35

Chapter 2

Patterns of Smoking Cessation Among U.S. Adults, 

Young Adults, and Youth

Introduction 37

Data Sources 37

Key Epidemiologic Measures 42

Trends in Current and Former Cigarette Smoking 43

Adults 43

Young Adults 45

Youth 45

Changing Characteristics of Current Cigarette Smokers 47

Adults 47

Young Adults 51

Youth 51

Key Disparities in Current Cigarette Smoking Among Adults and Youth 57

Disparities by Behavioral Health Condition 57

Disparities by Chronic Disease Status 57

Disparities by Geographic Location 57

Disparities by Sexual Orientation and Gender Identity 58

Disparities in Smoking in Pregnant Women 58

Disparities in Smoking Among Active Duty Service Members 59

Correlation of Smoking-Related Risk Factors 59

Cigarette Smoking Cessation Among Adults and Youth 59

Recent Successful Cessation 59

Adults 61

Quit Ratio 61

Adults 61

Young Adults 66

Youth 66

Trends in the Cessation Continuum for Current Smokers 66

Attempts to Quit Smoking During the Past Year 67

Trends in Attempts to Quit Smoking During the Past Year 71

Number and Duration of Quit Attempts During the Past Year 71

Interest in Quitting Smoking 78

Trends in Interest in Quitting Smoking 78

History of a Quit Attempt 79
36

Other Tobacco Products: Use and Cessation 80

Adults 80

Young Adults 84

Youth 84

Clinical Interventions for Smoking Cessation: Prevalence and Trends 86

Screening for Tobacco Use and Receipt of Advice to Quit from Health Professionals 86

Adults 86

Young Adults 90

Youth 93

Use of Counseling and Medications to Quit Smoking 93

Adults 93

Young Adults 95

Youth 95

Use of Other Cessation Strategies 97

Adults 97

Young Adults 100

Youth 100

Key Disparities in Cessation Among Adults 100

Summary of the Evidence and Implications 102

Conclusions 104

References 105
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 37

Smoking Cessation

Introduction

This chapter documents key patterns and trends in 

cigarette smoking cessation in the United States among 

adults overall (persons 18 years of age and older), young 

adults (18–24 years of age), and youth (12–17 years of age). 

The chapter also reviews the changing demographic and 

smoking-related characteristics of cigarette smokers, with 

a focus on how these changes may influence future trends 

in cessation.

This chapter also describes persistent disparities 

in cessation by age, race/ethnicity, level of education, 

status of health insurance, and other demographic characteristics. In addition, this chapter highlights trends and 

recent findings for several different measures, including 

the quit ratio (the proportion of ever smokers who are 

former smokers); recent successful cessation; past-year 

quit attempts; interest in quitting; receipt of cessation 

advice from healthcare professionals; and use of effective 

cessation strategies, such as counseling and medication. 

As with previous Surgeon General’s reports, this chapter 

focuses primarily on cigarette smoking (U.S. Department 

of Health and Human Services [USDHHS] 1990, 2014); 

however, given the shifting patterns of tobacco product 

use in the United States, it also touches on cessation as 

it relates to all tobacco products. Monitoring key trends 

and current patterns in tobacco use and cessation is critical for informing the development and implementation of policies and programs to increase cessation and, 

as a result, reduce the morbidity, mortality, and associated financial costs caused by tobacco product use in the 

United States.

Data Sources

A variety of national surveillance systems in the 

United States collect data on smoking cessation among 

adults and youth. These systems typically collect an array 

of information on cigarette smoking history; use of other 

tobacco products; and various aspects of cessation, such 

as quit intentions, quit attempts, and successful cessation. 

These surveys use different data collection methods and 

may define specific cessation behaviors using comparable, 

but not identical, approaches. Accordingly, it is important 

to monitor the results from national surveys that include 

cessation-related data involving adults, young adults, and 

youth to create a comprehensive picture of cessation prevalence and patterns.

Appendix 2.1 describes the surveys referenced in 

this chapter, all of which are cross-sectional except for 

the Population Assessment of Tobacco and Health (PATH) 

Study. The primary source for data on adults was the 

National Health Interview Survey (NHIS), and the primary sources for data on youth were the national Youth 

Risk Behavior Survey (YRBS), conducted as part of the 

Youth Risk Behavior Surveillance System (YRBSS), and 

the National Youth Tobacco Survey (NYTS) (Table  2.1). 

These surveys were chosen because of their scientific and 

methodologic reliability and validity and because they 

are conducted as part of long-standing surveillance systems (Thacker et al. 1988; Centers for Disease Control and 

Prevention [CDC] 2001). Additionally, most of these surveys have historically been used to track progress toward 

national cessation goals, including the U.S. Department 

of Health and Human Services’ Healthy People initiative 

(Office of Disease Prevention and Health Promotion n.d.b).

These data systems have additional strengths, 

including the timeliness of data releases and proven data 

collection methodologies, which use anonymous or confidential self-reported surveys that yield relatively high 

response rates. Self-reported data have been found to 

adequately reflect patterns of cigarette smoking among 

adults, including whether a respondent who has smoked 

in the past is currently not smoking, using scientifically 

validated biomarkers and other approaches (Connor 

Gorber et al. 2009; Wong et al. 2012); however, few studies 

have examined the validity of other cessation-related measures (Brigham et al. 2010; Persoskie and Nelson 2013).

NHIS, which has been a major source of health data 

among the U.S. adult population since the 1950s, is an 

annual household interview survey of the civilian, noninstitutionalized population. At the time this report was 

compiled, NHIS data on cigarette smoking among adults 

18 years of age and older were available from 1965 to 2017, 

and data on cigarette smoking cessation for daily smokers 

and nondaily smokers were available from 1997 to 2017. In 

addition, since 2000, NHIS has fielded a CCS every 5 years, 

which includes detailed questions on cigarette smoking 

cessation; NHIS also fielded the CCS in 1987 and 1992, but 

the cessation questions were not consistent between these 

surveys. Therefore, for analyses of adult cessation trends, 

the present report uses the longest series of years available 

for each cessation measure. Data on the characteristics of 
BRFSS HINTS MTF NAMCS NATS NHIS NYTS PATH TUS-CPS YRBS

Sponsoring 

agency or 

organization

Centers for

Disease Control 

and Prevention; 

Health Resources

and Services

Administration;

Administration 

on Aging; U.S.

Department of

Veterans Affairs; 

and Substance 

Abuse and Mental

Health Services

Administration

Health

Communication 

and Informatics 

Research Branch,

Division of 

Cancer Control 

and Population

Sciences, 

National Cancer 

Institute

National Institute

on Drug Abuse,

administered by 

the University 

of Michigan’s 

Institute for 

Social Research

Centers for 

Disease Control 

and Prevention

Centers for

Disease Control 

and Prevention 

and U.S. Food 

and Drug 

Administration

National Center

for Health 

Statistics

Centers for

Disease Control 

and Prevention 

(with support 

from U.S. Food 

and Drug

Administration 

since 2011)

U.S. Food

and Drug

Administration;

National Institute 

on Drug Abuse

National Cancer

Institute 

(2014–2015 wave 

cosponsored by 

the U.S. Food 

and Drug 

Administration)

Centers for

Disease Control 

and Prevention

Type Cross-sectional Cross-sectional Cross-sectional 

and longitudinal

Cross-sectional Cross-sectional Cross-sectional Cross-sectional Longitudinal Cross-sectional 

and longitudinal

Cross-sectional

Years 2017 2017 2011–2017 2004–2011 2013–2014 1965–2017;

Cancer Control 

Supplements 

2000, 2005, 2010, 

and 2015

1999, 2000, 2002,

2004, 2006, 2009, 

2015, and 2017

2013–2014, 

2014–2015

2001–2002,

2003, 2006–2007, 

2010–2011, and 

2014–2015

1991, 1993, 1995,

1997, 1999, 2001, 

2003, 2005, 2007, 

2009, 2011, 2013, 

2015, and 2017

Mode Telephone-based

questionnairethat 

state health

departments 

conduct monthly 

over landline 

and cellular

telephones using 

a standardized

questionnaire 

and technical and

methodologic

assistance

provided by CDC

Householdbased, mailed 

questionnaire

School-based,

self-administered

questionnaire

• Review medical 

records for 

information 

about patient 

visits

Interview 

physicians and 

community 

health center 

providers

Telephone-based

questionnaire

Computerassisted personal 

interview

School-based,

self-administered 

questionnaire 

(paper-based)

Computerassisted personal

interview

Questionnaire

via telephone 

and in-person 

interviews

School-based,

self-administered 

questionnaire 

(paper-based)

•

A Report of the Surgeon General

38 Chapter 2

Table 2.1 Sources of national survey data on smoking cessation used for this report, 1965–2017; United States
BRFSS HINTS MTF NAMCS NATS NHIS NYTS PATH TUS-CPS YRBS

Response rate 2017: 45.9% •

•

•

2017: 25.0%

HINTS-FDA: 

34.1% (NCI 

2017a)

HINTS 5

Cycle 1 (2017):

32.4% (NCI

2017b)

•

•

•

2015:

–

–

12th-grade 

RR: 83%

Schools: 382

2016:

–

–

12th-grade 

RR: 80%

Schools: 372

2017:

– 12th-grade 

RR: 79%

•

•

•

•

•

•

•

•

2009: 62.4%

2010: 57.3%

2011: 54.1%

2012: 39.4%

2013: 40.4%

2014: 39.0%

2015: 29.6%

2016: 32.7%

2013–2014:

36.1% overall 

(47.6% landline 

and 17.1%, 

cellular)

•

•

•

•

2015a:

–

–

–

Household: 

70.1%

Family: 

69.3%

Sample 

adult: 

63.4%

2016a: 

–

–

–

Household: 

67.9% 

Family: 

67.1%

Sample 

adult: 

61.9%

2017a: 

– Household: 

66.5%

–

–

Family: 

65.7%

Sample 

adult: 

53.0%

For years 

1997–2017,the 

question about 

a past-year 

quit attempt 

was asked of 

all current 

cigarette 

smokers

• 2015:

–

–

–

School: 

72.6%

Student: 

87.4%

Overall: 

63.4%

•

•

2016: 

–

–

–

School: 

81.5%

Student: 

87.9%

Overall: 

71.6%

2017:

– School: 

76.8%

–

–

Student: 

88.7%

Overall: 

68.1% 

•

•

2013–2014:

–

–

74.0%

(adult)

78.4%

(youth)

2014–2015:

–

–

83.1%

(adult)

88.4% 

(youth)

2014–2015:

Average selfresponse rate 

(for all waves 

combined) 54.2%

•

•

2015:

–

–

–

School: 

69%

Student: 

86%

Overall: 

60%

2017:

–

–

–

School: 

75%

Student: 

81%

Overall: 

60%

Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 39

Table 2.1 Continued
BRFSS HINTS MTF NAMCS NATS NHIS NYTS PATH TUS-CPS YRBS

Sample size 2017: 450,016 •

•

•

•

2017: 3,335

HINTS-FDA: 

1,736

HINTS 5

Cycle 1 (2017):

3,285

• 2015:

– 12th-grade 

students: 

13,730 

Schools:382

2016:

– 12th-grade 

students: 

12,600

Schools: 372

2017:

– 12th-grade 

students 

13,522

Schools: 360

• Patient records 

extracted:

– 2009: 

32,281 from 

a sample 

of 3,319 

physicians

– 2010: 

31,229 from 

a sample 

of 3,525 

physicians

2011: 

30,872 from 

a sample 

of 3,819 

physicians

2012: 

76,330 from 

a sample 

of 15,740 

physicians

2013: 

54,873 from 

a sample 

of 11,212 

physicians

2014: 

45,710 from 

a sample 

of 9,989 

physicians

2015: 

28,332 from 

a sample 

of 8,091 

physicians

2016: 

13,165 from 

a sample 

of 3,699 

physicians

2013–2014:

75,233 

respondents 

(70%landline 

and30% cellular)

• Adults >18 

years of age:

–

–

–

2015: 33,672

2016: 33,028

2017: 26,742

Overall 

households:

–

–

–

2015: 41,493

2016: 30,220

2017: 32,617

• Students in 

grades 6–12:

– 2015: 17,711

2016: 20,675

2017: 17,872

• 2013–2014:

45,971 (32,320

adults/16,651 

youth)

2014–2015:

40,534 (28,362

adults/12,172 

youth)

2014–2015:

163,920

• Students in 

grades 9–12:

–

–

2015: 15,624

2017: 14,765

•

•

–

–

–

–

–

–

•

– •

–

–

–

–

A Report of the Surgeon General

40 Chapter 2

Table 2.1 Continued
BRFSS HINTS MTF NAMCS NATS NHIS NYTS PATH TUS-CPS YRBS

Cessation 

measure(s)

Quit ratio Use of Internetbased programs 

or tools in quit 

attempts

Interest in 

quitting

•

•

Screening for 

tobacco use

Counseling 

foruse of or 

exposure to 

tobacco

Advice to quit Quit ratio, 

recent successful 

cessation, pastyear quit attempt, 

Cancer Control 

Supplements, 

interest in 

cessation, 

provider advice 

to quit, and 

use of effective 

treatments

Advice to quit and 

use of counseling 

and medications 

to quitb

Quit attempts, 

quit ratio, recent 

successful 

cessation; use of 

NRT, medications, 

or counseling 

to quit

Past-year quit 

attempts, interest 

in quitting, 

recent smoking 

cessation, or 

receipt of medical 

doctor’s advice 

to quit

Past-year quit 

attempt

Table 2.1 Continued

Notes: BRFSS = Behavioral Risk Factor Surveillance System; CDC = Centers for Disease Control and Prevention; HINTS = Health Information National Trends Survey; MTF = Monitoring the Future; 

NATS = National Adult Tobacco Survey; NAMCS = National Ambulatory Medical Care Survey; NHIS = National Health Interview Survey; NYTS = National Youth Tobacco Survey; PATH = Population 

Assessment of Tobacco and Health; RR = relative risk; TUS-CPS = Tobacco Use Supplement to the Current Population Survey; YRBS = National Youth Risk Behavior Survey.

aRR for household component, and unconditional RR for family and sample adult components.

bThe measure of advice to quit has changed over time: 2009 (“During the past 12 months, did a medical doctor, dentist, or nurse tell you to stop smoking?”) and 2015 (“During the past 12 months, 

did any doctor, dentist, or nurse give you advice not to use tobacco that is smoked or put in your mouth?”). In 2017, NYTS did not contain either of these measures (advice to quit; use of counseling/

cessation medications). There are other cessation measures that are not listed here (e.g., thinking about quitting during the past 12 months, and stopped using because trying to quit).

Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 41
A Report of the Surgeon General

42 Chapter 2

cigarette smokers are reviewed beginning with the year 

2000 to correspond with the available cessation data.

YRBSS monitors six categories of health-related 

behaviors that contribute to the leading causes of death 

and disability among youth and adults. In operation since 

1991, the national YRBS is a biennial survey that utilizes 

probability samples of students in public and private high 

schools; students anonymously complete questionnaires 

administered in schools. The survey is nationally representative of the U.S. high school population. This Surgeon 

General’s report uses biennial data from the national YRBS 

to examine trends in youth cigarette smoking and pastyear quit attempts among current cigarette smokers. For 

trends in cigarette smoking cessation among youth, this 

report uses biennial data from 1991 to 2015 from the 

national YRBS. However, this report does not include state 

and local data from YRBS surveys because (a) only one state 

and two districts produced weighted data for all years of 

the YRBS and (b) some of these surveys had small sample 

sizes for the measures examined in this report (CDC 2013).

NYTS is a cross-sectional, voluntary, school-based, 

self-administered, pencil-and-paper survey of U.S. middle 

and high school students. A three-stage cluster sampling 

procedure is used to generate a nationally representative 

sample of U.S. students who attend public and private 

schools in grades 6–12. Because the NYTS is a tobaccofocused survey as opposed to a general health survey, it 

collects more comprehensive data than YRBS on a variety 

of tobacco-related measures from middle school and high 

school students, including tobacco product use, smoking 

cessation, exposure to secondhand smoke, tobacco-related 

knowledge and attitudes, access to tobacco products, and 

other tobacco-related indicators. The NYTS has been conducted most years since 1999. This chapter examined data 

from 2000, 2004, 2009, and 2015, corresponding roughly 

with the years of adult data from the NHIS Cancer Control 

Supplement (CCS). In 2017, the most recent wave of data 

available at the time this report was compiled, cessation 

of all tobacco products was assessed, and separate questions were not asked about cigarette smoking cessation 

specifically.

As reviewed in more detail in Appendix  2.1, this 

chapter also considers other sources of data, including 

the Tobacco Use Supplement to the Current Population 

Survey (TUS-CPS), the Behavioral Risk Factor Surveillance 

System (BRFSS), the National Adult Tobacco Survey 

(NATS), the National Ambulatory Medical Care Survey 

(NAMCS), the Health Information National Trends Survey 

(HINTS), and the Monitoring the Future (MTF) Study. Data 

from Nielsen Retail Management Services were also used 

to assess sales of over-the-counter nicotine replacement 

therapy (NRT). The data contain projected NRT sales from 

two major retail channels: expanded all outlets combined 

and convenience stores. The former category includes 

aggregated sales from food stores, drug stores, mass merchandizers, club stores, dollar stores, and military commissaries. In addition, published baseline and longitudinal 

analyses from the PATH Study are summarized.

Key Epidemiologic Measures

Appendix 2.2 defines the survey measures used in 

this chapter. In brief, this chapter examines a variety of 

epidemiologic areas related to cigarette smoking and cessation, including trends in current and former cigarette 

smoking and the smoking characteristics of adult and 

youth current cigarette smokers; disparities in current 

smoking, trends in the quit ratio, recent successful cessation, past-year quit attempts, current interest in quitting, and ever trying to quit smoking cigarettes among 

adult and youth smokers; tobacco screening and advice 

to quit delivered by health professionals; counseling and 

use of Food and Drug Administration (FDA)-approved 

medications for smoking cessation; use of other strategies for smoking cessation; and disparities in smoking 

cessation. This chapter also briefly addresses cessation of 

other tobacco products to the extent possible, given that 

national surveys include few measures of cessation for 

noncigarette tobacco products. Patterns of use of noncigarette tobacco products were included in the 2014 Surgeon 

General’s report (USDHHS 2014). However, because limited cessation information is available for noncigarette 

tobacco products, this report does not review trends in the 

use of these products and changes in the characteristics of 

the populations that use these products.

Data are presented in an order that first highlights 

the primary public health goal of tobacco use cessation 

(i.e.,  successful cessation), including the following three 

measures: prevalence of former smoking (persons who 

ever smoked >100 cigarettes who do not currently smoke), 

quit ratio (the proportion of ever smokers who are former 

smokers), and prevalence of recent smoking cessation (persons who quit smoking for >6 months in the past year). 

These measures are then followed by intermediary measures that reflect a smoker’s journey to cessation (i.e., the 

cessation continuum), starting with the most proximate 

measure (prevalence of past-year quit attempts) and moving 

backward on the continuum from assessing a smoker’s current interest in quitting completely to whether he or she 
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 43

Smoking Cessation

has ever made a quit attempt (Institute of Medicine 2007). 

The chapter concludes by examining tobacco screening and 

cessation interventions provided by health professionals 

and the utilization of other selected cessation strategies.

For adults overall, the most recent year of data from 

NHIS is presented for each indicator by key demographic 

characteristics (e.g., sex, age [18–24, 25–44, and 45–64 years 

of age and 65 years of age and older], race/ethnicity, level 

of education, geographic region, and status of health 

insurance), followed by trends over time among adults 

for men and women overall and for non-Hispanic Whites 

(hereafter referred to as Whites), non-Hispanic Blacks 

(hereafter referred to as Blacks), and Hispanics. These data 

on adults are then followed by corresponding sections for 

analyses on young adults (18–24 years of age) and youth 

from various data sources. Some measures for young 

adults are missing, and statistically stable estimates could 

not be produced because of small sample sizes.

Trends in Current and Former Cigarette Smoking

Tests for linear and quadratic (nonlinear) trends were 

performed and controlled for variations in sex and race/

ethnicity over time. Models for adults overall controlled for 

age over time, and models for youth controlled for grade 

level. A test for linear trend is statistically significant if a 

straight line (indicating a consistent increase or decrease) 

fits the adjusted data significantly better than no linear 

trend (i.e., the null hypothesis of no linear trend over time 

is rejected). Similarly, a test for quadratic trend is statistically significant if a curved line with one bend (indicating 

an accelerated or decelerated rate of change during the 

assessed period) fits the adjusted data better than no quadratic trend. Quadratic trends were initially assessed. If the 

quadratic trend was not statistically significant, then tests 

for linear trends were performed. Tests for other time functions (i.e., trend shapes) were not assessed; it is possible 

that other time functions could also fit the data.

Adults

The NHIS definition of current cigarette smoking 

has changed over time. For the purposes of this report, 

the definition of current smoking has been standardized. Specifically, current cigarette smokers are defined as 

those who smoked at least 100 cigarettes in their lifetime 

and who smoked every day or on some days at the time of 

the survey. Former cigarette smokers are defined as those 

who smoked at least 100 cigarettes during their lifetime 

but were not smoking at the time of the survey.

Among adults in 2018, the prevalence of current 

cigarette smoking was 13.8%, the lowest measured prevalence among U.S. adults since NHIS data collection for 

this measure began in 1965; the prevalence of former 

cigarette smoking was 20.9% (NHIS, public use data, 

2018) (Blackwell and Villarroel 2018; Wang et al. 2018a). 

From 1965 to 2017, the prevalence of current smoking 

declined by 36.2  percentage points (relative percentage 

change: 69.6%) among men (from 52.0% to 15.8%) 

and 21.9  percentage points (relative percentage change: 

64.2%) among women (from 34.1% to 12.2%) (p <0.001 

for quadratic trend for both groups) (Figure  2.1). The 

prevalence of former smoking among all men peaked in 

1985 (at 30.9%), and the prevalence of former smoking 

among women peaked in 1994 (at 20.0%) (p <0.001 for 

quadratic trend for both groups). Among men, 1991 was 

the first year in which the prevalence of former smoking 

was higher than the prevalence of current smoking; however, not until 2010–2017 was the prevalence of former 

smoking consistently greater each year than the prevalence of current smoking. Among women, the prevalence 

of former smoking first surpassed the prevalence of current smoking in 2011 and remained higher through 2017.

Declines in the prevalence of current smoking 

were also observed across racial and ethnic subgroups 

(Figure  2.2) (p  <0.001 for linear trend for Whites from 

42.2% in 1965 to 15.2% in 2017, Blacks [p <0.001 for linear 

trend] from 46.0% in 1965 to 14.9% in 2017, and Hispanics 

[p <0.0001 for linear trend] from 31.6% in 1978 to 9.9% 

in 2017). Although the prevalence of former smoking 

exceeded the prevalence of current smoking among 

Whites during 2002–2017 and among Hispanics during 

2014–2017, the prevalence of former smoking among 

Blacks never exceeded the prevalence of current cigarette 

smoking during 1965–2017 (p <0.001 for quadratic trends 

for former smoking among Whites and Blacks and a linear 

trend [p <0.001] for Hispanics). The pattern of lower prevalence of former smoking than current smoking among 

Blacks may be the result of both their lower prevalence of 

initiation and their lower quit ratios compared with other 

racial/ethnic groups (USDHHS 2014).

It is important to note that the definition of a 

former smoker is broad and contains both persons who 

quit many years ago and persons who are actively trying 

to quit (i.e.,  they were not smoking at the time of the 

survey but could have quit for only 1 day). Decreases in 

the prevalence of former cigarette smoking among adults 

during the past 20–30 years primarily reflect decreases in 
A Report of the Surgeon General

44 Chapter 2

Figure 2.1 Trends in prevalence (%) of current and former cigarette smoking among adults 18 years of age and 

older, by sex; National Health Interview Survey (NHIS) 1965–2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 1965–2017.

Note: From 1965 to 2017, data were reported for the following years: 1965, 1966, 1970, 1974, 1976–1980, 1983, 1985, 1987, 1988, 

1990–1995, and 1997–2017.

Figure 2.2 Trends in prevalence (%) of current and former cigarette smoking among adults 18 years of age and 

older, by race/ethnicity; National Health Interview Survey (NHIS) 1965–2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 1965–2017.

Note: From 1965 to 2015, data were reported for the following years: 1965, 1966, 1970, 1974, 1976–1980, 1983, 1985, 1987, 1988, 

1990–1995, and 1997–2017.

aData were not collected for 1965, 1966, 1970, 1974, 1976, and 1977.

bData were statistically unreliable (relative standard error >30% or denominator <50 sample cases) for the following years: 1980, 

1987, 1992–1995, 2002, 2003, 2005, 2007–2013, and 2015–2017.

cData were statistically unreliable (relative standard error >30% or denominator <50 sample cases) for 1992 and 2016.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 45

Smoking Cessation

cigarette smoking initiation, as illustrated by data from 

birth cohorts (USDHHS 2014). Specifically, this means 

that the prevalence of former smoking has primarily 

decreased because youth and young adults, in particular, 

are less likely to initiate cigarette smoking than they might 

have been in the past. Therefore, the pool of persons who 

are eligible to quit has decreased over time. Nevertheless, 

during the past decade, adult former cigarette smokers 

have become more common than current smokers, with 

the exception of Black adults.

Young Adults

Current cigarette smokers are defined as those 

who smoked at least 100 cigarettes in their lifetime and 

who smoked every day or on some days at the time of the 

survey. Among U.S. young adults (18–24 years of age) in 

2017, the prevalence of current cigarette smoking was 

10.4%, and the prevalence of former cigarette smoking was 

5.1% (NHIS, public use data, 2017) (Wang et al. 2018a). 

Similar to data for adults overall, the prevalence of current 

smoking during 1965–2017 declined by 42.3  percentage 

points (relative percentage change: 77.9%) among young 

adult men (from 54.3% in 1965 to 12.0% in 2015; p <0.001 

for linear trend) and 29.6 percentage points (relative percentage change: 77.1%) among young adult women (from 

38.4% in 1965 to 8.8% in 2017; p  <0.001 for quadratic 

trend) (Figure 2.3). In contrast to the findings for adults 

overall, the prevalence of former smoking among young 

adult men peaked in 1977 (at 13.6%), and the prevalence 

of former smoking among young adult women peaked 

in 1978 (at 10.4%). Among young adult men and young 

adult women, the prevalence of former smoking has never 

exceeded the prevalence of current smoking (Figure 2.3).

Declines in the prevalence of current smoking 

among young adults across racial and ethnic subgroups 

were also similar to those for adults overall (Figure 2.4), 

declining for young adult Whites from 45.4% in 1965 to 

13.5% in 2017 (p <0.001 for quadratic trend), for young 

adult Blacks from 49.2% in 1965 to 8.6% in 2017 (p <0.001 

for quadratic trend), and for young adult Hispanics from 

36.1% in 1978 to 5.6% in 2017 (p <0.001 for linear trend) 

(Figure 2.4). In contrast to the findings for adults overall, 

the prevalence of former smoking among young adults in 

any of the three racial/ethnic groups never exceeded the 

prevalence of current smoking (Figure 2.4).

Youth

Current cigarette smoking in YRBS is defined as 

having smoked cigarettes on at least 1  day during the 

30 days before the survey. In 2017, the prevalence of current 

Figure 2.3 Trends in prevalence (%) of current and former cigarette smoking among young adults 18–24 years of 

age, by sex; National Health Interview Survey (NHIS) 1965–2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 1965–2017.

Note: From 1965 to 2017, data were reported for the following years: 1965, 1966, 1970, 1974, 1976–1980, 1983, 1985, 1987, 1988, 

1990–1995, and 1997–2017.
A Report of the Surgeon General

46 Chapter 2

smoking among U.S. students in grades  9–12 was 8.8% 

(Kann et al. 2018). Many youth experiment with cigarette 

smoking, and some progress to a more established pattern 

of smoking. Those with a more established pattern may be 

particularly important to study for future cessation trends, 

as they are most likely to become adult smokers (USDHHS 

2012). Among students in grades 9–12, the prevalence of 

current frequent cigarette smoking (ever smokers who 

had smoked 20  or more days during the past 30 days) 

was 2.7% (Kann et  al. 2018). The prevalence of current 

smoking increased during 1991–1997 (27.5–36.4%) and 

then decreased during 1997–2017 (36.4–8.8%), and a significant quadratic trend was observed (Kann et al. 2018). 

Similarly, the prevalence of current frequent smoking 

increased during 1991–1999 (12.8–17.0%) and then 

decreased during 2001–2017 (13.9–2.7%), and a  significant quadratic trend was also observed (Figure 2.5).

Similar nonlinear trends in these measures over time 

were observed by sex (YRBS, public use data, 1991–2017) 

and race/ethnicity (Figures 2.6a and 2.6b). The prevalence 

of current frequent smoking was consistently and statistically higher in Whites than in Blacks and Hispanics.

The YRBS does not contain a measure of former 

smoking that is similar to the NHIS measure of former 

Figure 2.4 Trends in prevalence (%) of current and former cigarette smoking among young adults 18–24 years of 

age, by race/ethnicity; National Health Interview Survey (NHIS) 1965–2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 1965–2017.

Note: From 1965 to 2017, data were reported for the following years: 1965, 1966, 1970, 1974, 1976–1980, 1983, 1985, 1987, 1988, 

1990–1995, and 1997–2017.

aData were not collected for 1965, 1966, 1970, 1974, 1976, and 1977.

bData were statistically unreliable (relative standard error >30% or denominator <50 sample cases) for the following years: 1980, 

1987, 1992–1995, 2002, 2003, 2005, 2007–2013, and 2015–2017.

cData were statistically unreliable (relative standard error >30% or denominator <50 sample cases) for 1992 and 2016.

smoking for adults (i.e.,  ever smoked at least 100  cigarettes but was not a current smoker at the time of the 

survey). However, during 2001–2013, the YRBS asked 

students whether they had ever smoked daily. Students 

who were former daily smokers (i.e.,  ever smokers who 

were not smoking currently but reported smoking daily 

in the past) presumably include the majority of youth who 

had smoked at least 100 cigarettes and had since stopped 

smoking. In 2013, the prevalence of former daily smoking 

(i.e., ever daily smokers who reported no current smoking) 

among students in grades 9–12 was 1.3%, and the prevalence of former nondaily smoking was 22.2% (Figure 2.5). 

From 2001 to 2013, a nonlinear decrease was observed 

in the prevalence of former daily smoking, and the prevalence of former nondaily smoking decreased linearly. 

Similar patterns were observed among females (YRBS, 

public use data, 2001–2013) and Whites (Figure 2.6b). In 

contrast, males (YRBS, public use data, 2001–2013) and 

Blacks (Figure 2.6b) had linear decreases for former daily 

smoking, but changes in this measure were not observed 

among Hispanics. In addition, nonlinear decreases in 

former nondaily smoking occurred among Blacks.

For all years, the prevalence of former nondaily 

smoking was higher than the prevalence of current 
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 47

Smoking Cessation

Figure 2.5 Trends in prevalence (%) of current frequenta, former dailyb, and former nondailyc cigarette smoking 

among high school students; National Youth Risk Behavior Survey (YRBS) 1991–2017; United States

Source: YRBS, Centers for Disease Control and Prevention, public use data, 1991–2017.

Note: The question about daily smoking was not asked in 2015 and 2017. aStudents who answered “yes” to “have you ever smoked” and “yes” to “do you currently smoke?”; and reported smoking on >19 days 

during the past 30 days.

bStudents who answered “yes” to “have you ever smoked” and “no” to “do you currently smoke?” and answered “yes” to “ever daily.”

cStudents who answered “yes” to “have you ever smoked” and “no” to “do you currently smoke?” and answered “no” to “ever daily.”

frequent and former daily smoking (Figure  2.5), indicating high percentages of youth tried (i.e., experimented 

with), but did not maintain, cigarette smoking. In contrast, the low prevalence of former daily smokers most 

likely reflects the low prevalence of daily smoking among 

students in grades 9–12 and the low prevalence of cessation among those who only recently became daily smokers 

(Fiore et al. 2008; USDHHS 2014).

Changing Characteristics of Current Cigarette Smokers

Adults

Demographic characteristics of current adult cigarette smokers have changed in recent years, reflecting 

changes in demographics of the U.S. population and 

advancements in national and state tobacco prevention 

and control policies (Howden and Meyer 2011; Humes 

et al. 2011; Ryan and Bauman 2016; National Center for 

Health Statistics 2018). These changes may have affected 

levels of interest in quitting cigarettes, the prevalence 

of quit attempts, and the prevalence of successful cessation. For example, during 2000–2017, notable changes 

occurred across several demographic variables (Table 2.2): 

• During 2000–2017, the proportion of current 

smokers who were 45–64  years of age increased 

from 30.9% to 39.9%, and the proportion of current smokers who were 65  years of age and older 

rose from 6.8% to 11.8%. Conversely, during this 

period, the proportions of current smokers who were 

18–24 or 25–44 years of age decreased, reflecting the 

decreased initiation of smoking among youth since 

1997 (USDHHS 2014).

• The proportion of current smokers who were Hispanic 

increased from 8.4% in 2000 to 11.3% in 2017, and 

the proportion of current smokers who were White 

decreased from 76.4% in 2000 to 69.5% in 2017.

• The proportion of current smokers 25 years of age 

and older whose highest level of education was 

a high school diploma decreased from 33.4% in 
A Report of the Surgeon General

48 Chapter 2

Figure 2.6a Trends in prevalence (%) of current frequenta cigarette smoking among high school students, 

by race/ethnicity; National Youth Risk Behavior Survey (YRBS) 1991–2017; United States

Source: YRBS, Centers for Disease Control and Prevention, public use data, 1991–2017.

Note: The question about daily smoking was not asked in 2015 and 2017. aStudents who answered “yes” to “have you ever smoked” and “yes” to “do you currently smoke?”; and reported smoking on >19 days 

during the past 30 days.

Figure 2.6b Trends in prevalence (%) of former dailya and former nondailyb cigarette smoking among high school 

students, by race/ethnicity; National Youth Risk Behavior Survey (YRBS) 1991–2017; United States

Source: YRBS, Centers for Disease Control and Prevention, public use data, 1991–2017.

