, prevalence, consumption, and quitting among race/ethnic minority groups in the United States. Although California boasted the lowest current cigarette use prevalence in the nation,6 American Indian/Alaska Natives and African Americans in the state had the highest smoking prevalence followed by California Whites, Asians, and Hispanic/Latinos.32,33 These data suggest that disproportionate levels of cigarette use remain. A prior study that examined smoking behaviors in California and compared it with the rest of the United States found that Whites, Hispanic/Latino, and Asian/Pacific Islanders in California were more likely to smoke fewer cigarettes per day or be nondaily smokers than the rest of the United States.30 However, this prior study was limited by pooling data and aggregating across decades of data, from 1992 to 2011, to have the power to examine racial/ethnic groups. The current study will expand prior work by examining trends of multiple smoking behaviors at each time point across nearly three decades of data, from 1992 to 2019, and within all racial/ethnic groups.

In studying the population-level impact of a changing tobacco control landscape, tracking trends in smoking behaviors can provide an overview of progress at various stages of the smoking continuum, from initiation to quitting. With the nation’s increasing racial/ethnic diversity, and California being one of the most racially/ethnically diverse states,34 examining these cigarette use indicators over time and within race/ethnic groups can provide a valuable population-level assessment of progress made, while identifying areas for improvement that can ultimately lead to progress in reducing morbidity and mortality disparities.

Methods

Data Source

The US Census Bureau’s Current Population Survey (CPS) assesses labor force characteristics among the civilian, noninstitutionalized US population ages 15 and older.35 The CPS is a stratified two-stage probability sample design in which primary sampling units are first selected and then a sampling of housing units are identified.35 Approximately 54 000 households are interviewed each month.35 Detailed methodology of the CPS are published elsewhere.35 Since the 1990s, Tobacco Use Supplements (TUS) sponsored by the National Cancer Institute and the Food and Drug Administration have been included with the CPS approximately every 3 years. Each TUS consists of three monthly samples spaced approximately 4 months apart. The current study analyzed data from the 1992/1993, 1995/1996, 1998/1999, 2001/2002, 2003, 2006/2007, 2010/2011, 2014/2015, and 2018/2019 TUS-CPS.36–41 The response rates ranged from 62% (2006/2007) to 75% (2018/2019).39,42 The analytical sample for this study was limited to self-responders, age 18 or older, who completed in-person interviews. Person-level TUS supplement weights adjust for nonresponse, in addition to maintaining national demographic information.42 These are publicly available data and are exempt from IRB review.

Measures

Demographic Characteristics

Demographic measures of interest included age, self-identified gender (women, men), level of education (less than high school, high school graduate, some college, and college graduate), and race/ethnicity. Hispanic or Latino origin or descent was first determined by the question “Are you Hispanic?” Those who answered “Yes” were categorized as Hispanic/Latino, regardless of race. The remaining respondents were then categorized by race. Race was initially reported as one of five categories (Black [henceforth African American]; American Indian/Alaska Native; Asian or Pacific Islander; White; or Other). The “Other” category was discontinued in 1996 and was excluded from this analysis. Starting in 2000, the Census allowed respondents to report more than one race, which was implemented in the TUS starting in 2003. Other or multiple races comprised at maximum only 1.4% of the data and were excluded from this analysis. Prior to 2003, participants could only select Asian/Pacific Islander as a single response group. Participants were able to identify with each individual group (ie, Asian Americans only or Pacific Islander only) starting in 2003. For consistency with data prior to 2003, Asians/Pacific Islanders were analyzed together after 2003.

Cigarette Use Behaviors

Ever smokers were those who responded “Yes” to the question, “Have you smoked at least 100 cigarettes in your entire life?” We defined cigarette use uptake as the proportion of ever smokers in the population between the age of 18–35.43 Although 99% of cigarette use uptake occurs by the age of 26,1,44 we extended the age range to capture late initiators who are likely to belong to a marginalized racial/ethnic group and smaller population groups,45,46 and in accordance with prior studies.26,43,47

Ever smokers who reported smoking cigarettes “every day” or “some days” at the time of data collection were categorized as current smokers (see PhenX ID: Adult Tobacco Use 30-Day Quantity and Frequency #030804).48,49 Current smoking prevalence is an indicator of how widespread the behavior is among adults in the nation.50

The number of cigarettes smoked per day (CPD) is a widely used measure of cigarette consumption or intensity of cigarette use.45,49,50 Cigarette consumption levels were measured by asking every day smokers “On the average, about how many cigarettes do you now smoke each day?” For those who indicated that they smoked “some days,” they were asked “On how many of the past 30 days did you smoke cigarettes?” and “On the average, on those days, how many cigarettes did you usually smoke each day?” For some day smokers, the number of days smoked in the last 30 days was multiplied by number of CPD then divided by thirty days to obtain the average number of CPD in the past month. Cigarette consumption levels were calculated and reported among adult (18 years and above) current smokers.25

Ever smokers who responded “not at all” to the question, “Do you now smoke every day, some days or not at all?” were categorized as quitters. As a population-level measure of smoking cessation, the quit ratio was calculated as the proportion of ever smokers who had quit.49,50 Nearly all smoking initiation occurs by age 25 and experimentation is unlikely to occur after this age.44 Aligned with published studies,26,29 we limit the quit ratio estimates to those aged 25 and older to capture those beyond experimentation.

