Professional Documents
Culture Documents
1. Introduction
Cigarettesmokingcontinuestobethesinglegreatestpreventablecauseofdiseaseand
death in the United States [1]. The US federal governments first nationally
representativesurveyofcigarettesmokingandothertobaccousebehaviorstookplacein
1955asasupplementtotheUSCensus[2].Sincethenfederallysponsoredtobacco
surveillancehasgrowntoincludeseveralestablisheddatacollectionsystemsroutinely
implementedatthenationallevel,someofwhichhavebeenadapted,sponsored,and
implementedatthestatelevel[35].AsoneoftheWorldHealthOrganization(WHO)
MPOWERpackagessixproventobaccopreventionandcontrolpolicies[6],tobacco
preventionandcontrolmonitoringsystemsandtheirmaintenanceandenhancementare
anessentialpartofpublichealthpractice[7].Specifically,WHOcallsformonitoring
systemsthattrackmultipleantiandprotobaccoattitude,behavior,andpolicyindicators;
disseminate findings to facilitate utilization; provide overall as well as demographic
subpopulationdataatthenational,state,and,wherepracticable,locallevels;maximize
system sustainability through crossdiscipline collaboration, strong management and
organization,andsoundfunding[6].
Understanding,documenting,andquantifyingthecharacteristicsofthetobaccouser,or
potential user, have been key to tobacco control efforts [4]. A variety of existing
monitoring,research,andevaluationsystemsareavailabletocollectsuchinformation
[4],withincreasingdemandforsurveillancedatatoinformevidencebasedpublichealth
tobacco initiatives necessitating their periodic review [5]. At the national level, the
National Health Interview Survey (NHIS) has been the data source used to measure
progressonHealthyPeopleadulttobaccouseprevalenceobjectivessincethefirstever
releaseofnationalhealthobjectives(HealthyPeople1990)[8,9].Adulttobaccouse
prevalencecanbeestimatedfromothernationalsurveysaswell[3],allowingevaluation
ofanydifferencesinprevalencemagnitudeorintrendsovertimebetweendatasources;
however, there have been few studies comparing their smoking prevalence estimates
[10].Acomparisonofestimatesfromthe1997NHISandnationalestimatesfromthe
1997BehavioralRiskFactorSurveillanceSystem(BRFSS)surveys[11]foundcurrent
smokingprevalencetobesignificantlyhigherinNHISthaninBRFSS(24.7%versus
23.1%). Differences were also observed in a Substance Abuse and Mental Health
Services Administration (SAMHSA) report [12] that described smoking prevalence
estimatesfromthe2005NationalSurveyonDrugUseandHealth(NSDUH).SAMHSA
reportedthatestimatesfromNSDUHwerehigher(26.5%)thanestimatesobtainedfrom
the2005NHIS(20.9%),evenafterapplyingtheNHIScurrentsmokingdefinitionto
NSDUHdatalimitingsmokersonlytothosewhoreportedsmoking100cigarettesin
theirlifetime(24.7%inNSDUHusingNHISdefinition).Ina2009reportcomparing
NHISandNSDUHcurrentsmokingprevalencefortheperiod19982005,Roduand
Cole[10]describeanincreasinglydivergentpictureofsmokingprevalenceintheUSA
between1999and2005.RodussecondaryanalysisofNHISandNSDUHdataindicated
thatby2005NHISprevalencehaddeclinedtoapproximately21%whiletheNSDUH
estimatewasapproximately25%,withthelatterbutnottheformersuggestingaplateau
insmokingprevalence.Thispatternthenreversedwitha2010reportusingNHISdata
thatindicatedastallintheprevalenceofadultsmokingfrom2005(20.9%)to2009
(20.6%) [13] while SAMHSAs primary analysis of NSDUH data suggested a
continuingdeclinefrom26.5%to24.9%duringthesameperiod[12].
Key methodological issues, such as sampling design, survey mode and setting, and
surveyquestionstandardizationandcontext,havethepotentialtoinfluencedataquality
and comparability [4]. Differences in the survey questions used to define current
smokingarethoughttobeoneoftheprobablemethodologicalsourcesofdiscrepancy
betweenNHISandNSDUHsmokingestimates.Mostnotably,NHISlimitsitsquestion
ofcurrentsmokingtorespondentswhoonapreviousquestionreportedsmoking100
cigarettesintheirlifetime(i.e.,NHISeversmokers,withneversmokersthendefined
asrespondentswithlifetimesmokinganywherebetween0and99cigarettes).NSDUH
also limits its current smoking definition based on reported ever smoking behavior;
however,otherthananimplicitzero,itdoesnotdesignateacutpointfornumberof
lifetimecigarettessmokedforcategorizingeversmokersversusneversmokers.