Note: The question about daily smoking was not asked in 2015 and 2017. aStudents who answered “yes” to “have you ever smoked” and “no” to “do you currently smoke?”; and answered “yes” to “daily.”

bStudents who answered “yes” to “have you ever smoked” and “no” to “do you currently smoke?”; and answered “no” to “daily.”
Characteristic 2000: % (95% CI) 2005: % (95% CI) 2010: % (95% CI) 2015: % (95% CI) 2017: % (95% CI)

Sex (% male) 52.9 (51.6–54.3) 54.9 (53.5–56.4) 53.8 (52.2–55.4) 53.4 (51.5–55.3) 54.7 (52.6–56.8)

Age group (in years)

18–24 15.2 (14.0–16.3) 15.2 (14.0–16.4) 13.4 (12.1–14.7) 10.6 (9.3–12.0) 8.9 (7.6–10.2)

25–44 47.2 (45.9–48.5) 43.4 (41.9–44.9) 40.3 (38.8–41.9) 40.1 (38.2–42.1) 39.4 (37.5–41.3)

45–64 30.9 (29.7–32.0) 34.8 (33.4–36.2) 38.1 (36.4–39.7) 38.6 (36.7–40.5) 39.9 (38.0–41.8)

≥65 6.8 (6.2–7.3) 6.6 (6.0–7.2) 8.2 (7.4–9.1) 10.6 (9.6–11.7) 11.8 (10.7–12.9)

Race/ethnicity

White, non-Hispanic 76.4 (75.2–77.7) 74.4 (72.9–76.0) 74.1 (72.6–75.6) 71.3 (69.5–73.1) 69.5 (67.1–71.8)

Black, non-Hispanic 11.1 (10.3–11.9) 11.4 (10.4–12.4) 12.4 (11.2–13.5) 12.9 (11.7–14.2) 12.6 (11.0–14.2)

Hispanic 8.4 (7.7–9.2) 10.0 (9.0–10.9) 9.0 (8.2–9.8) 10.4 (9.3–11.5) 11.3 (9.5–13.1)

American Indian/Alaska 

Native, non-Hispanic

0.8 (0.5–1.1) 0.8 (0.4–1.1) 0.8 (0.5–1.1) 0.9 (0.6–1.2) 1.2 (0.7–1.8)

Asian, non-Hispanic 2.0 (1.5–2.5) 2.3 (1.8–2.9) 2.2 (1.8–2.6) 2.6 (2.1–3.2) 3.0 (2.3–3.8)

Multiple races, non-Hispanic 1.2 (0.9–1.5) 1.1 (0.8–1.5) 1.5 (1.2–1.9) 1.9 (1.4–2.3) 2.3 (1.8–2.9)

Level of educationb

≤12 years (no diploma) 21.5 (20.4–22.6) 19.8 (18.5–21.1) 18.4 (17.1–19.8) 19.8 (18.3–21.3) 18.0 (16.4–19.7)

GED certificate 5.5 (4.8–6.1) 5.6 (4.9–6.4) 6.7 (5.8–7.6) 6.1 (5.2–7.0) 7.0 (6.0–8.0)

High school diploma 33.4 (32.0–34.9) 32.0 (30.5–33.5) 29.4 (27.8–31.0) 27.4 (25.7–29.2) 27.2 (25.5–28.9)

Some college (no degree) 18.0 (17.0–19.1) 19.0 (17.8–20.2) 21.2 (19.8–22.5) 20.5 (18.9–22.1) 20.0 (18.4–21.6)

Associate degree 8.7 (7.9–9.5) 10.5 (9.5–11.4) 10.7 (9.6–11.8) 13.0 (11.7–14.2) 12.6 (11.3–13.9)

Undergraduate degree 9.5 (8.6–10.3) 9.6 (8.7–10.5) 10.0 (8.9–11.0) 10.0 (8.8–11.2) 11.1 (9.7–12.4)

Graduate degree 3.4 (2.8–3.9) 3.5 (3.0–4.1) 3.7 (3.0–4.4) 3.2 (2.5–3.8) 4.0 (3.2–4.8)

Poverty status (% below poverty level) 14.8 (13.7–15.8) 16.3 (15.2–17.4) 19.5 (18.2–20.9) 21.0 (19.6–22.5) 19.2 (17.5–20.9)

Geographic region

Northeast 18.0 (16.7–19.3) 16.8 (15.5–18.2) 15.9 (14.6–17.2) 15.6 (13.9–17.2) 14.7 (12.8–16.6)

Midwest 27.8 (26.4–29.1) 28.7 (27.1–30.2) 26.2 (24.6–27.8) 27.8 (25.6–29.9) 26.4 (24.3–28.6)

South 37.9 (36.2–39.5) 37.7 (35.8–39.5) 38.7 (36.8–40.6) 37.7 (35.7–39.7) 40.3 (37.9–42.6)

West 16.4 (15.2–17.5) 16.8 (15.6–18.1) 19.2 (17.7–20.8) 19.0 (17.3–20.7) 18.6 (16.7–20.5)

Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 49

Table 2.2 Distribution of selected demographic characteristics of adult current cigarette smokersa 18 years of age and older; National Health Interview 

Survey (NHIS) 2000, 2005, 2010, 2015, and 2017; United States
Characteristic 2000: % (95% CI) 2005: % (95% CI) 2010: % (95% CI) 2015: % (95% CI) 2017: % (95% CI)

Health insurance coverage

Private 61.9 (60.5–63.3) 56.4 (54.7–58.1) 48.3 (46.6–50.0) 48.1 (46.1–50.1) 48.7 (46.6–50.8)

Medicaid (includes persons with 

Medicaid and Medicare)

7.7 (7.0–8.5) 11.0 (10.1–11.9) 13.4 (12.4–14.4) 21.6 (19.9–23.3) 20.9 (19.1–22.7)

Medicare only 1.9 (1.6–2.3) 1.8 (1.5–2.1) 2.8 (2.3–3.2) 4.0 (3.3–4.7) 4.6 (3.9–5.4)

Other coverage 3.7 (3.3–4.2) 4.3 (3.7–4.8) 5.7 (5.0–6.4) 6.7 (5.8–7.6) 7.6 (6.6–8.6)

Uninsured 24.0 (22.9–25.2) 26.3 (24.9–27.7) 29.5 (28.1–30.9) 18.8 (17.2–20.3) 17.7 (16.1–19.2)

A Report of the Surgeon General

50 Chapter 2

Table 2.2 Continued

Source: NHIS, National Center for Health Statistics, public use data, 2000, 2005, 2010, 2015, and 2017.

Notes: CI = confidence interval; GED = General Educational Development. aPersons who reported smoking ≥100 cigarettes during their lifetime and who, at the time of the interview, reported smoking every day or some days.

bAmong only adults 25 years of age and older.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 51

Smoking Cessation

2000 to 27.2% in 2017; the proportion of current 

smokers with 12 or fewer years of education (with 

no diploma) decreased from 21.5% in 2000 to 18.0% 

in 2017; and the proportion of current smokers with 

an associate degree increased from 8.7% to 12.6% 

during the time period.

• The proportion of current smokers living below the 

poverty level increased from 2000 (14.8%) to 2017 

(19.2%).

• The proportion of current smokers covered by 

Medicaid rose from 7.7% in 2000 to 20.9% in 2017, 

and the proportion of current smokers with private 

health insurance decreased from 61.9% in 2000 to 

48.7% in 2017.

• The proportion of current smokers covered only by 

Medicare increased from 1.9% in 2000 to 4.6% in 

2017, and the proportion of current smokers who 

were uninsured increased from 24.0% in 2000 to 

29.5% in 2010 but then decreased to 17.7% in 2017.

Tobacco-use characteristics among current adult 

cigarette smokers also changed during 2000–2017. The 

proportion of current smokers who did not smoke every 

day increased from 17.9% in 2000 to 25.1% in 2017 

(Table  2.3), and the proportion of current smokers who 

smoked fewer than 14 cigarettes per day also increased: 

the proportion of smokers who smoked 1–4 cigarettes per 

day rose from 4.0% in 2000 to 7.0% in 2017; and the proportion of smokers who smoked 5–14 cigarettes per day 

rose from 25.4% to 34.9%. The proportion of smokers 

who usually smoked menthol cigarettes increased from 

26.4% in 2005 to 31.6% in 2010 but did not change significantly (31.5%) in 2015 (data on menthol cigarettes 

were not available in 2017). Use of other tobacco products 

(cigars, smokeless tobacco, and/or pipes) by current cigarette smokers increased from 10.2% in 2000 to 14.5% in 

2017. Current adult cigarette smokers who were also current users of electronic cigarettes (e-cigarettes) decreased 

from 13.6% in 2015 to 10.0% in 2017 (NHIS, public use 

data, 2015, 2017). Current e-cigarette users who were also 

current cigarette smokers decreased from 58.8% in 2015 

to 49.6% in 2017 (NHIS, public use data, 2015, 2017).

Young Adults

Trends in demographic characteristics among 

young adult current smokers (18–24  years of age) were 

similar to trends among all adults, except that the proportion of young adult smokers living below the poverty level 

was the highest in 2010 (29.9%) (Table 2.4), and the proportion of adult current smokers living below the poverty 

level was highest in 2015 (21.0%) (Table  2.2). The proportion of young adult current smokers who had private 

insurance was lowest (38.2%) in 2010. Among adult current smokers, the lowest proportion with private insurance (48.1%) was in 2015 (Table 2.2).

Changes in the distribution of tobacco product use 

over time among young adults are similar to those for all 

adults (Table  2.5). In 2017, the proportion of cigarette 

smokers who were some-day smokers was higher among 

young adults (34.7%) than among adults overall (25.1%) 

(Table 2.3), and the proportion who smoked 15–24 cigarettes per day was lower among young adults (15.8%) than 

among adults overall (27.8%). In addition, in 2017, the 

prevalence of cigar smoking, smokeless tobacco use, and 

pipe use among current smokers was higher among young 

adults (19.2%, 9.3%, and 7.7%, respectively) (Table  2.5) 

than it was among adults overall (10.6%, 3.5%, and 2.7%, 

respectively) (Table  2.3); the same was also true for the 

combined category of any cigar, smokeless tobacco, and/or 

pipe use (28.4% vs. 14.5%).

Youth

Findings from the national YRBS indicate that, 

among high school students (grades 9−12) who were current frequent cigarette smokers (ever smokers who had 

smoked >19  days during the past 30  days), the proportion who were White decreased from 84.5% in 2001 to 

75.6% in 2005 and remained lower through 2017 (73.7%, 

p  <0.001 for quadratic trend)), and the proportion who 

were Hispanic increased from 6.2% in 2001 to 13.6% in 

2015 to 14.5% in 2017 (Table 2.6; p <0.001 for quadratic 

trend). The proportion who were Black remained statistically unchanged during this period (3.9% in 2001 and 

5.3% in 2017).

Use of smokeless tobacco increased during 2001–

2015 among frequent youth smokers (from 19.9% to 

35.2%) (Table  2.7); comparable data were not available 

from the 2017 YRBS because the smokeless tobacco question changed. In 2017, the majority of frequent youth 

smokers (68.0%) also used e-cigarettes. According to 

NYTS, use of menthol cigarettes among high school students increased among frequent smokers, from 33.7% in 

2000 to 52.9% in 2017 (Table 2.8) to 53.0% in 2018 (NYTS, 

public use data, 2018). Similar findings were observed 

among current youth cigarette smokers, in a comparison 

of NYTS data between 1999–2009 and 2010–2013 using a 

slightly different definition of use of menthol cigarettes 

(Courtemanche et  al. 2017). Of note, caution should be 

taken when assessing trends among youth or comparing 
Characteristic 2000: % (95% CI) 2005: % (95% CI) 2010: % (95% CI) 2015: % (95% CI) 2017: % (95% CI)

Cigarette smoking frequency, amount

Some-day smokers 17.9 (16.8–19.0) 19.4 (18.2–20.6) 21.9 (20.5–23.2) 24.4 (22.8–26.0) 25.1 (23.4–26.9)

Daily smokers, 1–4 cpd 4.0 (3.4–4.4) 4.4 (3.7–5.0) 5.9 (5.2–6.6) 6.6 (5.8–7.5) 7.0 (5.9–8.1)

Daily smokers, 5–14 cpd 25.4 (24.2–26.6) 29.4 (27.9–30.8) 32.5 (31.0–33.9) 34.4 (32.6–36.2) 34.9 (33.1–36.8)

Daily smokers, 15–24 cpd 37.7 (36.4–39.0) 35.4 (33.9–36.9) 32.5 (30.9–34.0) 28.5 (26.7–30.2) 27.8 (26.0–29.6)

Daily smokers, ≥25 cpd 15.1 (14.1–16.1) 11.4 (10.4–12.5) 7.3 (6.4–8.2) 6.1 (5.1–7.0) 5.1 (4.3–5.9)

Usually smokes menthol

Yes NA 26.4 (24.9–27.9) 31.6 (30.0–33.3) 31.5 (29.7–33.4) NA

No NA 71.3 (69.9–72.7) 66.3 (64.7–67.9) 66.0 (64.1–67.9) NA

No usual type NA 2.3 (1.8–2.8) 2.0 (1.6–2.5) 2.4 (1.9–3.0) NA

Current use of other tobacco products

Cigars 7.4 (6.7–8.1) 8.0 (7.1–8.9) 10.3 (9.2–11.3) 8.7 (7.6–9.8) 10.6 (9.1–12.0)

Smokeless tobacco 2.7 (2.2–3.2) 3.5 (2.7–4.3) 3.6 (3.0–4.3) 4.0 (3.1–4.9) 3.5 (2.8–4.2)

Pipes 1.4 (1.1–1.7) 1.4 (1.0–1.8) NA 2.6 (2.0–3.3) 2.7 (2.0–3.3)

Any use of cigars, smokeless 

tobacco, pipes

10.2 (9.4–11.1) 11.3 (10.3–12.4) NA 13.3 (11.9–14.6) 14.5 (12.9–16.1)

E-cigarettes NA NA NA 13.6 (12.2–14.9) 10.0 (8.8–11.1)

A Report of the Surgeon General

52 Chapter 2

Source: NHIS, National Center for Health Statistics, public use data, 2000, 2005, 2010, 2015, and 2017.

Notes: CI = confidence interval; aPersons who reported smoking ≥100 cigarettes during their lifetime and who, at the time of the interview, reported smoking every day or some days.

Table 2.3 Distribution of tobacco use characteristics among adult current cigarette smokersa 18 years of age and older; National Health Interview Survey 

(NHIS) 2000, 2005, 2010, 2015, and 2017; United States
Characteristic 2000: % (95% CI) 2005: % (95% CI) 2010: % (95% CI) 2015: % (95% CI) 2017: % (95% CI)

Sex (% male) 53.0 (49.5–56.6) 57.5 (53.0–61.9) 57.2 (51.9–62.5) 58.2 (51.5–64.8) 57.6 (49.9–65.4)

Race/ethnicity

White, non-Hispanic 77.7 (74.6–80.6) 73.0 (68.9–77.0) 72.7 (68.3–77.1) 64.3 (58.1–70.6) 71.2 (64.2–78.2)

Black, non-Hispanic 8.8 (6.7–10.8) 9.5 (6.9–12.1) 12.0 (8.7–15.4) 12.9 (8.5–17.4) 11.4 (6.6–16.3)

Hispanic 9.5 (7.5–11.5) 12.8 (10.3–15.2) 10.3 (7.5–13.1) 14.5 (10.2–18.9) 12.1 (7.0–17.2)

American Indian/Alaska 

Native, non-Hispanic

—b —b —b —b —b

Asian, non-Hispanic 1.9 (0.9–3.0) —b 2.3 (1.3–3.4) 3.1 (1.3–4.9) —b

Multiple races, non-Hispanic 1.7 (0.8–2.6) —b —b —b —b

Poverty status (% below poverty level) 21.0 (17.7–24.2) 24.2 (19.5–28.9) 29.9 (25.1–34.7) 24.5 (19.3–29.6) 24.5 (17.7–31.3)

Geographic region

Northeast 17.5 (14.1–20.9) 13.0 (9.8–16.3) 16.7 (12.2–21.2) 16.2 (10.2–22.3) 13.4 (6.5–20.3)

Midwest 32.4 (28.3–36.5) 31.6 (27.5–35.8) 28.1 (23.8–32.5) 30.0 (23.5–36.4) 27.3 (21.2–33.4)

South 35.8 (31.6–39.9) 40.8 (35.8–45.8) 36.8 (31.8–41.7) 33.3 (27.1–39.6) 42.0 (34.3–49.7)

West 14.4 (11.9–16.9) 14.5 (11.9–17.2) 18.4 (14.6–22.2) 20.5 (15.2–25.7) 17.3 (11.7–22.8)

Health insurance coverage

Private 52.9 (49.0–56.9) 43.5 (39.0–48.0) 38.2 (33.1–43.3) 47.4 (40.3–54.5) 46.5 (39.4–53.6)

Medicaid and persons with Medicaid 

and Medicare

9.0 (7.0–10.8) 13.7 (10.8–16.5) 16.9 (13.2–20.6) 26.2 (20.3–32.0) 21.5 (15.2–27.8)

Other coverage —b 1.8 (0.8–2.8) 3.0 (1.4–4.7) —b —b

Uninsured 35.6 (31.7–39.5) 40.4 (36.0–44.8) 41.0 (35.9–46.2) 22.0 (17.0–27.0) 28.1 (21.4–34.7)

Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 53

Source: NHIS, National Center for Health Statistics, public use data, 2000, 2005, 2010, 2015, and 2017.

Notes: CI = confidence interval.

aPersons who reported smoking ≥100 cigarettes during their lifetime and who, at the time of the interview, reported smoking every day or some days.

bPrevalence estimates with a relative standard error ≥30% are not presented due to low precision.

Table 2.4 Distribution of selected demographic characteristics of young adult current cigarette smokersa 18–24 years of age; National Health Interview 

Survey (NHIS) 2000, 2005, 2010, 2015, and 2017; United States
Characteristic 2000: % (95% CI) 2005: % (95% CI) 2010: % (95% CI) 2015: % (95% CI) 2017: % (95% CI)

Cigarette smoking frequency, amount

Some-day smoker 21.8 (18.5–25.1) 24.4 (20.6–28.3) 30.0 (25.4–34.5) 40.8 (34.1–47.6) 34.7 (28.1–41.2)

Daily smoker, 1–4 cpd 5.4 (3.7–7.0) 7.6 (5.0–10.2) 8.8 (6.0–11.6) 9.5 (5.5–13.6) 8.6 (4.5–12.7)

Daily smoker, 5–14 cpd 36.2 (32.4–40.0) 38.7 (34.6–42.7) 36.6 (31.7–41.6) 36.2 (29.3–43.1) 40.6 (33.0–48.1)

Daily smoker, 15–24 cpd 30.9 (27.5–34.3) 24.0 (20.1–27.9) 21.9 (17.7–26.0) 12.1 (7.8–16.4) 15.8 (10.1–21.5)

Daily smoker, ≥25 cpd 5.8 (3.9–7.6) —b —b —b —b

Usually smokes menthol

Yes NA 30.7 (26.1–35.2) 43.8 (38.5–49.0) 35.4 (28.5–42.4) NA

No NA 66.3 (61.6–71.1) 52.7 (47.4–58.0) 58.7 (51.4–66.0) NA

No usual type NA 3.0 (1.7–4.3) 3.5 (1.6–5.4) 5.9 (2.5–9.2) NA

Current use of other tobacco products

Cigars 10.0 (7.6–12.4) 10.8 (7.7–13.9) 15.6 (11.8–19.4) 10.0 (6.0–14.0) 19.2 (13.3–25.1)

Smokeless tobacco 4.6 (2.6–6.5) 8.1 (4.0–12.2) 6.7 (4.1–9.3) 10.6 (5.4–15.7) 9.3 (5.2–13.3)

Pipes 2.5 (1.3–3.6) 2.4 (1.1–3.7) NA 6.1 (2.8–9.3) 7.7 (4.0–11.5)

Anyuseof cigars,smokeless 

tobacco, and pipes

15.0 (12.0–18.1) 17.3 (12.8–21.9) NA 21.5 (15.3–27.8) 28.4 (21.7–35.0)

E-cigarettes NA NA NA 18.6 (13.1–21.7) 16.1 (11.0–21.1)

A Report of the Surgeon General

54 Chapter 2

Source: NHIS, National Center for Health Statistics, public use data, 2000, 2005, 2010, 2015, and 2017.

Notes: CI = confidence interval; cpd = cigarettes smoked per day; NA = not available. aPersons who reported smoking ≥100 cigarettes during their lifetime and who, at the time of the interview, reported smoking every day or some days.

bPrevalence estimates with a relative standard error ≥30% are not presented due to low precision.

Table 2.5 Distribution of tobacco use characteristics of young adult current cigarette smokersa 18–24 years of age; National Health Interview Survey 

(NHIS) 2000, 2005, 2010, 2015, and 2017; United States
Characteristic 2001: % (95% CI) 2005: % (95% CI) 2009: % (95% CI) 2015: % (95% CI) 2017: % (95% CI)

Sex (% male) 52.0 (48.1–55.9) 50.3 (46.4–54.3) 57.2 (53.2–61.0) 52.0 (47.0–56.9) 49.1 (42.0–56.3)

Grade

9 19.2 (15.4–23.7) 21.8 (18.5–25.5) 18.1 (15.1–21.6) 17.4 (11.0–26.6) 14.4 (9.9–20.5)

10 23.3 (20.0–26.8) 21.0 (17.3–25.2) 20.6 (17.9–23.6) 22.9 (17.4–29.5) 17.1 (12.1–23.6)

11 25.3 (21.0–30.3) 26.3 (23.0–30.0) 26.9 (23.1–31.0) 23.4 (17.3–30.8) 26.5 (20.0–34.2)

12 32.2 (28.5–36.1) 30.9 (26.8–35.4) 34.4 (31.0–38.1) 36.3 (30.6–42.4) 42.0 (35.2–49.2)

Race/ethnicityb

White, non-Hispanic 84.5 (81.1–87.4) 75.6 (69.5–80.8) 78.9 (73.8–83.3) 66.0 (57.6–73.5) 73.7 (67.6–78.9)

Black, non-Hispanic 3.9 (2.7–5.7) 5.4 (3.3–8.6) 4.2 (2.6–7.0) 7.1 (4.1–12.1) 5.3 (2.3–11.9)

Hispanic 6.2 (4.4–8.6) 10.5 (7.6–14.2) 10.2 (7.8–13.1) 13.6 (9.7–18.7) 14.5 (10.8–19.3)

Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 55

Source: YRBS, Centers for Disease Control and Prevention, public use data, 2001, 2005, 2009, 2015, and 2017.

Notes: CI = confidence interval. aStudents who answered “yes” to “have you ever smoked?”; and “yes” to “do you currently smoke?”; and reported smoking on >19 days during the past 30 days.

bEstimates will not add up to 100% because data were not reported for students of other/multiple races/ethnicities.

Table 2.6 Distribution of demographic characteristics of high school students who are frequent cigarette smokersa; National Youth Risk Behavior Survey 

(YRBS) 2001, 2005, 2009, 2015, and 2017; United States
Other tobacco products 2001: % (95% CI) 2005: % (95% CI) 2009: % (95% CI) 2015: % (95% CI) 2017: % (95% CI)

Cigarsb 44.3 (40.0–48.8) 47.6 (42.7–52.7) 52.7 (45.6–59.7) 54.1 (47.1–61.0) 54.8 (46.7–62.7)

Smokeless tobaccoc 19.9 (15.9–24.5) 23.5 (19.9–27.6) 35.5 (31.1–40.2) 35.2 (29.2–41.7) NA

Electronic vapor productsd NA NA NA 76.4 (70.8–81.2) 68.0 (58.2–76.4)

Usuallysmokesmentholcigarettes 2000: % (95% CI) 2004: % (95% CI) 2009: % (95% CI) 2015: % (95% CI) 2017: % (95% CI)

Yes 33.7 (28.7–38.7) 47.2 (40.3–54.1) 50.5 (44.1–56.9) 48.8 (39.8–57.8) 52.9 (41.0–64.7)

No 63.7 (58.7–68.6) 52.8 (45.9–59.7) 49.5 (43.1–55.9) 45.2 (36.6–53.8) 42.2 (30.0–54.3)

No usual brand 2.7 (1.9–3.4) NA NA NA NA

Not sure NA NA NA 6.0 (1.9–10.0) —b

A Report of the Surgeon General

56 Chapter 2

Source: YRBS, Centers for Disease Control and Prevention, public use data, 2001, 2005, 2009, 2015, and 2017.

Notes: CI = confidence interval; NA = not available.

aStudents who answered “yes” to “have you ever smoked?”; “yes” to “do you currently smoke?”; and reported smoking ≥20 days during the past 30 days.

bSmoked cigars, cigarillos, or little cigars on at least 1 day during the 30 days before the survey.

cUsed chewing tobacco, snuff, or dip on at least 1 day during the 30 days before the survey.

dUsed e-cigarettes, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, or hookah pens during the 30 days before the survey.

Source: NYTS, Centers for Disease Control and Prevention, public use data, 2000, 2004, 2009, 2015, and 2017.

Notes: CI = confidence interval; NA = not available; 

aStudents who answered “yes” to “have you ever tried cigarette smoking?” were categorized as (a) current infrequent smokers for smoking 1–19 days during the past 30 days

or (b) current frequent smokers for smoking ≥20 days during the past 30 days.

bPrevalence estimates with a relative standard error ≥30% are not presented due to low precision.

Table 2.7 Prevalence of use of other tobacco products among high school students who are frequent cigarette smokersa; National Youth Risk Behavior 

Survey (YRBS) 2001, 2005, 2009, 2015, and 2017; United States

Table 2.8 Prevalence of use of menthol cigarettes among high school students who currently smoke cigarettes, by frequency of smokinga; National 

Youth Tobacco Survey (NYTS) 2000, 2004, 2009, 2015, and 2017; United States
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 57

Smoking Cessation

Key Disparities in Current Cigarette Smoking Among Adults 

and Youth

Numerous Surgeon General’s reports have reviewed 

disparities in the prevalence of current smoking (USDHHS 

1998, 2001, 2012, 2014). In 2017, the prevalence of current cigarette smoking was 20.0% or higher in a variety of 

vulnerable or high-risk groups:

• 36.8% among those who had obtained a General 

Educational Development (GED) certificate but 

went no further in their education;

• 35.2% among persons with serious psychological 

distress, a proxy variable for mental illness;

• 24.7% among persons with no health insurance;

• 24.5% among Medicaid enrollees;

• 24.0% among American Indians/Alaska Natives; and

• 20.3% among lesbian, gay, and bisexual adults 

(Wang et al. 2018a).

Disparities by Behavioral Health 

Condition

Data from the U.S. National Survey on Drug Use and 

Health (NSDUH) from 2005 to 2013 indicate that current 

smoking among adults reporting anxiety, depression, or 

substance abuse disorders ranged from 39.6% to 56.3% 

(Stanton et  al. 2016). In the 2014 NSDUH, the prevalence of current smoking among persons who abused 

or were dependent on illicit drugs other than marijuana 

was 63.3%, and among those who abused or were dependent on marijuana, it was 51.3% (Weinberger et al. 2018). 

Data from the 2012 NHIS indicate that the age-adjusted 

prevalence of current smoking was 53.0% among those 

with a lifetime history of bipolar disorder, 31.5% among 

those with a lifetime history of depression, 30.6% among 

those with a lifetime history of attention deficit disorder or 

attention deficit hyperactivity disorder, and 28.3% among 

those with a lifetime history of phobias or fears (NHIS, 

public use data, 2012).

Disparities by Chronic Disease 

Status

Using 2017 NHIS data, the prevalence of current smoking was high among persons with emphysema (35.2%) and those with chronic bronchitis (29.7%). 

Among those with other smoking-related diseases (lung 

cancer, other cancers, coronary heart disease, and stroke) 

(see Chapter 4), the prevalence of current smoking ranged 

from 13.5% to 35.2% and was 14.8% among those with 

other chronic diseases1 and 12.2% among those with no 

chronic diseases (NHIS, public use data, 2017).

Disparities by Geographic Location

The prevalence of current smoking varies widely 

by geographic location. Data from the 2017 NHIS indicate that by region, cigarette smoking was higher in 

the Midwest (16.9%) and South (15.5%) than in the 

Northeast (11.2%) and West (11.0%) (Wang et al. 2018a). 

Data from the 2017 BRFSS indicate that by state, West 

Virginia, Kentucky, and Louisiana had the highest prevalence of current cigarette smoking (26.0%, 24.6%, and 

23.1%, respectively), and the states of Utah, California, 

and Connecticut had the lowest prevalence (8.9%, 11.3%, 

and 12.7%, respectively) (CDC 2017). Data from the 2013 

1Other chronic diseases are defined as those that are not related to smoking, including hypertension; other heart condition or heart disease; ulcer; and cancers, including blood, bone, brain, breast, gallbladder, lymphoma, melanoma, ovarian, prostate, skin (non-melanoma 

and other), soft tissue, testicular, thyroid, and other types of cancer.

the timing of the increases among youth with the increases 

among adults (Table 2.3) because wording of the question 

in NYTS changed over time, which may have influenced 

the likelihood of an affirmative response. For example, 

in 2000, the question was, “Is the brand of cigarettes you 

usually smoked during the past 30 days mentholated?” but 

in questionnaires in 2015 and 2017, the question changed 

to, “Menthol cigarettes are cigarettes that taste like mint. 

During the past 30 days, were the cigarettes that you usually smoked menthol?” (CDC 2018).
A Report of the Surgeon General

58 Chapter 2

BRFSS indicate that persons who live in rural counties 

have a higher prevalence of smoking than persons who 

live in metropolitan areas, with estimates ranging from 

a high of 25.1% in rural counties to a low of 16.1% in 

large metropolitan centers (Matthews et  al. 2017). In a 

multivariate logistic regression model controlling for age, 

sex, poverty, and geographic region, the 2013–2014 PATH 

Study observed that, compared with urban residents, 

rural residents had 25% greater odds of being current 

cigarette smokers (smoked in the past 30 days) (Roberts 

et al. 2017).

Disparities by Sexual Orientation 

and Gender Identity

The prevalence of cigarette smoking among lesbian, gay, bisexual, and transgender (LGBT) individuals 

is higher than the prevalence of smoking among heterosexual or straight persons. According to NHIS data, 

in 2017, current cigarette smoking was 20.3% among 

lesbian, gay, and bisexual adults compared with 13.7% 

among heterosexual or straight adults (Wang et  al. 

2018a). Variations in the prevalence of cigarette smoking 

also exist across sexual orientation and gender minority 

subgroups. Data from the 2012–2013 NATS indicated that 

cigarette smoking was particularly high among bisexual 

women, and that sexual minority women started smoking 

and transitioned to daily smoking earlier than their heterosexual or straight counterparts (Johnson et al. 2016). 

Data from the 2009–2010 NATS indicated that menthol 

cigarette smoking was significantly higher among LGBT 

adult smokers, particularly among LGBT women, than 

among their heterosexual counterparts (Fallin et  al. 

2015). Limited information exists on the prevalence of 

cigarette smoking by gender identity. A 2013 cross-sectional online survey of U.S. adults found that the prevalence of cigarette smoking was higher among transgender adults than among cisgender adults (Buchting 

et al. 2017).

Similar disparities in the prevalence of smoking 

by sexual orientation and gender identity exist among 

youth. Data from the 2017 YRBS indicated that current 

cigarette smoking by high school students in grades 

9–12  was higher among gay, lesbian, and bisexual students (16.2%) than among heterosexual students (8.1%) 

and those unsure of their sexual orientation (10.1%) 

(Kann et  al. 2018). Moreover, 2017 YRBS data from 

19 states and large urban school districts found that ever 

use of cigarettes was significantly higher among transgender high school students (32.9%) than among cisgender male (23.2%) and cisgender female (22.0%) students (Johns et al. 2019).

Sexual orientation and gender identity are two separate and distinct measures, and existing surveillance data 

suggest disparities in smoking prevalence by both sexual 

orientation and gender identity. Taken together, these 

findings reinforce the heterogeneity of tobacco product 

use by sexual orientation and the critical importance 

of (a)  tobacco control efforts designed to reach sexual 

and gender minorities and (b)  tobacco survey measures 

designed specifically to ask adults and youth about gender 

identity separately from sexual orientation.

Disparities in Smoking in Pregnant 

Women

Smoking during pregnancy can have devastating 

health consequences for the mother, such as the outcome 

of the pregnancy, and for the future health of the child, 

making quitting smoking an important part of prenatal 

care (USDHHS 2014) (also see in this report related sections on smoking cessation and reproductive health in 

Chapter  4). According to data from birth certificates of 

children of women who gave birth in 2016, 7.2% of women 

in the United States reported smoking during pregnancy 

(Drake et al. 2018).

In a study using the first wave of data from the 2013–

2014 PATH Study, the prevalence of current cigarette 

smoking among women of reproductive age was 20.1%, 

and current cigarette smoking was highly correlated with 

the use of other tobacco products (Lopez et al. 2018). Data 

from the 2013 Pregnancy Risk Assessment Monitoring 

System (PRAMS) indicated that 21.1% of women had 

smoked during the 3 months before pregnancy, and 14.0% 

had smoked postpartum. Estimates of the prevalence of 

smoking in working women of reproductive age and in 

working pregnant women from the 2009–2013 NHIS are 

generally lower than estimates in PRAMS, with 17.3% and 

6.8% of these women, respectively, being current smokers 

(Mazurek and England 2016).

In 2016, disparities in cigarette smoking during 

pregnancy occurred by age, race/ethnicity, educational 

level, and geographic location (Drake et  al. 2018). For 

smoking during pregnancy, women 20–24 years of age had 

the highest prevalence (10.7%) by age group; American 

Indian/Alaska Native women had the highest prevalence 

(16.7%) by race/ethnicity; and women with a high school 

diploma or GED had the highest prevalence by level of 

education (12.2%). Prevalence of current smoking among 

pregnant women was highest in West Virginia (25.1%), 

Kentucky (18.4%), and Montana (16.5%) and lowest in 

Arizona, California, Connecticut, Hawaii, New Jersey, New 

York, Nevada, Texas, Utah, and Washington, D.C. (each 

<5.0%) (Drake et al. 2018).
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 59

Smoking Cessation

Disparities in Smoking Among 

Active Duty Service Members

Tobacco use can negatively impact the readiness and resilience of active duty service members and 

is a major concern to the Military Health System of the 

U.S. Department of Defense (Bondurant and Wedge 2009). 

In June 2019, the Surgeons General of the Air Force, 

Army, Navy, and United States released an open letter 

stating tobacco use is a threat to the health and fitness of 

U.S. military forces and compromises readiness, which is 

the foundation of a strong national defense (Adams et al. 

2019). An estimated 38% of current cigarette smokers 

in the military initiated smoking after enlisting (Carter 

2016), and tobacco use has been associated with higher 

dropout rates during basic training, poorer visual acuity, 

higher rates of leaving military service during the first 

year, and higher rates of absenteeism (Bondurant and 

Wedge 2009). Factors that may promote tobacco use in 

the military include stress, peer influence, and easy access 

to less expensive tobacco products (Haddock et al. 2014). 

Additionally, the tobacco industry has previously been 

shown to target marketing toward active duty service 

members (Smith and Malone 2009).

In addition to the health-related burden, tobacco 

use also exacts significant financial costs to the military. In 2009, it was estimated that tobacco use costs the 

U.S. Department of Defense $1.6 billion a year for medical care, increased hospitalizations, and absenteeism 

(Bondurant and Wedge 2009). Additionally, in 2010, 

Veterans Health Administration (VHA) spent $2.7 billion 

on smoking-related ambulatory care, prescription drugs, 

hospitalizations, and home healthcare (Barnett et al. 2015).

According to data from the 2015 Health Related 

Behaviors Survey (HRBS) from the U.S. Department of 

Defense, 13.9% of service members currently smoked cigarettes, a prevalence that is two-fold higher among military 

personnel who have been deployed (28.0%) (Meadows 

et al. 2018). Additionally, among active duty service members, disparities exist by branch of service, sex, age group, 

race/ethnicity, education, and pay grade. For example, 

cigarette smoking is highest among those in the Marine 

Corps (20.7%); men (14.4%); persons 17–24 years of age 

(19.5%); those who reported being Other race/ethnicity 

(16.1%), White (14.6%), or Hispanic (14.6%); those with a 

high school education or less (25.1%); and those with low 

salaries (E1–E4 pay grade) (17.9%).

Correlation of Smoking-Related 

Risk Factors

As with many health behaviors and chronic diseases, several risk factors for cigarette smoking are highly 

correlated (Remington et al. 2016). For example, in 2017, 

the prevalence of serious psychological distress was 9.6% 

among those who completed grades  9–12 (with neither 

a high school diploma nor a GED certificate) compared 

with 2.8% among those with at least a high school education (NHIS, public use data, 2017). Similarly, those 

who completed grades 9–12 (with neither a diploma or a 

GED certificate) were more likely than those with more 

than a high school education to live below the poverty 

level (27.9%  vs. 7.2%, respectively) or to be uninsured 

(20.3%  vs. 7.3%, respectively) (NHIS, public use data, 

2017). Persons with multiple risk factors for current 

smoking had a higher prevalence of smoking than those 

with a single risk factor. For example, the prevalence of 

smoking was 58.5% among those with serious psychological distress who completed 9–12 years of education with 

neither a diploma or a GED certificate, but it was 32.7% 

among those with serious psychological distress with 

at least a high school education (Figures  2.7a and 2.7b 

[NHIS, public use data, 2017]).