Statistical Analysis

Statistical analyses were conducted using SAS software version 9.4.51 All analyses were stratified by two categories of state residence (California alone and the United States without California) and were conducted for each racial/ethnic group. Prevalence estimates were weighted using respondents’ person-level TUS-CPS survey weights. Variance estimates used replicate weights with Fay’s balanced repeated replication.52

To remove additional complications due to changes in US demographics over the 27 years examined in this article, within race/ethnicity categories data were standardized to the 2010 US population.53 Data were standardized to 48 cells (2 sex × 4 education × 6 ages: 18–24, 25–35, 36–45, 46–55, 56–65, 66+, as appropriate). Standardization was done by calculating the statistic of interest for each cell, multiplying that by the proportion each cell represented of the US population, and summing over all cells. Variance estimates were made using the replicate weights to calculate replicate estimates. Nonoverlapping 95% confidence intervals are considered a conservative indication of statistical significance over time or between California and the rest of the United States. We also estimated a linear trend and calculated differences in slope across time within California and United States with the null hypothesis that the slope is not different from zero. We also calculated slope differences between California and United States with the null hypothesis that slopes were equal.

Results

Demographic Characteristics/Sample

Sample sizes, mean age of respondents, and weighted percentages for gender and education level for California and the United States for the last three data collection periods (2010/2011, 2014/2015, and 2018/2019) of the TUS-CPS by race/ethnicity are presented in Table 1. The remaining demographic data for 1992–1999 and 2001–2007 are provided in Supplementary Tables 1S and 2S, respectively. Over the entire period, the mean age of respondents in the United States and California was highest among Whites (45.3–49.7 years) and lowest among Hispanics/Latinos (35.8–40.9 years). Compared with men over time, there were larger proportions of women among American Indians/Alaska Natives and African Americans in both the United States and California, whereas there were larger proportions of White women compared with men in the United States. Across all years in both the United States and California, there were larger proportions of Asian/Pacific Islander college graduates relative to other race/ethnic groups.

Table 1.

Demographic Characteristics by Race/Ethnicity, 2010–2011, 2014–2015, and 2018–2019

2010–2011 2014–2015 2018–2019
California Rest of the United States California Rest of the United States California Rest of the United States
Unwt N % CI Unwt N % CI Unwt N % CI Unwt N % CI Unwt N % CI Unwt N % CI
Black or African American
Age (mean years) 730 44.4 0.7 15 487 43.4 0.1 654 44.4 0.9 15 739 44.3 0.1 168 51.2 2.0 4318 44.5 0.2
Men 304 46.5 1.2 6086 44.8 0.2 273 48.1 1.4 6223 44.7 0.2 81 48.2 2.2 1745 45.5 0.3
Women 426 53.5 1.2 9401 55.2 0.2 381 51.9 1.4 9516 55.3 0.2 87 51.8 2.2 2573 54.5 0.3
Education
 Less than high school 73 10.0 1.7 2667 16.9 0.5 48 8.1 1.8 2337 13.8 0.5 17 9.1 3.6 502 9.8 0.7
 High school graduate 198 27.1 2.0 5120 33.4 0.6 171 27.3 2.8 5211 33.2 0.7 42 24.7 4.2 1399 32.7 1.2
 Some college 404 55.4 2.6 6630 43.6 0.7 355 53.3 3.1 6882 45.4 0.7 57 35.1 5.3 1349 32.5 1.1
 College graduate 55 7.5 1.3 1070 6.2 0.3 80 11.3 1.8 1309 7.6 0.3 52 31.2 5.2 1068 25.0 1.0
Hispanic/Latino
Age (mean years) 4276 39.7 0.3 13 554 40.2 0.1 3557 40.2 0.3 13 685 40.9 0.1 1024 40.8 0.6 3959 41.9 0.2
Men 1890 50.9 0.6 6015 51.4 0.3 1592 49.6 0.9 6094 49.8 0.3 434 49.1 1.4 1747 49.8 0.5
Women 2386 49.1 0.6 7539 48.6 0.3 1965 50.4 0.9 7591 50.2 0.3 590 50.9 1.4 2212 50.2 0.5
Education
 Less than high school 1618 36.5 1.4 4395 32.5 0.8 1162 31.0 1.5 3901 28.1 0.6 256 23.6 2.0 980 23.6 1.2
 High school graduate 1171 28.6 1.1 4030 30.4 0.6 1008 29.1 1.2 4190 31.0 0.6 314 31.0 2.3 1229 32.6 1.1
 Some college 1358 32.0 1.3 4544 33.1 0.8 1241 36.2 1.4 4896 36.5 0.7 302 31.5 2.2 976 25.4 1.1
 College graduate 129 2.9 0.4 585 4.0 0.3 146 3.7 0.4 698 4.5 0.3 152 13.9 1.6 774 18.4 1.0
Asian, Native Hawaiian, Pacific Islander
Age (mean years) 1588 45.9 0.6 5458 42.8 0.3 1455 46.0 0.6 5457 43.4 0.3 529 45.2 1.0 1601 44.0 0.5
Men 735 45.4 1.3 2580 48.1 0.6 707 45.7 1.3 2618 47.1 0.7 256 46.2 2.1 780 46.5 1.1
Women 853 54.6 1.3 2878 51.9 0.6 748 54.3 1.3 2839 52.9 0.7 273 53.8 2.1 821 53.5 1.1
Education
 Less than high school 132 8.3 1.2 499 10.1 1.2 114 7.7 1.0 475 8.9 0.7 25 4.7 1.3 115 7.9 1.1
 High school graduate 265 16.3 1.4 1152 19.0 1.1 198 13.7 1.4 1073 17.4 0.8 72 14.7 2.5 258 15.7 1.6
 Some college 931 59.0 1.9 2657 48.8 1.3 832 58.8 1.9 2636 49.1 1.1 99 21.8 2.6 308 19.2 1.6
 College graduate 260 16.3 1.5 1150 22.2 1.0 311 19.8 1.7 1273 24.6 1.0 333 58.8 3.1 920 57.1 2.0
American Indian/Alaskan Native
Age (mean years) 60 45.9 2.7 1403 43.0 0.7 61 44.6 3.7 1522 43.1 0.7 22 53.6 4.0 407 43.8 1.2
Men 27 49.4 7.8 578 44.0 2.2 23 38.4 10.4 621 45.9 1.9 10 45.1 16.5 187 52.6 3.5
Women 33 50.6 7.8 825 56.0 2.2 38 61.6 10.4 901 54.1 1.9 12 54.9 16.5 220 47.4 3.5
Education
 Less than High School 10 14.9 7.2 297 18.2 2.4 5 6.0 3.1 288 16.5 1.7 1 3.5 4.1 57 11.9 2.6
 High School Graduate 9 20.0 8.2 448 34.7 2.7 24 43.7 9.4 512 32.6 2.1 5 23.0 13.4 144 32.6 4.1
 Some College 38 59.7 9.1 595 41.7 3.3 32 50.3 9.3 653 46.4 2.3 13 58.3 16.6 145 37.8 4.0
 College Graduate 3 5.4 4.7 63 5.4 1.1 — — — 69 4.5 0.9 3 15.1 9.6 61 17.7 2.9
Non-Hispanic White
Age (mean years) 6683 48.7 0.3 119 849 48.2 0.0 6371 49.7 0.4 113 443 49.4 0.0 1818 50.8 0.6 32 345 50.0 0.1
Men 3059 49.3 0.5 53 519 48.2 0.1 2938 48.7 0.7 51 451 48.4 0.1 855 50.2 1.1 14 837 48.4 0.1
Women 3624 50.7 0.5 66 330 51.8 0.1 3433 51.3 0.7 61 992 51.6 0.1 963 49.8 1.1 17 508 51.6 0.1
Education
 Less than high school 340 5.1 0.4 9861 8.5 0.2 240 4.0 0.4 7910 6.9 0.1 68 3.7 0.8 1775 5.3 0.2
 High school graduate 1329 20.0 0.9 36 445 30.3 0.3 1164 18.2 0.8 32 212 28.0 0.3 293 17.4 1.5 8636 26.8 0.5
 Some college 3981 60.0 1.0 59 718 50.0 0.3 3855 61.0 1.0 58 477 52.4 0.3 553 30.2 1.6 9515 29.4 0.4
 College graduate 1033 14.9 0.7 13 825 11.2 0.2 1112 16.7 0.8 14 844 12.7 0.2 904 48.8 1.7 12 419 38.5 0.5
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Means and % are weighted estimates standardized by race/ethnicity to the 2010 US population. Unwt N = unweighted N; 95% CI = 95% confidence interval.