Levelsofcigaretteconsumptionsuchasnumberofcigarettessmokedperday,number
ofdayssmokedpermonth,andamountoflifetimecigaretteusehaveoftenservedasa
proxy for other key tobacco control indicators, such as secondhand smoke exposure,
nicotineaddiction,andhealthrisk[14].This,however,maynotnecessarilybeadvisable
practice.AreviewbyHusten(2009)[14]concludedthatconsumptionisacrudemeasure
ofbothtoxinexposureandnicotinedependenceand,withrespecttotoxinexposure,
likelyinaccurateaswell.Likewise,withrespecttohealthrisk,thereviewconcludedthat
nolevelofconsumptioncouldbeconsideredsafe,andthususedtodemarcatearisk
threshold.Researchspecifictowhether100lifetimecigarettesisadiscriminatingcut
point for distinguishing ever smokers versus never smokersand, subsequently, for
definingwhois,everhasbeen,ormaybecomeacurrentsmokerislimited[15]but
indicatesthatittoomaybeunsuitable.Inastudyofcravingpatterns,tolerance,and
subjectiveresponsestothepharmacologicaleffectsofsmoking,findingsfromPomerleau
etal.(2004)[16]indicated20cigarettesperlifetimemaybeamoreprudentmarkerthan
100forsuchadifferentiation.Othershaveproposedthatliabilityfordependenceand
subsequentuptakeofsmokingmayevenbedistinguishableafteranindividualsveryfirst
puff[17].Additionally,nondailyandlightdailysmokingbehaviorsconsistentwith
current cigarette smoking but lifetime smoking <100 cigaretteshave been found to
significantlyvaryacrossracial/ethnicsubpopulations[1824].FindingsfromTrinidad
et al. (2009) [24] indicated nonHispanic black, Asian/Pacific Islander, and
Hispanic/Latino smokers were more likely to be nondaily and light daily smokers
comparedwithnonHispanicwhites,evenaftercontrollingforage,gender,andeducation
level.ThiswasparticularlytrueofHispanic/Latinosmokers,whowere3.2timesmore
likelytobenondailysmokersand4.6timesmorelikelytobedailysmokerswhosmoke
5 cigarettes per day as compared with nonHispanic white smokers. Furthermore,
Hispanic/Latino nondaily smokers smokedfewer days per month andsmokedfewer
cigarettesperdayonthedaystheydidsmokecomparedwithnonHispanicwhites.
Infrequentsmokingandsmokingtrajectoriesamongadultsremainopenresearchissues.
Youthdataemergingoverthepastdecade,however,haveconsistentlyconcludedthe
trajectoryofsmokingbeginswiththelossofautonomythatoccursduringinfrequentuse
[2530].Amongadultswhohaveadoptedthepracticeofinfrequentsmoking,research
notonlysuggestsitcanremainastablepatternlastinglongperiodsoftime[3133]but
that it also poses substantial health risk with adverse outcomes paralleling dangers
observedamongdailysmoking,especiallyforcardiovasculardisease[34].Suchresults
have notable implications for the understanding of tobacco dependence and the
development of prevention and cessation strategies, especially for racial/ethnic
minorities.
WhiledifferencesincurrentsmokingestimatesbetweenNHISandNSDUHhavebeen
previously reported [10,12], more indepth examination directed specifically at
methodologyandhowdifferencesmayaffectcomparabilitywithothersurveysisneeded
[10,35].Therefore,thecurrentreportmakescomparisonsbetweenNHISandNSDUH
prevalence estimates using, for NHIS data, the standard NHIS definition of current
smoking, which includes a screener question for a level of lifetime smoking 100
cigarettesand,forNSDUHdata,usingboththestandardNSDUHdefinitionofcurrent
smoking,whichdoesnotusethescreenerquestion,andamodifieddefinitionthatapplies
theNHIScurrentsmokingdefinition(i.e.,with100cigaretterestriction)toNSDUHdata.
Specifically, the following research questions are addressed: (1) how and for what
subpopulationsandsmokingbehaviorsmightthe100lifetimecigarettescriterionaffect
adultprevalenceestimates?and(2)whatsubpopulationsaremostlikelytohavesmoked
duringthepast30daysbutnotmeetthe100lifetimecigarettescriterion?Findingsare
presentedbysociodemographiccharacteristicsforcurrentsmokingandfordailysmoking
amongcurrentsmokers.
an overall response rate of 62.9%. Further details about the sampling and survey
methodologyusedintheNHIScanbefoundelsewhere[36].