Cigarette Smoking Cessation Among Adults and Youth

Recent Successful Cessation

Recent successful cessation is defined as having 

smoked during the past year but having quit for at least 

6 months at the time of the survey interview. The denominator in the prevalence calculation includes all persons 

who smoked during the past year (i.e., both current cigarette smokers and former smokers who reported quitting 

during the past year). Furthermore, to be included in the 

denominator, current smokers had to have smoked for at 

least 2 years—corresponding to the Healthy People 2020 

definition for recent smoking cessation success (measure TU-5.1) (Office of Disease Prevention and Health 

Promotion n.d.a). Recent smoking cessation gives a more 

proximate measure of current patterns in smoking cessation than prevalence of former smoking; however, recent 

smoking cessation may overestimate sustained quitting 

because some former smokers will relapse to smoking after 

6 months (Hughes et al. 2008). Estimates of long-term sustained quit rates using smoking prevalence and initiation 
A Report of the Surgeon General

60 Chapter 2

Figure 2.7a Prevalence of current cigarette smoking by level of education and presence or absence of serious 

psychological distress and poverty status among adults 25 years of age and older: National Health 

Interview Survey (NHIS) 2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 2017.

Note: GED = General Educational Development.

Figure 2.7b Prevalence of current cigarette smoking by level of education and status of health insurance among 

adults 25 years of age and older: National Health Interview Survey (NHIS) 2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 2017.

Note: GED = General Educational Development.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 61

Smoking Cessation

data from NHIS and NSDUH, as well as death rates of 

smokers from the Cancer Intervention and Surveillance 

Modeling Network, indicate that permanent annual quit 

rates during 2008–2014 were 4.5% using NHIS data and 

4.2% using NSDUH data (Mendez et al. 2017).

Adults

Data from the 2017 NHIS indicate that 7.6% of adults 

who were ever cigarette smokers reported recent successful cessation (Table 2.9). Recent successful cessation 

generally decreased with age (14.0% among young adults 

[18–24  years of age] and 6.3% among adults [65  years 

of age and older]) (Table  2.9). Among the 50  states, the 

District of Columbia, Guam, and Puerto Rico, the highest 

prevalence of recent successful cessation was observed in 

South Dakota, Connecticut, Minnesota, and the District 

of Columbia. (7.5–7.9%), and the lowest prevalence was 

observed in Mississippi, Indiana, Nevada, Pennsylvania, 

and Tennessee (3.3–3.9%) (Table 2.10). It is important to 

note that, because the BRFSS does not ask current smokers 

about the number of years smoked, the BRFSS measure is 

not restricted to current smokers who smoked for at least 

2 years; therefore, this measure is not directly comparable 

to that used in NHIS (see Appendix 2.2 for more information). The PATH Study observed that (a) 15.5% of current 

cigarette smokers at Wave 1 (September 2013–December 

2014) who reported at Wave 2 (October 2014–October 2015) 

that they had attempted to quit in the past 12 months were 

abstinent for 30 or more days at Wave 2 and (b) cigarette 

smokers with a college degree had a higher prevalence of 

cessation (i.e., abstinence of >30 days) (20.0%) than those 

with lower levels of education (14.9%) (Benmarhnia et al. 

2018). In a second analysis of the PATH Study, Berry and 

colleagues (2019) did not limit the analysis to current 

cigarette smokers who were trying to quit, but instead 

examined quitting among all current cigarette smokers at 

Wave 1. Through multivariate logistic regression models, 

the study observed that (a) daily smokers were less likely 

(odds ratio [OR] = 0.27; 95% confidence interval [CI], 0.19–

0.38) to quit than some-day smokers and (b) daily smokers 

who had tried to quit during the year before Wave 1 were 

more likely to quit (OR  =  1.25; 95% CI, 1.00–1.57) for 

30 or more days at Wave 2 than those who did not attempt 

to quit during the previous year. In a third analysis of the 

PATH Study, Rodu and Plurphanswat (2017) examined correlates at Wave 1 of having quit smoking during the past 

year. The study found that, among cigarette smokers who 

tried to quit during the past year, the odds of having quit in 

the past year decreased with increased age, with increased 

number of quit attempts, and with increased level of education; and odds of having quit in the past year were lower 

among Blacks than they were among Whites (OR = 0.70; 

95% CI, 0.50–0.97).

During 2000−2015, a linear increase in recent successful cessation was observed (from 5.7% to 7.4%), as 

noted previously (Babb et al. 2017). Using data from NHIS, 

Mendez and colleagues (2017) also observed an increase 

in permanent annual quit rates from 2.4% (1990–1995) 

to 4.5% (2008–2014). No significant trends for this measure were observed among young adults (NHIS, public use 

data, 2000, 2005, 2010, and 2015).

Quit Ratio

The quit ratio represents the percentage of ever 

smokers who have quit smoking and is defined as the 

number of former smokers divided by the number of ever 

smokers. Similar to the prevalence of former smoking, 

quit ratio is a broad cessation measure encompassing cigarette smokers who quit many decades ago through those 

who have quit for 1 day at the time of their survey interview. However, although the denominator for the prevalence of former smoking includes all adults in the United 

States, the denominator for quit ratio includes only persons who have ever smoked 100 or more cigarettes in their 

lifetime. Data from the 2017 NHIS show that the quit ratio 

for U.S. adults was 61.7% (Table 2.9), indicating that there 

are more former cigarette smokers in the United States 

than current cigarette smokers (by a ratio of almost 3:2). 

The quit ratio in 2017 represents a 6-percentage-point 

increase over the quit ratio in 2012 (55.1%) and reflects 

a continued increasing trend in the population-based quit 

ratio since 1965 (USDHHS 2014).

Adults

 Data from the 2017 NHIS indicate that the quit ratio 

increased linearly with age, ranging from 32.7% among 

18- to 24-year-olds to 82.9% among those 65 years of age 

and older (Table 2.9). The quit ratio has been consistently 

highest among adults 65 years of age and older and consistently lowest among young adults (Figure 2.8a). The quit 

ratio has increased in all adult age groups since 1965, with 

some variability from year to year.

Data from the 2017 NHIS indicate that quit ratios 

were lower among Blacks (46.1%) than Asians (64.3%), 

Whites (63.9%), and Hispanics (61.5%) (Table 2.9). Persons 

of multiple races (50.0%) had lower quit ratios than Whites 

(63.9%). The quit ratio increased among White and Black 

adults from 1965 to 2017, and it increased between 1980 

and 2017 among Hispanics (data on Hispanics were not 

available before 1980), with variability from year to year 

(Figure 2.8b).

Data from the 2017 NHIS also indicate that the 

quit ratio generally increased with level of education. 
A Report of the Surgeon General

62 Chapter 2

Table 2.9 Percentage of ever cigarette smokers 18 years of age and older who have recently successfully quit and 

quit smoking (quit ratio), by selected characteristics; National Health Interview Survey (NHIS) 2017; 

United States

Characteristic

Recent successful cessation:a

% (95% CI) Quit ratio: % (95% CI)

Total 7.6 (6.6–8.6) 61.7 (60.4–63.0)

Sex     

Men 7.2 (5.9–8.5) 61.9 (60.2–63.6)

Women 8.1 (6.5–9.6) 61.5 (59.6–63.3)

Age group (years)     

18–24 14.0 (9.4–18.7) 32.7 (26.6–38.8)

25–44 7.9 (6.5–9.4) 50.7 (48.4–53.0)

45–64 6.1 (4.5–7.6) 59.7 (57.7–61.7)

≥65 6.3 (3.9–8.6) 82.9 (81.3–84.5)

Race/ethnicity     

White, non-Hispanic 7.4 (6.3–8.5) 63.9 (62.5–65.3)

Black, non-Hispanic 7.0 (4.0–10.1) 46.1 (42.3–50.0)

Hispanic 9.1 (5.7–12.5) 61.5 (57.3–65.7)

American Indian/Alaska Native, non-Hispanic —b —b

Asian, non-Hispanic —b 64.3 (57.3–71.2)

Multiple races, non-Hispanic —b 50.0 (41.2–58.8)

Level of educationc     

≤12 years (no diploma) 5.8 (3.7–7.9) 50.6 (47.2–53.9)

GED certificate 6.1 (3.1–9.0) 42.4 (37.1–47.7)

High school diploma 6.1 (4.1–8.0) 58.4 (56.0–60.9)

Some college (no degree) 8.2 (5.6–10.8) 62.4 (59.9–65.0)

Associate degree 5.7 (3.5–8.0) 63.3 (60.2–66.5)

Undergraduate degree 8.7 (5.7–11.7) 76.1 (73.3–78.9)

Graduate degree 11.0 (6.0–16.0) 82.8 (79.8–85.8)

Poverty status     

At or above poverty level 8.0 (6.9–9.2) 64.5 (63.2–65.8)

Below poverty level 5.8 (3.9–7.6) 42.2 (38.7–45.7)

U.S. Census region     

Northeast 8.6 (5.8–11.4) 68.0 (65.0–70.9)

Midwest 6.8 (4.8–8.7) 59.3 (56.7–61.9)

South 7.7 (6.0–9.3) 56.6 (54.5–58.7)

West 7.8 (5.8–9.7) 67.6 (65.1–70.1)

Health insurance coverage     

Private 8.5 (6.9–10.1) 67.9 (66.4–69.4)

Medicaid (includes persons with Medicaid and Medicare) 6.6 (4.6–8.7) 41.1 (37.5–44.6)

Medicare only —b 81.5 (78.6–84.4)

Other coverage 6.6 (3.7–9.5) 60.4 (56.4–64.4)

Uninsured 7.5 (5.0–10.0) 38.7 (35.0–42.5)
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 63

Smoking Cessation

Table 2.10 Percentage of current and ever smokers 18 years of age and older who quit smoking (quit ratio)a and 

prevalence of recent successful cessationb and a past-year quit attempt,c by state; Behavioral Risk Factor 

Surveillance System (BRFSS) 2017; United States

State/territory Quit ratio: % (95% CI)

Recent successful cessation: 

% (95% CI)

Past-year quit attempt: 

% (95% CI)

Overall 59.2 (57.0–61.4) — —

Alabama 52.8 (50.3–55.3) 4.7 (3.2–6.2) 67.5 (64.1–70.9)

Alaska 54.9 (50.6–59.3) 5.1 (2.8–7.4) 63.6 (57.2–70.0)

Arizona 61.3 (59.7–63.0) 6.3 (5.0–7.6) 66.6 (64.2–69.0)

Arkansas 53.4 (49.7–57.1) 5.2 (2.9–7.5) 66.7 (61.7–71.8)

California 66.3 (63.9–68.7) 7.0 (5.2–8.8) 68.0 (64.2–71.7)

Colorado 63.6 (61.6–65.6) 6.2 (4.5–7.8) 68.2 (65.2–71.1)

Connecticut 67.1 (65.0–69.2) 7.7 (5.6–9.9) 71.6 (68.3–74.9)

Delaware 59.5 (56.2–62.9) 6.3 (3.4–9.2) 71.0 (66.5–75.4)

District of Columbia 56.3 (53.0–59.6) 7.0 (4.7–9.3) 69.3 (64.9–73.8)

Florida 60.8 (58.5–63.1) 5.2 (3.8–6.7) 67.6 (64.4–70.8)

Georgia 53.8 (51.1–56.5) 4.4 (2.9–6.0) 64.3 (60.5–68.1)

Hawaii 67.6 (65.2–70.0) 6.6 (4.2–8.9) 67.0 (63.2–70.8)

Idaho 62.4 (59.3–65.6) 6.0 (3.1–8.9) 62.2 (57.2–67.1)

Illinois 59.8 (57.1–62.6) 5.4 (3.5–7.2) 64.8 (60.7–68.9)

Indiana 52.9 (51.2–54.6) 3.9 (3.0–4.9) 62.0 (59.6–64.3)

Iowa 59.0 (57.0–61.1) 4.7 (3.5–6.0) 59.9 (56.9–63.0)

Kansas 58.3 (57.0–59.7) 5.0 (4.1–6.0) 64.3 (62.4–66.2)

Kentucky 51.0 (48.4–53.5) 4.3 (2.8–5.7) 62.1 (58.7–65.5)

Louisiana 49.9 (47.1–52.7) 5.3 (3.7–7.0) 69.7 (66.3–73.2)

Maine 64.7 (62.5–66.9) 6.1 (4.3–7.9) 62.2 (58.5–66.0)

Maryland 61.4 (59.2–63.6) 5.3 (3.5–7.1) 65.9 (62.4–69.3)

Massachusetts 64.7 (61.7–67.7) 5.0 (3.2–6.9) 64.6 (59.8–69.3)

Michigan 58.1 (56.2–59.9) 4.5 (3.4–5.6) 66.2 (63.6–68.8)

Minnesota 64.5 (63.0–66.0) 7.5 (6.2–8.7) 63.8 (61.5–66.1)

Mississippi 49.3 (46.2–52.4) 3.3 (1.9–4.6) 61.1 (56.8–65.5)

Missouri 55.4 (53.0–57.8) 5.5 (3.9–7.0) 59.7 (56.2–63.1)

Montana 61.4 (58.7–64.0) 4.8 (3.1–6.4) 60.6 (56.6–64.7)

Nebraska 61.5 (59.6–63.5) 5.7 (4.2–7.1) 63.9 (61.0–66.8)

Nevada 57.7 (53.9–61.5) 3.9 (2.2–5.7) 62.7 (57.2–68.2)

New Hampshire 65.9 (63.0–68.8) 5.6 (3.5–7.7) 63.7 (58.8–68.6)

Table 2.9 Continued

Source: NHIS, National Center for Health Statistics, public use data, 2017; Babb and colleagues (2017).

Notes: CI = confidence interval; GED = General Educational Development.

aThe numerator includes former smokers who quit smoking for ≥6 months during the past year. The denominator for this measure 

includes both current smokers who smoked for ≥2 years and former smokers who quit during the past year. 

bPrevalence estimates with a relative standard error ≥30% are not presented due to low precision.

cAmong only adults 25 years of age and older.
A Report of the Surgeon General

64 Chapter 2

For example, in 2017, the quit ratio among those with 

a graduate degree (82.8%) was far higher than the quit 

ratio among those who had 12 or fewer years of education 

(with no diploma) (50.6%) or a GED certificate (42.4%) 

(Table  2.9). Those living below the federal poverty level 

had a much lower quit ratio (42.2%) than persons at or 

above the poverty level (64.5%). By geographic region, the 

Northeast (68.0%) and West (67.6%) had higher quit ratios 

than the Midwest (59.3%) and the South (56.6%). By status 

of health insurance, those who were uninsured (38.7%) or 

enrolled in Medicaid (41.1%) had the lowest quit ratios.

Data from the 2017 BRFSS indicate that quit ratios 

were greater than 50% in every state except Mississippi 

(49.3%) and Louisiana (49.9%) (Guam also had a prevalence  <50%) (Table  2.10). Thus, in the vast majority of 

states, more than half of the persons who had ever smoked 

cigarettes had quit smoking. In three states (Hawaii 

[67.7%], Connecticut [67.1%], and Washington [66.8%]), 

more than two-thirds of ever smokers had quit smoking, 

and the quit ratio in 20 other states and Puerto Rico was 

between 60.1% and 66.3%. These are marked improvements from 2004, when only 34  states had quit ratios 

Table 2.10 Continued

State/territory Quit ratio: % (95% CI)

Recent successful cessation: 

% (95% CI)

Past-year quit attempt: 

% (95% CI)

New Jersey 64.8 (62.4–67.2) 5.5 (3.8–7.2) 71.3 (67.7–74.9)

New Mexico 57.7 (55.0–60.5) 5.3 (3.5–7.1) 65.5 (61.7–69.3)

New York 62.1 (60.1–64.1) 6.2 (4.6–7.9) 66.4 (63.4–69.5)

North Carolina 60.1 (57.3–62.9) 4.8 (3.1–6.4) 65.4 (61.3–69.6)

North Dakota 57.7 (55.3–60.2) 4.2 (2.8–5.6) 62.2 (58.7–65.7)

Ohio 53.6 (51.6–55.6) 4.4 (3.1–5.7) 61.7 (58.9–64.6)

Oklahoma 54.9 (52.5–57.3) 5.9 (4.4–7.4) 65.9 (62.5–69.2)

Oregon 61.5 (59.1–64.0) 4.6 (3.1–6.0) 62.5 (58.8–66.2)

Pennsylvania 59.0 (56.6–61.3) 3.9 (2.7–5.1) 64.3 (60.9–67.6)

Rhode Island 65.6 (62.7–68.5) 6.3 (4.0–8.7) 69.6 (64.9–74.3)

South Carolina 58.5 (56.5–60.5) 4.7 (3.2–6.2) 65.8 (62.9–68.7)

South Dakota 57.1 (53.6–60.6) 7.9 (5.0–10.8) 64.5 (59.4–69.6)

Tennessee 51.2 (48.5–54.0) 3.9 (2.4–5.4) 60.3 (56.6–64.0)

Texas 55.8 (52.6–59.1) 5.4 (3.4–7.3) 70.7 (66.6–74.7)

Utah 62.8 (60.3–65.3) 6.1 (4.3–7.9) 66.4 (62.8–70.1)

Vermont 65.1 (62.6–67.6) 6.3 (4.1–8.5) 66.0 (62.0–70.0)

Virginia 59.2 (57.0–61.4) 5.6 (3.9–7.4) 66.4 (63.2–69.6)

Washington 66.8 (65.1–68.6) 6.3 (4.9–7.7) 68.1 (65.4–70.7)

West Virginia 50.2 (47.9–52.5) 5.8 (4.3–7.3) 61.6 (58.5–64.8)

Wisconsin 61.5 (58.8–64.2) 5.1 (3.2–6.9) 58.6 (54.3–62.8)

Wyoming 58.1 (55.2–61.0) 6.7 (4.4–9.1) 65.0 (61.0–69.0)

Guam 43.6 (38.5–48.7) 6.7 (3.8–9.7) 72.3 (66.7–77.9)

Puerto Rico 62.3 (58.5–66.1) 6.3 (2.9–9.6) 67.1 (61.5–72.7)

Source: BRFSS, Centers for Disease Control and Prevention, public use data, 2017.

Notes: CI = confidence interval.

aQuit ratio is calculated as the proportion of current smokers who reported having stopped smoking for >1 day during the past year 

because they were trying to quit smoking, and former smokers who quit smoking during the past year (numerator), among all current 

and former smokers who only quit in the past year (denominator).

bThe percentage of former smokers who quit smoking for >6 months during the past year among current smokers and former smokers 

who quit during the past year.

cCurrent smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying to quit 

smoking and former smokers who quit during the past year.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 65

Smoking Cessation

Figure 2.8b Percentage of ever smokers 18 years of age and older who quit smoking (quit ratio), by race/ethnicity; 

National Health Interview Survey (NHIS), 1965–2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 1965–2017.

Note: From 1965 to 1996, data were reported for the following years (as indicated by the dotted line): 1965, 1970, 1974, 1978, 1980, 

1983, 1985, 1987, 1990, 1993, and 1995. Data were reported annually for years 1997–2017 (as indicated by the solid line).

Figure 2.8a Percentage of ever smokers 18 years of age and older who quit smoking (quit ratio), by age group; 

National Health Interview Survey (NHIS), 1965–2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 1965–2017.

Note: From 1965 to 1996, data were reported for the following years (as indicated by the dotted line): 1965, 1970, 1974, 1978, 1980, 

1983, 1985, 1987, 1990, 1993, and 1995. Data were reported annually for years 1997–2017 (as indicated by the solid line).
A Report of the Surgeon General

66 Chapter 2

greater than 50% and just 4 states had quit ratios greater 

than 60% (CDC 2005). In 2004, the median quit ratio 

across 49 states and the District of Columbia was 52.4%, 

and in 2017, the median quit ratio for all 50 states and the 

District of Columbia was 59.2%.

Young Adults

The quit ratio among young adults has consistently been the lowest of all adult age groups since 1965 

(Figure  2.8a). The quit ratio among young adult ever 

smokers has increased since 1965 (from 13.1% in 1965 

to 32.7% in 2017); however, little change has occurred 

since the 1980s. The positive relationship between quit 

ratio and age is due in part to the accumulation of quitters 

with age; specifically, the numerator among older ever 

smokers includes persons who quit many decades ago, 

but among young adult ever smokers, a decade ago would 

be when they were 8–14 years of age—a time when many 

were smoking their first cigarette, not quitting (USDHHS 

2012). This positive relationship is also due, in part, to 

the increased mortality among older current smokers 

compared with long-term former smokers, which would 

decrease the denominator among older versus younger 

ever smokers (USDHHS 2014).

Youth

Compared with adults, smoking behaviors among 

youth are less established and the prevalence of quitting 

is much lower (USDHHS 2012). Therefore, quit ratios 

among youth are not included in this report because they 

would most likely reflect cessation attributable to both 

quitting and experimentation, or discontinuation of nonestablished smoking patterns (USDHHS 2012).

Trends in the Cessation Continuum 

for Current Smokers

Data from TUS-CPS from 2006–2007, 2010–2011, 

and 2014–2015 were used to develop a cigarette smoking 

cessation continuum for adults 18 years of age and older 

who were current smokers. A cessation continuum was constructed to describe more completely the dynamic process 

of smoking cessation, including interest in quitting, quitting history, and past-year quit attempts. The continuum 

included six subgroups of current cigarette smokers: 

• Persons who had never tried to quit and who were 

currently not interested in quitting,

• Persons who had never tried to quit but were currently interested in quitting,

• Persons who had ever tried to quit but did not try in 

the past year and who were currently not interested 

in quitting,

• Persons who had ever tried to quit but did not try to 

quit in the past year and who were currently interested in quitting,

• Persons who tried to quit in the past year but were 

currently not interested in quitting, and

• Persons who tried to quit in the past year and were 

currently interested in quitting.

It is important to note that, although the definition 

of those who ever tried to quit includes cigarette smokers 

whose quit attempt lasted less than 1 day, the definition of 

trying to quit in the past year includes only quit attempts 

that lasted for 1 day or longer (i.e., not attempts that lasted 

for less than 1  day) among current daily smokers and 

some-day smokers who smoked 12 or more days in the past 

30 days—thereby underestimating the prevalence of pastyear quit attempts (Hughes et  al. 2013). The more conservative definition of past-year quit attempt was selected 

to match more closely the past-year quit attempt question 

on NHIS, which has the greatest number of years of data 

on the prevalence of past-year quit attempts. Appendix 2.2 

presents more information about the potential effect of 

excluding past-year quit attempts of less than 1  day on 

prevalence estimates.

The proportion of current adult smokers who had 

never tried to quit but were interested in quitting increased 

from 16.8% (95% CI, 16.2–17.3) in 2006–2007 to 23.7% 

(95%  CI, 22.9–24.4) in 2010–2011, and then decreased 

to 20.3% (95% CI, 19.6–21.0) in 2014–2015 (Figure 2.9). 

From 2006–2007 to 2010–2011, the proportions of three 

groups changed: (a)  the proportion of current adult 

smokers who had never tried to quit and were not interested in quitting increased from 11.3% (95% CI, 10.8–11.8) 

to 15.9% (95% CI, 15.3–16.6), (b) the proportion of current adult smokers who had ever tried to quit but did not 

try during the past year and at the time of the survey were 

not interested in quitting decreased from 6.1% (95% CI, 

5.7–6.4) to 3.9% (95% CI, 3.6–4.2), and (c) the proportion 

of current adult smokers who had ever tried to quit but did 

not try during the past year and were interested in quitting decreased from 23.2% (95% CI, 22.6–23.7) to 14.0% 

(95% CI, 13.5–14.6). The proportion of those who had tried 

to quit during the past year and were interested in quitting 

increased from 39.1% (95% CI, 38.3–40.0) in 2010–2011 

to 43.5% (95% CI, 42.7–44.3) in 2014–2015.

For all years, the proportion of those who were 

interested in quitting was greater than the proportion of 
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 67

Smoking Cessation

those who were not interested in quitting, regardless of 

quit attempt status. In addition, the ratio between those 

interested and those not interested in quitting increased 

across the quit attempt continuum from those who had 

never tried to quit to those who had tried to quit during 

the past year. The following sections examine trends and 

demographic differences in the cessation components of 

this continuum.

Attempts to Quit Smoking During the Past Year

Adults

According to NHIS, in 2015, 55.4% of adult cigarette 

smokers had made a past-year quit attempt (Table 2.11). 

This included current smokers (those who had smoked 

100 cigarettes in their lifetime and now smoked some days 

or every day) who had made a quit attempt lasting at least 

1 day during the past year and former smokers who had 

quit during the past year. Persons younger than 45 years 

of age had a higher prevalence of quit attempts than 

those 45 years of age and older. Asians (69.4%) and Blacks 

(63.4%) had a higher prevalence of quit attempts during 

the past year compared with Whites (53.3%). Those with 

Medicare had a lower prevalence of making a quit attempt 

during the past year compared with those who had private 

insurance. The prevalence of quit attempts did not change 

during 2015–2017 (both 55.4%) (NHIS, public use data, 

2017). Also, the prevalence of quit attempts did not change 

within each of the demographic groups, and the quit 

attempt patterns by demographic subgroups were similar 

except for level of education and insurance status. In 2017, 

the prevalence of past-year quit attempts was higher among 

persons with graduate degrees (64.9%) than among those 

with 12 or fewer years of education and no diploma (50.4%) 

and those with a high school diploma (47.6%); prevalence 

of past-year quit attempts was higher among those with 

an associate degree (59.8%) than among those with a high 

school diploma (47.6%) (NHIS, public use data, 2017). In 

2017, the prevalence of past-year quit attempts was lower 

among both those with Medicare (40.5%) and the uninsured (50.9%) than among those with private insurance 

(58.6%) (NHIS 2017, public use data, 2017).

In 2015, quit attempts varied by smoking frequency but not by status of smoking menthol cigarettes 

(Table  2.12). Among adults 18  years of age or older in 

2015, nondaily smokers had a higher prevalence of pastyear quit attempts (63.6%) compared with daily smokers 

(44.6%). These findings are similar to those obtained in 

previous analyses of nationally representative data (Tindle 

and Shiffman 2011; Schauer et al. 2014b; Keeler et  al. 

2017) and to data in the 2017 NHIS (NHIS, public use 

data, 2017). Although quit attempts during the past year 

did not differ significantly across age groups of nondaily 

Figure 2.9 Cessation continuum for current cigarette smokers 18 years of age and older; Tobacco Use Supplement 

to the Current Population Survey (TUS-CPS) 2006–2007, 2010–2011, 2014–2015; United States

Source: TUS-CPS, public use data, 2006–2007, 2010–2011, and 2014–2015. aEver tried to quit but did not try to quit during the past year.
A Report of the Surgeon General

68 Chapter 2

Table 2.11 Prevalence of a past-year quit attempta and interest in quitting smokingb among adult cigarette smokers 

18 years of age and older, by selected characteristics; National Health Interview Survey (NHIS) 2015; 

United States

Characteristic

Past-year quit attempt: 

% (95% CI)

Interest in quitting: 

% (95% CI)

Total 55.4 (53.5–57.3) 68.0 (65.9–70.0)

Sex

Men 55.3 (52.7–57.9) 66.7 (63.8–69.6)

Women 55.6 (53.0–58.1) 69.4 (66.7–72.1)

Age group (years)

18–24 66.7 (61.0–72.4) 62.3 (55.7–69.0)

25–44 59.8 (57.3–62.3) 72.7 (69.7–75.7)

45–64 49.6 (46.8–52.5) 68.7 (65.8–71.6)

≥65 47.2 (42.2–52.3) 53.7 (48.4–58.9)

Race/ethnicity

White, non-Hispanic 53.3 (50.8–55.7) 67.5 (65.0–70.0)

Black, non-Hispanic 63.4 (59.0–67.9) 72.8 (68.2–77.4)

Hispanic 56.2 (51.6–60.9) 67.4 (61.9–72.8)

American Indian/Alaska Native, non-Hispanic 52.1 (32.1–72.2) 55.6 (35.8–75.4)

Asian, non-Hispanicc 69.4 (62.1–76.7) 69.6 (59.5–79.8)

Multiple races, non-Hispanic 57.8 (47.2–68.4) 59.8 (45.7–73.9)

Level of educationd

≤12 years (no diploma) 50.4 (46.2–54.5) 68.0 (63.7–72.2)

GED certificate 48.1 (40.1–56.0) 65.7 (58.0–73.4)

High school diploma 52.2 (48.3–56.2) 65.5 (61.9–69.1)

Some college (no degree) 57.8 (53.6–61.9) 70.2 (66.1–74.4)

Associate degree 57.4 (52.2–62.7) 70.6 (65.3–76.0)

Undergraduate degree 57.6 (51.5–63.8) 73.3 (67.7–78.8)

Graduate degree 55.8 (46.0–65.6) 74.0 (65.1–82.9)

Poverty status

At or above poverty level 55.5 (53.3–57.7) 68.2 (65.9–70.4)

Below poverty level 55.2 (51.6–58.8) 67.3 (63.4–71.1)

U.S. Census region

Northeast 58.8 (54.6–63.0) 74.5 (69.0–80.1)

Midwest 54.0 (49.7–58.4) 67.1 (63.1–71.1)

South 54.3 (51.6–57.0) 67.2 (64.0–70.4)

West 56.9 (52.5–61.3) 65.5 (60.7–70.2)

Health insurance coverage

Private 57.2 (54.6–59.9) 69.0 (66.1–71.8)

Medicaid (includes persons with Medicaid and Medicare) 56.3 (52.5–60.1) 69.2 (65.3–73.2)

Medicare only 42.3 (35.5–49.4) 47.7 (40.3–55.2)

Other coverage 50.7 (43.9–57.4) 63.6 (57.2–69.9)

Uninsured 53.5 (49.7–57.2) 69.5 (65.2–73.9)
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 69

Smoking Cessation

Table 2.11 Continued

Source: Babb and colleagues (2017).

Notes: CI = confidence interval; GED = General Educational Development.

aCurrent smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying to quit 

smoking and former smokers who quit during the past year.

bCurrent smokers who reported that they wanted to stop smoking completely.

cDoes not include Native Hawaiians or Other Pacific Islanders.

dAmong only adults 25 years of age and older.

Table 2.12 Prevalence of a past-year quit attempta among adult current cigarette smokers 18 years of age and older, 

by selected smoking-related and demographic characteristics; National Health Interview Survey (NHIS) 

2015; United States

Characteristic

Nondaily: 

% (95% CI)

Daily: 

% (95% CI)

Menthol: 

% (95% CI)

Nonmenthol: 

% (95% CI)

Total 63.6 (60.2–67.1) 44.6 (42.3–46.9) 51.5 (47.9–55.1) 48.3 (45.6–51.1)

Sex 

Male 60.9 (56.3–65.4) 45.0 (41.7–48.3) 52.7 (47.5–57.9) 49.0 (45.4–52.7)

Female 67.8 (62.6–72.9) 44.2 (41.2–47.1) 50.5 (45.8–55.2) 47.4 (43.8–51.1)

Age group (years)

18–24 63.5 (53.8–73.3) 58.8 (50.3–67.3) 60.5 (50.2–70.7) 64.8 (54.4–75.1)

25–44 64.1 (59.0–69.2) 49.4 (45.9–52.9) 54.8 (49.7–60.0) 51.9 (48.0–55.8)

45–64 64.5 (59.1–69.9) 39.1 (36.0–42.2) 46.2 (40.7–51.7) 43.1 (39.4–46.8)

≥65 57.4 (46.4–68.4) 37.4 (31.8–43.0) 42.7 (31.8–53.6) 42.1 (35.9–48.3)

Race/ethnicity

White, non-Hispanic 66.4 (61.6–71.1) 41.9 (39.2–44.7) 47.1 (42.2–52.0) 46.8 (43.7–50.0)

Black, non-Hispanic 70.1 (62.0–78.1) 56.6 (51.0–62.3) 60.0 (54.2–65.8) 62.4 (52.9–72.0)

Hispanic 50.3 (42.3–58.3) 48.0 (41.7–54.3) 48.2 (39.6–56.8) 53.5 (46.6–60.3)

American Indian/Alaska Native, 

non-Hispanic

—b —b —b —b

Asian, non-Hispanic 67.2 (53.0–81.4) 55.9 (43.3–68.5) —b 56.5 (42.7–70.2)

Multiple races, non-Hispanic —b 40.0 (26.6–53.4) —b 42.6 (25.1–60.2)

Level of educationc

≤12 years (no diploma) 67.4 (57.4–77.3) 40.7 (35.7–45.7) 50.7 (43.1–58.2) 43.4 (38.3–48.5)

GED certificate —b 40.2 (31.8–48.7) 55.3 (42.4–68.2) 39.1 (28.4–49.8)

High school diploma 67.0 (59.0–75.0) 41.5 (37.0–45.9) 49.1 (41.9–56.2) 45.9 (40.8–51.0)

Some college (no degree) 66.4 (59.2–73.7) 47.2 (42.2–52.2) 50.2 (42.5–58.0) 52.3 (46.9–57.7)

Associate degree 56.7 (47.1–66.3) 48.0 (41.6–54.5) 52.5 (41.5–63.5) 48.5 (40.8–56.1)

Undergraduate degree 61.1 (50.9–71.3) 43.2 (35.4–51.0) 53.9 (42.7–65.1) 46.3 (38.2–54.4)

Graduate degree 46.3 (30.4–62.2) 45.6 (31.5–59.7) —b 49.8 (37.2–62.3)

Poverty status

At or above poverty level 63.7 (59.8–67.6) 43.8 (41.1–46.5) 51.0 (46.7–55.2) 48.1 (44.9–51.3)

Below poverty level 63.5 (55.5–71.4) 47.5 (43.1–51.9) 53.2 (46.9–59.6) 49.5 (44.6–54.4)

U.S. Census region

Northeast 72.4 (64.1–80.7) 47.2 (41.6–52.8) 58.2 (49.7–66.7) 51.8 (43.7–60.0)
A Report of the Surgeon General

70 Chapter 2

smokers, the prevalence of quit attempts among daily 

smokers (Table 2.12) was higher among persons younger 

than 45 years of age than among those 45 years of age and 

older; in 2017, the prevalence of quit attempts was higher 

among those younger than 45  years of age than among 

only those 65 years of age and older. Among daily smokers, 

Blacks had a higher prevalence of quit attempts compared 

with Whites (NHIS, public use data, 2017). Among nondaily smokers in 2015, Whites and Blacks were more likely 

than Hispanics to make a quit attempt (Table 2.12); these 

racial/ethnic differences were not observed in 2017: Whites 

(55.9%), Blacks (67.8%), and Hispanics (57.8%) (NHIS, 

public use data, 2017). Also, among nondaily smokers, for 

all education levels below a graduate degree, the prevalence 

of making a past-year quit attempt was greater than 50%, 

although prevalence across educational groups was not 

statistically significant. In contrast, among daily smokers, 

the prevalence of making a past-year quit attempt was 

greater than 50% in only three groups: those 18–24 years 

of age, Blacks, and Asians (NHIS, public use data, 2017).

According to findings from the 2017 BRFSS, the 

prevalence of having a past-year quit attempt among cigarette smokers was greater than 60% in every state except 

Wisconsin (58.6%), Missouri (59.7%), and Iowa (59.9%) 

(Table 2.10). The prevalence of having a past-year quit 

attempt exceeded 70% in four states and one U.S. territory: Connecticut (71.6%), New Jersey (71.3%), Delaware 

(71.0%), Texas (70.7%), and Guam (72.3%).

Young Adults

Quit attempts among young adults varied significantly across demographic subgroups (NHIS, public use 

data, 2017). During 1997–2017, significant nonlinear 

increases in quit attempts among young adults were 

found among males, females, and Whites (p  <.05 for 

quadratic trends), and significant linear increases were 

found among Hispanics (p  <.05 for linear trends), but 

there were no significant changes in quit attempts among 

Blacks (NHIS, public use data, 1997–2017). Since 2009, 

across males and females and across Whites, Blacks, and 

Hispanics, the majority of cigarette smokers had tried 

to quit smoking during the past year. The prevalence of 

quit attempts among young adults differed across states; 

the prevalence of a quit attempt was highest in Vermont 

(86.5%), Mississippi (85.7%), and Florida (85.5%) and 

lowest in Oregon (58.9%), District of Columbia (59.6%), 

and Illinois (60.5%) (BRFSS, public use data, 2017).