Smoking Uptake: Ever Smoking Among 18- to 35-Year-Old Population

Population-level cigarette use data by race/ethnicity for all survey years are shown in Table 2. For African Americans, there were no significant differences in smoking uptake slopes between California and the United States (p = .08; see Supplementary Figure 1S). For African Americans in California, the prevalence for smoking uptake in 1992/1993 was 30.1% ± 18.2, which decreased to 10.9% ± 36.4 in 2018/2019. Smoking uptake rates for African Americans in the rest of the United States went from 26.7% ± 4.3 in 1992/1993 to 17.7% ± 21.9 in 2018/2019. The estimated slopes for California (p = .0009) and United States (p < .0001) were significantly different from zero.

Table 2.

Population-Level Cigarette Use Behaviors by Race/Ethnicity, Tobacco Use Supplement to the Current Population Survey, 1992–2019

Uptake Current use Consumption (CPD) Quit ratio
California Rest of the United States California Rest of the United States California Rest of the United States California Rest of the United States
Year % CI % CI % CI % CI Mean CI Mean CI % CI % CI
African American
1992–1993 30.1 18.0 26.5 4.3 25.3 11.5 24.7 3.1 10.3 3.7 11.6 1.3 44.2 15.5 41.6 5.5
1995–1996 27.8 25.0 23.5 5.8 23.3 15.0 23.3 3.3 10.4 4.9 11.5 1.8 46.5 23.6 41.7 6.4
1998–1999 29.6 27.3 21.4 6.0 24.2 11.9 22.0 4.2 11.1 4.8 11.5 1.6 45.1 31.2 41.2 6.6
2001–2002 21.2 28.3 21.7 5.8 18.9 15.8 20.6 3.4 9.2 3.9 10.9 1.5 46.8 33.6 41.5 7.3
2003 24.7 33.9 21.1 5.9 18.6 15.5 18.6 3.6 8.4 4.5 10.7 1.5 47.8 27.0 41.7 8.1
2006–2007 17.5 45.0 20.5 9.1 18.7 24.2 17.8 5.1 7.0 5.2 10.0 2.8 41.1 28.7 42.9 11.1
2010–2011 20.0 34.1 18.8 7.6 14.7 16.3 16.6 4.5 5.1 4.0 9.0 2.1 45.3 43.8 41.3 10.9
2014–2015 18.1 36.0 18.6 8.2 14.9 18.1 16.1 5.1 4.8 4.0 8.3 2.3 45.2 33.2 40.4 13.1
2018–2019 10.9 36.4 17.7 21.9 12.2 22.0 14.8 10.4 3.0 1.6 8.0 4.0 38.8 24.8 42.7 25.0
American Indian/Alaskan Native
1992–1993 38.5 27.1 53.9 20.0 1.6 19.3 39.5 12.0 10.4 4.5 15.8 3.4 31.2 17.4 34.6 12.2
1995–1996 61.7 48.0 52.7 24.2 2.8 27.8 37.7 15.6 10.1 3.6 16.4 5.0 32.2 30.8 38.4 18.5
1998–1999 29.1 52.8 47.6 29.7 2.7 29.6 33.4 15.4 7.7 3.6 15.0 5.4 33.0 26.4 44.2 17.5
2001–2002 29.3 41.3 47.1 27.7 2.9 16.0 33.4 17.8 4.0 2.1 14.8 4.7 29.6 18.2 40.7 22.4
2003 42.4 43.4 46.2 30.8 3.1 24.4 32.7 19.2 2.7 -- 12.1 4.6 20.3 15.2 38.2 24.6
2006–2007 24.8 31.1 44.9 45.2 5.0 14.2 30.9 27.0 2.1 2.4 12.6 7.1 21.9 -- 37.8 25.3
2010–2011 38.9 27.7 48.1 50.6 4.7 31.6 29.8 31.7 2.6 1.8 10.9 6.3 23.1 20.3 38.6 26.1
2014–2015 25.2 52.4 35.4 33.4 4.9 24.2 25.8 20.0 2.4 2.4 10.9 5.6 31.9 13.7 39.8 28.0
2018–2019 9.1 — 41.2 53.6 8.3 23.4 29.3 31.9 0.8 -- 9.4 5.0 13.1 19.4 38.1 48.4
Asian, Native Hawaiian, Pacific Islander
1992–1993 18.9 13.0 22.2 6.7 13.8 5.6 14.0 3.9 9.9 3.6 13.1 3.7 45.9 17.6 54.2 11.9
1995–1996 19.6 15.2 19.8 9.5 12.8 9.0 13.3 5.4 9.5 4.6 11.3 4.2 50.5 29.1 50.5 20.5
1998–1999 24.6 18.1 20.6 9.4 13.0 8.6 13.0 5.0 9.1 4.3 10.4 4.7 52.5 22.7 50.1 20.0
2001–2002 21.8 19.6 21.1 10.7 10.5 8.7 12.8 5.3 6.2 3.9 10.2 3.2 55.5 24.6 49.5 19.4
2003 16.8 17.1 17.7 9.1 9.1 7.8 10.8 5.0 5.3 3.8 9.4 5.0 61.8 27.2 49.5 19.0
2006–2007 18.7 21.1 17.2 13.9 11.1 11.5 10.1 7.0 7.2 10.4 10.2 6.0 49.1 39.6 50.1 29.3
2010–2011 15.1 17.4 14.9 12.5 9.3 8.9 8.6 5.6 5.9 5.1 8.5 4.4 52.9 39.1 52.7 23.3
2014–2015 14.6 29.2 14.2 11.0 7.3 12.4 8.4 5.5 5.6 5.1 6.9 3.7 60.4 41.5 53.3 26.4
2018–2019 7.5 22.4 12.5 23.7 6.6 12.0 8.1 10.4 2.4 5.6 5.2 4.1 46.7 58.7 52.2 43.2
Hispanic/Latino
1992–1993 23.2 6.3 29.3 5.6 14.7 4.7 20.9 3.7 8.4 2.6 11.1 1.7 52.4 11.5 44.0 6.8
1995–1996 22.6 10.1 27.1 6.3 14.5 7.4 19.6 4.0 6.6 3.1 10.6 2.2 49.9 16.6 44.1 9.1
1998–1999 20.0 9.6 26.1 6.9 12.9 5.8 17.9 4.0 7.2 3.8 9.9 1.7 53.6 16.1 46.3 9.4
2001–2002 19.3 10.7 25.0 6.0 11.7 7.3 17.6 3.9 5.9 2.8 9.5 2.1 52.5 22.1 42.4 10.1
2003 15.7 9.6 20.8 6.1 9.7 5.4 14.7 3.4 6.5 3.1 8.9 2.1 54.9 19.5 42.2 8.1
2006–2007 15.3 11.7 21.1 7.4 9.3 6.0 14.0 4.8 5.7 4.7 8.7 3.0 54.3 28.8 44.7 14.4
2010–2011 13.7 11.1 18.6 7.1 7.7 5.2 12.3 4.8 5.6 6.2 7.5 3.1 58.0 24.2 45.2 14.6
2014–2015 13.1 13.6 17.1 7.8 6.9 6.3 10.2 3.9 5.4 4.7 7.1 2.8 58.7 29.6 48.6 12.8
2018–2019 11.8 24.7 15.2 12.6 7.6 11.4 9.2 6.6 4.4 4.3 7.1 4.5 59.3 43.5 52.3 31.2
Non-Hispanic White
1992–1993 36.8 7.9 40.4 1.6 20.9 2.4 22.5 0.9 16.8 2.1 18.0 0.6 61.5 4.6 58.9 1.4
1995–1996 36.6 11.7 40.3 2.8 20.7 4.6 22.5 1.2 15.6 2.8 17.5 0.9 61.0 8.2 58.3 1.8
1998–1999 40.1 11.4 40.6 2.7 19.4 5.6 21.6 1.1 14.3 2.9 17.0 0.7 62.8 9.0 58.8 2.1
2001–2002 36.1 13.5 40.0 2.9 17.8 5.7 21.2 1.4 13.6 2.8 16.0 0.8 62.8 8.8 58.9 2.7
2003 31.6 9.9 37.5 3.1 16.7 5.1 19.8 1.4 13.0 3.9 15.7 0.9 62.9 8.6 58.7 2.5
2006–2007 32.7 17.3 38.2 5.0 16.0 6.9 20.0 1.9 12.2 3.9 14.9 1.2 63.6 12.8 58.6 2.9
2010–2011 29.8 16.1 34.9 4.7 14.3 8.0 18.2 2.0 10.9 4.4 13.6 1.1 63.3 14.7 59.0 3.5
2014–2015 24.5 17.7 32.5 4.9 11.4 7.2 17.1 1.7 10.2 4.3 12.7 1.2 66.4 17.9 61.0 3.3
2018–2019 19.4 27.4 26.0 8.3 11.9 13.8 15.8 3.4 10.2 8.0 12.1 2.2 63.8 31.1 60.6 6.7
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Means and % are weighted estimates standardized by race/ethnicity to the 2010 US population. 95% CI = 95% confidence interval; CPD = average number cigarettes smoked per day.