Youth

Using data from the 2015 national YRBS, among the 

10.8% of students in grades 9–12 who currently smoked 

cigarettes, 45.4% had tried to quit smoking cigarettes 

during the 12 months preceding the survey (Kann et al. 

2016). The prevalence of having tried to quit smoking 

cigarettes was higher among female (52.8%) than male 

(39.7%) students. The prevalence of having tried to quit 

Table 2.12 Continued

Characteristic

Nondaily: 

% (95% CI)

Daily: 

% (95% CI)

Menthol: 

% (95% CI)

Nonmenthol: 

% (95% CI)

U.S. Census region (continued)

Midwest 71.2 (63.2–79.3) 41.5 (36.5–46.5) 48.8 (41.0–56.7) 46.5 (40.7–52.4)

South 59.3 (54.2–64.3) 45.0 (41.7–48.2) 50.5 (45.2–55.7) 47.5 (43.9–51.1)

West 56.8 (49.8–63.8) 46.7 (41.1–52.2) 51.8 (43.5–60.0) 49.8 (43.7–55.8)

Health insurance coverage

Private 63.8 (59.1–68.4) 43.6 (40.4–46.9) 53.3 (48.5–58.1) 47.0 (43.0–51.0)

Medicaid (includes persons 

with Medicaid and Medicare)

65.2 (57.2–73.2) 48.0 (43.2–52.8) 55.0 (48.2–61.8) 49.9 (44.6–55.2)

Medicare only —b 36.2 (28.0–44.3) 41.2 (24.2–58.1) 38.0 (28.8–47.3)

Other coverage 69.6 (56.1–83.1) 39.9 (32.7–47.0) 37.7 (25.7–49.7) 48.5 (40.5–56.5)

Uninsured 60.9 (52.9–69.0) 45.7 (40.9–50.4) 49.5 (42.2–56.8) 49.9 (44.6–55.2)

Source: NHIS, National Center for Health Statistics, public use data, 2015.

Notes: CI = confidence interval; GED = General Educational Development.

aCurrent smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying to quit 

smoking and former smokers who quit during the past year.

bPrevalence estimates with a relative standard error ≥30% are not presented due to low precision.

cAmong only adults 25 years of age and older. 
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 71

Smoking Cessation

smoking cigarettes was higher among 9th-grade (47.8%), 

10th-grade (51.6%), and 12th-grade (47.7%) students 

than among 11th-grade students (37.9%). In contrast to 

the report from the national YRBS, the analysis of data 

from NYTS found that, in 2015, the prevalence of having a 

past-year quit attempt among students in grades 9–12 was 

57.8% (NYTS, public use data, 2015), or 12.4 percentage 

points higher than the YRBS finding (Table  2.13a). 

Appendix 2.2 discusses factors contributing to this difference and other differences between the two surveys. The 

analysis of data from the 2017 NYTS also found that the 

prevalence of a past-year quit attempt was 61.1% among 

students in grades  9–12 and 67.2% among students in 

grades 6–8 (Tables 2.13a and 2.13b) (the YRBS did not ask 

this question in 2017).

Trends in Attempts to Quit Smoking During the 

Past Year

Adults

According to data from NHIS, from 1997 to 2017, 

the prevalence of a past-year quit attempt increased significantly among men and women (p <0.05 for quadratic 

trends) (Figure 2.10). The percentage of female cigarette 

smokers who made a past-year quit attempt increased 

from 1997 (49.5%) to 2008 (54.1%); this percentage was 

50% or greater from 2005 to 2017 and peaked at 57.7% 

in 2014; however, percentages from 2008 to 2017 were 

not statistically significantly different. The prevalence of 

past-year quit attempts among men also increased from 

1997 (48.9%) to 2009 (52.2%) (Figure 2.10); it was 50% or 

higher every year from 2009 to 2017 and peaked at 55.3% 

in 2015; however, percentages from 2009 to 2017 were not 

significantly different.

During 1997–2017, there were significant increasing 

trends in quit attempts among Whites, Blacks, and 

Hispanics (p  <0.05 for quadratic trends among Whites 

and Blacks and p <0.05 for linear trend among Hispanics). 

Among Whites, the prevalence of past-year quit attempts 

rose from 48.5% in 1997 to 54.4% in 2014; larger increases 

were observed among Blacks from 1997 (49.0%) to 2016 

(63.8%) and among Hispanics from 1997 (53.3%) to 

2012 (61.1%) (Figure  2.11); prevalence was not statistically different from 2014 to 2017 for Whites, 2016 to 2017 

for Blacks, and 2012 to 2017 for Hispanics. The prevalence of past-year quit attempts peaked in 2016 among 

Blacks (63.8%), in 2014 among Whites (54.4%), and in 

2012 among Hispanics (61.6%). From 2013 (Lavinghouze 

et al. 2015) to 2017 (Table 2.10), the prevalence of a quit 

attempt increased in Delaware, decreased in Missouri and 

Wisconsin, and remained stable in all other states and the 

District of Columbia.

Young Adults

Among young adults, significant nonlinear increases 

in quit attempts were found among males, females, and 

Whites (p  <0.05 for quadratic trends), and significant 

linear increases were observed for Hispanics (p <0.05 for 

linear trends) (NHIS, public use data, 1997–2017). Peak 

prevalence of past-year quit attempts occurred in 2013 

among young adult males (60.6%), in 2014 among young 

adult females (65.6%), and in 2015 among young adult 

Whites (66.6%).

Youth

Data from the national YRBS showed, among high 

school students who were current cigarette smokers, a significant linear decrease in the prevalence of past-year quit 

attempts from 2001 to 2015 among males (from 53.4% to 

39.7%) and females (from 61.4% to 52.8%) (Figure 2.12). 

A similar linear decrease occurred in the prevalence of 

past-year quit attempts among Whites (from 57.2% in 

2001 to 44.1% in 2015), but no change occurred among 

Hispanics (50.3% in 2001 and 49.6% in 2015) (YRBS, 

public use data, 2001–2015). The sample size for Blacks 

was insufficient to yield statistically stable estimates.

In contrast, data from the NYTS (Tables  2.13a and 

2.13b) suggest a more stable trend in the prevalence of pastyear quit attempts among high school students between 

2000 (59.3%) and 2017 (61.1%). These differences could 

be the result of multiple factors, including variations in the 

length of the questionnaire and its content, time of administration (i.e., spring vs. fall semester), periodicity of the 

survey (i.e., biennial vs. annual), and sample demographics. 

Analysis of data from NYTS indicates that the prevalence of 

a past-year quit attempt among middle school students in 

grades 6–8 increased from 59.9% in 2000 to 77.0% in 2015 

and then remained unchanged in 2017 (67.2%).

Number and Duration of Quit Attempts During 

the Past Year

Adults

Successfully quitting cigarette smoking usually 

involves multiple quit attempts. For example, estimates 

from a longitudinal study of adult smokers in Ontario, 

Canada, indicated that among those currently trying to 

quit, the highest probability of successful cessation on a 

given quit attempt, accounting for self-reported lifetime 

quit attempts, occurred on quit attempts  4–6 (Chaiton 

et al. 2016). However, further life table analyses of these 

smokers estimated that the average number of quit 

attempts before successfully quitting for at least 1 year was 

29.6 (95% CI, 27.6–31.7) (Chaiton et al. 2016). Analysis of 
Quitting behaviors 2000: % (95% CI) 2004: % (95% CI) 2009: % (95% CI) 2015: % (95% CI) 2017: % (95% CI)

Tried to quit cigarettes ≥1 days during 

the past year

59.3 (57.4–61.2) 57.6 (54.9–60.3) 53.7 (49.8–57.7) 57.8 (53.0–62.6) 61.1 (54.8–67.4)

Number of times tried to quit cigarettes 

during the past yearb

1 35.0 (33.3–36.8) 23.7 (20.7–26.8) 22.2 (18.7–25.6) 24.6 (17.8–31.3) 24.8 (19.1–30.5)

2 29.8 (27.8–31.7) 22.0 (19.3–24.6) 22.0 (18.6–25.4) 20.0 (15.0–25.0) 19.5 (14.4–24.7)

3–5 23.7 (22.1–25.4) 26.5 (23.5–29.5) 25.1 (21.5–28.8) 25.2 (20.6–29.8) 18.2 (13.8–22.6)

6–9 4.4 (3.6–5.2) 8.8 (7.2–10.5) 8.8 (6.9–10.8) 7.7 (5.2–10.3) 10.5 (7.1–13.8)

≥10 7.1 (5.9–8.3) 19.0 (15.9–22.1) 21.9 (18.1–25.7) 22.5 (17.7–27.3) 27.0 (22.6–31.5)

Considered quitting cigarettes within

30 days NA 41.6 (36.5–46.6) 44.3 (39.8–48.9) 30.1 (25.0–35.1) 33.6 (29.4–37.8)

6 months NA 30.1 (26.1–34.1) 32.5 (28.6–36.5) 21.5 (15.4–27.5) 18.3 (13.6–23.1)

Not within 6 months NA 28.3 (24.5–32.2) 23.1 (19.0–27.3) 48.5 (42.3–54.6) 48.1 (42.7–53.5)

A Report of the Surgeon General

72 Chapter 2

Source: NYTS, Centers for Disease Control and Prevention, public use data, 2000, 2004, 2009, 2015, and 2017.

Notes: CI = confidence interval; NA = not applicable, question not asked in this year. aSmoked cigarettes during the past 30 days.

bAmong those who tried to quit smoking cigarettes during the past year.

Table 2.13a Quitting behaviors among current cigarette smokersa in high school (grades 9–12); National Youth Tobacco Survey (NYTS) 2000, 2004, 

2009, 2015, and 2017; United States
Quitting behaviors 2000: % (95% CI) 2004: % (95% CI) 2009: % (95% CI) 2015: % (95% CI) 2017: % (95% CI)

Tried to quit cigarettes ≥1 day during 

the past year

59.9 (56.8–63.0) 64.7 (60.2–69.2) 63.2 (53.6–72.7) 77.0 (71.0–83.0) 67.2 (58.3–76.1)

Number of times tried to quit cigarettes 

during the pastyear 

1 35.2 (31.6–38.8) 20.4 (16.4–24.4) 22.8 (17.7–27.8) 21.7 (12.2–31.2) 15.3 (8.6–22.0)

2 27.6 (24.1–31.1) 16.9 (14.1–19.7) 20.0 (14.8–25.2) —c 19.1 (9.3–28.9)

3–5 18.6 (15.8–21.3) 23.3 (19.5–27.1) 21.9 (16.1–27.7) 21.8 (13.3–30.4) 24.0 (12.7–35.3)

6–9 6.3 (3.9–8.8) 10.1 (7.4–12.7) 7.0 (3.8–10.1) —c —c

≥10 12.3 (9.9–14.7) 29.3 (26.0–32.5) 28.4 (22.9–33.8) 23.9 (12.1–35.7) 33.3 (22.7–43.9)

Considered quitting cigarettes within

30 days NA 57.8 (51.0–64.6) 56.7 (44.1–69.2) 51.7 (39.0–64.4) 45.5 (31.8–59.1)

6 months NA 17.6 (13.2–22.1) 25.6 (14.6–36.6) —c 18.4 (9.0–27.8)

Not within 6 months NA 24.5 (19.5–29.5) 17.8 (10.2–25.3) 38.8 (24.6–53.1) 36.2 (24.6–47.7)

b

Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 73

Source: NYTS, Centers for Disease Control and Prevention, public use data, 2000, 2004, 2009, 2015, and 2017.

Notes: CI = confidence interval; NA = not applicable, question not asked in this year.

aSmoked cigarettes during the past 30 days.

bAmong those who tried to quit smoking cigarettes during the past year. 

cPrevalence estimates with a relative standard error ≥30% are not presented due to low precision.

Table 2.13b Quitting behaviors among current cigarette smokersa in middle school (grades 6–8); National Youth Tobacco Survey (NYTS) 2000, 2004, 

2009, 2015, and 2017; United States
A Report of the Surgeon General

74 Chapter 2

Figure 2.11 Prevalence of past-year quit attemptsa among adult cigarette smokers 18 years of age and older, 

by race/ethnicity; National Health Interview Survey (NHIS) 1997–2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 1997–2017. aCurrent smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying to quit 

smoking and former smokers who quit during the past year.

Figure 2.10 Prevalence of past-year quit attemptsa among adult cigarette smokers 18 years of age and older, by sex; 

National Health Interview Survey (NHIS) 1997–2017; United States

Source: NHIS, National Center for Health Statistics, public use data, 1997–2017. aCurrent smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying to quit 

smoking and former smokers who quit during the past year.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 75

Smoking Cessation

the 2014–2015 TUS-CPS data found that, among current 

daily smokers or some-day smokers who had smoked on 

12 or more days during the past 30 days and had tried to 

quit during the past year, the most common range of pastyear quit attempts was two or three (40.4%). The percentages were 30.7% for one attempt and 28.9% for at least 

four attempts (Table 2.14).

According to findings using the 2014–2015 TUS-CPS 

data, for more than one-third of current smokers (daily 

smokers plus some-day smokers who had smoked for 

12  or more days during the past month) who had tried 

to quit during the past year, their longest quit attempt 

lasted between 1 and 6 days (35.7%), and 10.7% had a quit 

attempt of 6 months or longer (Table 2.14). The percentage 

with a past-year quit attempt lasting 6 months or longer 

increased from 7.5% in 2001–2002 to 11.1% in 2006–2007 

and 14.6% in 2010–2011 but declined to 10.7% in 2014–

2015. The percentage with a past-year quit attempt lasting 

30 days to less than 6 months also declined from 32.8% 

in 2010–2011 to 24.4% in 2015, and the percentage with 

a quit attempt of 1–6 days increased from 21.5% in 2010–

2011 to 35.7% in 2014–2015.

Young Adults

Among young adult current cigarette smokers (daily 

smokers plus some-day smokers who had smoked on 12 or 

more days during the past 30 days) who had made a quit 

attempt during the past year, the distribution of quit 

attempts was similar to that for all adults (Table  2.15). 

For all years except 2006–2007, a smaller proportion of 

young adult smokers (compared with adult smokers 

overall) reported a longest quit attempt during the past 

year of 1–6 days. In contrast to adults overall, the prevalence of a long quit attempt—that is, 30 days to less than 

6 months or 6 months or longer—did not change significantly over time.

Youth

Findings from the 2017 NYTS indicate that among 

high school current cigarette smokers who had tried to 

quit during the past year, more than one-fourth (27.0%) 

reported trying 10  or more times in the past year and 

slightly less than one-fourth reported trying to quit one 

time (24.8%) (Table  2.13a). In addition, approximately 

one-fifth reported trying to quit two times (19.5%) or 

three to five times (18.2%), and 10.5% reported trying to 

quit six to nine times. Among current cigarette smokers 

in middle school who tried to quit during the past year, 

one-third (33.3%) reported trying to quit 10  or more 

times, and a smaller percentage (15.3%) reported trying 

to quit one time. Although the prevalence of one or two 

quit attempts decreased from 2000 to 2004 among middle 

Figure 2.12 Prevalence of past-year quit attempts among students in grades 9–12 who currently smoke cigarettesa, 

by sex; National Youth Risk Behavior Survey (YRBS) 2001–2015; United States

Source: YRBS, Centers for Disease Control and Prevention, public use data, 2001–2015. aRespondents who reported that they had smoked cigarettes on at least 1 day during the 30 days before the survey and also reported 

that they had tried to quit smoking during the past 12 months.
A Report of the Surgeon General

76 Chapter 2

Table 2.14 Quitting behaviors among current cigarette smokersa 18 years of age and older, by year; Tobacco Use 

Supplement to the Current Population Survey (TUS-CPS) 2001–2002, 2006–2007, 2010–2011, and 

2014–2015; United States

Quitting behaviors

2001–2002: 

% (95% CI)

2006–2007: 

% (95% CI)

2010–2011: 

% (95% CI)

2014–2015: 

% (95% CI)

Ever tried to quitb 71.2 (70.5–71.8) 72.2 (71.6–72.9) 60.4 (59.6–61.2) 64.4 (63.6–65.2)

Tried to quit during the past year NA 42.5 (41.8–43.3) 42.6 (41.8–43.3) 46.7 (45.9–47.5)

Tried to quit >1 days during the 

past year

50.0 (49.2–50.7) 35.5 (34.7–36.2) 37.2 (36.4–37.9) 41.3 (40.4–42.2)

Number of times tried to quit 

during the past yearc

1 31.9 (30.9–33.0) 36.1 (35.0–37.3) 32.3 (31.2–33.4) 30.7 (29.5–31.9) 

2–3 40.7 (39.5–41.8) 37.9 (36.7–39.0) 41.2 (40.0–42.4) 40.4 (39.1–41.7) 

≥4 27.4 (26.4–28.4) 26.0 (25.0–27.0) 26.5 (25.4– 27.6) 28.9 (27.7–30.1)

Duration of longest quit attempt 

during the past 12 monthsc

1–6 days 35.1 (33.9–36.2) 33.4 (32.3–34.6) 21.5 (18.7–24.3) 35.7 (34.5–37.0)

7–29 days 32.7 (31.7–33.8) 30.0 (28.9–31.0) 31.1 (27.8–34.4) 29.1 (28.0–30.3) 

30 days to <6 months 24.7 (23.8–25.6) 25.5 (24.6–26.5) 32.8 (29.4–36.2) 24.4 (23.3–25.6) 

>6 months 7.5 (6.9–8.1) 11.1 (10.3–11.8) 14.6 (12.0–17.2) 10.7 (9.8–11.6)

Considered quitting within:c

30 days 18.2 (17.6–18.7) 17.9 (17.3–18.5) 16.4 (15.9–16.9) 19.7 (18.9–20.4) 

6 months 26.5 (26.0–27.1) 26.5 (25.9–27.1) 24.2 (23.6–24.9) 25.8 (25.1–26.5) 

Not within 6 months 55.3 (54.6–56.0) 55.6 (54.9–56.3) 59.4 (58.6–60.2) 54.5 (53.7–55.3)

Level of interest in quittingc

1 (not at all interested) NA 20.2 (19.6–20.8) 23.2 (22.4–24.0) 22.5 (21.7–23.2)

2–5 NA 31.9 (31.3–32.6) 32.2 (31.5–33.0) 30.3 (29.6–31.1) 

6–8 NA 23.3 (22.7–23.9) 21.3 (20.7–21.9) 22.5 (21.9–23.2) 

9 or 10 (extremely interested) NA 24.6 (24.0–25.2) 23.3 (22.6–23.9) 24.7 (24.0–25.4)

Think they would be likely to 

succeed in quitting if tried 

during the next 6 monthsd

Not likely NA 11.8 (11.3–12.3) 11.0 (10.4–11.6) 10.8 (10.1–11.4) 

A little likely NA 22.3 (21.6–23.0) 21.8 (21.0–22.5) 21.6 (20.9–22.3) 

Somewhat likely NA 37.1 (36.4–37.9) 37.9 (37.1–38.7) 38.4 (37.5–39.3) 

Very likely NA 28.8 (28.1–29.5) 29.3 (28.5–30.1) 29.3 (28.3–30.2)

Source: TUS-CPS, National Cancer Institute, public use data, 2001–2002, 2006–2007, 2010–2011, and 2014–2015.

Notes: CI = confidence interval; NA = not applicable.

aSmoked 12 or more days during the past 30 days and had tried to quit during the past year.

bFor 2001–2002, estimates are from the question, “Have you ever stopped smoking for one day or longer because you were trying to 

quit smoking?” In other years, the question for current some-day smokers who smoked less than 12 days during past 30 days included, 

“Have you ever tried to quit smoking completely?” and for current daily smokers and some-day smokers who smoked 12 or more days

during the past 30 days included, “Have you ever made a serious attempt to stop smoking because you were trying to quit—even if you 

stopped for less than a day?” Also, in 2006–2007, current daily smokers and some-day smokers who smoked less than 12 days/month 

were asked, “Have you ever stopped smoking one day or longer because you were trying to quit smoking?”

cAmong current daily smokers and some-day smokers who smoked 12 or more days during the past 30 days who tried to quit during the 

past year.

dAmong those who were interested in quitting. 
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 77

Smoking Cessation

Table 2.15 Quitting behaviors among current cigarette smokersa 18–24 years of age, by year; Tobacco Use Supplement 

to the Current Population Survey (TUS-CPS) 2001–2002, 2006–2007, 2010–2011, 2014–2015; 

United States

Quitting behaviors

2001–2002: 

% (95% CI)

2006–2007: 

% (95% CI)

2010–2011: 

% (95% CI)

2014–2015: 

% (95% CI)

Ever tried to quitb 67.7 (65.9–69.5) 65.7 (63.7–67.7) 56.7 (54.4–58.9) 61.6 (58.7–64.5)

Tried to quit during the past year NA 50.1 (47.8–52.4) 47.9 (45.5–50.2) 52.6 (49.6–55.7)

Tried to quit ≥1 day during the 

past year

69.1 (67.0–71.3) 43.8 (41.5–46.1) 42.9 (40.5–45.4) 50.0 (46.7–53.2)

Number of times tried to quit 

during the past yearc

1 30.4 (28.2–32.6) 34.0 (30.8–37.3) 29.4 (25.9–32.9) 30.4 (26.2–34.5)

2–3 41.7 (39.2–44.2) 38.3 (35.2–41.5) 46.4 (42.5–50.2) 42.1 (37.6–46.7)

≥4 27.9 (25.6–30.1) 27.6 (24.8–30.5) 24.2 (20.9–27.6) 27.5 (23.5–31.4)

Duration of longest quit attempt

during the past 12 monthsc

1–6 days 30.7 (28.3–33.0) 26.0 (23.1–28.9) 20.1 (12.2–28.0) 25.5 (22.0–29.0)

7–29 days 34.5 (32.0–36.9) 32.9 (29.9–35.8) 32.0 (22.5–41.5) 34.0 (29.8–38.2)

30 days to <6 months 26.9 (24.5–29.3) 28.0 (25.2–30.9) 33.2 (24.2–42.2) 28.3 (24.7–31.8)

≥6 months 7.9 (6.5–9.4) 13.1 (10.8–15.3) 14.7 (8.4–21.1) 12.3 (9.2–15.3)

Considered quitting within:c

30 days 20.3 (18.6–22.0) 17.5 (15.8–19.2) 16.6 (14.9–18.3) 19.1 (16.6–21.6)

6 months 27.8 (26.1–29.4) 25.4 (23.7–27.1) 23.8 (21.6–26.0) 24.6 (22.0–27.3)

Not within 6 months 52.0 (50.1–53.8) 57.1 (54.8–59.4) 59.6 (57.0–62.2) 56.3 (53.1–59.5)

Level of interest in quittingc

1 (not at all interested) NA 17.5 (15.9–19.1) 20.5 (18.3–22.7) 19.5(16.9–22.1)

2–5 NA 37.1 (35.0–39.1) 36.9 (34.5–39.3) 36.9 (33.8–40.0)

6–8 NA 27.6 (25.5–29.7) 24.8 (22.8–26.7) 23.8 (20.9–26.6)

9 or 10 (extremely interested) NA 17.8 (16.1–19.4) 17.9 (16.0–19.8) 19.8 (17.2–22.4)

Think they would be likely to 

succeed in quitting if tried 

during the next 6 monthsd

Not likely NA 10.8 (9.2–12.5) 11.0 (10.4–11.6) 8.8 (6.7–10.9)

A little likely NA 22.8 (20.9–24.6) 21.8 (21.0–22.5) 18.4 (16.0–20.9)

Somewhat likely NA 38.1 (35.9–40.4) 37.9 (37.1–38.7) 39.3 (35.9–42.6)

Very likely NA 28.3 (26.2–30.3) 29.3 (28.5–30.1) 33.5 (30.3–36.7)

Source: TUS-CPS, National Cancer Institute, public use data, 2001–2002, 2006–2007, 2010–2011, and 2014–2015.

Notes: CI = confidence interval; NA = not applicable.

aSmoked 100 cigarettes in their lifetime and currently smoked some days or every day.

bFor 2001–2002, estimates are from the question, “Have you ever stopped smoking for one day or longer because you were trying to 

quit smoking?” In other years, questions for current some-day smokers who smoked less than 12 days during the past 30 days included, 

“Have you ever tried to quit smoking completely?” and for current daily smokers and some-day smokers who smoked 12 or more days

during the past 30 days included, “Have you ever made a serious attempt to stop smoking because you were trying to quit—even if you 

stopped for less than a day?” Also, in 2006–2007, current daily smokers and some-day smokers who smoked less than 12 days/month 

were asked, “Have you ever stopped smoking one day or longer because you were trying to quit smoking?”

cAmong current daily smokers and some-day smokers who smoked 12 or more days during the past 30 days who tried to quit during 

the past year.

dAmong those who were interested in quitting.
A Report of the Surgeon General

78 Chapter 2

and high school smokers who tried to quit during the past 

year, the prevalence of one or two quit attempts remained 

relatively stable from 2004 to 2017. In contrast, the prevalence of 10 or more quit attempts increased during 2000–

2004 among current cigarette smokers in both middle 

school and high school who tried to quit in the past year 

and increased further among high school students from 

19.0% in 2004 to 27.0% in 2017.

Interest in Quitting Smoking

Adults

NHIS data for 2015 indicated that 68.0% of current 

cigarette smokers were interested in quitting smoking 

completely (Table 2.11). However, when a 10-point scale 

was used for the 2014−2015 TUS-CPS (Table  2.14) to 

determine any interest, the estimate was somewhat higher 

(77.5%). In contrast to the prevalence of quit attempts, 

the prevalence of interest in quitting was highest among 

those 25–44 years of age (72.7%) and lowest among those 

65 years of age and older (53.7%) and those 18–24 years of 

age (62.3%) (Table 2.11). This age difference was reflected 

in the results for health insurance: those with Medicare 

only were less interested in quitting (47.7) than those with 

other types of insurance. However, for 29 of the 30 demographic groups that were examined, only the group with 

Medicare only did not have a majority of current cigarette 

smokers who wanted to quit smoking completely. A more 

proximate measure of interest in quitting smoking may be 

whether the current cigarette smoker is interested in quitting in the next 30 days or 6 months. According to data from 

the 2014–2015 TUS-CPS, the majority of smokers were 

not considering quitting within 6 months (54.5%), 25.8% 

were considering quitting within 6  months, and 19.7% 

were considering quitting within 30 days (Table 2.14).

Young Adults

In 2015, an estimated 62.3% of young adult 

(18−24 years of age) current cigarette smokers wanted to 

stop smoking completely (Table  2.11); this measure did 

not vary across demographic subgroups (NHIS, public 

use data, 2015). According to data from the 2014–2015 

TUS-CPS, young adult current cigarette smokers (daily 

smokers plus some-day smokers who had smoked on 12 or 

more days during the past 30 days) had a lower prevalence 

(19.8%) of having an extreme interest (determined by a 

report of “9” or “10” on a 10-point scale) in quitting smoking 

(Table 2.15) than adults overall (24.7%) (Table 2.14). The 

distribution of the periods in which young adult current 

smokers were considering quitting (i.e.,  within 30  days, 

within 6 months, or not within 6 months) (Table 2.15) was 

similar to that for adults overall (Table 2.14).

Youth

In the MTF Study, combined data from 2011 to 

2017 (Table  2.16) indicated that 21.8% of high school 

seniors (12th graders) who were current smokers wanted 

to stop smoking “now.” Seniors whose parents had the 

highest level of education were less likely to want to stop 

smoking immediately (15.0%) than were those whose 

parental education fell into the second-to-lowest category 

(26.4%) and the middle category (22.1%). Another measure related to interest in quitting in the MTF Study is 

whether the smoker thinks that he or she will be smoking 

in 5 years. The majority of high school seniors who were 

current smokers thought that they would probably or definitely not be smoking in 5 years (60.3%). The percentage 

who thought that they would not be smoking in 5 years 

increased with level of parental education, from 50.7% 

among those with the lowest level to 68.8% among those 

with the highest level.

According to NYTS, in 2017, 33.6% of students in 

grades  9–12 and 45.5% of students in grades  6–8 who 

were current cigarette smokers were considering quitting smoking in the next 30 days, and 18.3% of students 

in grades 9–12 and 18.4% of students in grades 6–8 were 

considering quitting in the next 6 months (Tables 2.13a 

and 2.13b).

Trends in Interest in Quitting Smoking

Adults

NHIS data showed no significant change from 2000 

(70.0%) to 2015 (68.0%) in the prevalence of being interested in completely stopping cigarette smoking among 

adults 18 years of age and older (Babb et al. 2017). Similarly, 

during 2000–2015, no significant change was observed in 

the prevalence of being interested in quitting among men, 

women, Whites, and Hispanics (NHIS, public use data, 

2000–2015). In contrast, interest in quitting increased 

among Blacks from 2000 (68.4%) to 2010 (75.6%), then 

remained stable in 2015 (72.8%) (p  <0.05 based on 

linear trend analysis; NHIS, public use data, 2000–2015). 

However, data from the TUS-CPS indicate that the proportion of current smokers who were considering quitting 

within the next 30 days may have slightly increased from 

2001–2002 (18.2%) to 2014–2015 (19.7%) (Table 2.14).

Young Adults

Similar to changes observed for adults overall, no 

significant changes were observed from 2000 to 2015 in 

interest in quitting among young adults overall. Unlike 

changes observed for adults overall, no significant changes 

were observed among any demographic subgroups (NHIS, 

public use data, 2000–2015). As for considering quitting 
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 79

Smoking Cessation

Table 2.16 Prevalence of cessation behaviors and attitudes among high school seniors who are current cigarette 

smokersa; Monitoring the Future (MTF) Study 2011–2017 combined data; United States

Characteristic

Ever tried to 

quit smoking: 

% (95% CI)

Tried to stop 

but could not: 

% (95% CI)

Wants to stop 

smoking now: 

% (95% CI)

Will probably or 

definitely not smoke in 

5 years: % (95% CI)

Total 44.8 (42.8–46.7) 22.1 (20.5–23.7) 21.8 (20.3–23.3) 60.3 (58.5–62.1)

Sex 

Male 43.9 (40.9–46.8) 21.3 (19.0–23.6)b 21.4 (19.3–23.5) 60.7 (58.3–63.2)

Female 44.2 (41.2–47.2) 21.3 (19.0–23.7)b 22.7 (20.3–25.1) 61.3 (58.6–64.0)

Race/ethnicity

White, non-Hispanic 43.6 (41.1–46.1) 21.9 (19.9–23.9) 22.8 (20.9–24.8) 61.6 (59.4–63.7)

Black, non-Hispanic 47.7 (40.7–54.6) 24.9 (18.7–31.2) 20.4 (14.5–26.2) 60.7 (52.6–68.7)

Hispanic 42.8 (37.9–47.6) 17.8 (13.5–22.0) 18.0 (13.8–22.2) 59.1 (53.5–64.8)

Parental educationc

1–2 (low) 44.7 (39.0–50.5) 21.9 (17.0–26.8) 20.7 (16.1–25.4) 50.7 (44.8–56.6)

2.5–3 48.9 (45.2–52.5) 24.9 (21.7–28.2) 26.4 (22.9–30.0) 57.8 (54.0–61.6)

3.5–4 45.1 (41.7–48.4) 21.8 (19.1–24.4) 22.1 (19.2–25.0) 61.1 (58.1–64.1)

4.5–5 39.8 (36.0–43.6) 18.9 (16.0–21.9) 19.8 (16.6–23.0) 65.9 (62.3–69.5)

5–6 (high) 38.8 (32.4–45.2) 15.5 (11.2–19.9) 15.0 (11.1–18.9) 68.8 (62.9–74.8)

U.S. Census region

Northeast 47.7 (43.9–51.6) 23.2 (20.1–26.3) 24.0 (20.7–27.3) 60.3 (56.2–64.4)

Midwest 43.6 (39.0–48.2) 22.0 (18.5–25.4) 21.7 (18.6–24.8) 61.3 (57.8–64.8)

South 45.2 (42.4–48.1) 23.0 (20.5–25.5) 22.6 (20.1–25.1) 58.5 (55.4–61.6)

West 42.6 (37.9–47.3) 19.2 (14.9–23.6) 18.4 (15.1–21.7) 62.7 (58.4–66.9)

Source: MTF Study, University of Michigan, Institute for Social Research, 2011–2017 (unpublished data).

Notes: CI = confidence interval. Data come from a randomly selected 33% of the entire sample (questions on cessation and attitudes were 

asked on two survey forms out of a total of six). The total weighted N for 30-day smoking is 4,320; variable-specific missing data reduce 

the sample size slightly overall and in results for each sociodemographic subgroup presented here.

aBased on responses to the question, “How frequently have you smoked cigarettes during the past 30 days?” Respondents who reported 

that they had smoked less than 1 cigarette per day or more were classified as current smokers.

bThe overall percentage does not fall between the sex-specific percentages because of missing values for sex.

cParental education is the average of a mother’s education and a father’s education based on answers from respondents about the 

highest level of education achieved by each parent, using the following scale: completed (1) grade school or less, (2) some high school, 

(3) high school, (4) some college, (5) college, and (6) graduate or professional school after college. Missing data were allowed for one 

of the two parents.

in the next 30 days, unlike adults overall, data from the 

TUS-CPS indicated that no significant change occurred 

over time in the prevalence of young adults who were considering quitting in the next 30 days (Table 2.15).

Youth

According to the MTF Study, the prevalence of high 

school seniors who were current smokers and wanted to 

stop smoking “now” decreased from 31.0% in 2000–2004 

to 16.5% in 2015–2017 (Table 2.17). The proportion who 

believed they would probably or definitely not be smoking 

in 5  years was similar between 2000–2004 (63.2%) and 

2015–2017 (65.4%). Using data from the NYTS, among 

current smokers in grades  9–12, the prevalence of considering quitting within 30 days decreased from 44.3% in 

2009 to 33.6% in 2017 (Table 2.13a). Similarly, the prevalence in this group of wanting to quit in the next 6 months 

decreased from 32.5% in 2009 to 18.3% in 2017.

History of a Quit Attempt

Adults

According to the TUS-CPS, in 2001–2002, 71.2% 

of current adult cigarette smokers had ever tried to quit 
A Report of the Surgeon General

80 Chapter 2

Table 2.17 Prevalence of cessation behaviors and attitudes among high school seniors who are current cigarette 

smokersa, by year; Monitoring the Future (MTF) Study 2000–2004, 2005–2009, 2010–2014, and 

2015–2017 combined data; United States

Characteristic

2000–2004: 

% (95% CI)

2005–2009: 

% (95% CI)

2010–2014: 

% (95% CI)

2015–2017: 

% (95% CI)

Ever tried to quit smoking 49.6 (47.2–52.0) 44.2 (42.1–46.3) 45.0 (41.9–48.1) 40.2 (35.6–44.8)

Tried to stop but could not 28.8 (26.6–30.9) 22.3 (20.7–24.0) 22.9 (20.4–25.4) 17.6 (14.2–21.0)

Wants to stop smoking now 31.0 (28.9–33.2) 21.8 (20.2–23.4) 22.9 (20.5–25.2) 16.5 (13.3–19.7)

Will probably or definitely 

not smoke in 5 years

63.2 (61.0–65.4) 62.5 (60.7–64.4) 58.7 (56.1–61.3) 65.4 (61.0–69.8)

Source: MTF, University of Michigan, Institute for Social Research, 2001–2017 (unpublished data).

Notes: CI = confidence interval.

aRespondents who reported that they had smoked one cigarette per day or more.

Other Tobacco Products: Use and Cessation

Adults

Data from the 2017 NHIS indicate that 3.8% of 

adults currently smoked cigars, cigarillos, or filtered little 

cigars; 2.8% of U.S. adults currently used e-cigarettes; 

2.1% used smokeless tobacco; 1.0% smoked regular pipes, 

water pipes, or hookahs; and 3.7% used 2 or more types 

of tobacco products (Wang et al. 2018a). The PATH Study 

found that in 2013–2014, 17.7% of U.S. adult respondents 

reported having ever tried e-cigarettes; among those, 3.8% 

of 18- to 24-year-old respondents reported becoming regular users of e-cigarettes (Kasza et al. 2017). In addition, 

5.5% of adults in Wave 1 (2013–2014) of PATH reported 

currently using e-cigarettes (now uses e-cigarettes every 

day or some days); among those who used e-cigarettes, 

42.2% reported infrequent use (current some-day use 

and used 0–2  days in the past 30 days), 36.5% reported 

moderate use (some-day use and used more than 2 days of 

the past 30 days), and 21.3% reported daily use (Coleman 

et al. 2017; Kasza et al. 2017). The 2013–2014 PATH Study 

also observed that the prevalence of current established 

use of cigarillos (1.7%; 95% CI, 1.5–1.8) was higher than 

the prevalence of use of filtered cigars (0.9%; 95%  CI, 

0.8–1.0), nonpremium cigars (other larger mass-market 

cigars) (0.8%; 95%  CI, 0.7–0.8), and premium cigars 

(0.7%; 95  CI, 0.6–0.7) (the term “current established 

users” was defined as persons who had ever heard of the 

cigar type, ever smoked the cigar type “fairly regularly,” 

smoking, even just once. This percentage remained relatively stable in 2006–2007 (72.2%), but by 2010–2011 

it had decreased by more than 10  percentage points, to 

60.4%. Although the percentage increased to 64.4% in 

2014–2015, it was lower than in 2001–2002 or 2006–2007 

(Table 2.14).

Young Adults

Through 2010–2011, young adult current smokers 

had a lower prevalence of ever having tried to quit smoking 

(Table 2.15) than adults overall (Table 2.14). But in 2014–

2015, the prevalence among young adults of ever having 

tried to quit smoking (61.6%) (Table 2.15) was similar to 

that of adults overall (64.4%, Table 2.14). The patterns of 

change over time in ever trying to quit smoking were similar between young adult smokers (Table 2.15) and adults 

overall (Table 2.14).

Youth

The MTF Study found that in 2011–2017, 44.8% of 

high school seniors who were current smokers had ever 

tried to quit smoking (Table 2.16). A significant decrease in 

this percentage was seen from 2000–2004 (49.6%) to 2015–

2017 (40.2%) (Table 2.17). Similarly, in 2015–2017, 17.6% 

of youth had tried to quit smoking but could not, which 

was lower than in 2000–2004 (28.8%) (Table 2.17). In 2011–

2017, high school seniors with parents with the secondlowest level of parental education were more likely than students with parents in the two highest categories of parental 

education to have ever tried to quit (48.9% vs. 39.8% and 

38.8%, respectively) (Table 2.16). In addition, high school 

seniors with parents with the second-lowest level of parental 

education were more likely to report that they had tried to 

quit but could not (24.9%) than those with parents in the 

highest category of parental education (15.5%).
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 81

Smoking Cessation

and now smoked every day or some days) (Corey et  al. 

2017). In addition, in the 2013–2014 PATH Study, 31.9% 

of adults reported smoking hookahs during the past year, 

and among these, 10.7% were daily or weekly users, 13.7% 

were monthly users, 42.1% used every couple of months, 

and 33.5% used about once a year (Robinson et al. 2018).

For all four types of tobacco products (i.e., e-cigarettes, 

cigars, smokeless tobacco, pipes), NHIS 2017 prevalence 

was higher among men than women, decreased with 

age and, correspondingly, was lower among those with 

Medicare only than among those with other types of insurance (Wang et al. 2018a). However, when each type of cigar 

product was examined separately for the 2013–2014 PATH 

Study, only use of cigarillos decreased with age; use of filtered cigars increased with age; and prevalence of premium 

cigars and nonpremium cigars was the highest among 

persons 35–54 years of age (Corey et al. 2017). Prevalence 

of cigar smoking was higher among Blacks than among 

Whites and Hispanics (Wang et al. 2018a); however, for the 

2013–2014 PATH Study, prevalence of premium and nonpremium cigar use was higher among Whites than Blacks 

(Corey et al. 2017).

Data from the 2017 NHIS indicate that smokeless 

tobacco use was higher among Whites than among Blacks 

and Hispanics (Wang et al. 2018a). E-cigarette use was also 

higher among Whites and persons of multiple races than 

Hispanics and Asians. Prevalence of pipe and/or hookah 

use was higher among Whites than Hispanics. Cigar use 

and smokeless tobacco use were higher in the Midwest 

than in the Northeast and the West, and the Midwest had 

a higher prevalence of pipe and/or hookah use than the 

Northeast. Data from the PATH Study suggest that there 

are urban–rural differences in the use of noncigarette 

tobacco products—for example, smokeless tobacco use 

was more prevalent in rural than urban counties; and the 

use of hookahs, cigarillos among women, and e-cigarettes 

among men was more prevalent in urban areas than in 

rural areas (Roberts et al. 2017).

Data from the 2017 NHIS indicate that the prevalence 

of e-cigarette and smokeless tobacco use was lower among 

those with a graduate degree than among those with an 

associate degree or lower level of education. E-cigarette 

use was higher among those with a GED than among 

those with any other level of education, and e-cigarette 

use was lower among those with an undergraduate degree 

than among those with a GED, a high school diploma, or 

those with some college and no degree. Smokeless tobacco 

use was also lower among those with an undergraduate 

degree than those with a high school diploma (Wang et al. 

2018a). For the 2013–2014 PATH Study, use of premium 

cigars increased as level of education increased, and use 

of nonpremium cigars, cigarillos, and filtered cigars was 

greatest among those with some college or an associate 

degree (Corey et al. 2017). Among pregnant women in the 

2013–2014 PATH Study, 4.9% used e-cigarettes, 2.5% used 

hookahs, and 2.3% used cigars (Kurti et al. 2017).

Cross-sectional evidence suggests that the majority 

of adult e-cigarette users in the United States are either 

current or former cigarette smokers. Among current adult 

e-cigarette users in the 2017 NHIS, 49.6% were current 

smokers of conventional cigarettes, 33.5% were former 

cigarette smokers, and 17.0% had never been cigarette 

smokers (NHIS, public use data, 2017).

Although significant declines in cigarette smoking 

have occurred among U.S. adults during the past 5 decades, 

the use of noncigarette tobacco products has increased 

in recent years (USDHHS 2014; Hu et al. 2016), making 

cessation of all tobacco products an important measure. 

In addition, health risk behaviors, similar to cigarette 

smokers, also tend to cluster among persons who use other 

tobacco products. For example, an analysis of patterns of 

alcohol, marijuana, and tobacco use in the PATH Study 

revealed that co-use of alcohol, cigarettes, and e-cigarettes 

was one of the top five use patterns among adults 25 years 

of age and older (Cohn et al. 2018). In addition, among 

young adults (18–24 years of age), mental health and substance use problems were associated with higher odds of 

alcohol and hookah co-use (OR = 1.48; 95% CI, 1.03–2.13; 

OR = 1.97; 95% CI, 1.04–3.74, respectively) than alcoholonly use. Among adults (25  years of age and older) and 

compared with alcohol-only users, mental health and substance use problems were associated with higher odds 

of alcohol, cigarette, and e-cigarette co-use (OR  =  1.55; 

95% CI, 1.24–1.93; OR = 2.22; 95% CI, 1.43–3.44, respectively) and with higher odds of alcohol and cigar co-use 

(OR = 1.60; 95% CI, 1.20–2.14; OR = 4.64; 95% CI, 3.10–

6.94, respectively) (Cohn et al. 2018).

Data from the 2017 NHIS indicated that 8.0% of 

adults were former users of smokeless tobacco; 11.6% 

were former users of e-cigarette; 12.2% were former users 

of pipes, water pipes, or hookahs; and 23.7% were former 

users of cigars, cigarillos, or little cigars (NHIS, public use 

data, 2017). In contrast to the measure of former cigarette 

smoking, former users of noncigarette tobacco products 

was defined as persons who ever used the product but were 

not currently using. The quit ratio (defined as the ratio 

of former smokers to ever smokers) was 92.1% for pipes, 

water pipes, and hookahs; 86.2% for cigars, cigarillos, and 

little cigars; 79.4% for smokeless tobacco; and 80.6% for 

e-cigarettes (NHIS, public use data, 2017). The 2014–2015 

TUS-CPS also examined the use of pipes: the prevalence of 

former use was 5.4% for a regular pipe and 4.1% for water 

or hookah pipes, and quit ratios were 93.9% for those who 

had used a regular pipe and 87.8% for those who had used 

a water or hookah pipe (TUS-CPS, public use data, 2014–

2015). In the 2013–2014 PATH Study, among women 
A Report of the Surgeon General

82 Chapter 2

15–44 years of age, prevalence of former use was 3.8% for 

e-cigarettes, 3.2% for cigars, 6.9% for hookah, 1.2% for 

pipes, and 0.4% for smokeless tobacco and snus (Lopez 

et al. 2018). Initial prospective longitudinal evidence from 

Wave 1 (2013–2014) and Wave 2 (2014–2015) of the PATH 

Study indicated that 48.8% of U.S. adult e-cigarette users 

overall at Wave 1 had discontinued their use of e-cigarettes 

at Wave 2 (Coleman et al. 2018). Cessation of e-cigarettes at 

Wave 2 decreased with increasing frequency of e-cigarette 

use at Wave 1. In addition, adjusted prevalence ratios indicated that e-cigarette users who also used combustible 

tobacco products at Wave 1 and e-cigarette users who used 

customizable e-cigarette devices were less likely to quit 

e-cigarette use at Wave 2. Among dual users of e-cigarettes 

and conventional cigarettes at Wave 1, 44.3% had maintained dual use at Wave 2; 43.5% had discontinued the use 

of e-cigarettes but maintained smoking conventional cigarettes; 7.0% had discontinued both products; and 5.1% 

had discontinued conventional cigarettes but continued 

smoking e-cigarettes (Coleman et al. 2018).

Additional longitudinal data from Kurti and colleagues (2018) from the PATH Study indicated that 1-year 

quit rates among nonpregnant women 18–44 years of age 

who were established tobacco users (i.e.,  used product 

fairly regularly in the past and currently used) were 

highest for users of cigars (60.6%), followed by hookah 

users (45.4%) and e-cigarette users (32.8%). Quit rates 

for users of these products were higher than the 1-year 

quit rate (11.5%) among women who had smoked 100 or 

more cigarettes in their lifetime. In separate multivariate logistic regression models containing data on both 

established and experimental users (used product in the 

past but not fairly regularly and used some days or every 

day at the time of the survey), experimental use was associated with increased odds of quitting e-cigarette use, 

hookah use, cigar use, and all tobacco use at Wave 2 compared with established use. In addition, respondents who 

used illicit drugs were more likely to quit e-cigarettes at 

Wave 2 than those who did not use these drugs, and those 

who belonged to a racial/ethnic group other than White, 

Black, or Hispanic were less likely to quit hookah use at 

Wave 2. Women with lower levels of education were less 

likely than those with higher levels of education to quit 

hookah use and all tobacco use. Hispanic women were 

more likely to quit all tobacco use than White women 

(Kurti et al. 2018).

Additional key cessation measures for individual 

tobacco products other than cigarettes generally have not 

been included in national surveillance systems. The 2014–

2015 TUS-CPS assessed past-year quit attempts for other 

tobacco products, but the population for these questions 

was limited to persons who used only one product. The 

2012–2014 NHIS included a question about trying to quit 

all tobacco use during the past year, and the 2013–2014 

NATS included a question about interest in quitting all 

tobacco products. In contrast, the PATH Study has data on 

interest and intentions to quit all tobacco products and on 

quit attempts, as well as longitudinal data on quitting, as 

described previously (Hyland et al. 2017).

In 2012–2014, 39.8% of persons who used two 

or more tobacco products (cigarettes, cigars, smokeless tobacco, or pipes) had tried to quit all tobacco use 

during the past year (NHIS, public use data, 2012–2014) 

(Table  2.18). Among cigarette smokers who also used 

another tobacco product, the prevalence of attempting to 

quit all tobacco products during the past year (40.1%) was 

lower than the prevalence of making an attempt to quit 

cigarette smoking (48.9%). This lower prevalence of trying 

to quit all tobacco use versus cigarette smoking was also 

observed among men; persons 25–64 years of age, Whites, 

Blacks, those with 12 or fewer years of education or a high 

school diploma, those living at or above the poverty level, 

those living in the South, and those without insurance. 

Similarly, the PATH Study found that adult users of more 

than one type of combustible tobacco product were less 

likely to try to quit tobacco use completely during the 

past year than cigarette-only users (OR = 0.82, p <0.05) 

(Kypriotakis et al. 2018).

Among those who used two or more tobacco products, the associations between having tried to quit all 

tobacco product use during the past year and demographic 

characteristics (Table  2.18) were similar to those for a 

past-year attempt to quit cigarette smoking (Table 2.11), 

except for race/ethnicity; specifically, no differences were 

observed among Whites, Blacks, and Asians (38.8%, 

39.5%, and 43.2%, respectively) (Table 2.18). Overall, the 

prevalence of trying to quit cigarette smoking during the 

past year did not differ significantly between those who 

smoked cigarettes only (47.1%) and cigarette smokers 

who used other tobacco products (48.9%) (Table  2.18). 

Thus, although cigarette smokers who use other tobacco 

products (i.e., cigars, smokeless tobacco, and pipes) have 

a similar prevalence of making a past-year cigarette quit 

attempt to that of cigarette-only smokers, they have a 

lower prevalence of trying to quit all tobacco use than 

trying to quit cigarette smoking during the past year.

The PATH Study, using Wave 1 data, also compared 

past-year tobacco quit attempts among adult users of various combinations of tobacco products and observed that 

cigarette-only (OR  =  0.59, p  <0.01), smokeless tobaccoonly (OR = 0.39, p <0.001), and polycombustible tobacco 

users (OR = 0.48, p <0.001) were less likely to attempt to 

quit than those who used both e-cigarettes and hookah 

(Kypriotakis et al. 2018). In addition, smokeless tobaccoonly users were less likely to attempt to quit than cigaretteonly users (OR = 0.66, p <0.001).
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 83

Smoking Cessation

Table 2.18 Prevalence of a past-year quit attempt for cigarette smokinga and all tobacco useb by type of tobacco used 

among adult current tobacco users 18 years of age and older, by selected demographic characteristics; 

National Health Interview Survey (NHIS) 2012–2014; United States

Attempted to quit cigarette smoking Attempted to quit all tobacco use

Characteristic

Cigarette-only 

smokers: % (95% CI)

Cigarette smokers 

who used other 

tobacco products: 

% (95% CI)

Cigarette smokers 

who used other 

tobacco products: 

% (95% CI)

Used ≥2 tobacco 

products: % (95% CI)

Total 47.1 (46.0–48.3) 48.9 (46.3–51.6) 40.1 (37.7–42.6) 39.8 (37.5–42.1)

Sex 

Male 46.0 (44.4–47.7) 47.2 (44.3–50.2) 38.7 (36.0–41.5) 38.5 (36.0–41.1)

Female 48.2 (46.6–49.7) 55.3 (48.9–61.6) 45.2 (38.4–52.1) 45.0 (38.3–51.8)

Age group (years)

18–24 54.3 (49.5–59.2) 57.6 (51.5–63.7) 50.6 (44.2–56.9) 50.3 (44.4–56.2)

25–44 50.3 (48.6–52.0) 49.7 (46.3–53.1) 40.3 (37.1–43.4) 39.5 (36.6–42.5)

45–64 44.3 (42.7–46.0) 43.0 (38.2–47.8) 33.4 (29.0–37.7) 33.8 (29.6–38.1)

≥65 38.3 (35.3–41.3) 31.4 (23.6–39.2) 23.7 (16.8–30.7) 23.0 (16.3–29.7)

Race/ethnicity

White, non-Hispanic 45.0 (43.6–46.4) 47.8 (44.7–50.9) 39.3 (36.4–42.3) 38.8 (36.1–41.6)

Black, non-Hispanic 52.9 (50.4–55.5) 50.3 (44.8–55.7) 38.0 (32.6–43.3) 39.5 (34.2–44.8)

Hispanic 52.5 (49.5–55.5) 60.4 (52.6–68.2) 50.1 (42.0–58.1) 49.2 (41.5–56.8)

American Indian/Alaska Native,

non-Hispanic

39.7 (28.3–51.2) —c —c —c

Asian, non-Hispanic 51.6 (45.0–58.2) 48.8 (33.1–64.5) 43.4 (28.8–57.9) 43.2 (29.2–57.3)

Multiple races, non-Hispanic 51.1 (43.5–58.7) 39.8 (26.9–52.8) 35.8 (23.0–48.6) 35.3 (22.9–47.8)

Level of educationd

≤12 years (no diploma) 43.6 (41.3–45.8) 45.8 (39.5–52.0) 33.1 (27.8–38.4) 33.6 (28.3–38.8)

GED certificate 47.3 (42.9–51.4) 48.9 (39.6–58.1) 43.4 (34.3–52.5) 43.4 (34.4–52.4)

High school diploma 43.8 (41.6–46.0) 40.3 (35.9–44.7) 30.2 (26.0–34.4) 31.1 (26.9–35.3)

Some college (no degree) 47.7 (45.2–50.1) 49.6 (44.3–55.0) 39.4 (34.1–44.6) 39.0 (34.0–44.0)

Associate degree 50.6 (47.4–53.9) 51.5 (39.7–63.2) 42.9 (32.9–52.9) 42.4 (33.2–51.5)

Undergraduate degree 50.8 (47.5–54.1) 45.7 (38.6–52.8) 39.6 (32.8–46.3) 35.8 (29.4–42.3)

Graduate degree 47.4 (42.3–52.4) 40.7 (28.9–52.6) 36.3 (24.9–47.7) 35.0 (24.1–45.9)

Poverty status

At or above poverty level 46.6 (45.2–48.0) 50.4 (47.1–53.8) 41.4 (38.2–44.7) 40.7 (37.7–43.7)

Below poverty level 49.0 (46.9–51.0) 43.9 (39.3–48.5) 35.7 (31.3–40.1) 36.6 (32.3–40.8)

U.S. Census region

Northeast 48.0 (45.2–50.8) 50.2 (44.2–56.1) 39.9 (33.7–46.0) 37.6 (32.0–43.1)

Midwest 46.8 (44.4–49.3) 49.2 (43.5–55.0) 40.7 (35.5–45.9) 40.8 (35.8–45.9)

South 47.1 (45.3–48.8) 48.7 (44.5–52.9) 39.1 (35.1–43.1) 38.6 (34.8–42.5)

West 46.7 (44.0–49.3) 48.3 (43.5–53.0) 41.2 (37.1–45.3) 41.6 (37.8–45.4)

Health insurance coverage

Private 47.1 (45.4–48.8) 51.0 (46.5–55.4) 43.1 (38.8–47.4) 41.9 (38.1–45.8)

Medicaid and those with 

Medicaid and Medicare

50.8 (48.4–53.2) 48.2 (42.5–54.0) 39.2 (33.5–44.8) 38.7 (33.2–44.3)
A Report of the Surgeon General

84 Chapter 2

Findings using data from the 2013–2014 NATS indicated that the majority (87.2%) of U.S. adults who used 

cigarettes and at least one other tobacco product were 

thinking about quitting all tobacco products for good 

(NATS, public use data, 2013–2014). This percentage was 

significantly higher than the comparable estimate for 

those who used at least two noncigarette tobacco products 

but no conventional cigarettes, which was 52.8%.

The PATH Study also examined adult tobacco users’ 

intentions to quit at Wave 1 and observed that both polycombustible tobacco users and smokeless tobacco users 

were somewhat less likely to be interested in quitting 

(OR = 0.92, p <001; and OR = 0.94, p <0.01, respectively) 

than cigarette-only smokers (Kypriotakis et al. 2018). In 

addition, polycombustible tobacco users were also less 

likely than cigarette-only smokers and smokeless tobaccoonly users to respond that they planned to quit for good 

(OR = 0.41, p <0.001; and OR = 0.48, p <0.01, respectively).

Young Adults

Findings using data from the 2017 NHIS indicated 

that quit ratios for young adults (18–24  years of age) 

who used other tobacco products ranged from 82.7% for 

pipes, 79.6% for e-cigarettes, 80.6% for cigars, and 63.4% 

for smokeless tobacco (NHIS, public use data, 2017). 

According to the 2014–2015 TUS-CPS, the prevalence of 

former use of a regular pipe among young adults was 3.6% 

(significantly lower than the prevalence among all adults 

of 5.4%), and the prevalence of former use of a water or 

hookah pipe was 9.5% (significantly higher than the prevalence among all adults of 4.1%) (TUS-CPS, public use 

data, 2014–2015). Data from the PATH Study indicated 

that among women who used tobacco at Wave  1, those 

18–24 years of age were more likely to quit all tobacco use 

at Wave 2 than those 25–44 years of age (Kurti et al. 2018).

Similar to data on adults overall, data from the 2012–

2014 NHIS indicated no differences in past-year quit attempts 

for cigarette smoking among young adult cigarette-only 

smokers and cigarette smokers who used another tobacco 

product (i.e., cigars, smokeless tobacco, and pipes) (NHIS, 

public use data, 2012–2014). In contrast to data on adults 

overall, no significant differences were observed between 

the prevalence of trying to quit all tobacco products (50.6%) 

and trying to quit cigarettes (57.6%) among young adult 

cigarette smokers who also used another tobacco product 

(NHIS, public use data, 2012–2014).

Youth

Data from the 2017 YRBS indicate that 13.2% of students in grades 9–12 were current users (used on at least 

1 day during the 30 days before the survey) of e-cigarettes; 

8.0% currently smoked cigars, cigarillos, or little cigars; 

Table 2.18 Continued

Attempted to quit cigarette smoking Attempted to quit all tobacco use

Characteristic

Cigarette-only 

smokers: % (95% CI)

Cigarette smokers 

who used other 

tobacco products: 

% (95% CI)

Cigarette smokers 

who used other 

tobacco products: 

% (95% CI)

Used ≥2 tobacco 

products: % (95% CI)

Health insurance coverage 

(continued)

Medicare only 36.5 (31.8–41.3) 31.2 (17.4–45.1) 24.9 (12.2–37.6) 25.7 (13.7–37.8)

Other coverage 47.3 (43.3–51.4) 47.8 (38.9–56.6) 40.0 (31.0–49.0) 39.5 (30.8–48.3)

Uninsured 46.7 (44.5–49.0) 47.4 (43.2–51.6) 36.5 (32.5–40.5) 37.2 (33.2–41.1)

Source: NHIS, National Center for Health Statistics, public use data, 2015.

Notes: CI = confidence interval; GED = General Educational Development.

aCurrent cigarette smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying 

to quit smoking.

bCurrent users of at least two tobacco products—cigarettes, other smoked tobacco products (including cigars, pipes, water pipes or 

hookahs, very small cigars, bidis, cigarillos), and smokeless tobacco (including chewing tobacco, snuff, dip, snus, dissolvable tobacco)—

who reported that they stopped using all kinds of tobacco products for >1 day during the past 12 months because they were trying to 

quit using tobacco. 

cPrevalence estimates with a relative standard error ≥30% are not presented due to low precision.

dAmong only adults 25 years of age and older.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 85

Smoking Cessation

and 5.5% currently used chewing tobacco, snuff, dip, snus, 

or dissolvable tobacco products (Kann et al. 2018). For all 

three types of assessed tobacco products (e-cigarettes, 

cigars, and smokeless tobacco products), prevalence of 

current use was higher among male than among female 

students and increased as grade level increased. The 

prevalence of current e-cigarette and smokeless tobacco 

use was higher among Whites than among Blacks and 

Hispanics, and higher among Hispanics than among 

Blacks. Whites also had a higher prevalence of current 

cigar use than Hispanics (Kann et al. 2018). Among students in grades 9–12 who used at least two tobacco products (cigarettes, e-cigarettes, cigar products, or smokeless 

tobacco) (10.5% of students), 52.7% (95% CI, 47.9–57.5) 

had tried to quit all tobacco product use in the past year 

(YRBS, public use data, 2017). The prevalence of having 

tried to quit using all tobacco products in the past year was 

higher among 12th-grade students (61.9%) than among 

9th-grade students (42.0%) (YRBS, public use data, 2017).

According to 2017 data from the NYTS, 9.2% of 

high school students and 2.4% of middle school students reported using two or more tobacco products, and 

e-cigarettes were the most commonly used tobacco product 

among high school (11.7%) and middle school (3.3%) students (Wang et al. 2018b). However, trends in the use of different tobacco products have varied. For example, decreases 

in cigarette and cigar smoking during 2011–2016 were 

offset by increases in hookah and e-cigarette use, resulting 

in no significant change in any tobacco use (Jamal et al. 

2017). E-cigarette use has continued to increase among 

U.S. youth more recently. During 2017–2018, current use 

of e-cigarettes among high school students rose 77.8% 

(from 11.7% to 20.8%) and among middle school students 

rose 48.5% (from 3.3% to 4.9%) (Gentzke et al. 2019). This 

increase resulted in a corresponding increase in overall 

tobacco product use among middle and high school students during 2017–2018: Current use of any tobacco 

product increased 38.3% (from 19.6% to 27.1%) among 

high school students and 28.6% (from 5.6% to 7.2%) 

among middle school students (Gentzke et al. 2019).

The majority of high school and middle school students who used at least two tobacco products had tried 

to quit all tobacco use for at least 1 day during the past 

year (55.9% and 62.0%, respectively) (Table 2.19). Among 

users who had tried to quit all tobacco products during 

the past year, the distribution of their number of attempts 

(Table  2.19) was similar to the distribution for quitting 

cigarettes (Tables  2.13a and  2.13b). Similarly, among 

those who used at least two tobacco products, the distribution of the timeframes of when they considered quitting 

all tobacco products (Table 2.19) was similar to the distribution for quitting cigarettes (Tables 2.13a and 2.13b).

Table 2.19 Quitting behaviors among current users of two or more tobacco products,a by grade in school; National 

Youth Tobacco Survey (NYTS) 2017; United States

Quitting behaviors

High school (grades 9–12): 

% (95% CI)

Middle school (grades 6–8): 

% (95% CI)

Tried to quit all tobacco ≥1 days during the past year 55.9 (51.5–60.4) 62.0 (51.2–72.7)

Number of times tried to quit all tobacco during the past yearb

1 22.7 (16.8–28.6) 15.6 (7.5–23.7)

2 16.0 (10.2–21.9) 21.9 (9.5–34.4)

3–5 24.1 (17.4–30.9) 22.8 (13.6–32.0)

6–9 12.5 (8.1–16.9) RSE >30%

>10 24.7 (20.1–29.3) 29.0 (16.2–41.7)

Considered quitting all tobacco within

30 days 25.3 (19.7–30.9) 43.4 (27.9–58.9)

6 months 17.9 (12.4–23.3) RSE >30%

Not within 6 months 56.8 (49.8–63.9) 39.4 (26.5–52.3)

Tried to quit cigarettes ≥1 day during the past year 63.1 (57.2–69.0) 68.2 (58.5–78.0)

Source: NYTS, Centers for Disease Control and Prevention, public use data, 2017.

Notes: CI = confidence interval; RSE = relative standard error. aAmong those who used at least two of the following tobacco products: cigarettes, e-cigarettes, cigars, cigarillos, little cigars, chewing 

tobacco, snuff, dip, bidis, hookahs, waterpipe with tobacco, pipe filled with tobacco, snus, dissolvable tobacco products.

bAmong those who tried to quit all tobacco products at least once during the past year.
A Report of the Surgeon General

86 Chapter 2

The Clinical Practice Guideline for Treating Tobacco 

Use and Dependence (Clinical Practice Guideline) recommends that healthcare providers screen all patients 

for tobacco use and deliver brief advice to quit to all 

tobacco users at every visit (Fiore et al. 2008). The Clinical 

Practice Guideline specifically recommends following 

the “5 A’s” model to deliver a brief cessation intervention 

in the primary care setting (i.e., Ask about tobacco use, 

Advise to quit, Assess willingness to quit, Assist by offering 

counseling and medication, and Arrange for follow-up). 

Chapter  6 of this report provides detailed information 

about these clinical interventions.

Two types of national data are available to track 

screening for tobacco use and counseling on tobacco cessation by healthcare professionals. The first type depends 

on abstracting medical records from a sample of visits 

to office-based physicians (e.g.,  NAMCS), which is used 

to assess screening for tobacco use and the provision of 

information on tobacco and/or prescriptions or orders 

for cessation medication to identified users. The second 

type of national surveillance data involves self-reports and 

includes assessment by patients of the receipt of advice to 

quit and the other 5 A’s, use of effective counseling and 

medications for cessation, and the use of unproven cessation strategies (datasets include NHIS, TUS-CPS, NATS, 

and NYTS).

Screening for Tobacco Use and 

Receipt of Advice to Quit from 

Health Professionals

Adults

Clinical Data from Abstractions of Medical 

Records

Reports from NAMCS that were based on the 

abstraction of medical records for outpatient visits to 

office-based physicians showed that, in 2009–2011, adults 

18 years of age and older made an estimated 2.5 billion 

outpatient visits. NAMCS started including a panel of 

community health centers in 2006, which included visits 

to physicians and to non-physician clinicians. Data for 

office-based and community health center-based physicians were included in analyses for 2009–2011. According 

to the review, screening for tobacco use was documented 

in 66.6% of the outpatient visits (average annual estimate) 

(Table  2.20), an increase from 62.7% during 2005–2008 

(CDC 2012). Of the total documented visits in 2009−2011, 

16.4% were made by current tobacco users, a decrease 

from 17.6% in 2005–2008. Among outpatient visits made 

by patients who were identified as current tobacco users in 

2009–2011, 20.1% reported counseling or education was 

ordered or provided during their visits, a percentage that 

reflects no change from 2005–2008 (CDC 2012), and 3.8% 

received a prescription or an order for cessation medication (Table 2.20).

These estimates were similar to estimates made by 

screening records for visits to outpatient departments of 

nonfederal general and short-stay hospitals. From 2005 

to 2010, screening for tobacco use occurred in 63.0% of 

these visits; 24.5% of visits from patients who were identified as current tobacco users included counseling on 

tobacco, prescriptions or orders for cessation medication, 

or both (Jamal et al. 2015). No significant changes in these 

measures occurred in hospital outpatient visits during 

2005–2010 (Jamal et al. 2015).

During 2009–2011 (Table  2.20), visits to psychiatrists had a lower proportion that included screening for 

tobacco use (56.3%) compared with visits to general and 

family practitioners (69.7%) or to obstetricians and gynecologists” (69.8%). Patients who were identified as current tobacco users varied by status of health insurance, 

as those with Medicaid/State Children’s Health Insurance 

Program (SCHIP)/Children’s Health Insurance Program 

(33.9%), those who were self-payers (23.6%), and those 

covered by other insurance (25.3%) were more likely to be 

current tobacco users than those with private insurance 

(15.3%) or Medicare (11.8%).

For office-based outpatient visits among current 

tobacco users (i.e.,  the patient was identified as a current tobacco user during screening), the prevalence of 

visits that included tobacco counseling was lower among 

patients 18–24 years of age (14.5%) than among patients 

45–64 years of age (22.1%) (Table 2.20).

Visits by tobacco users with other types of insurance 

(9.4%) were less likely to include counseling than were 

visits among persons in any of the other insurance subgroups (e.g., worker’s compensation, no charge/charity). 

Tobacco-using patients who visited their primary care 

physicians were more likely to receive counseling 

(25.0%  of their visits) than were tobacco-using patients 

who visited doctors who were not their primary care physicians (16.2%  of visits). A similar finding was made in 

Clinical Interventions for Smoking Cessation: Prevalence 

and Trends
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 87

Smoking Cessation

Table 2.20 Receipt of screening for tobacco use, counseling, and a prescription for a cessation medication during 

outpatient visits to office-based physicians among adults 18 years of age and older, by patient and 

physician characteristics; National Ambulatory Medical Care Survey (NAMCS) 2009–2011 combined 

data; United States

Characteristic

Visits with screening 

for tobacco usea: 

% (95% CI)

Visits with current 

tobacco useb: 

% (95% CI)

Visits with current 

tobacco use and 

tobacco counselingc: 

% (95% CI)

Visits with current 

tobacco use and 

prescription 

of cessation 

medicationd: 

% (95% CI)

Total 66.6 (64.7–68.5) 16.4 (15.4–17.5) 20.1 (17.9–22.5) 3.8 (3.1–4.7)

Sex

Male 65.7 (63.2–68.2) 19.8 (18.4–21.2) 19.8 (17.2–22.7) 3.7 (2.9–4.7)

Female 67.2 (64.7–69.6) 14.3 (13.3–15.3) 20.4 (17.9–23.1) 4.0 (3.1–5.1)

Age (in years)

18–24 67.2 (63.9–70.3) 17.8 (16.0–19.9) 14.5 (10.9–18.9) —e

25–44 68.2 (65.7–70.7) 19.8 (18.1–21.6) 18.7 (15.9–21.8) 4.4 (3.1–6.1)

45–64 66.6 (64.0–69.1) 20.1 (18.7–21.6) 22.1 (19.2–25.2) 4.5 (3.7–5.6)

≥65 65.3 (62.7–67.9) 9.1 (8.3–9.9) 19.9 (16.5–23.8) 1.3 (0.8–2.1)

Race/ethnicity

White, non-Hispanic 67.8 (65.4–70.1) 17.1 (16.0–18.2) 20.0 (17.4–22.9) 4.1 (3.3–5.1)

Black, non-Hispanic 61.7 (56.2–66.9) 18.2 (16.1–20.5) 23.4 (18.8–28.7) 2.8 (1.5–4.9)

Hispanic 64.3 (60.5–68.0) 11.3 (9.9–12.8) 18.5 (13.8–24.4) —e

Other race/multiple race, 

non-Hispanic

63.8 (55.8–71.1) 11.2 (8.6–14.5) 14.1 (8.6–22.2) —e

Health insurance coverage

Private insurance 68.3 (65.8–70.7) 15.3 (14.3–16.3) 20.4 (18.0–23.0) 4.2 (3.3–5.2)

Medicare 66.3 (63.5–69.0) 11.8 (10.8–12.9) 21.3 (18.0–24.9) 3.2 (2.2–4.7)

Medicaid/SCHIP/CHIP 66.1 (61.2–70.8) 33.9 (30.3–37.6) 23.0 (17.6–29.5) 4.5 (3.0–6.7)

Self-pay 61.5 (55.9–66.9) 23.6 (20.6–27.0) 19.3 (14.8–24.8) 4.7 (3.1–7.0)

Other f 66.1 (60.4–71.4) 25.3 (21.4–29.5) 9.4 (6.2–14.2) —e

Patient’s primary care physician

Yes 69.9 (66.8–72.8) 18.3 (16.6–20.1) 24.7 (21.4–28.9) 5.1 (3.8–6.7)

No 66.6 (64.2–68.8) 14.8 (14.0–15.8) 16.2 (14.0–18.7) 2.8 (2.2–3.5)

Physician specialty

General or family practice 69.7 (65.9–73.2) 21.6 (19.9–23.5) 22.1 (18.9–25.7) 4.8 (3.8–6.1)

Internal medicine 67.1 (60.7–72.9) 16.2 (13.9–18.9) 27.8 (22.3–34.1) 4.1 (2.5–6.9)

Obstetrics and gynecology 69.8 (64.4–74.7) 10.6 (9.0–12.5) 16.7 (11.1–24.3) —e

Cardiovascular disease 67.8 (61.7–73.4) 12.3 (10.6–14.2) 38.6 (31.7–46.1) —e

Psychiatry 56.3 (49.4–63.1) 23.9 (19.6–28.8) 28.8 (19.0–41.1) 13.3 (9.9–17.7)

All other specialties 64.8 (61.7–67.8) 14.6 (13.6–15.7) 12.9 (10.5–15.8) 2.1 (1.5–3.1)

Time spent with physician

<20 minutes 64.8 (61.9–67.7) 15.8 (14.8–16.9) 17.6 (15.3–20.1) 3.3 (2.6–4.2)

≥20 minutes 68.8 (66.4–71.1) 17.0 (15.7–18.5) 22.8 (19.9–26.0) 4.4 (3.4–5.6)

Source: NAMCS, National Center for Health Statistics, public use data, 2009–2011.
A Report of the Surgeon General

88 Chapter 2

the examination of the 2005–2010 data on visits to hospital outpatient departments (Jamal et al. 2015). Among 

patients who used tobacco, those who visited cardiovascular disease specialists were more likely to receive counseling on tobacco use (38.6%) than were patients who 

visited general and family practitioners (22.0%), obstetricians and gynecologists (16.7%), or all other specialists 

(12.9%). Similar differences by type of healthcare insurance, primary care physician, and physician specialty were 

observed in the 2005–2008 NAMCS (CDC 2012).