Among California Asian/Pacific Islanders, the rate of smoking uptake was at 19% ± 13.0 in 1992/1993 and decreased to 7.5% ± 22.4 in 2018/2019. Among those in the United States, the rate of smoking uptake was 22.2% ± 6.7 in 1992/1993 and decreased to 12.5% ± 23.7 in 2018/2019. Asian/Pacific Islander smoking uptake in California represented a relative 60% decrease since 1992/1993 (p = .0047) and in the rest of the United States represented a relative 43.6% decrease (p < .0001), but these slopes were not statistically significant different from each other (p = .987).

American Indian/Alaska Natives and Hispanics/Latinos had consistently lower rates of smoking uptake in California compared with their US counterparts. For American Indian/Alaska Natives in California, smoking uptake was 38.5% ± 27.1 in 1992/1993 and declined to 9.1% in 2018/2019, though the confidence intervals could not be estimated due to the small sample size. For those in the rest of the United States, smoking uptake rates were higher at 53.9% ± 20.0 in 1992/1993 and declined to 41.2% ± 53.6 in 2018/2019. The confidence intervals overlap across time points and between California and US observed data; therefore, conclusions on changes over time or between samples cannot be made.

Among Hispanics/Latinos in California, smoking uptake was 23.2% ± 6.3 in 1992/1993 that declined to 11.8% ± 24.7 in 2018/2019, representing a significant decline across time (p < .0001). For those in the United States, smoking uptake was slightly higher at 29.3% ± 5.6 in 1992/1993, which declined to 15.2% ± 12.6 in 2018/2019, representing a significant decline across time (p < .0001). The patterns of decline were similar for both California and United States, and slopes were not statistically different from one another (p = .46).

Among Whites in California, smoking uptake prevalence was 36.8% ± 7.9 in 1992/1993 and remained relatively steady until 2001/2002 when it decreased to 19.4% ± 27.4 in 2018/2019, a significant decrease in slope (p = .03). In comparison, the smoking uptake rate among Whites in the United States was 40.4% ± 1.6 and remained relatively steady until 2001/2002 when it decreased to 26.0% ± 8.3 in 2018/2019, also a significant decrease in slope (p < .0001). There was no statistically significant difference between California and US slopes (p = .39).

Current Cigarette Smoking Prevalence

For African Americans, Asians/Pacific Islanders, and American Indian/Alaskan Natives (p = .33), there were no significant differences in decline between California and the United States in current smoking (see Supplementary Figure 2S). For African Americans in California, the current smoking rate was 25.3% ± 11.5 in 1992/1993 declined to 12.2% ± 22.0 in 2018/2019, representing a significant decrease across time (p < .0001). For those in the United States, the current smoking rate was comparable at 24.7% ± 3.1 in 1992/1993 and declined to 14.8% ± 10.4 in 2018/2019, also representing a significant decrease across time (p < .0001). The rate of change between California and US African Americans was not statistically different from each other (p = .27).

Asians/Pacific Islanders in California had a current smoking rate of 13.8% ± 5.6 in 1992/1993 and declined to 6.6% ± 12.0 in 2018/2019, a significant decline over time (p < .0001). Those in the rest of the United States had comparable rates in 1992/1993 at 14.0% ± 3.9 and declined about 6 percentage points to 8.1% ± 10.4 in 2018/2019, also a significant decline over time (p < .0001). The difference in slope between California and US Asian/Pacific Islanders was not statistically different from one another (p = .81).

Among American Indians/Alaska Natives in California, the current smoking rate was 26.3% ± 19.3 in 1992/1993 declined to 5.9% ± 23.4 in 2018/2019. This represents a significant decrease over time (p < .0001); however, overlapping 95% confidence intervals of the observed data for each time point suggest caution in interpreting these results. For those in the rest of the United States, current smoking rates were higher at 39.5% ± 12.0 in 1992/1993 and declined to 29.3% ± 31.9 by 2018/2019. This represented a significant decrease over time (p = .0005), but the wide and overlapping confidence intervals of the observed data suggest caution in interpreting these results. The rate of change between California and US American Indian/Alaska Natives was not significantly different from one another (p = .33).

The current smoking rates for Hispanics/Latinos and Whites all displayed lower prevalence in 1992/1993 and later in 2018/2019 in California compared with their US counterparts. California consistently held lower rates of use than their US counterparts. Among Hispanics/Latinos, the current smoking rate in California was 14.7% ± 4.7 in 1992/1993 and declined to 7.6% ± 11.4 by 2018/2019, representing a significant decrease over time (p < .0001). For Hispanic/Latinos in the rest of the United States, current smoking was 21.0% ± 3.7 in 1992/1993 and declined to 9.2% ± 6.6 by 2018/2019, representing a significant decrease over time (p < .0001). The estimated rates of change between California and US Hispanic/Latinos were significantly different from one another (p = .02), with the United States showing a slightly steeper rate of decline.

For Whites in California, current smoking fell from 21.0% ± 2.4 in 1992/1993 to 11.9% ± 13.8 by 2018/2019, representing a significant decrease across time (p < .0001). Among Whites in the United States, the current smoking rate was 22.5% ± 0.9 in 1992/1993 and declined to 15.8% ± 3.4 by 2018/2019, representing a significant decrease across time (p < .0001). The estimated rates of change between Whites in California and United States were significantly different from one another (p < .03), with California showing a steeper rate of decline overtime.

Cigarette Consumption: Cigarettes per Day

Patterns in cigarette consumption varied by race/ethnicity across time (see Supplementary Figure 3S). For African Americans in California, the average number of CPD was 10.3 ± 3.7 in 1992/1993, increased in 1998/1999 to match the CPD of those in the rest of the United States, then declined sharply to 3.0 CPD ± 1.6 in 2018/2019. The estimated slope indicates a significant decline across time (p < .0001). For those in the rest of the United States, the average CPD decreased steadily from 11.6 CPD ± 1.3 in 1992/1993 to about 8.0 CPD ± 4.0 by 2018/2019. The estimated slope indicates a significant decline across time (p < .0001). The decrease in the average number of CPD observed in California was significantly different from that of the United States (p < .0001), indicating a much steeper decline in California.

Asians/Pacific Islanders in California smoked an average of 9.9 CPD ± 3.6 in 1992/1993 and decreased to 2.4 CPD ± 5.6 in 2018/2019, with the estimated slope representing a significant decrease over time (p < .0001). In comparison, those in the rest of the United States smoked on average 13.1 CPD ± 3.7 in 1992/1993 and decreased to 5.2 CPD ± 4.1 in 2018/2019, with the estimated slope also significant (p < .0001). The rate of decline between California and the United States was similar in average CPD reductions with no statistically significant difference between the two slopes (p < .77).

American Indian/Alaskan Natives in California smoked an average of 10.4 CPD ± 4.5 in 1992/93 and sharp and rapid decrease to 0.8 CPD; however, the sample was too small to estimate the 95% confidence interval for 2018/2019. American Indian/Alaskan Native current smokers in the rest of the United States also showed a decrease from 15.8 CPD ± 3.4 in 1992/1993 to 9.4 CPD ± 5.0 in 2018/2019. Due to the small sample, there was insufficient data for a valid test of slopes for California and United States, and to test the differences between the groups. However, using a more conservative approach, the 95% confidence intervals do not overlap between California and US samples in years post-1999, indicating lower number of CPD among California American Indian/Alaskan Natives compared with their US counterparts.

Among California Hispanic/Latino current smokers, a decrease from 8.4 CPD ± 2.6 in 1992/1993 to 4.4 CPD ± 4.3 in 2018/2019 was observed. The estimated slope indicated a significant decline (p < .0001). Among Hispanics/Latinos in the United States, the average CPD decreased from 11.1 CPD ± 1.7 in 1992/1993 to 7.1 CPD ± 4.5 in 2018/2019. The estimated slope indicated a significant rate of decline (p < .0001). Although the average number of CPD is higher in the United States, the rate of change between California and US Hispanics/Latinos was similar, and there was no statistically significant difference in the estimated slopes (p = .11).

White current smokers in California smoked an average of 16.8 CPD ± 2.1 in 1992/1993 and decreased to 10.2 CPD ± 8.0 in 2018/2019. The estimated slope indicated a significant decline (p < .0001). Whites in the rest of the United States smoked on average 18.0 CPD ± 0.6 in 1992/1993 and decreased to 12.1 CPD ± 2.2 in 2018/2019. The estimated slope indicated a significant rate of decline (p < .0001). The estimated slopes among Whites in California were similar to those in the rest of the United States, showing no statistically significant difference in the decline (p = .06).

Cessation/Quit Ratio

The quit ratio (for those who quit, over all ever-smokers aged 25 years or older) represented as a percentage for each race/ethnic group is presented in Supplementary Figure 4S. The quit ratio for African Americans in California remained relatively stable across time from 44.2% ± 15.5 in 1992/1993 to 38.8% ± 24.8 in 2018/2019. The estimated slope indicated that there was no significant difference between the slope and zero (p = .08). The quit ratio and stability across time were similar for African Americans in the rest of the United States, from 41.6% ± 5.5 in 1992/1993 to 42.7% ± 25.0 in 2018/2019. The estimated slope is no different from zero (p = .87). There was no significant difference in slopes for African Americans in California versus those in the United States (p = .12).

Among Asians/PIs in California, the quit ratio was 45.9% ± 17.6 in 1992/1993, increased to 61.8% ± 27.2 by 2003, and fluctuated over time, such that by 2018/2019, the quit ratio was 46.7% ± 58.7. The estimated slope showed a significant increase across time (p = .04). In the rest of the United States, the quit ratio among Asians/PIs was 54.2% ± 11.9 in 1992/1993, fluctuated between 49.5% and 53.3% over the years, with the latest quit ratio at 52.2% ± 43.2 in 2018/2019. The estimated slope was not different from zero (p = .6). The slopes between Asians/PIs in California were significantly different from those in the rest of the United States (p = .04), with California showing a slight increase over time compared with a steady line for the United States.

Among American Indians/Alaska Natives in California, the quit ratio was 31.2% ± 17.4 in 1992/1993 and decreased to about 20% in 2003 before increasing to 32.3% ± 13.7 by 2014/2015 and decreasing to 13.1% ± 19.4 in 2018/2019. Despite fluctuations over time, the quit ratio in California in 2014/2015 was similar to the level in 1992/1993 and declined further in 2018/2019. The estimated slope across time was not statistically different from zero (p = .16). For the rest of the United States, the quit ratio was 34.6% ± 12.2 in 1992/1993 and fluctuated between 34% and 44% across the years and ending at 38.1% ± 48.4 in 2018/2019. The estimated slope for the United States was also not statistically different from zero (p = .54). Change across time comparing California and United States was not statistically different from one another (p = .16).