Among current smokers who visited office-based 

physicians, the percentage of visits at which tobacco cessation medications were prescribed varied by age group. 

The percentage was lower for visits by those 65 years of 

age and older compared with those 25–44 or 45–64 years 

of age (Table  2.20). Outpatient visits by current cigarette smokers that included a prescription of cessation 

medication also varied by whether the physician was the 

patient’s primary care physician (5.1% of visits) or was 

not (2.8% of visits). Visits to psychiatrists had a higher 

proportion with prescribed medication (13.3%) than 

visits to all other specialists. These differences by age and 

physician specialty were also observed in the 2005–2008 

NAMCS (CDC 2012).

Self-Reported Data from Cigarette Smokers

According to NHIS data, in 2015, 83.9% of adult 

cigarette smokers saw a physician or other health professional during the past year, and among this group, 57.2% 

reported receiving advice to quit smoking (Table  2.21). 

The prevalence of smokers who received advice to quit 

was higher among older age groups (45–64 years of age 

[65.7%] and those aged 65 years of age and older [65.7%]) 

than among younger age groups (18–24  years of age 

[44.4%] and 25–44  years of age [49.8%]). Whites were 

more likely to receive advice to quit (60.2%) than were 

Asians (34.2%), American Indians/Alaska Natives (38.1%), 

or Hispanics (42.2%) (Table 2.21). Smokers living in the 

Northeast were more likely to report being advised to quit 

smoking (65.1%) than smokers living in the West (50.6%) 

or the South (55.2%). In addition, the prevalence of 

smokers who received advice to quit was lower in the West 

(50.6%) than it was in the Midwest (60.0%). Uninsured 

smokers were less likely to report receiving advice to quit 

(44.1%) than smokers with any type of insurance (range: 

56.8–69.2%). There were no significant differences in 

receipt of advice to quit between persons identifying as 

lesbian, gay, or bisexual (57.7%) (Table  2.22) and those 

identifying as heterosexual (57.1%). These demographic 

differences were similar to those seen in the 2010 NHIS, 

although sexual orientation was not assessed prior to the 

2013 NHIS (CDC 2011).

According to the 2009–2010 NATS, the prevalence 

of self-reported receipt of advice from a health professional to quit smoking was 65.8% among current cigarette smokers who had seen a health professional during 

the past year (King et al. 2013). This figure is higher than 

the estimate using the 2010 NHIS, in which 48.3% of 

current cigarette smokers and former smokers who quit 

during the past year reported receiving cessation advice 

(CDC 2011). Appendix 2.1 discusses NATS and NHIS, and 

Appendix  2.2 discusses methodologic features that may 

have contributed to this difference, including that NATS 

was a tobacco-focused survey that may have contributed 

to a social desirability bias among cigarette smokers to 

answer that they received cessation advice. Using data 

from the 2010–2011 TUS-CPS, 64.8% of current cigarette smokers reported receiving advice to quit (TUS-CPS, 

public use data, 2010–2011), which was similar to the estimate from the 2009–2010 NATS. Although the TUS-CPS 

was another tobacco-focused survey and may have been 

subject to social desirability bias, it is also possible that 

data from NHIS may underestimate the prevalence of cigarette smokers receiving advice to quit.

Also using the 2009–2010 NATS, 87.9% of current 

smokers who visited a health professional recalled being 

asked if they smoked cigarettes, and 42.6% recalled being 

asked if they wanted to quit (King et  al. 2013). Among 

Table 2.20 Continued

Note: CHIP = Children’s Health Insurance Program; CI = confidence interval; SCHIP = State Children’s Health Insurance Program.

aVisits during which the status (yes, no) of current tobacco use (cigarettes, cigars, or snuff or chewing tobacco) was recorded. 

Denominator includes current tobacco use, no current use, unknown, and blanks.

bDocumented visits during which current tobacco use (smoking cigarettes or cigars or using snuff or chewing tobacco) was recorded.

cTobacco counseling refers to the provision of any information related to tobacco use in any form, including cigarettes, cigars, snuff, 

and chewing tobacco, and also includes information about exposure to tobacco in the form of secondhand smoke, smoking cessation, 

and the prevention of tobacco use; referrals to other healthcare providers for smoking cessation programs are also included.

dCessation medications include nicotine replacement therapy (nicotine patch, gum, lozenge, nasal spray, and inhaler), bupropion, 

and varenicline.

ePrevalence estimates with a relative standard error ≥30% are not presented due to low precision.

f

Includes response options “Worker’s compensation, No charge/Charity, Other.”
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 89

Smoking Cessation

Table 2.21 Prevalence of receiving a health professional’s advice to quit smokinga and use of counselingb

and medicationsc for cessation among cigarette smokers 18 years of age and older, by selected 

characteristics; National Health Interview Survey (NHIS) 2015; United States

Characteristic

Received health 

professional's advice 

to quit: % (95% CI)

Used counseling: 

% (95% CI)

Used medication: 

% (95% CI)

Used counseling 

and/or medication: 

% (95% CI)

Overall 57.2 (55.3–59.1) 6.8 (5.7–7.9) 29.0 (26.8–31.2) 31.2 (28.9–33.5)

Sex

Men 55.2 (52.5–57.9) 5.8 (4.3–7.4) 27.0 (24.0–30.0) 29.1 (26.0–32.2)

Women 59.3 (56.6–61.9) 7.9 (6.4–9.5) 31.3 (28.2–34.3) 33.6 (30.5–36.6)

Age group (in years)

18–24 44.4 (37.1–51.6) —c 15.6 (9.5–21.7) 16.8 (10.6–23.0)

25–44 49.8 (46.6–53.0) 6.1 (4.5–7.8) 25.5 (22.2–28.7) 27.4 (24.1–30.8)

45–64 65.7 (62.9–68.4) 8.8 (6.9–11.1) 37.7 (34.0–41.4) 40.2 (36.4–43.9)

≥65 65.7 (61.4–70.0) 9.2 (5.3–13.1) 33.7 (27.7–39.7) 37.0 (31.0–43.1)

Race/ethnicity

White, non-Hispanic 60.2 (58.0–62.4) 6.9 (5.5–8.3) 32.6 (29.8–35.4) 34.3 (31.4–37.2)

Black, non-Hispanic 55.7 (50.2–61.1) 7.6 (4.5–10.8) 25.2 (20.1–30.3) 28.9 (23.5–34.4)

Hispanic 42.2 (37.0–47.5) 5.1 (2.4–7.7) 16.6 (12.4–20.9) 19.2 (14.4–24.0)

American Indian/Alaska Native, 

non-Hispanic

38.1 (21.4–54.8) —c —c —c

Asian, non-Hispanicd 34.2 (24.2–44.3) —c 17.4 (9.4–25.4) 20.5 (12.2–28.8)

Multiple races, non-Hispanic 69.6 (59.2–80.1) —c 22.1 (10.5–33.6) 24.6 (12.7–36.4)

Level of educatione

≤12 years (no diploma) 60.8 (56.6–65.1) 5.4 (3.1–7.6) 26.5 (21.8–31.2) 28.7 (23.8–33.6)

GED certificate 61.6 (52.4–70.7) —c 30.8 (21.5–40.1) 31.4 (22.0–40.7)

High school diploma 58.1 (53.9–62.3) 7.0 (4.7–9.4) 30.3 (25.5–35.1) 33.1 (28.1–38.1)

Some college (no degree) 59.1 (55.3–63.0) 8.6 (6.0–11.1) 32.5 (28.1–36.9) 34.6 (30.1–39.2)

Associate degree 61.6 (56.4–66.8) 8.6 (5.1–12.2) 33.2 (27.4–39.0) 36.0 (29.8–42.3)

Undergraduate degree 52.6 (46.6–58.5) 7.4 (3.7–11.1) 33.2 (26.5–39.8) 35.1 (28.4–41.7)

Graduate degree 57.7 (48.5–66.8) —c 32.8 (22.9–42.6) 35.9 (25.7–46.0)

Poverty status

At or above poverty level 57.8 (55.6–60.1) 6.8 (5.6–8.1) 29.5 (27.1–31.8) 31.7 (29.2–34.2)

Below poverty level 54.7 (50.7–58.7) 6.7 (4.6–8.9) 27.0 (21.6–31.6) 29.0 (24.2–33.7)

U.S. Census region

Northeast 65.1 (60.2–70.1) 8.2 (4.9–11.5) 34.7 (27.9–41.5) 37.6 (30.9–44.2)

Midwest 60.0 (56.1–63.9) 4.9 (3.0–6.8) 28.9 (24.9–32.8) 30.2 (26.1–34.4)

South 55.2 (52.2–58.2) 7.2 (5.3–9.0) 27.2 (23.8–30.6) 29.3 (25.7–33.0)

West 50.6 (46.9–54.4) 7.5 (5.1–9.9) 28.0 (23.1–32.8) 30.7 (25.5–35.9)

Health insurance coverage

Private 56.8 (54.0–59.5) 6.8 (5.3–8.3) 29.9 (27.0–32.7) 32.1 (29.1–35.1)

Medicaid and dual eligibles 59.9 (55.7–64.1) 8.0 (5.3–10.7) 32.2 (27.3–37.2) 34.5 (29.3–39.6)

Medicare Advantage 66.6 (56.5–76.6) —c 26.5 (15.5–37.4) 31.6 (19.7–43.4)
A Report of the Surgeon General

90 Chapter 2

those wanting to quit, 78.2% were offered assistance, and 

17.5% were scheduled for follow-up. Among persons who 

received assistance, 50.6% were provided with access to 

booklets, videos, websites, or other information; 37.5% 

were referred to a quitline, class, program, or counseling; 

and 57.8% received recommendations or prescriptions for 

cessation medication. Thus, in the 5 A’s model of clinician 

cessation intervention, the prevalence of provider intervention was higher for asking, assessing, and assisting 

than for more time-comprehensive and time-intensive 

components, such as scheduling for follow-up.

Trends

For 2000–2015, NHIS data indicate a nonlinear 

(quadratic) trend in the prevalence of receiving advice 

to quit smoking. Among adult current cigarette smokers 

who had visited a healthcare professional during the 

past year, prevalence of receiving advice to quit smoking 

increased from 52.4% in 2000 to 57.0% in 2005, decreased 

to 48.2% in 2010, but then increased again to 57.2% in 

2015 (Babb et al. 2017). These trends did not differ by sex 

(NHIS, public use data, 2000–2015). Similar trends were 

observed among Whites, Blacks, and Hispanics. However, 

among Asians, advice from healthcare professionals to 

quit decreased linearly over time, from 54.7% in 2000 to 

34.2% in 2015 (NHIS, public use data, 2000–2015).

Young Adults

Clinical Data Obtained by Abstracting 

Medical Records

According to combined data for 2004–2010 from 

NAMCS, an average of 65.7% of physician visits among 

patients 18–21 years of age included screening for tobacco 

use; among these, an average of 16.1% visits were made 

by current tobacco users (Jamal et al. 2014). Among visits 

made by persons identified as current tobacco users, 

19.1% received any assistance with cessation, including 

counseling on tobacco in the form of health education 

ordered or provided at the visit, a prescription or order for 

a cessation medication, or both.

Using 2004–2010 data from NAMCS, Jamal and colleagues (2014) examined physician visits among 11-  to 

21-year-old patients and found that a higher proportion of 

visits included screening for tobacco use among patients 

with private insurance (71.0%) and Medicaid or SCHIP 

(69.6%) than among patients with other types of insurance (59.9%). In addition, a higher proportion of visits to 

a patient’s primary care physician included screening for 

tobacco use (72.7%) compared with visits with nonprimary care physicians (67.9%), and a higher proportion of 

visits to a pediatrician (74.7%) included tobacco screening 

compared with visits to general or family practitioners 

Table 2.21 Continued

Characteristic

Received health 

professional's advice 

to quit: % (95% CI)

Used counseling: 

% (95% CI)

Used medication: 

% (95% CI)

Used counseling 

and/or medication: 

% (95% CI)

Health insurance coverage 

(continued)

Medicare only 

(excluding Advantage)

62.0 (51.7–72.3) —c 28.5 (15.5–41.5) 35.9 (22.6–49.1)

Other coverage 69.2 (62.8–75.7) 5.2 (2.7–7.7) 34.9 (26.2–43.6) 36.0 (27.3–44.7)

Uninsured 44.1 (38.8–49.3) 4.3 (2.2–6.4) 20.0 (15.6–24.6) 21.4 (17.0–25.8)

Source: Babb and colleagues (2017).

Notes: CI = confidence interval; GED = General Educational Development.

aReported receiving advice from a medical doctor, dentist, or other health professional to quit smoking or quit using other kinds of 

tobacco among current smokers and those who quit during the past year who saw a doctor or other health professional during the 

past year.

bUsed one-on-one counseling; attended a stop-smoking clinic, class, or support group; and/or sought a telephone helpline or quitline 

during the past year among current smokers who tried to quit during the past year or used when stopped smoking among former 

smokers who quit during the past 2 years.

cUsed nicotine patch, nicotine gum or lozenge, nicotine-containing nasal spray or inhaler, varenicline (U.S. trade name Chantix), and/or 

bupropion (including trade names Zyban and Wellbutrin) during the past year among current smokers who tried to quit during the past 

year or used when they stopped smoking among former smokers who quit during the past 2 years.

dDoes not include Native Hawaiians or Other Pacific Islanders.

eAmong only adults 25 years of age and older.
Subpopulation

Interested in

quitting:

% (95% CI)

(2015)

Past-year 

quit attempt:

% (95% CI)

(2017)

Received health 

professional’s 

advice to quit:

% (95% CI)

(2015)

Used counseling 

and/or medication:

% (95% CI)

(2015)

Quit ratio:

% (95% CI)

(2017)

Recent successful 

cessation:

% (95% CI)

(2017)

Cigarette smoking frequencyh

Some-day smokers 71.0 (67.4–74.7) 58.5 (54.5–62.5) 44.6 (40.2–49.0) 24.2 (19.7–28.7) NA NA

Daily smokers, 1–4 cpd 71.8 (65.0–78.7) 59.8 (52.0–67.6) 51.3 (43.7–59.0) 33.6 (24.4–42.7) NA NA

Daily smokers, 5–14 cpd 68.8 (65.6–72.0) 49.8 (46.5–53.2) 64.5 (61.1–67.8) 36.2 (31.5–41.0) NA NA

Daily smokers, 15–24 cpd 66.3 (62.6–70.0) 40.2 (36.7–43.7) 68.4 (64.4–72.3) 42.5 (36.5–48.4) NA NA

Daily smokers, ≥25 cpd 55.6 (48.1–63.2) 29.5 (22.6–36.4) 79.3 (73.1–85.6) 46.7 (32.5–60.9) NA NA

Usually smokes mentholh

Yes 71.3 (68.1–74.5) NA 58.6 (54.8–62.4) 32.8 (28.4–37.1) NA NA

No 67.3 (64.7–69.9) NA 62.8 (60.4–65.3) 35.9 (31.6–38.7) NA NA

No usual type 40.0 (28.2–51.9) NA 34.1 (21.8–46.4) —i NA NA

Serious psychological distress

Yes (Kessler scorej ≥13) 67.4 (61.3–73.5) 58.2 (51.8–64.6) 70.1 (64.5–75.8) 41.6 (33.7–49.5) 40.7 (35.4–46.1) 7.2 (3.9–10.5)

No (Kessler score <13) 68.2 (66.0–70.3) 55.0 (53.1–56.9) 55.7 (53.7–57.7) 30.1 (27.8–32.5) 63.0 (61.6–64.3) 7.7 (6.7–8.8)

Chronic illness diagnosis

Any smoking-related 

chronic diseasek

67.9 (65.1–70.8) 56.5 (54.0–58.9) 67.3 (64.7–69.8) 35.4 (32.0–38.8) 65.2 (63.6–66.8) 6.8 (5.6–8.0)

Other chronic diseasel 69.4 (66.6–72.2) 55.8 (53.3–58.3) 66.5 (64.0–69.1) 37.2 (33.6–40.7) 67.6 (66.1–69.1) 6.5 (5.0–7.9)

No chronic disease 69.3 (66.8–71.8) 56.1 (54.0–58.3) 64.8 (62.6–67.1) 36.1 (33.0–39.2) 64.8 (63.4–66.2) 6.7 (5.5–7.8)

Disability/limitationm

Yes 66.4 (61.4–71.3) 54.0 (50.0–58.0) 71.8 (67.4–76.2) 39.0 (32.1–45.9) 59.4 (56.7–62.1) 5.4 (3.5–7.4)

No 66.8 (63.5–70.2) 54.6 (51.9–57.2) 53.6 (50.5–56.8) 28.5 (25.1–31.9) 62.6 (60.7–64.4) 8.4 (6.8–9.9)

Sexual orientation

Heterosexual 68.1 (65.9–70.2) 55.4 (53.4–57.3) 57.1 (55.1–59.1) 31.7 (29.3–34.1) 62.1 (60.8–63.4) 7.5 (6.4–8.5)

Lesbian/gay/bisexual 66.7 (56.9–76.6) 54.6 (46.4–62.9) 57.7 (48.5–66.9) 14.5 (7.9–21.1) 50.6 (44.1–57.0) —i

Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 91

Table 2.22 Prevalence of interest in quittinga, past-year quit attemptb, receipt of a health professional’s advice to quitc, use of counselingd and/or 

medicatione, quit ratiof

, and recent successful cessationg among smokers 18 years of age and older, by selected subpopulations; National 

Health Interview Survey (NHIS) 2015, 2017; United States
Subpopulation

Interested in

quitting:

% (95% CI)

(2015)

Past-year 

quit attempt:

% (95% CI)

(2017)

Received health 

professional’s 

advice to quit:

% (95% CI)

(2015)

Used counseling 

and/or medication:

% (95% CI)

(2015)

Quit ratio:

% (95% CI)

(2017)

Recent successful 

cessation:

% (95% CI)

(2017)

Binge drinking (past month)

Yes 70.1 (66.0–74.2) 54.8 (51.2–58.4) 53.5 (49.3–57.7) 29.9 (25.2–34.5) 51.5 (48.7–54.4) 6.4 (4.8–8.1)

No 67.2 (64.8–69.6) 55.8 (53.6–58.0) 58.8 (56.6–61.0) 32.1 (29.5–34.7) 64.8 (63.4–66.1) 8.0 (6.7–9.2)

A Report of the Surgeon General

92 Chapter 2

Table 2.22 Continued

Source: NHIS, National Center for Health Statistics, public use data, 2015, 2017; Babb and colleagues (2017).

Notes: CI = confidence interval; cpd = cigarettes smoked per day; 

aCurrent smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying to quit smoking and former smokers who quit 

during the past year.

bCurrent smokers who reported that they wanted to stop smoking completely.

cReceived advice from a medical doctor, dentist, or other health professional to quit smoking or quit using other kinds of tobacco among current smokers and those who 

quit during the past year who saw a doctor or other health professional during the past year.

dUsed one-on-one counseling; attended a stop-smoking clinic, class, or support group; and/or sought a telephone helpline or quitline during the past year among current 

smokers who tried to quit during the past year or among former smokers who quit during the past 2 years.

eUsed nicotine patch, nicotine gum or lozenge, nicotine-containing nasal spray or inhaler, varenicline (U.S. trade name Chantix), and/or bupropion (including trade names 

Zyban and Wellbutrin) during the past year among current smokers who tried to quit during the past year or among former smokers who quit during the past 2 years.

f

The percentage of ever smokers who have quit smoking. Defined as the number of former smokers divided by the number of ever smokers.

gHaving smoked during the past year but having been quit for at least 6 months at the time of the survey interview. The denominator in the prevalence calculation includes 

all persons who smoked during the past year (i.e., both current cigarette smokers and former smokers who reported quitting during the past year).

hAnalysis limited to current smokers.

i

Prevalence estimates with a relative standard error ≥30% are not presented due to low precision.

j

The Kessler Psychological Distress Scale was developed for mental health screening in population surveys. The 10-item questionnaire is intended to yield a global measure 

of distress based on questions about anxiety and depressive symptoms that a person has experienced in the most recent 4-week period.

kIncludes lung cancer, other tobacco-related cancers (bladder, cervical, colon, esophageal, kidney, larynx-windpipe, leukemia, liver, mouth/tongue/lip, pancreas, rectum, 

stomach, throat-pharynx, and uterine), coronary heart disease, stroke, emphysema, chronic bronchitis, asthma, diabetes, and arthritis.

l

Includes hypertension, other heart condition or heart disease, ulcer, and cancers including blood, bone, brain, breast, gallbladder, lymphoma, melanoma, ovarian, prostate, 

skin (non-melanoma and other), soft tissue, testicular, thyroid, and other.

mDefined on the basis of self-reported presence of selected limitations, including vision, hearing, cognition, and movement. Limitations in performing activities of daily living 

were defined on the basis of responses to the following question: “Does [person] have difficulty dressing or bathing?” Limitations in performing instrumental activities of daily 

living were defined on the basis of responses to the following question: “Because of a physical, mental, or emotional condition, does [person] have difficulty doing errands 

alone such as visiting a doctor’s office or shopping?” Any disability was defined as a “yes” response pertaining to at least one of the limitations (vision, hearing, cognition, 

movement, activities of daily living, or instrumental activities of daily living). Results include responses from a random sample of half of the respondents from the 2017 

Person File who were asked about limitations and weights from the Family Disability Questions File.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 93

Smoking Cessation

or internal medicine physicians (68.3%), psychiatrists 

(62.4%), or physicians in all other specialties, except 

obstetrics and gynecology (65.0%). A higher proportion 

of visits in which preventive care was the major reason for 

the visit (28.9%) included cessation assistance (including 

counseling, medication, or both) compared with visits for 

other reasons (16.7%) (Jamal et al. 2014).

Data from Self-Reports of Cigarette Smokers 

Among young adult current cigarette smokers 

(18–24  years of age), differences in the prevalence of 

receiving a health professional’s advice to quit were similar 

to differences in the advice received by all adults in 2015. 

However, regional differences were more pronounced, as 

28.6% of smokers in the South were advised to quit compared with 66.7% of smokers in the Northeast and 57.3% 

of smokers in the Midwest (NHIS, public use data, 2015).

Trends

Among adults 18–24  years of age, NHIS data for 

2000–2015 indicated that trends in receiving advice from a 

provider to quit among men were similar to the quadratic 

trends among all adults (Babb et al. 2017), but there was 

no significant increase among women from 2010 (42.4%) 

to 2015 (42.0%) (NHIS, public use data, 2000–2015).

Youth

Clinical Data Obtained by Abstracting 

Medical Records

According to combined data for 2004–2010 from 

NAMCS, an average of 71.5% of outpatient visits by patients 

11–17  years of age included screening for tobacco use; 

among these, an average of 3.0% outpatient visits were 

made by current tobacco users (Jamal et al. 2014). Among 

visits made by persons identified as current tobacco users, 

21.8% included the receipt of any cessation assistance, 

including tobacco counseling in the form of health education ordered or provided at the visit, a prescription or 

order for a cessation medication, or both. Using 2004–

2010 data from NAMCS, Jamal and colleagues (2014) 

examined demographic differences in the screening and 

provision of education and/or medication among visits by 

patients 11–21  years of age; these were discussed previously in the section on young adults.

Self-Reported Data

In 2015, according to data from the NYTS, 46.2% of 

high school students and 23.9% of middle school students 

who had visited a healthcare provider during the past 

year, were asked at any visit during that year if they had 

used tobacco (Tables 2.23a and 2.23b). Twelfth-grade students (54.3%) were more likely than 9th-grade students 

(40.6%) and 10th-grade students (41.6%) to report being 

asked about tobacco use. This question was not asked in 

the 2016 or 2017 NYTS.

According to 2017 data from the NYTS, 31.4% of 

high school students and 28.1% of middle school students who had smoked cigarettes during the past 30 days 

had been advised by a doctor, dentist, or nurse not to use 

tobacco. The prevalence of receiving advice to quit was 

similar between these students and students who used 

any type of tobacco (29.5% of high school students and 

24.6% of middle school students) (NYTS, public use data, 

2017). According to data from the 2011 NYTS, high school 

students who smoked on more than 19 days during the 

past 30 days were more likely to receive a health professional’s advice to not use tobacco (54.0%) than those who 

smoked on 1–19 of the past 30 days (33.0%) (Schauer et al. 

2014a). According to the 2013 NSDUH, 26.3% of past30-day tobacco users 12–17  years of age were screened 

for tobacco use and advised to quit (Collins et al. 2017). 

Furthermore, males were more likely to be advised to quit 

than females, and Hispanics were less likely to be advised 

to quit than Whites.

Use of Counseling and Medications 

to Quit Smoking

Adults

In 2015, according to data from the NHIS, the use 

of cessation counseling and/or medication among current smokers who had tried to quit during the past year 

and former smokers who had successfully quit during the 

past 2 years was 31.2% (Table 2.21). In all, 6.8% had used 

counseling, 29.0% had used medications, and 4.7% had 

used both (Babb et al. 2017). Counseling services (alone 

or in combination) included a telephone quitline (4.1%); 

one-on-one counseling (2.8%); and a stop-smoking clinic, 

class, or support group (2.4%). Medications included the 

seven FDA-approved medications for smoking cessation 

(alone or in combination); the prevalence of medication 

use was 16.6% for the nicotine patch, 12.5% for nicotine 

gum or lozenges, 2.4% for nicotine nasal spray or inhaler, 

7.9% for varenicline, and 2.7% for bupropion.

According to NHIS, in 2015, the use of effective treatment (counseling and/or medications) was lower among 

persons 18–24  years of age (16.8%) than in any of the 

other age groups (Table 2.21). In addition, prevalence of 

the use of counseling and/or medication was lower among 

smokers 25–44 years of age (27.4%) than among smokers 

45–64 years of age (40.2%) or those 65 years of age and 
A Report of the Surgeon General

94 Chapter 2

Table 2.23a Prevalence of being asked about tobacco usea and being advised not to use tobaccob among high school 

students (grades 9–12) who saw a healthcare provider during the past year, by grade in school; National 

Youth Tobacco Survey (NYTS) 2015; United States

Characteristic Asked about tobacco use: % (95% CI)

Current cigarette smokers advised not 

to use tobacco: % (95% CI)

Total 46.2 (43.6–48.8) 30.2 (28.0–32.4)

Sex

Male 45.2 (42.2–48.2) 34.1 (27.3–41.0)

Female 47.4 (44.4–50.4) 32.9 (26.4–39.4)

Grade

9 40.6 (36.8–44.4) 27.2 (18.9–35.5)

10 41.6 (38.2–45.0) 28.6 (19.7–37.5)

11 49.7 (46.1–53.4) 38.1 (29.8–46.3)

12 54.3 (51.5–57.2) 36.6 (28.8–44.3)

Race/ethnicity

White, non-Hispanic 47.5 (44.2–50.8) 33.1 (27.8–38.4)

Black, non-Hispanic 45.9 (42.0–49.9) 33.5 (16.8–50.2)

Other, non-Hispanic 44.8 (40.2–49.4) 33.5 (14.9–52.1)

Hispanic 44.3 (40.5–48.1) 35.4 (24.6–46.1)

Source: NYTS, public use data, 2015.

Notes: This question was not asked in the 2016 or 2017 NYTS. CI = confidence interval.

aBeing asked about tobacco use was defined as being asked at any visit to a doctor, dentist, or nurse during the past year if the student 

used tobacco that is smoked or put in the mouth.

bBeing advised not to use tobacco was defined as being advised by a doctor, dentist, or nurse during the past 12 months not to use tobacco 

that is smoked or put in the mouth among current cigarette smokers (smoked cigarettes during the 30 days preceding the survey).

Table 2.23b Prevalence of being asked about tobacco usea and being advised not to use tobaccob among middle school 

students (grades 6–8) who saw a healthcare provider during the past year, by grade in school; National 

Youth Tobacco Survey (NYTS) 2015; United States

Characteristic Asked about tobacco use: % (95% CI)

Current cigarette smokers advised not 

to use tobacco: % (95% CI)

Total 23.9 (21.9–26.0) 22.9 (21.0–24.8)

Sex

Male 23.4 (21.2–25.5) 31.5 (17.0–46.0)

Female 24.7 (22.1–27.2) 25.6 (14.7–36.5)

Race/ethnicity

White, non-Hispanic 24.0 (20.9–27.0) 26.5 (17.5–35.4)

Black, non-Hispanic 28.6 (24.0–33.2) —c

Other, non-Hispanic 21.2 (17.4–25.0) —c

Hispanic 23.5 (21.3–25.8) —c

Source: NYTS, public use data, 2015.

Notes: This question was not asked in the 2016 or 2017 NYTS. CI = confidence interval; RSE = relative standard error.

aBeing asked about tobacco use was defined as being asked at any visit to a doctor, dentist, or nurse during the past year if the student 

used tobacco that is smoked or put in the mouth.

bBeing advised not to use tobacco was defined as being advised by a doctor, dentist, or nurse during the past 12 months not to use tobacco 

that is smoked or put in the mouth among current cigarette smokers (smoked cigarettes during the 30 days preceding the survey).

cData are not shown because sample size was <50 and the relative standard error of the estimate was >30%.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 95

Smoking Cessation

older (37.0%). Hispanics used effective treatments less 

often than Whites (19.2% vs. 34.3%). Uninsured smokers 

were less likely to use effective treatments (21.4%) than 

were smokers who were privately insured (32.1%), had 

Medicaid (34.5%), or had other coverage (36.0%). Use of 

counseling and/or medication was also lower among lesbian, gay, and bisexual smokers than among heterosexuals 

(14.5% vs. 31.7%) (Table 2.22).

According to data from the 2014–2015 TUS-CPS, 

the prevalence of using a telephone quitline for cessation was 3.5% among current cigarette smokers who had 

tried to quit during the past year (Table  2.24), a figure 

that was quite similar to the prevalence using the 2015 

NHIS for using such a quitline among current smokers 

who had tried to quit during the past year combined with 

former smokers who had quit during the past 2  years 

(4.1%) (Babb et al. 2017). Use of a telephone quitline by 

current cigarette smokers during the last time they tried 

to quit within the past year was higher among women 

(4.2%) than men (2.8%), among those 45–64 years of age 

(4.4%) than those aged 65  years and older (2.1%), and 

among those living below the poverty level (5.2%) than 

among those living at or above the poverty level (3.0%) 

(Table 2.24).

Young Adults

In 2015, according to data from the NHIS, 16.8% of 

young adult current smokers 18–24 years of age who had 

tried to quit during the past year and former smokers who 

successfully quit during the past 2  years used cessation 

counseling and/or medications (Table  2.21) (Babb et  al. 

2017). This included 15.6% who used only medications, 

but because of small numbers and low precision (relative 

standard error ≥30%), the percentages who used either 

counseling only or both counseling and medication could 

not be estimated (Babb et al. 2017). Regardless, both percentages were lower than those for smokers 25 years of 

age and older (Babb et al. 2017). The association between 

demographic characteristics and treatment use among 

young adults could not be examined using 2015 NHIS 

data because of small sample sizes and the low precision 

of estimates (relative standard error ≥30%).

Youth

In 2015, according to data from the NYTS, 17.8% 

of high school current cigarette smokers who had tried 

to quit during the past year used a program, counseling, 

and/or medication to quit during the past 12 months, and 

69.9% reported that they had “tried to quit on my own 

or quit cold turkey” (Table  2.25). Among middle school 

students, 30.4% of current cigarette smokers used a program, counseling, and/or medication to quit, and 81.9% 

tried to quit cold turkey. However, caution is warranted 

in interpreting these results because a large proportion 

of middle school students reported using both a strategy 

to quit and quitting cold turkey, suggesting that they had 

different interpretations of what was meant by “quitting 

on their own” or quitting cold turkey.

Among high school students who were current cigarette smokers and had attempted to quit during the past 

year, the use of a program, counseling, and/or medication 

was higher among males (22.8%; 95% CI, 15.6–30.1) than 

females (8.9%; 95% CI, 4.2–13.6) (NYTS, public use data, 

2015; not shown in Table 2.25). Estimates for other demographic characteristics were of low precision and therefore were not examined (relative standard error ≥30%).

Trends Among Adults

The prevalence among current cigarette smokers of 

using effective cessation treatments increased nonlinearly 

during 2000–2015. A significant increase was observed 

from 2000 (21.9%) to 2010 (31.7%), but there was no 

change during 2010–2015 (31.2%) (Babb et  al. 2017). 

A similar trend was observed among women (2000, 22.4%; 

2005, 32.7%; 2010, 35.1%; and 2015, 33.6%). Among men, 

a linear increase in the use of effective treatments was seen 

from 2000 (21.4%) to 2015 (29.1%) (NHIS, public use data, 

2000–2015). Trends in the use of cessation aids also differed 

by race/ethnicity: Trends among Whites and Hispanics were 

similar to those for adults overall, but a linear increase was 

observed for Blacks (Figure 2.13). Data from Nielsen Retail 

Management Services showed sales of NRT gum, lozenge, 

and patch totaled $1.0 billion in 2018 (adjusted for inflation to 2018 dollars) (Figure 2.14). From Quarter 2 of 2014 

to Quarter 4 of 2018, NRT gum had the highest sales followed by NRT lozenge and NRT patch. During this time 

period, sales of NRT gum increased steadily from Quarter 2 

of 2014 to Quarter 4 of 2015, peaked in Quarter 2 of 2016 

at $145.6 million, and then decreased through Quarter 4 

of 2018 ($132.0  million). In contrast, sales of NRT lozenge increased fairly steadily from Quarter  2 of 2014 to 

Quarter  4 of 2018, when sales peaked at $78.2  million. 

Sales of NRT patch appeared to have a seasonal pattern 

from 2014 to 2018, as sales peaked in the first quarter of 

each year and then generally declined throughout the year. 

Sales of NRT patch peaked in Quarter 1 of 2016 ($48.3 million) but then decreased generally through 2018 despite its 

annual first-quarter peaks.