The quit ratio among Hispanics/Latinos and Whites both showed increases across time with California holding generally higher ratios than the rest of the United States. Hispanics/Latinos in California demonstrated an increase in quit ratios from 52.4% ± 11.5 in 1992/1993 to 59.3% ± 43.5 by 2018/2019. The estimated slope showed a significant increase over time (p = .05). Hispanics/Latinos in the rest of the United States went from 44.0% ± 6.8 in 1992/1993 to 52.3% ± 31.2 in 2018/2019. The estimated slope was not statistically different from zero (p = .14). Comparison in slopes between California Hispanics/Latinos to their US counterparts shows no statistically significant difference (p = .27).

Among Whites in California, the quit ratio increased from 61.5% ± 4.6 in 1992/1993 to 63.8% ± 31.1 by 2018/2019, though the estimated slope was not significantly different from zero (p = .08). In comparison, the quit ratio for Whites in the rest of the United States increased slightly from 58.9% ± 1.4 in 1992/1993 to 60.6% ± 6.7 in 2018/2019, with the estimated slope significantly different from zero (p = .02). By 2018/2019, the quit ratio among Whites was higher in California compared with US counterparts; the rest of the estimated slopes show no significant difference (p = .23).

Discussion

California funded the nation’s first state-wide tobacco control program in 1988 through a cigarette excise tax passed by voters.4,54 A decade later, the Tobacco Master Settlement Agreement led to several other statewide tobacco control programs.55 California’s program was comprehensive in its coordinated efforts to reduce initiation, reduce consumption levels, and increase smoking cessation.5,56 In addition to taxation, the program also included changing social norms around the acceptability of smoking, organized communities to influence local ordinances to restrict public and workplace smoking areas, and restrict tobacco advertising particularly near schools and selling products to minors.4 During this time period, California was in a vanguard position for the nation with its efforts to denormalize cigarette smoking.4 Indeed, these efforts have been reflected in changes in smoking behaviors24 and associated with reductions in lung cancer rates in California compared with the rest of the United States.29 In the current study, we also see these reductions in cigarette smoking uptake, reflected across all racial/ethnic groups in California and the United States. The changes in young adult uptake from 1992 to 2019 indicate significant reductions across the nation within each racial/ethnic group and trends indicating California starting at a lower baseline and maintaining a lower incidence of smoking uptake. Considering that most cigarette users initiate by the age of 26,44 tobacco control efforts to prevent or delay the uptake of smoking is the most effective strategy to prevent tobacco-related morbidity and mortality.1,44 Although California may have been at the forefront of state-wide tobacco control efforts, other states followed suit and later surpassed California in terms of resource allocation toward tobacco control.57,58 In 2009, the Family Smoking Prevention and Tobacco Control Act was signed into law giving the Food and Drug Administration authority to regulate the manufacture, distribution, and marketing of tobacco products nationwide.59 Collectively, state and federal tobacco control efforts in the past decade may be seen as “catching up” with California in terms of smoking uptake, resulting in nonsignificant differences in changes across time or in comparing recent time points.

The measure of current smoking provides a more robust snapshot of the proportion of smokers across each time point. For all racial/ethnic groups in California and the United States, we see significant declines in current smoking prevalence across the decades. Of note, we see a greater decline among California Whites compared with their US counterparts. Although the prevalence for both groups started at about the same level in the early 1990s, the collective influence of California’s tobacco control programs and shifting of social norms surrounding cigarette use may have had its most profound impact and continuing impact on this group. Other studies using different datasets have shown rapid declines in smoking initiation and use among young adult Californians compared with US counterparts.6,43 Our study confirms those findings, but only among White populations. In contrast, although both California and US Hispanic/Latino groups demonstrated significant reductions in current use across the decades, US Hispanic/Latino groups showed a steeper decline compared with their California counterparts. Hispanic/Latino ethnicity encompasses several subgroups that differ in their smoking behaviors. California’s Hispanic/Latino populations are largely Mexican in origin or ancestry,31 and the current use prevalence of this group is similar to White populations.60 Other Hispanic/Latino subpopulations, such as Puerto Rican and Cuban ancestry, tend to have higher prevalence and smoke at greater intensity.31,61,62 The impact of tobacco control at the federal level and states in which a larger proportion of these subpopulations reside may have had stronger impact in demonstrating reduction in current smoking in the rest of the United States. Future studies need to disaggregate Hispanic/Latino subpopulations and take into account nativity and length of time in the United States or acculturation,31,62 as these are important factors to better address tobacco use disparities observed among these groups. Much of the successes that California has had in reducing lung cancer compared with the rest of the United States43 may be largely attributed to the reductions in cigarette use prevalence documented among the non-Hispanic White population and perhaps the collective reductions in cigarette consumption levels across all race/ethnic groups.

National reductions in cigarette consumption levels across race/ethnic groups have been substantial, with all groups experiencing at least a 30% reduction in the number of CPD. Compared with the United States, reductions in CPD over time were even more pronounced in California, though only significantly different among African Americans. African Americans are typically lighter consumers of cigarettes13,16,45,63 and are more likely to be nondaily smokers.11,13,45 A strong tobacco control environment such as California may influence both the reduction in consumption and also quitting.64 Despite the positive population-level shift toward lighter consumption for African Americans, we do not see progression in terms of quitting. African Americans want to quit at higher rates than other racial/ethnic groups,65,66 and they make more quit attempts but are less successful than White and Hispanic/Latino counterparts.67 Studies suggest that continued targeted tobacco marketing in communities with higher proportion of African Americans,68–72 and continued sale of mentholated products,65,69,73 contribute to the group’s lower quit success rates. More work is needed to address the transition from light consumption to quitting, specifically for African American populations. Other studies have also documented a lack of significant changes in the quit ratio among African Americans contrasted with significant increases among Hispanic/Latino and White US populations,74,75 further demonstrating the need to better target and address the needs of these priority groups.