Trends Among Young Adults

Among young adults 18–24 years of age, trends in 

the use of effective cessation treatments among female 

smokers and White smokers were similar to trends among 

adults overall; but among men, use of effective cessation 
A Report of the Surgeon General

96 Chapter 2

Table 2.24 Prevalence of using strategies to quit cigarette smokinga among current cigarette smokersb 18 years of 

age and older who tried to quit during the past year, by selected characteristics; Tobacco Use Supplement 

to the Current Population Survey (TUS-CPS) 2014–2015; United States

Characteristic

Used telephone 

quitline: 

% (95% CI)

Used Internet 

or web-based 

program or tool: 

% (95% CI)

Used switching 

to smokeless 

tobacco: 

% (95% CI)

Used switching 

to cigar or pipe: 

% (95% CI)

Used switching 

to e-cigarettes: 

% (95% CI)

Overall 3.5 (3.1–3.9) 2.1 (1.8–2.4) 5.4 (4.8–6.0) 2.7 (2.4–3.1) 34.7 (33.6–35.7)

Sex

Men 2.8 (2.3–3.4) 1.7 (1.3–2.1) 7.7 (6.7–8.7) 4.0 (3.3–4.6) 32.7 (31.2–34.3)

Women 4.2 (3.6–4.7) 2.5 (2.0–3.0) 3.0 (2.4–3.5) 1.5 (1.0–1.9) 36.8 (35.3–38.3)

Age group (in years)

18–24 2.7 (1.4–4.0) 2.4 (1.1–3.6) 7.8 (5.6–10.0) 3.7 (2.2–5.1) 39.2 (35.2–43.2)

25–44 3.2 (2.6–3.8) 2.3 (1.7–2.8) 5.8 (4.8–6.7) 2.3 (1.7–2.8) 38.0 (36.3–39.8)

45–64 4.4 (3.7–5.1) 1.9 (1.4–2.4) 4.5 (3.8–5.3) 3.0 (2.4–3.6) 32.2 (30.6–33.7)

≥65 2.1 (1.2–3.0) 1.8 (1.0–2.6) 3.8 (2.5–5.1) 2.5 (1.6–3.5) 23.7 (20.7–26.7)

Race/ethnicity

White, non-Hispanic 3.2 (2.8–3.7) 2.1 (1.7–2.5) 5.5 (4.8–6.1) 2.5 (2.0–2.9) 38.8 (37.6–40.0)

Black, non-Hispanic 4.0 (2.8–5.2) 2.3 (1.3–3.2) 4.6 (3.3–6.0) 4.0 (2.7–5.3) 23.1 (20.3–25.9)

Hispanic 4.3 (2.6–6.1) 2.2 (1.0–3.3) 4.7 (3.0–6.5) 3.0 (1.5–4.4) 22.8 (19.6–26.0)

American Indian/Alaska 

Native, non-Hispanic

—c —c —c —c 24.5 (16.7–32.2)

Asian, non-Hispanic —c —c —c —c 25.4 (18.1–32.7)

Multiple races, non-Hispanic —c —c —c —c 50.6 (42.4–58.9)

Level of educationd

≤12 years (no diploma) 4.3 (3.2–5.3) 1.0 (0.6–1.5) 4.5 (3.4–5.7) 3.5 (2.4–4.5) 28.4 (25.9–31.0)

High school diploma 3.0 (2.4–3.7) 1.7 (1.2–2.2) 5.5 (4.6–6.5) 2.6 (2.0–3.2) 34.6 (32.7–36.4)

Some college (no degree) 3.2 (2.5–4.0) 2.5 (1.8–3.2) 5.9 (4.8–7.1) 2.9 (2.1–3.8) 37.8 (35.4–40.2)

Associate degree 4.6 (3.1–6.1) 2.2 (0.9–3.6) 5.2 (3.8–6.7) 2.0 (0.9–3.0) 37.7 (34.8–40.6)

Undergraduate degree 3.5 (2.2–4.8) 4.1 (2.7–5.5) 5.0 (3.4–6.6) 2.0 (0.9–3.1) 35.7 (32.3–39.1)

Graduate degree 3.1 (0.5–5.8) 3.4 (1.2–5.7) 6.2 (2.8–9.6) 3.5 (1.3–5.7) 32.4 (26.3–38.6)

Poverty status

At or above poverty level 3.0 (2.6–3.4) 2.1 (1.7–2.5) 5.5 (4.9–6.1) 2.4 (2.0–2.8) 35.1 (34.0–36.3)

Below poverty level 5.2 (4.2–6.2) 2.1 (1.5–2.6) 5.1 (4.1–6.1) 3.9 (2.9–4.8) 33.2 (30.7–35.7)

U.S. Census region

Northeast 3.9 (2.7–5.0) 2.3 (1.4–3.1) 4.7 (3.4–6.1) 3.0 (1.9–4.1) 32.2 (29.2–35.1)

Midwest 3.1 (2.3–3.9) 1.7 (1.2–2.3) 5.6 (4.4–6.8) 2.2 (1.5–2.8) 35.6 (33.5–37.7)

South 3.2 (2.7–3.8) 2.2 (1.6–2.7) 5.3 (4.5–6.2) 3.1 (2.4–3.7) 35.3 (33.5–37.1)

West 4.2 (3.2–5.1) 2.4 (1.6–3.2) 5.9 (4.7–7.2) 2.6 (1.7–3.5) 34.5 (31.7–37.2)

Source: TUS-CPS, National Cancer Institute, public use data, 2014–2015.

Notes: CI = confidence interval. 

aUsed during their last quit attempt among those who tried to quit for at least 1 day during the past 12 months.

bPersons who reported smoking more than 100 cigarettes during their lifetime and who, at the time of the interview, reported smoking 

every day or some days.

cPrevalence estimates with a relative standard error ≥30% are not presented due to low precision.

dAmong only adults 25 years of age and older.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 97

Smoking Cessation

treatments increased from 2000 (5.7%) to 2005 (15.9%) 

and then remained unchanged through 2015 (17.2%) 

(NHIS, public use data, 2000–2015). Estimates for other 

racial/ethnic groups are not presented because of low precision (relative standard error ≥30%).

Trends Among Youth

Use of cessation treatments (e.g., school or community programs, telephone quitlines, nicotine patches, nicotine gum, or any other medications) among high school 

and middle school students decreased during 2000–2004, 

and the use of cessation treatments in 2015 was similar to 

that seen in 2000 (Table 2.25).

Use of Other Cessation Strategies

Adults

According to the 2014–2015 TUS-CPS, among adult 

cigarette smokers who tried to quit smoking during the 

past year, switching to e-cigarettes was the most prevalent 

strategy (34.7%) used the last time they tried to quit 

(Table 2.24), despite inconclusive data on the efficacy of 

these products for promoting long-term cessation (see 

Chapter 7) (Hartmann-Boyce et al. 2016; Kalkhoran and 

Glantz 2016; Coleman et al. 2017; Verplaetse et al. 2018; 

Young-Wolff et al. 2018; Berry et al. 2019). The percentage 

of adult smokers switching to e-cigarettes was similar to 

the percentage of adult cigarette smokers (as estimated 

in the 2015 NHIS) who used any evidence-based cessation treatment (31.2%) (Table  2.21). According to the 

TUS-CPS data, switching to e-cigarettes in an attempt to 

quit smoking conventional cigarettes was more common 

among women (36.8%) than men (32.7%). Cigarette 

smokers younger than 45 years of age were more likely 

to try to quit by switching to e-cigarettes than were 

older smokers, and their use of e-cigarettes to try to 

quit was greater than their use of proven cessation treatments (Table 2.21). Whites (38.8%) and persons of multiple races (50.6%) were more likely than smokers of all 

other racial/ethnic groups to switch to e-cigarettes in an 

attempt to quit (Table 2.24), and the percentage of those 

who switched to e-cigarettes in an attempt to quit was 

Table 2.25 Strategies used to quit smoking among high school and middle school current cigarette smokersa who 

tried to quit during the past year; National Youth Tobacco Survey (NYTS) 2000, 2004, 2009, and 2015; 

United States

Quitting behaviors 2000: % (95% CI) 2004: % (95% CI) 2009: % (95% CI) 2015: % (95% CI)

High school (grades 9–12)

Used a program, counseling, 

and/or medicationb

16.5 (15.0–18.0) 11.8 (9.3–14.3) 10.2 (6.7– 13.7) 17.8 (12.9–22.7)

Attended a program in my school 4.7 (3.8–5.6) 2.6 (1.2–4.0) —c —c

Used nicotine gum, nicotine 

patch, or any medicine to quit

12.2 (10.9–13.5) 8.9 (6.9–10.9) 7.8 (5.0–10.7) 10.8 (7.1–14.5)

Tried to quit on my own or quit 

“cold turkey”

NA NA NA 69.9 (58.3–81.5)

Middle school (grades 6–8)

Used a program, counseling, 

and/or medicationb

31.8 (27.8–35.9) 17.4 (13.8–20.9) 26.1 (19.4–32.7) 30.4 (18.4–42.3)

Attended a program in my school 9.9 (7.4–12.5) 3.0 (1.6–4.3) —c —c

Used nicotine gum, nicotine 

patch, or any medicine to quit

19.7 (16.4–23.0) 13.4 (10.5–16.2) 19.7 (13.1–26.2) 23.7 (13.4–33.9)

Tried to quit on my own or quit 

“cold turkey”

NA NA NA 81.9 (77.4–86.4)

Source: NYTS, Centers for Disease Control and Prevention, public use data, 2000, 2004, 2009, and 2015.

Notes: CI = confidence interval; NA = not available.

aSmoked cigarettes during the past 30 days.

bAttended a program in school or a program in the community; called a telephone helpline or telephone quitline; and/or used nicotine 

gum, nicotine patch, and/or any medication to quit.

cPrevalence estimates with a relative standard error ≥30% are not presented due to low precision.
A Report of the Surgeon General

98 Chapter 2

higher than the percentage of smokers who used effective 

cessation treatments (Table 2.21) for both groups. Persons 

with 12 or fewer years of education (with no high school 

diploma) were less likely to switch to e-cigarettes in an 

attempt to quit smoking than those with higher levels of 

education, with the exception of those with a graduate 

degree (Table 2.24). The use of e-cigarettes for cessation 

was also a commonly reported strategy among cigarette 

smokers in Wave  1 of the PATH Study: 25.2% reported 

using e-cigarettes to quit, and 23.5% reported using an 

FDA-approved cessation medication—NRT (18.7%), varenicline (5.7%), or bupropion (3.1%) (Benmarhnia et al. 

2018). Similar to the TUS-CPS, younger (18–34 years of 

age) cigarette smokers in the PATH Study who were trying 

to quit had a higher prevalence of using e-cigarettes as 

a cessation aid than those 35  years of age and older 

(Benmarhnia et al. 2018). In their analysis of data from the 

PATH Study, Harlow and colleagues (2018) observed that, 

among cigarette-only smokers at Wave 1, Whites, persons 

with greater than a high school education, and persons 

living at or above 200% of the poverty level were more 

likely to become exclusive e-cigarette users at Wave  2 

than Blacks and Hispanics, persons with a high school 

education or GED, and persons living below the poverty 

level, respectively. Whites were also more likely than 

Blacks and Hispanics to become dual users of e-cigarettes 

and cigarettes at Wave  2, and Whites were more likely 

to have quit conventional cigarettes (with no uptake of 

e-cigarettes) than Blacks at Wave 2. Persons with greater 

than high school education and those living at or above 

200% of the poverty level were also more likely to quit 

conventional cigarettes (with no uptake of e-cigarettes) 

than those with lower levels of education and persons with 

less income, respectively.

According to 2013–2014 data from the NATS, 

among former smokers who quit during the past year 

and had ever used e-cigarettes, 45.9% had completely 

switched to e-cigarettes from conventional cigarettes at 

some time during the past 12 months (NATS, public use 

data, 2013–2014). Among the recent former smokers who 

reported having switched to e-cigarettes during the past 

year, 66.0% were current e-cigarette users (NATS, public 

use data, 2013–2014). In contrast, among recent former 

smokers who had ever used e-cigarettes but did not 

report switching to e-cigarettes during the past year, just 

13.4% were current e-cigarette users (NATS, public use 

Figure 2.13 Prevalence of use of counseling or medications for cessationa among adult smokers 18 years of age and 

older, by race/ethnicity; National Health Interview Survey (NHIS) 2000–2015; United States

Source: NHIS, National Center for Health Statistics, public use data, 2000, 2005, 2010, and 2015. aFor 2010 and 2015, used one-on-one counseling; a stop-smoking clinic, class, or support group; telephone helpline or quitline; 

nicotine patch, nicotine gum, or lozenge; nicotine-containing nasal spray or inhaler; or varenicline (U.S. trade name Chantix) and/or 

bupropion (including trade names Zyban and Wellbutrin) during the past year among current smokers who tried to quit during the 

past year or among former smokers who quit during the past 2 years. For 2005, the list included a nicotine tablet and excluded varenicline, as that drug was not approved by the Food and Drug Administration until 2006. For 2000, the list included a stop-smoking 

program and excluded a stop-smoking class or support group, nicotine lozenge (not approved by the Food and Drug Administration 

until 2002), and varenicline.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 99

Smoking Cessation

data, 2013–2014). In their analysis of data from the PATH 

Study, Harlow and colleagues (2018) found that cigarette 

smokers at Wave 1 who reported new use of e-cigarettes at 

Wave 2 had almost the same prevalence of quitting cigarettes from Wave 1 to Wave 2 (8.06%) as those who did 

not begin using e-cigarettes at Wave 2 (8.42%). However, 

using multivariate logistic regression models, Berry and 

colleagues (2019) found that adult cigarette smokers who 

initiated daily e-cigarette use at Wave 1 had 7.88 times the 

odds of having quit cigarette smoking at Wave 2 than those 

who did not use e-cigarettes. In contrast, adult cigarette 

smokers who initiated experimental e-cigarette use (current e-cigarette use but no regular use) were less likely 

to quit cigarette smoking than those who were not using 

e-cigarettes (OR  =  0.51; 95%  CI, 0.26–1.00). Similarly, 

findings from Wave 1 to Wave 2 of the PATH Study indicated that cigarette smokers who were daily e-cigarette 

users at Wave  1 had higher odds of quitting cigarette 

smoking at Wave 2 (OR = 1.56; 95% CI, 1.12–2.18) than 

never e-cigarette users. But among men, former cigarette smokers who were daily or nondaily e-cigarette users 

at Wave  1 were more likely than men who were never 

e-cigarette users to relapse to cigarette smoking at Wave 2 

(OR = 2.96; 95% CI, 1.49–5.86 and OR = 3.05; 95% CI, 

1.29–7.17, respectively) (Verplaetse et al. 2018).

According to the 2014–2015 TUS-CPS data, more 

cigarette smokers reported switching to e-cigarettes 

(31.2%) in an attempt to quit than switching to smokeless tobacco (5.4%), switching to cigars or pipes (2.7%), or 

using the Internet or a web-based program or tool (2.1%) 

(Table  2.24). The estimate for switching to smokeless 

tobacco in an attempt to quit cigarette smoking is similar 

to that from the 2013–2014 NATS, where 4.9% of former 

cigarette smokers who had quit during the past year had 

switched to smokeless tobacco to quit smoking (NATS, 

public use data, 2013–2014). According to data from the 

2014–2015 TUS-CPS, higher percentages of men than 

women switched to cigars or pipes in an attempt to quit 

(4.0% vs. 1.5%) or switched to smokeless tobacco in an 

attempt to quit (7.7% vs. 3.0%) (Table 2.24). Also, 18- to 

24-year-old smokers were more likely to switch to smokeless tobacco in an attempt to quit than smokers who were 

45 years of age and older. In addition, persons living below 

the poverty level were more likely to switch to cigars or 

Figure 2.14 Quarterly, inflation-adjusteda dollar sales of over-the-counter nicotine replacement therapy, by type; 

Quarter 2, 2014–Quarter 4, 2018; United States

Source: FDA CTP’s licensed Nielsen Retail Measurement Services data.

Note: Nielsen Retail Measurement Services data, including projected sales from expanded all outlet combined and convenience stores. 

Types of outlets include food and grocery stores, drug stores, mass merchandizers, club stores, dollar stores, military commissaries, 

and convenience stores. Data do not include food stores with annual sales volume <$2 million, certain specialty food stores, drug 

stores with annual volume <$1 million, certain club stores, certain dollar stores, and Internet sales (including those from pointof-sale retailers). Data do not include the category of “other” NRT, which represented 0.07% of sales during this period. Nielsen did 

not participate in the data analysis, summary, or interpretation. CTP = Center for Tobacco Products; FDA = U.S. Food and Drug 

Administration; NRT = nicotine replacement therapy. aAdjusted to 2018 dollars using data from the Bureau of Labor Statistics on the Consumer Price Index for all items.
A Report of the Surgeon General

100 Chapter 2

pipes (3.9%) in an attempt to quit than those living at or 

above the poverty level (2.4%). Finally, smokers with an 

undergraduate degree (4.1%) were more likely to use the 

Internet for help with cessation than those with a high 

school education or less.

Although the estimate for use of specific Internet or 

web-based programs or tools for quitting smoking was low 

(2.1%) in the 2014–2015 TUS-CPS (Table 2.24), according 

to the 2017 HINTS, 43.7% of current cigarette smokers 

who were 18  years of age and older and were Internet 

users had used the Internet during the past 12  months 

to look for information about quitting smoking. Of note, 

the HINTS did not ask whether they used specific Internet 

programs or tools in their quit attempt (Graham and 

Amato 2018).

Data from the 2010–2011 TUS-CPS assessed different 

cessation strategies from those described above for the 

2014−2015 version. According to the 2010–2011 TUS-CPS, 

the most common cessation strategy among smokers who 

had tried to quit during the past year was trying to quit 

abruptly (78.0%), followed by gradually reducing consumption (43.0%) and receiving help from friends and family 

(32.4%) (Schauer et  al. 2015). In the 2013–2014 PATH 

Study, the three most prevalent cessation methods among 

current smokers who tried to quit in the past 12 months 

and former smokers who quit during the past 12 months 

were unaided quit attempts (i.e., no reported use of support or cessation strategy) (47.1% and 47.7%, respectively), 

support from friends and family (18.7% and 16.5%, respectively), and use of other tobacco products (18.3% and 

24.8%, respectively) (Rodu and Plurphanswat 2017).

Young Adults

According to the 2014–2015 TUS-CPS, the prevalence of young adults’ (18–24 years of age) use of other cessation strategies, including switching to another tobacco 

product and using the Internet, was similar to the estimates for adults overall (Table  2.24). Similar to the case 

with adults overall, no differences in use were observed by 

race/ethnicity and geographic region among young adults; 

however, estimates were of low statistical precision for other 

cessation strategies among young adults, and e-cigarette 

use could not be examined by poverty status because estimates were of low precision (relative standard error ≥30%) 

and statistically unstable (TUS-CPS, public use data, 2014–

2015). In contrast to findings for all adults (Table 2.24), the 

prevalence of switching to e-cigarettes in an attempt to quit 

cigarette smoking among young adults did not differ by sex 

(men: 38.7%; 95% CI, 33.1–44.3; women: 39.8%; 95% CI, 

33.8–45.8) (TUS-CPS, public use data, 2014–2015).

Youth

Unlike surveillance systems for adults, surveillance 

systems that focus on youth do not assess whether cigarette smokers in that age group who were trying to quit 

during the past year had switched to another tobacco 

product. However, in the 2017 NYTS, among youth who 

had ever used e-cigarettes, an estimated 5.3% of middle 

school students (grades 6–8) and 5.6% of high school students (grades 9–12) reported one of the reasons they had 

used e-cigarettes was to try to quit using other tobacco 

products (NYTS, public use data, 2017).

Key Disparities in Cessation Among Adults

In addition to the disparities in key measures of cessation by age, race/ethnicity, geographic region, status 

of health insurance, and sexual orientation that were 

described previously, important disparities exist by the 

amount and frequency of cigarette smoking and other 

health-related and demographic factors (Babb et al. 2017).

With regard to the frequency of cigarette smoking, 

in 2015, current daily smokers who smoked >25 cigarettes 

per day had a lower prevalence of being interested in quitting (55.6%) than current some-day smokers (71.0%) and 

daily smokers of 1–14  cigarettes per day (daily, 1–4  cigarettes per day: 71.8%; daily, 5–14  cigarettes per day: 

68.8%) (Table  2.22). In addition, in 2017, current daily 

smokers who smoked >25 cigarettes per day had a lower 

prevalence of a past-year quit attempt (29.5%) than someday smokers (58.5%) and daily smokers of lesser amounts 

(daily, 1–4 cigarettes per day: 59.8%; daily, 5–14 cigarettes 

per day: 49.8%; daily, 15–24 cigarettes per day: 30.2%). In 

contrast, in 2017, both the prevalence of having received 

advice to quit and use of counseling and/or medication 

for cessation increased with the frequency and amount of 

smoking. Current some-day smokers had the lowest prevalence of using counseling and/or medications (24.2% vs. 

46.7% for daily smokers who smoked 25  or more cigarettes per day), a finding likely related to (a) their lower 

prevalence of receiving advice from a health professional 

and (b) the lack of evidence for medication utilization by 

some-day smokers (Fiore et al. 2008).

Persons who had serious psychological distress, a 

smoking-related chronic disease, or a disability/limitation 

were more likely to receive a health professional’s advice 

to quit than those without these conditions (70.1%  vs. 

55.7%, 67.3% vs. 64.8%, and 71.8% vs. 53.6%, respectively) 

(Table 2.22). This may be because such persons have more 
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 101

Smoking Cessation

contact with the healthcare system and because quitting 

could improve, or avoid exacerbating, conditions that are 

related to smoking. Those who had serious psychological 

distress or a disability/limitation were more likely to use 

cessation treatments than those without such conditions 

(41.6% vs. 30.1% and 39.0% vs. 28.5%, respectively).

Disparities also exist in rates of quitting smoking 

while pregnant. In a study based on birth certificates, 

which included 46  states and the District of Columbia, 

10.9% of women who gave birth in 2014 smoked during the 

3 months before pregnancy (Curtin and Mathews 2016). 

Of these women, 24.2% reported smoking no cigarettes 

during each trimester of pregnancy and thus presumably quit before becoming pregnant, and 20.6% of women 

who smoked in the first or second trimesters quit by the 

third trimester. By level of education, cessation during the 

3 months before pregnancy was lowest among those with 

less than a high school education (14.1%) and highest 

among those with a bachelor’s degree or more education 

(53.7%). By insurance status, cessation was lowest among 

those with Medicaid insurance or who self-paid (18.9% 

and 17.3%, respectively) and highest among those with 

private insurance (38.3%). In addition, Asian women cigarette smokers were more than twice as likely to quit during 

the 3 months before their pregnancy (45.0%) as American 

Indian or Alaska Native women (21.8%). In an analysis of 

data from the PATH Study, Kurti and colleagues (2018) 

observed that, among nonpregnant women, 18–44 years 

of age who used tobacco at Wave 1 and became pregnant 

at Wave  2, 98.3% had quit hookah use, 88.0% had quit 

cigar use, 81.3% had quit e-cigarette use, and 58.7% had 

quit any tobacco use. The prevalence of quitting hookah, 

cigars, and e-cigarettes was higher than the prevalence of 

quitting cigarettes (53.4%).

Residing in a rural or nonmetropolitan area as 

opposed to an urban area or a metropolitan area is also 

associated with cessation-related disparities. According 

to the 2017 BRFSS, the quit ratio (see the “Quit Ratio” 

section earlier in this chapter) and the prevalence of a 

past-year quit attempt were significantly lower among 

cigarette smokers who lived in micropolitan (54.8% and 

61.1%, respectively) and rural (54.8% and 62.2%, respectively) counties than among those who lived in large fringe 

(62.8% and 66.2%, respectively) or large central metropolitan areas (59.9% and 68.2%, respectively) (Table 2.26). 

Quit ratios were also lower among persons in micropolitan and rural counties than among those in small and 

medium metropolitan counties, and prevalence of a pastyear quit attempt was also lower among persons in micropolitan counties than among those in medium metropolitan counties. In addition, recent successful cessation was 

significantly higher among persons living in large metropolitan fringe areas (5.9%) compared with those living in 

micropolitan (4.3%) counties.

Table 2.26 Percentage of ever cigarette smokers 18 years of age and older who quit smoking (quit ratio)a and 

prevalence of recent successful cessationb and a past-year quit attempt,c by urban or rural status; 

Behavioral Risk Factor Surveillance System (BRFSS) 2017; United States

Quit ratio: % (95% CI)

Recent successful cessation: 

% (95% CI)

Past-year quit attempt: 

% (95% CI)

Overall 59.3 (58.8–59.8) 5.3 (5.0–5.7) 65.5 (64.7–66.2)

Large metropolitan center 59.9 (58.6–61.1) 5.8 (5.0–6.7) 68.2 (66.5–69.9)

Large fringe metropolitan 62.8 (61.8–63.8) 5.9 (5.2–6.7) 66.2 (64.7–67.6)

Medium metropolitan 59.4 (58.5–60.3) 5.1 (4.6–5.8) 65.3 (63.9–66.6)

Small metropolitan 57.5 (56.3–58.7) 5.1 (4.5–5.9) 63.8 (62.0–65.6)

Micropolitan 54.8 (53.6–56.1) 4.3 (3.6–5.1) 61.1 (59.4–62.9)

Noncore 54.8 (53.4–56.2) 4.5 (3.8–5.3) 62.6 (60.7–64.5)

Source: BRFSS, Centers for Disease Control and Prevention, public use data, 2017.

Notes: CI = confidence interval. A metropolitan statistical area is defined as a group of counties that contain at least one urbanized area 

of 50,000 or more inhabitants. A micropolitan statistical area is defined as a group of counties that contain at least one urban cluster of 

at least 10,000 but less than 50,000 inhabitants.

aQuit ratio is calculated as the proportion of current smokers who reported having stopped smoking for >1 day during the past year 

because they were trying to quit smoking, and former smokers who quit smoking during the past year (numerator), among all current 

and former smokers who only quit in the past year (denominator).

bThe percentage of former smokers who quit smoking for >6 months during the past year among current smokers and former smokers 

who quit during the past year.

cCurrent smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying to quit 

smoking and former smokers who quit during the past year.
A Report of the Surgeon General

102 Chapter 2

In the United States, 61.7% of adults who have 

ever been a cigarette smoker have now quit, highlighting 

the marked progress in smoking cessation observed 

in this chapter. Among adults, past-year quit attempts 

and recent (i.e.,  recent successful cessation) and longer 

term (i.e., quit ratio) cessation measures have increased 

over the past 2 decades. Nevertheless, survey data indicate that several subpopulations—including those with 

less education, racial/ethnic minorities, and those who 

are older in age—are less likely to try to quit each year 

than those in the general population. These disparities, in 

turn, may be affected by other variables, such as receiving 

advice from a health professional to quit smoking, using 

evidence-based resources, and patterns and frequency of 

cigarette smoking.

Disparities across cessation-related variables existed 

by level of educational attainment, which is closely correlated with income, poverty, overall socioeconomic 

status, status of health insurance, and geographic location. Notably, smokers with the lowest levels of education 

(<12 years or GED certificate) had significantly lower quit 

ratios compared with smokers with the highest levels of 

education (undergraduate or graduate degree).

These socioeconomic disparities also may be partly 

explained by emerging geographic disparities, given that 

rural populations, who tend to have lower socioeconomic 

status (U.S. Department of the Census 2016), have lower 

quit ratios and a lower prevalence of recent successful cessation than metropolitan populations, despite having a 

similar prevalence of past-year quit attempts. In addition, 

quit ratios and the prevalence of recent successful cessation and past-year quit attempts vary widely across U.S. 

states and territories. These variations might be linked 

to differences in state and local tobacco control policies, 

healthcare coverage and policies, and historical relationships of resident populations with tobacco (e.g., growers 

of tobacco). Tobacco growing, pervasive tobacco advertising and marketing (e.g.,  sponsorships of rodeos and 

auto races), and more prevalent exposure to secondhand 

smoke in public and private settings may also be influential environmental factors that make quitting more difficult among rural residents compared with urban residents 

(Chaloupka et al. 2002; Roeseler et al. 2010; USDHHS 2011; 

Vander Weg et al. 2011). Rural areas may also have fewer 

resources, including a more limited capacity to implement 

comprehensive tobacco control programs (American Lung 

Association 2012).

Persons of lower socioeconomic status, including 

lower levels of education, have a higher incidence of 

lung cancer and other tobacco-related diseases than 

persons in higher socioeconomic groups (Clegg et  al. 

2009; Singh et al. 2011), making persons of lower socioeconomic status a critical population for treating nicotine dependence. Challenges to quitting smoking among 

this subpopulation may include heavier patterns of cigarette smoking and earlier initiation (Siahpush et al. 2010; 

Ham et al. 2011). In addition, predatory marketing by the 

tobacco industry, reflected in part by an increased density 

of retail outlets and more retail and point-of-sale promotions in low-income areas, may contribute to an environment that is challenging for successful cessation (BrownJohnson et  al. 2014; Center for Public Health Systems 

Science 2014, 2016).

Disparities also exist by race/ethnicity. For example, 

Black adult smokers have a higher prevalence of pastyear quit attempts than White adult smokers. However, 

prevalence of recent successful cessation does not vary 

by race/ethnicity, suggesting that a higher percentage of 

Black adults are trying to quit cigarette smoking than 

White adults but are less successful. This may also be 

reflected in the lower quit ratio among Blacks compared 

with Whites. The use of menthol cigarettes may play a 

role in this disparity, as Black smokers are more likely to 

use menthol cigarettes than other racial/ethnic groups 

(Giovino et al. 2015); however, research findings on the 

relation between menthol use and successful cessation are 

mixed (Delnevo et al. 2011; Levy et al. 2011; Keeler et al. 

2017). Although data presented in this chapter show that 

Blacks who smoke menthol cigarettes are just as likely 

to try to quit smoking as those who do not smoke menthol cigarettes (Table 2.12), menthol use might increase 

dependence on nicotine and make quitting more difficult 

(Hoffman and Simmons 2011). In addition, similar to targeting populations with low socioeconomic status, predatory marketing by the tobacco industry is common in 

geographic areas with large numbers of Black residents, 

which may negatively influence cessation (Yu et al. 2010; 

Richardson et al. 2015; Alexander et al. 2016).

Age is another demographic factor with pronounced 

cessation disparities. To date, both past-year quit attempts 

and recent successful cessation decrease as adult cigarette 

smokers’ ages increase. Although quitting smoking at any 

age is beneficial, smokers who quit by the time they are 

35–44 years of age avoid most of the risk of dying from a 

smoking-related disease (Doll et al. 2004; Jha et al. 2013). 

Continued public health strategies that specifically target 

adults 45 years of age and older are needed to increase quit 

attempts, given the inverse relationships between age and 

both quit attempts and the prevalence of recent successful 

cessation. In addition, among youth, trends in past-year 

Summary of the Evidence and Implications
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 103

Smoking Cessation

quit attempts have remained stable or slightly declined, 

depending on the data source. More research is needed to 

better understand how the growing use of other tobacco 

products will affect cigarette smoking cessation and to 

assess cessation from other tobacco products that youth 

and young adults are using regularly.

Factors contributing to the previously noted disparities could also be affected by a health professional’s 

advice to quit tobacco and by the use of evidence-based 

cessation approaches, such as counseling and medication. For example, receiving advice from a health professional to quit smoking and using evidence-based cessation 

resources increased from 2000 to 2015; however, 42.8% 

of cigarette smokers who saw a healthcare professional 

during the past year did not receive advice to quit, and 

less than one-third (31.2%) of cigarette smokers who tried 

to quit during the past year used evidence-based cessation resources. Cigarette smokers younger than 45 years 

of age were less likely than older cigarette smokers to be 

advised to quit or to use an evidence-based cessation treatment. One potential explanation for these findings is that 

young adult cigarette smokers are more likely than older 

smokers to be some-day smokers (also called intermittent 

or nondaily smokers) and light daily smokers (smoking 

<5 cigarettes per day) (Babb et al. 2017).

Data presented previously in this chapter suggest 

that light daily and some-day smokers are among the most 

interested in quitting, and they have the highest prevalence of past-year quit attempts. Nevertheless, many do 

not consider themselves to be smokers (Levinson et  al. 

2007; Smith et  al. 2012) and, thus, may not be identified as a smoker by clinical screening. Furthermore, light 

daily and nondaily smokers may be able to abstain from 

cigarettes on some days but continue smoking on other 

days. As discussed in Chapter  6, existing clinical guidance concludes that there is insufficient evidence for the 

use of pharmacotherapy to assist with cessation in light 

smokers (Fiore et  al. 2008). Given these challenges and 

the increasing prevalence of some-day and light daily 

smokers, new approaches may be needed to help persons 

in these subgroups quit successfully.

Clinical interventions may also play an important 

role in helping youth quit smoking cigarettes. Although 

screening for tobacco use among 11-  to 17-year-olds is 

fairly high in ambulatory care settings (71.5%), only 

approximately 20% of tobacco users were provided assistance for tobacco cessation (Jamal et al. 2014). The 2008 

update of the Clinical Practice Guideline on Treating 

Tobacco Dependence recommends that clinicians provide 

counseling interventions to aid youth smokers in quitting 

(Fiore et al. 2008). Far less is known about how to help 

youth quit compared with how to help adults, and use of 

effective cessation strategies is lower among youth than 

adults (Fiore et al. 2008). Because many youth, like the 

young adults discussed previously, are some-day smokers, 

more research is needed on how to address these occasional users and on effective and appropriate clinical 

interventions for youth overall.

Data presented in this chapter suggest that fewer 

than 2 of every 3 of adult smokers who saw a healthcare 

provider in the past year were advised to quit smoking, 

fewer than 1  of every 3  reported using cessation medications to help them quit, and fewer than 1  of every 

10 reported using counseling. Taken together, these findings reinforce the need for the implementation of additional public health interventions that aim to increase cessation counseling in clinical settings and the number of 

quit attempts among adults and youth (Fiore et al. 2008; 

The Community Guide 2014).

Encouraging and helping tobacco users to quit 

remains the quickest approach to reducing tobacco-related 

disease, death, and healthcare costs (Institute of Medicine 

2007), including through both individual (see Chapter 6) 

and population-based (see Chapter  7) interventions. 

However, as is noted in this chapter, use of tobacco cessation resources among persons who use tobacco remains 

low: among adults, 18 years of age and older, only 29.0% 

used cessation medication, just 6.8% used any counseling, 

and only 4.1% used a telephone-based quitline, which is a 

freely available resource in all states (see Chapter 6). Use 

of counseling and/or medication was lower among young 

adults (16.6%) than among all adults (31.2%) (Babb et al. 

2017). To further increase cessation among adults and 

youth, public health efforts can continue the aforementioned strategies and encourage healthcare providers 

to consistently identify smokers, advise them to quit, 

and offer them cessation treatments (Fiore et  al. 2008; 

U.S. Preventive Services Task Force 2015). Nevertheless, 

it  is also important to recognize that a majority of cigarette smokers who quit do so without using evidencebased treatments. As is described in Chapter  6, identifying ways to continue to promote quit attempts to help 

cigarette smokers in quitting, even among those who do 

not intend to use treatment or are not interested in using 

treatment, is still needed. Furthermore, continuing to 

include questions in population-based surveys to assess 

(a)  the prevalence of tobacco screening and interventions and (b) the proportion of smokers who use cessation 

counseling and medication is needed for ongoing tracking 

of smokers’ engagement with evidence-based treatments 

that can improve the odds of quitting and staying quit.

Importantly, this chapter’s review of epidemiologic 

data focused on cigarette smoking because measures 

of other tobacco product use and cessation are limited. 

Therefore, many of the analyses centered on cigarettes may 

underestimate the impact that the use of other tobacco 
A Report of the Surgeon General

104 Chapter 2

products, such as little cigars and e-cigarettes, has on 

tobacco cessation. Although limited national surveillance 

data are available on cessation of noncigarette tobacco 

products, survey data indicate that adult cigarette smokers 

who use cigars, smokeless tobacco, and/or pipes are less 

likely to try to quit all tobacco products than to try to quit 

cigarette smoking; however, this is not the case among 

young adult cigarette smokers, who are as likely to try to 

quit all tobacco products as they are to try to quit cigarette 

smoking (NYTS, public use data, 2017). Polytobacco use, 

which is the use of two or more tobacco products, is now 

common (3.7% in 2017) (Wang et  al. 2018a), especially 

among youth and young adults (USDHHS 2014), and 

e-cigarettes have been the most prevalent tobacco product 

used among middle and high school students since 2014 

(Wang et al. 2018b). Therefore, enhanced national surveillance of both use and cessation of these tobacco products 

is warranted (USDHHS 2014), Since the PATH Study is 

a nationally representative, longitudinal cohort study of 

adults and youth 12 years of age and older, it will continue 

to contribute key information on patterns of use of these 

tobacco products, including initiation, cessation, relapse, 

and transitions between tobacco products (Hyland et al. 

2017; Coleman et al. 2018; Kurti et al. 2018; Kypriotakis 

et al. 2018; Lopez et al. 2018). However, comprehensive 

surveillance of all of the diverse tobacco products being 

used by the American public is essential to effectively 

inform tobacco control policies, planning, and practices.