The magnitude of cigarette consumption reductions among Asians/Pacific Islanders, Hispanics/Latinos, and Whites in California were similar to those in the United States. These reductions in CPD are encouraging, but further improvements are needed as light and intermittent smokers are still at increased risk for tobacco-related morbidity and mortality.76,77 It is possible that federal, state, and local taxation of cigarettes may have helped to reduce the overall number of CPD over time for all groups 69,78,79 and contributed to the diminished differences in CPD between California and United States among some race/ethnic groups. However, the stark difference seen between California and US American Indian/Alaskan Native and African American reductions in CPD may be due to California’s investment in tobacco control efforts tailored specifically for those groups80 and by extension similar targeted efforts may hasten reductions in the consumption of cigarettes for other racial/ethnic groups and vulnerable populations.

The quit ratio among California and US Whites, and among California Hispanic/Latinos show both a significant increase overtime and are at rates substantially higher than other groups throughout the decades. The quit ratio for California Hispanic/Latino population appears to have increased to similar levels of California non-Hispanic Whites, indicating major success in reaching parity. A number of studies have shown that rates of successful smoking cessation among African American smokers are lower than they are among Whites, despite reports citing lower cigarette consumption.16,65,67 Similarly, generally Hispanics/Latinos do not experience higher rates of successful quitting than Whites, despite lower consumption patterns.15,75,81 Although our results show quit ratios are similar between Hispanic/Latinos and Whites in California, efforts to increase quit attempts and successful long-term quitting remain a priority. There is little evidence indicating that American Indians/Alaska Natives and Asian Americans quit at higher rates than Whites.81,82 Although we see tremendous success in the decline of overall tobacco use prevalence and particularly reductions in cigarettes per day for American Indians/Alaska Natives, these quit ratios demonstrate an important and striking need to focus efforts on quitting success. Our findings point to a specific need for tobacco control efforts to move beyond reductions in consumption and focus on successful quitting among racial/ethnic minority populations.

Limitations and Future Directions

Several limitations must be considered when interpreting the results of this study. The data are from independent cross-sectional samples and based on self-reported data, which may introduce bias. The TUS-CPS data are limited to noninstitutionalized, civilian populations and collected from in-person interviews among US households. In-person survey administration mode was shown to produce accurate responses over telephone interviews,83 but factors that limit representation based on the availability of those willing to do in-person interviews can only be statistically adjusted. These data were analyzed to be representative of the US population; however, our results may be underestimating smoking prevalence due to our study population being limited to noninstitutionalized, civilian populations. For example, some of the populations that are excluded include the overrepresentation of African American young adult smokers who are incarcerated,84 high prevalence of current smoking among chronic homeless adults,85–87 and high use prevalence among military populations.88

Another consideration is that the quit ratio is a limited measure and cannot assess how long a person has quit or if they are successful in quitting long term. The quit ratio serves as a snapshot of the proportion of the population who were established smokers and are not currently smoking. Future studies should investigate different measures and factors that lead to successful quitting, as our results indicate that more effort is needed to increase that quit ratio for all racial/ethnic groups. Furthermore, we must do more to understand how best to address these tobacco use disparities by investing more in disaggregating data, namely Asian, Native Hawaiian, Pacific Islanders, and Hispanic/Latino subpopulations. To do so, we can better address the cessation needs of those at greatest risk. American Indian/Alaskan Native populations are especially important given some of the high tobacco use trends observed, but the small sample size does not allow for valid interpretation of the data. More efforts are needed to address the disparities we see among these groups.

This study compares California to the rest of the United States because of California’s strong and consistent tobacco control efforts and its diverse population. Other states such as Massachusetts, New Jersey, and New York,57 among others, have also developed strong tobacco regulation and have relatively diverse populations. When these progressive tobacco control states are combined with the rest of the United States, it may diminish the differences observed between California and the United States. Given that California’s progressive statewide tobacco control efforts were followed by others along with federal tobacco control efforts, we should expect some lag and closing of the gap between California and US smoking indicators. Yet, we still see continued disparities among some racial/ethnic minority groups. The results of this study point specifically to successes in reducing uptake and CPD, but current use and quitting are areas that need to be targeted for improvement. These patterns across these cigarette use indicators for different racial/ethnic groups hold valuable lessons in how we should continue to invest in future tobacco control efforts.

Conclusion

Over the past 25 years, in the era of increased tobacco control, there have been noteworthy reductions in cigarette smoking prevalence and consumption rates across all race/ethnic groups in the United States and in California. As the US diversifies further, these lessons will continue to aid policy makers in how to best invest in tobacco control efforts. Investments in disaggregating Asian, Native Hawaiian, Pacific Islander, and Hispanic/Latino subpopulations in surveillance studies and prioritizing tailored interventions will help to further reduce consumption and support cessation. Similarly, American Indian/Alaskan Native and African American populations are potentially at the lowest levels of consumption but future studies and investments are needed to transition these groups to successful cessation. Future efforts to increase cigarette cessation rates, particularly among race/ethnic minority groups, should continue to be a major priority for tobacco control.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Note: References 51–88 are available as Supplementary Material.

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Acknowledgments

The authors thank Ruby Ling for her contributions to the literature review and development of this manuscript.

Funding

Research reported in this publication was supported by the Tobacco-Related Disease Research Program (TRDRP) of the University of California, Office of the President (grant no. 28IR-0066; PI: Trinidad) and the National Institutes of Health (NIH; grant no. 1R01CA234539; PI: Pierce). The content is solely the responsibility of the authors and does not necessarily represent the official views of TRDRP or the NIH.

Declaration of Interests

None declared.

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