In addition, continued surveillance of the use of 

switching to other tobacco products by smokers who are 

trying to quit cigarettes is needed. Switching to smokeless 

tobacco and cigars as a quit strategy is relatively uncommon 

(see “Other Tobacco Products: Use and Cessation” in this 

chapter). However, switching to e-cigarettes in an attempt 

to quit cigarette smoking (34.7% in 2014−2015) was as 

popular a cessation strategy among those who tried to 

quit during the past year as was the use of counseling 

and/or the seven FDA-approved smoking cessation medications (31.2% in 2015) (Fiore et  al. 2008; Babb et  al. 

2017), even though the efficacy of using e-cigarettes for 

smoking cessation is inconclusive. For example, switching 

to e-cigarettes in an attempt to quit cigarette smoking is 

the most prevalent cessation strategy among all demographic groups, despite the lack of clear evidence for the 

long-term effectiveness and safety of e-cigarettes as a cessation approach (Hartmann-Boyce et al. 2016; Kalkhoran 

and Glantz 2016). More research is needed to better 

understand the patterns of usage of noncigarette products and their relationship with quitting cigarettes and 

all tobacco use. In addition, research is needed to understand long-term outcomes among cigarette smokers who 

report switching to noncigarette products to quit cigarette smoking, including dual usage, the substitution 

of noncigarette products use for cigarette smoking, and 

the potential use of noncigarette products as temporary 

cessation aids with eventual cessation of all tobacco use. 

The findings on the use of switching to another tobacco 

product to quit conventional cigarettes underscore the 

pressing need to (a) consider more effective and efficient 

ways to reach smokers with evidence-based cessation support and (b) continue to research the efficacy of emerging 

strategies to reduce combustible tobacco use.

Conclusions

1. In the United States, more than three out of every 

five adults who were ever cigarette smokers have 

quit smoking.

2. Past-year quit attempts and recent and longer term 

cessation have increased over the past 2  decades 

among adult cigarette smokers.

3. Marked disparities in cessation behaviors, such 

as making a past-year quit attempt and achieving 

recent successful cessation, persist across certain 

population subgroups defined by educational attainment, poverty status, age, health insurance status, 

race/ethnicity, and geography.

4. Advice from health professionals to quit smoking has 

increased since 2000; however, four out of every nine 

adult cigarette smokers who saw a health professional 

during the past year did not receive advice to quit.

5. Use of evidence-based cessation counseling and/or 

medications has increased among adult cigarette 

smokers since 2000; however, more than two-thirds 

of adult cigarette smokers who tried to quit during 

the past year did not use evidence-based treatment.

6. A large proportion of adult smokers report using 

non-evidence-based approaches when trying to quit 

smoking, such as switching to other tobacco products.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 105

Smoking Cessation

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111

Chapter 2 Appendices

Appendix 2.1: Sources of Data 113

National Health Interview Survey 113

Youth Risk Behavior Surveillance System 113

Tobacco Use Supplement to the Current Population Survey 113

Behavioral Risk Factor Surveillance System 114

National Adult Tobacco Survey 114

National Ambulatory Medical Care Survey 114

Population Assessment of Tobacco and Health Study 114

Health Information National Trends Survey 115

Monitoring the Future Study 115

National Youth Tobacco Survey 115

Appendix 2.2: Measures of Cessation 116

Validity of Measures of Cessation Among Youth 116

Validity of Measures of Tobacco Use Among Adults 116

Definitions 117

Current and Former Cigarette Smoking 117

Quit Ratio 117

Recent Successful Cessation 117

Cessation Continuum 118

Past-Year Quit Attempts 118

Number and Duration of Quit Attempts 118

Interest in Quitting 119

Ever Tried to Quit Smoking 119

Cessation of Other Tobacco Products 119

Screening for Tobacco Use 119

Advice to Quit—Clinical Data from Abstractions of Medical Records 119

Advice to Quit—Self-Reported Data 120

Use of Counseling and Medications to Quit Smoking 120

Use of Other Cessation Strategies 120

References 121

Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 113

Smoking Cessation

Appendix 2.1: Sources of Data

Data summarized in this chapter come from two 

national surveys, the National Health Interview Survey 

(NHIS) and the National Youth Risk Behavior Survey 

(YRBS) (Table 2.1), which are described below. After 

descriptions of NHIS and YRBS, brief summaries of other 

national surveys that provided limited information for this 

chapter are provided.

National Health Interview Survey

NHIS, a multipurpose survey conducted by the 

National Center for Health Statistics of the Centers for 

Disease Control and Prevention (CDC), is the principal 

source of information on the health of the civilian, noninstitutionalized population of the United States. NHIS 

has been conducted continuously since 1957. Questions 

on smoking have been included in selected survey years 

since 1965, and detailed items allowing classification by 

race/ethnicity have been included since 1978. Information 

on quit attempts among all cigarette smokers has been 

assessed since 1991. Detailed questions on tobacco use 

cessation are included in a CCS to NHIS, which was initiated in 1987 and subsequently conducted in 1992, 2000, 

2005, 2010, and 2015, with relatively consistent questions on cessation included from 2000 to 2015. Face-toface interviews are used to collect confidential data from a 

representative sample of the population using the place of 

residence of individual respondents.

The sampling plan follows a multistage area probability design that permits the representative sampling 

of households and noninstitutional group living quarters 

(e.g., college dormitories) in all 50 states and the District 

of Columbia. Non-Hispanic African American or Black, 

Hispanic or Latino, and Asian persons were oversampled 

during 2006–2015. For each family included in NHIS, 

one sample child (younger than 18 years of age) and one 

sample adult are randomly selected, and information on 

each is collected. For children and those adults not capable 

of doing so, information is provided by a knowledgeable 

adult family member. Since 1974, only self-reports of cigarette smoking and use of other tobacco products have 

been used, and thus no proxy data have been used since 

that year on questions of importance to this report. Since 

1997, NHIS has been conducted using computer-assisted 

personal interviewing by interviewers from the U.S. 

Census Bureau; sampling and interviewing are continuous 

throughout each year. CDC (2017c) has detailed information on NHIS questionnaires and sampling on its website.

Youth Risk Behavior Surveillance 

System

Developed in 1990 by CDC, the Youth Risk Behavior 

Surveillance System (YRBSS) monitors priority health 

risk behaviors, including past-year quit attempts among 

current cigarette smokers, among high school students 

in the United States. In addition to the surveys that are 

conducted by state, local, territorial, and tribal health 

and education agencies, there is the national YRBS conducted by CDC. The current report includes data from 

the national YRBS only, which has a sampling frame of 

all public and private school students in grades 9–12 in 

the 50 states and the District of Columbia. A three-stage 

cluster sample design is used to sample (1)  large-sized 

counties or groups of smaller adjacent counties, (2) public 

and private schools with a probability proportional to the 

schools’ enrollment, and (3) one or two randomly selected 

classes in each grade. Examples of classes include homerooms, classes of a required discipline (e.g.,  English or 

social studies), and all classes meeting during a required 

period (e.g., second period). All students in a sampled class 

are eligible to participate. Oversampling is used to achieve 

sufficiently large subsamples of Black or African American 

and Hispanic or Latino students to enable separate analyses of these subgroups. Schools that decline to participate 

in the original sample are not replaced. Students complete 

self-administered, paper-and-pencil questionnaires and 

record their answers directly in the questionnaire booklet 

(CDC 2013). Local procedures to obtain the permission 

of parents are followed. Trained personnel administer the 

questionnaires to students in their classrooms for the 

national survey. The participation of students is both voluntary and anonymous (CDC 2013).

Tobacco Use Supplement to the 

Current Population Survey

The Tobacco Use Supplement to the Current 

Population Survey (TUS-CPS) is a National Cancer 

Institute-sponsored survey of tobacco use that has been 

administered as part of the U.S. Census Bureau’s Current 

Population Survey approximately every 3–4 years since 

1992–1993 (since 2000, surveys were conducted for 2001–

2002, 2003, 2006–2007, 2010–2011, and 2014–2015). In 

each cycle, the TUS-CPS collects nationally representative 

data from about 240,000 adults (data collected between 
A Report of the Surgeon General

114 Chapter 2 Appendices

1992 and 2006 also included youth 15–17 years of age). 

About two-thirds of respondents complete the questionnaire by telephone, and responses for the remaining onethird are obtained through in-person interviews. More 

detailed information about the TUS-CPS is available from 

the National Cancer Institute (NCI) (n.d.b).

Behavioral Risk Factor Surveillance 

System

In 1984, CDC initiated the state-based Behavioral 

Risk Factor Surveillance System (BRFSS), a cross-sectional 

telephone survey that state health departments conduct 

monthly over landline and cellular telephones (included 

since 2011), using a standardized questionnaire and technical and methodologic assistance provided by CDC. The 

BRFSS is used to collect data among U.S. adults 18 years 

of age and older regarding their risk behaviors and preventive health practices that can affect their health status. Data 

from respondents are forwarded to CDC to be aggregated 

for each state, returned with standard tabulations, and published at year’s end by each state. In 2011, BRFSS adopted 

new methods, including the addition of cellular telephone households to its sample, and used new methods of 

weighting to adjust survey data for differences between the 

demographic characteristics of respondents and the survey 

population (CDC 2012). As a result of these methodologic 

changes, data from 2011 to 2017 cannot be compared with 

years before 2011. In 2017, more than 450,000 interviews 

were conducted with respondents from all 50  states, the 

District of Columbia, and participating U.S. territories 

and other geographic areas. The number of completed 

interviews at each site ranged from 1,508 to 22,059, and 

the median response rate was 45.9%. For this Surgeon 

General’s report, data have been weighted to reflect the 

age, race/ethnicity, and sex distribution of each participating state. CDC (2017a) offers detailed information about 

the BRFSS.

National Adult Tobacco Survey

The 2013–2014 National Adult Tobacco Survey 

(NATS)—a stratified, random-digit-dialed (RDD), telephone survey of noninstitutionalized adults 18 years of age 

and older—was conducted from October 2013 to October 

2014. The survey was part of a collaborative effort between 

CDC and the U.S. Food and Drug Administration (FDA). 

The survey sought to determine the prevalence and correlates of tobacco use behaviors among a nationally representative sample of U.S. adults. The 2013–2014 NATS 

included 75,233 respondents (70% landline, 30% cellular), 

and the overall response rate was 36.1% (47.6%, landline; 

17.1%, cellular). Data were weighted to provide nationally 

representative estimates of prevalence. Detailed information on NATS is available at CDC (2016).

National Ambulatory Medical Care 

Survey

The National Ambulatory Medical Care Survey 

(NAMCS), conducted by CDC’s National Center for Health 

Statistics, is a survey designed to meet the need for objective, reliable information about the provision and use of 

ambulatory medical care services in the United States. 

Findings are based on a sample of visits to nonfederal, 

office-based physicians who are primarily engaged in 

direct patient care. Abstraction of medical records includes 

documentation of screening for tobacco use, counseling 

on tobacco cessation in the form of health education 

ordered or provided during the visit, and tobacco cessation medications ordered or continued during the visit. 

In 2009, 32,281 records were abstracted from a sample of 

3,319 physicians, with a response rate of 62.4% (in 2010, 

31,229 records were abstracted from a sample of 3,525 physicians, with a response rate of 57.3%, and in 2011, 

30,872 records were abstracted from a sample of 3,819 physicians, with a response rate of 54.1%). CDC (2017b) offers 

on its website more detailed information about NAMCS.

Population Assessment of Tobacco 

and Health Study

The Population Assessment of Tobacco and Health 

(PATH) Study was launched in October 2011 through 

a collaboration between the FDA Center for Tobacco 

Products and the National Institutes of Health, National 

Institute for Drug Abuse. PATH is a nationally representative, longitudinal cohort study that uses computerassisted interviews to collect information from approximately 49,000 current, never, and former tobacco users, 

including noninstitutionalized youth (12–17 years of age) 

and adults (18 years of age and older). The study also collects biospecimens (i.e., buccal cell, urine, blood) from 

consenting adults. Wave  1 of data collection was completed in 2014 (September 2013–December 2014), and 

four subsequent waves have been completed: Wave  2 

(October 2014–October 2015), Wave  3 (October 2015–

October 2016), Wave 4 (December 2016–November 2017), 

and an additional wave among only 12-  to 17-year-old 

youth (December 2017 to November 2018).
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 115

Smoking Cessation

The goal of the Path Study is to monitor and assess 

behavioral and biological between-person differences and 

within-person changes over time in tobacco product use 

patterns and behaviors, attitudes and risk perceptions, 

tobacco-related biomarkers of exposure and harm, and 

health conditions. The findings may inform FDA regulatory activities related to product standards (e.g., toxicity, 

appeal, abuse liability/addictiveness), health warnings, 

and the authorization of new and modified risk tobacco 

products, as well as FDA’s public education efforts.

Health Information National Trends 

Survey

The Health Information National Trends Survey 

(HINTS) was developed by the Health Communication 

and Informatics Research Branch of the Division of Cancer 

Control and Population Sciences of NCI. The HINTS is a 

biennial, cross-sectional survey that routinely collects data 

about the use of cancer-related information, including 

information on quitting smoking, from a nationally representative sample of adults 18 years of age and older in 

the civilian noninstitutionalized population of the United 

States. Data from the survey are used to assess the impact 

of the health information environment. There have been 

nine iterations of the HINTS: in 2003, 2005, 2007, 2011, 

2012, 2013, 2014, 2015, and 2017. The 2017 survey, which 

was used for this report, was conducted primarily by telephone (95%) with incentives promised of either $0, $5, or 

$15 upon survey completion (there were 3,335 completed 

surveys, a 25.0% response rate). More detailed information about the HINTS is available from NCI (n.d.a).

Monitoring the Future Study

The Monitoring the Future (MTF) Study, conducted 

annually since its inception in 1975, is conducted by the 

University of Michigan’s Institute for Social Research and 

supported through grants from the National Institute on 

Drug Abuse. The MTF—a study of American youth, college students, and adults through 45 years of age—monitors changes in the beliefs, attitudes, and behaviors relevant to drug use and other health and social issues among 

young persons in the United States. This report presents 

data on high school seniors from confidential, self-administered paper-and-pencil questionnaires used to survey 

nationally representative samples of 12th-grade students 

in public and private schools in 48 of the 50 states (all but 

Alaska and Hawaii). From 2011 to 2015, the years used in 

this report, sample sizes for the 12th-grade students (from 

121 to 129 schools) who participated in the MTF Study 

ranged from 13,015 to 14,855, and response rates ranged 

from 82% to 83% (Miech et al. 2016).

National Youth Tobacco Survey

The National Youth Tobacco Survey (NYTS) was developed by CDC to assist with the evaluation of the National 

Tobacco Control Program (NTCP) and state tobacco control programs. CDC and FDA have co-administered the 

survey since 2011. The NYTS, which provides nationally 

representative data on tobacco-related behaviors among 

middle school (grades 6–8) and high school (grades 9–12) 

students, was first conducted in fall 1999 and was subsequently conducted in 2000, 2002, 2004, 2006, 2009, and 

2011–2017. The NYTS sampling frame consists of all students enrolled in public, Catholic, and other private middle 

schools and high schools (grades 6–12) in the 50 states 

and Washington, D.C. Participation is voluntary and anonymous. Participants complete a self-administered paperand-pencil questionnaire and record their responses on 

a computer-scannable questionnaire booklet. For the 

NYTS years used in this report (2000, 2004, 2009, 2015, 

and 2017), sample sizes were as low as 17,711 and as high 

as  35,828; the number of participating schools ranged 

from 185 to 324; and response rates ranged from 63.4% 

to 84.8% (Office on Smoking and Health et al. 2001; CDC 

2010; Singh et al. 2016).
A Report of the Surgeon General

116 Chapter 2 Appendices

Appendix 2.2: Measures of Cessation

Validity of Measures of Cessation 

Among Youth

All of the data on cessation among youth that are presented in this report are based on self-reported responses 

to questionnaires. Because tobacco use is viewed by many 

as a socially undesirable behavior, there is a risk of inaccurate or dishonest responses. Because it was not feasible to 

verify the self-reported data included here, it is important for 

researchers to interpret these data with some caution and an 

understanding of possible sources of inaccuracy. Many factors can affect the validity of self-reported data—factors that 

can be categorized as cognitive or situational. Cognitive processes that affect responses include comprehension of the 

question, retrieval of relevant information from memory, 

decision making about the adequacy of the information 

retrieved, and the generation of a response (Brener et al. 

2003). Each of these processes can contribute to errors in 

responses and, subsequently, to problems with validity.

Situational factors that affect the validity of selfreported data refer to characteristics of the external environment in which the survey is being conducted. These 

include the setting (i.e.,  school or home based), the 

method (i.e., self-administered questionnaire or in-person 

interview), the social desirability of the behavior being 

reported, and the perception of privacy and/or confidentiality of responses (U.S. Department of Health and Human 

Services [USDHHS] 1994; Brener et al. 2003).

Many studies have found that youth are more likely 

to report engaging in sensitive behaviors when a survey is 

completed in a school setting rather than in their homes 

(Gfroerer et al. 1997; Hedges and Jarvis 1998; Kann et al. 

2002). A study that compared the school-based National 

Youth Risk Behavior Survey (YRBS) with the householdbased YRBS supplement to the National Health Interview 

Survey (NHIS) found that the school-based survey produced a significantly higher reporting of many sensitive behaviors, such as driving after drinking alcohol, 

binge drinking, and current use of marijuana and cocaine 

(Brener et al. 2006). Four measures of various stages of the 

smoking uptake process were higher in the school-based 

survey, but estimates for current cigarette use and frequent 

cigarette use, although elevated in the school-based survey, 

did not differ significantly from estimates generated in the 

household-based survey. Few differences in nonsensitive 

behaviors were observed. Two other studies (Gfroerer et al. 

1997; Brener et al. 2003) indicated that, although estimates 

based on self-reports of current use of alcohol and illicit 

drugs were higher in school-based than in household-based 

surveys, estimates of current cigarette smoking were quite 

similar across settings. It is noteworthy that all three of 

these studies use self-administered rather than intervieweradministered interviews/questionnaires. Nevertheless, the 

privacy that school surveys provide is important, especially if smoking becomes more socially unacceptable over 

time. Household-based surveys, however, are more likely 

to include youth who drop out of school or are frequently 

absent from school, and youth in these groups are more 

likely to smoke. In addition, the Population Assessment of 

Tobacco and Health (PATH) Study (which uses audio, computer-administered self-interviews in a respondent’s household) recently conducted a reliability and validity study of 

current use of a variety of tobacco products among youth 

12–17 years of age, finding high levels of agreement across 

interviews conducted 6–24  days apart (Tourangeau et  al. 

2018). There was also a high level of agreement between 

self-reported current tobacco use and salivary cotinine 

tests among a combined sample of adults and youth (87.5% 

of the reports and tests agreed).

Overall, the factors described above may affect point 

estimates of cessation. If these factors remain stable over 

the years, however, they should not affect the trends seen 

over time.

Validity of Measures of Tobacco 

Use Among Adults

All of the data on tobacco use among adults presented in this report were based on self-reported responses 

to questionnaires. Biochemical validation studies suggest 

that data on self-reported cigarette smoking are generally 

valid, except in certain situations, such as when data are collected in conjunction with intense smoking cessation programs or with certain populations, such as pregnant women 

(Velicer et al. 1992; Kendrick et al. 1995). Misclassification 

may also be more common among intermittent smokers, 

who may not classify themselves as smokers because they 

do not perceive themselves as being addicted or because of 

social desirability bias. Additionally, smokers may misreport 

the number of cigarettes they smoke per day because of 

“digit preference” (a preference for multiples of 10) (Klesges 

et al. 1995). Although self-reported data have been found 

to adequately reflect cigarette smoking patterns (including 

whether a respondent who has smoked in the past is currently not smoking) (Connor Gorber et al. 2009; Wong et al. 

2012; Tourangeau et al. 2018), few studies have examined the 

validity of other cessation measures (Brigham et al. 2010; 
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 117

Smoking Cessation

Persoskie and Nelson 2013). It should be noted, however, 

that much of the research literature on the validity of selfreported data is restricted to cigarette smoking—and not 

measures of cessation or other tobacco products. However, 

among adult tobacco users, a recent PATH Study found 

high levels of agreement at initial interview and subsequent 

re-interview 6–24 days later between self-reported current 

use of cigarettes, electronic nicotine products, traditional 

cigars, cigarillos, filtered cigars, pipes, snus, hookahs, and 

smokeless tobacco (Tourangeau et  al. 2018). High agreement was also found for self-reported information on current tobacco use and salivary cotinine among a combined 

sample of youth and adults (Tourangeau et al. 2018). Thus, a 

discussion of the factors that may affect validity is important 

so that the data presented in this report are interpreted with 

some caution and an understanding of possible sources of 

inaccuracy. Clearly, many factors can affect the validity of 

self-reported data, such as response biases and the particular 

methodologic features of the surveys. For example, methodologic differences in survey administration include but are 

not limited to timing, order of survey questions, sampling, 

mode of data collection (e.g.,  computer-assisted personal 

interviewing vs. computer-assisted telephone interviewing), 

participation rates, and operational definitions (Ryan et al. 

2012). In addition, responses to questions may be subject to 

more social desirability biases in surveys that are focused 

solely on tobacco use versus those where tobacco use is just 

one of several health behaviors being assessed, as research 

has found that the context in which sensitive questions are 

asked can effect responses to survey questions (Tourangeau 

and Yan 2007; Krumpal 2013).

Definitions

Measures of cessation differ between surveys of 

youth and those focused on adults. Three surveys (NHIS, 

Behavioral Risk Factor Surveillance System [BRFSS], 

and Tobacco Use Supplement to the Current Population 

Survey [TUS-CPS]) included in this chapter provide information about cessation among adults and young adults, 

while three other surveys (YRBS, Monitoring the Future 

[MTF] Study, and National Youth Tobacco Survey [NYTS]) 

provide information about smoking among youth. For 

each smoking measure, the definitions used in the various 

surveys are summarized below.

Current and Former Cigarette Smoking

Adults and Young Adults

In NHIS from 1965 to 1991, current cigarette 

smokers were defined as respondents who had smoked at 

least 100 cigarettes and who answered “yes” to the question, 

“Do you smoke cigarettes now?” Beginning in 1992, NHIS 

assessed whether respondents smoked cigarettes every day, 

some days, or not at all. Persons who smoked every day 

or some days were classified as current cigarette smokers. 

Also in NHIS, former cigarette smokers were those 

who reported smoking at least 100 cigarettes during their 

lifetime but currently did not smoke.

Youth

The YRBS defines current cigarette smoking among 

students as having smoked cigarettes on at least 1 day 

during the 30 days before the survey. To be classified as a 

current smoker, students had to answer “yes” to questions 

about ever smoking and current smoking. In addition, students who were current smokers and reported smoking on 

20 or more of the past 30 days were categorized as current 

frequent cigarette smokers. This measure was examined 

for youth because current frequent cigarette smokers most 

likely have a more established pattern of use and are more 

likely to smoke as adults, thereby potentially representing 

the future group of adult smokers who are trying to quit. 

Former smoking among youth in the YRBS was categorized as either (a) former daily smokers, representing 

those who had an established pattern of smoking daily 

but were not currently smoking and perhaps reflecting 

youth who had quit smoking; and (b)  former nondaily 

smokers, who may contain a higher proportion of youth 

who experimented with smoking, in addition to those 

who quit smoking. Students who answered “yes” to ever 

smoke and “no” to currently smoke were categorized as 

(a) former daily smokers, if they answered “yes” to ever 

daily; or (b)  former nondaily smokers, if they answered 

“no” to ever daily.

Quit Ratio

Adults

In NHIS, the quit ratio is defined as the ratio of 

former smokers to ever smokers; ever smokers were those 

who had smoked at least 100 cigarettes in their lifetimes. 

Former smokers were defined as ever smokers who did not 

currently smoke at the time of the survey. Because smoking 

behaviors are less established among youth and young 

adults, this measure was not examined for those groups.

Recent Successful Cessation

Adults and Young Adults

In NHIS, the recent smoking cessation percentage 

includes in the numerator only former smokers who quit 

smoking 6–12 months ago (i.e., persons who reported 
A Report of the Surgeon General

118 Chapter 2 Appendices

having smoked 100  cigarettes in their life but were not 

smoking at time of interview and had quit smoking 

6–12  months prior). The denominator for this measure 

includes both current smokers who smoked for at least 

2  years and former smokers who quit during the past 

year. This measure was not examined for youth. Because 

the BRFSS did not include a question about the length 

of time that current cigarette smokers had smoked, the 

estimate from BRFSS does not include this restriction 

in its denominator and, therefore, is not comparable to 

the estimate from NHIS. Nevertheless, when the restriction of having smoked for at least 2 years is removed from 

the denominator in NHIS, the resulting estimate of the 

prevalence of recent successful cessation is 7.4% (95% CI, 

6.4–8.4%) (NHIS, NCHS, public use data, 2017), which is 

similar to the estimate with this restriction (7.6%, 95% 

CI, 6.6–8.6%) (Table 2.13).

Cessation Continuum

Using TUS-CPS data, a cessation continuum was 

constructed to more completely describe the dynamic 

process of smoking cessation. This measure was examined 

only for adult current smokers. The continuum included 

the proportion of current smokers who had ever tried to 

quit smoking, whether they had attempted to quit during 

the past year, and their current interest in quitting.

Past-Year Quit Attempts

Adults and Young Adults

NHIS defines past-year quit attempts among current smokers as those who answer “yes” to, “During the 

past 12  months, have you quit smoking for one day or 

longer?” In the 1998 NHIS, the question was revised to, 

“During the past 12 months, have you stopped smoking 

for more than one day because you were trying to quit 

smoking?” This measure also includes former smokers 

who quit during the past year. It is important to note that 

in addition to excluding those who may have quit for 1 day 

during the past year, this measure does not include pastyear quit attempts of less than 1 day. Therefore, the measure may underestimate quit-attempt prevalence. Data 

from the 2014–2015 TUS-CPS indicated that among current cigarette smokers, the prevalence of past-year quit 

attempts increased by 5.4 percentage points from 41.3% to 

46.7% when self-reported quit attempts of less than 1 day 

were included (Table 2.14). Questions defining past-year 

quit attempts in the 2014–2015 TUS-CPS included asking 

some-day smokers who smoked fewer than 12 days in the 

past 30 days, “During the past 12 months, have you tried 

to quit smoking completely?” and asking daily smokers 

and some-day smokers who smoked on 12 or more days 

during the past 30 days, “During the past 12 months, have 

you stopped smoking for one day or longer because you 

were trying to quit smoking?” Those who answered “no” 

to this question were asked, “During the past 12 months, 

have you made a serious attempt to stop smoking because 

you were trying to quit—even if you stopped for less than a 

day?” Quit attempts of less than 1 day comprised 12.9% of 

past-year quit attempts among current daily smokers and 

some-day smokers who smoked on 12 or more days during 

the past 30 days (TUS-CPS, public use data, 2014–2015).

It is also important to note that Table 2.14 estimates 

past-year quit attempt prevalence in 2014–2015 TUS-CPS 

only among current smokers and does not include former 

smokers who quit in the past year; therefore, the quit 

attempt prevalence in Table 2.14 (41.3%) is much lower 

than the quit attempt prevalence in Table  2.11, which 

is estimated from the 2015 NHIS and includes former 

smokers who quit during the past year (55.4%). However, 

the absence of former smokers who quit during the past 

year from the 2014–2015 TUS-CPS estimate does not 

entirely explain the difference in prevalence. In the combined 2014–2015 NHIS among current smokers only, the 

quit attempt prevalence was 48.9% (NHIS, public use 

data, 2014–2015), which was still above the quit attempt 

prevalence of 41.3% among the same group in the 2014–

2015 TUS-CPS.

Youth

In the YRBS, students were asked the question, 

“During the past 12  months, did you ever try to quit 

smoking cigarettes?”

The NYTS defines past-year quit attempts as those 

made by current smokers who reported having tried to 

quit smoking for a day or longer during the past year.

Number and Duration of Quit Attempts

Adults and Young Adults

In the 2014–2015 TUS-CPS, among current daily 

smokers and some-day smokers who smoked at least 12 or 

more days during the past 30  days, the question, “How 

many TIMES during the past 12 months have you stopped 

smoking for one day or longer because you were trying to 

quit smoking?” was asked of those who responded “yes” 

to the question, “During the past 12  months, have you 

stopped smoking for one day or longer because you were 

trying to quit smoking?”

Duration of quit attempts was examined with the 

questions, “During the past 12 months, what is the length 

of time of this single quit attempt where you stopped 

smoking because you were trying to quit smoking” and 

“Thinking of those attempts during the past 12 months, 
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 119

Smoking Cessation

what was the length of time of the one attempt that lasted 

the longest?”

Youth

In the 2017 NYTS, middle and high school students who were current smokers and had tried to quit 

smoking during the past year were asked, “During the 

past 12 months, how many times have you stopped using 

all tobacco products for one day or longer because you 

were trying to quit all tobacco products for good?” The 

response options were “I did not smoke cigarettes during 

the past 12  months,” “I did not try to quit during the 

past 12 months,” “1 time,” “2 times,” “3 to 5 times,” “6 to 

9 times,” and “10 or more times.”

Interest in Quitting

Adults and Young Adults

In the 2014–2015 TUS-CPS, among current daily 

and some-day smokers, interest in quitting was assessed 

using a 10-point scale. Participants were asked, “Overall, 

on a scale from 1 to 10, where 1 is not at all interested and 

10 is extremely interested, how interested are you in quitting smoking?”

NHIS defines interest in quitting as current smokers 

who reported that they wanted to stop smoking completely. 

Youth

In the 2011–2015 MTF Study, interest in quitting 

was assessed by asking high school seniors who were 

current smokers whether they wanted to stop smoking 

“now.” Another measure included in this survey concerned whether the smoker thought that he or she would 

be smoking in 5 years.

In the 2015 NYTS, interest in quitting was assessed 

by asking current smokers, “Are you seriously thinking 

about quitting cigarettes?”

Ever Tried to Quit Smoking

Adults and Young Adults

In the 2001–2002 TUS-CPS, estimates for ever 

trying to quit smoking relied on one question, “Have you 

ever stopped smoking for one day or longer because you 

were trying to quit smoking?” In other years, questions for 

current some-day smokers who had smoked fewer than 

12  days during the past 30  days were asked, “Have you 

ever tried to quit smoking completely?” and current daily 

smokers and some-day smokers who had smoked 12  or 

more days during the past 30 were asked, “Have you ever 

made a serious attempt to stop smoking because you were 

trying to quit—even if you stopped for less than a day?” 

For the 2006–2007 TUS-CPS, current daily smokers and 

some-day smokers who smoked 12 or more days during 

the past 30 days were also asked, “Have you ever stopped 

smoking one day or longer because you were trying to quit 

smoking?”

Youth

In the MTF Study, high school seniors who were 

current smokers were asked if they had ever tried to quit 

smoking.

Cessation of Other Tobacco Products

Adults and Young Adults

In NHIS, cessation of other tobacco products was 

examined using past-year quit attempts (“During the past 

12 months, have you stopped using all kinds of tobacco 

products for more than one day because you were trying 

to quit using tobacco?” “All kinds” meant trying to quit 

using tobacco completely, including smoking cigarettes, 

smoking products other than cigarettes, and using smokeless tobacco products.). This question was asked of current cigarette smokers who used another tobacco product 

or who used two or more tobacco products.

Screening for Tobacco Use

Adults and Young Adults

Screening for tobacco use was examined using 

2009–2011 NAMCS data, based on abstraction of medical 

records for visits to office-based physicians during which 

current tobacco use (smoked cigarettes or cigars or used 

snuff or chewing tobacco) or no current use was recorded. 

The same measure was used for youth. Because of methodologic changes, this chapter does not report the most 

recent NAMCS data (2012–2013).

Advice to Quit—Clinical Data from Abstractions 

of Medical Records

Adults and Young Adults

Using 2009–2011 NAMCS data, receipt of advice to 

quit was based on abstraction of medical records for visits 

to office-based physicians by identified current tobacco 

users (i.e., the patient was identified as a current tobacco 

user during screening). Receipt of advice is defined as 

visits where tobacco counseling was recorded. Tobacco 

counseling refers to any information provided that related 

to tobacco use in any form, including cigarettes, cigars, 

snuff, and chewing tobacco, and on exposure to tobacco 
A Report of the Surgeon General

120 Chapter 2 Appendices

in the form of secondhand smoke, smoking cessation, and 

prevention of tobacco use, as well as referrals to other 

healthcare providers for smoking cessation programs. 

The same measure was used for youth. Because of methodologic changes, this chapter does not report the most 

recent NAMCS data (2012–2013).

Advice to Quit—Self-Reported Data

Adults and Young Adults

In the 2015 NHIS, receipt of advice to quit was 

assessed among current smokers and former smokers who 

quit during the past year and also saw a doctor or other 

health professional during the past year. Receipt of advice 

to quit was defined as having been given advice from a 

medical doctor, dentist, or other health professional to quit 

smoking or to quit using other kinds of tobacco among 

current cigarette smokers and former smokers who quit 

during the past year.

Youth

In the 2013 NYTS, high school and middle school 

students were asked whether at any visit to a doctor, dentist, or nurse during the time covered by the survey, they 

had been asked by the provider whether they used tobacco 

that is smoked or put in the mouth. A separate measure, 

being advised not to use tobacco, was defined using current cigarette smokers (smoked cigarettes during the 

30 days preceding the survey) as being advised by a doctor, 

dentist, or nurse during the past 12  months not to use 

tobacco that is smoked or put in the mouth.

Use of Counseling and Medications to Quit 

Smoking

Adults and Young Adults

To define the use of counseling, NHIS considers 

two groups, current smokers who tried to quit during the 

past year and former smokers who quit during the past 

2 years. Counseling is defined as having used one-on-one 

counseling; a stop-smoking clinic, class, or support group; 

and/or a telephone helpline or quitline during the past year, 

among current smokers who tried to quit in the past year 

and among former smokers who quit in the past 2 years. 

The 2014–2015 TUS-CPS asked current smokers who tried 

to quit during the past year about their use of a telephone 

helpline or quitline the last time they tried to quit.

NHIS defines use of medications as having used 

during the past year the nicotine patch, nicotine gum 

or lozenge, a nicotine-containing nasal spray or inhaler, 

varenicline (U.S. trade name Chantix), and/or bupropion 

(including trade names Zyban and Wellbutrin).

Youth

The 2000, 2004, and 2009 NYTS asked high school 

and middle school students if they did any of the following during the past 12 months to help themselves stop 

smoking: attend a program in their school, attend a program in their community, call a helpline or quitline, use 

nicotine gum or lozenge, use a nicotine patch, and/or use 

any medication. (In 2000, the strategies of using nicotine 

gum and using a nicotine patch were asked together as 

one strategy.) The same cessation strategies were assessed 

in the 2015 NYTS but the question changed to, “In the 

past 12 months, did you do any of the following to help 

you quit using tobacco of any kind for good?” and the word 

“telephone” was added before “helpline” and “quitline.”

Use of Other Cessation Strategies

Adults and Young Adults

The 2014–2015 TUS-CPS asked current smokers 

who tried to quit during the past year about their use 

of the Internet or a web-based program or tool the last 

time they tried to quit. Current smokers were also asked 

if they did any of the following the last time they tried to 

quit: tried to quit by switching to (a) smokeless tobacco, 

such as chewing tobacco, snuff, or snus; (b) regular cigars, 

cigarillos, little filtered cigars, or any pipes filled with 

tobacco, and (c) electronic or e-cigarettes. The survey did 

not operationalize what switching meant (i.e., completely 

switching vs. dual use while reducing cigarette smoking).

Youth

The 2015 NYTS asked high school and middle school 

students if they had tried to quit “on my own” or cold turkey 

during the past 12 months to help themselves quit using 

tobacco of any kind for good. The 2015 NYTS also asked if 

one of the reasons why they had used e-cigarettes was to 

try to quit using tobacco products, such as cigarettes.
Patterns of Smoking Cessation Among U.S. Adults, Young Adults, and Youth 121

Smoking Cessation

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