2.3. NSDUH
The NSDUH is a national healthsurveysponsoredby SAMHSA and is designed to
provide information about the use of alcohol, tobacco, and illegal drugs in the non
institutionalized US household population aged12 years and older [37]. The survey
sampledesignisastratified,multistage,areaprobabilitydesign.Since1999,thesurvey
hasbeenadministeredthroughconfidential,anonymous,facetofaceinterviewsinthe
household by trained interviewers using a combination of direct CAPI and audio
computerassistedselfinterviewing(ACASI)inwhichtherespondentreadsquestionson
acomputerscreenorlistenstoquestionsthroughheadphonesandthenrecordsanswers
intoacomputer,toincreasehonestreportingofsensitive behaviors.Thetobaccouse
sectionwasconductedviaselfadministeredACASI.Therepresentativesurveysample
and subsequent data weighting permit calculation of national estimates. The design
oversamplesyouthandyoungadultstoallowformorepreciseestimatesinthesegroups.
Thereisnooversamplingofracial/ethnicgroups.The2006householdresponseratewas
90.6%,andtheinterviewresponserateforadults18years[38]was72.9%,yieldingan
adultoverallresponserateof66.0%.Thehousehold,adultinterview[39],andadult
overallresponserateswere89.5%,72.7%,and65.0%,respectively,forthe2007survey
and89.0%,73.3%,and65.3%,respectively,forthe2008survey.Furtherdetailsabout
the sampling and survey methodology used in the NSDUH can be found elsewhere
[37,40,41].
2.4. Variable Definitions
ForbothNHISandNSDUH,weexaminedcurrentsmokingstatusand,amongcurrent
smokers,dailysmoking.ForNSDUH,wealsoexaminedleveloflifetimecigaretteuse
amongcurrentsmokers.Definitionsforeachmeasurefollow.
2.5. Current Smoking
2.5.1. NHIS
The standard NHIS current smoking definition (hereafter simply termed the NHIS
definition)hascomprisedoftwoquestions[42]since1965(J.Madans,NCHS,personal
communication,Nov.10,2011),withthepresentwordinginusesince1992[43].The
firstquestion,askedofallrespondents,ishaveyousmokedatleast100cigarettesin
yourentirelife?Respondentsansweringyesareclassifiedaseversmokers,andthose
whoanswernoareclassifiedasneversmokersandexcludedfromsubsequentcigarette
use questions. Ever smokers are then asked a second question: do you now smoke
cigaretteseveryday,somedaysornotatall?Respondentswhoanswereverydayor
somedaysareclassifiedascurrentsmokers(Figure1).
ForNSDUHS,leveloflifetimecigaretteuseamongcurrentsmokerswasdefinedusing
the question have you smoked at least 100 cigarettes in your entire life?, with
dichotomizedyes/noresponse optionsdifferentiatingthosewhohave smoked 100
cigarettesintheirlifetimeversusthosewhohavesmoked<100.
2.8. Demographic Information
Forbothsurveys,smokingstatuswasexaminedbyagegroup(1825,2634,3549,50
64,65),gender(male,female),race/ethnicity(nonHispanicwhite,NonHispanicblack,
Hispanic or Latino, Asian, American Indian/Alaska Native), and education among
persons aged 26 years (< high school, high school graduate, some college, college
graduate).
2.9. Statistical Analyses
For all analyses, respective sample weights were applied to the data to adjust for
nonresponseandthevaryingprobabilitiesofselection,includingthoseresultingfrom
oversampling,yieldingnationallyrepresentativefindings.SUDAAN10.0[45],which
accounts for the complex survey sample design, was used to generate prevalence
estimatesand95%confidenceintervals.
For NHIS and NSDUH, 2008 prevalence estimates were calculated, overall and by
demographicsubgroup,forcurrentsmokinganddailysmokingamongcurrentsmokers,
andtwosetsofbetweensurveycomparisonsthenmade.Thefirstcomparisonwasmade
using the NHIS current smoking definition versus the NSDUHS definition, and the
secondusingtheNHIScurrentsmokingdefinitionversustheNSDUHMdefinition.To
explore lifetime smoking of <100 cigarettes among current smokers, 20062008
NSDUHScombinedprevalenceestimateswerecalculated,overallandbydemographic
subgroup.Twosidedttestswereperformedforboth2008NHISversus2008NSDUH
comparisons to identify statistically significant differences at an alpha level of 0.05.
Adjustedoddsratioswith95%confidenceintervalswerecalculatedforthe20062008
NSDUHScombinedanalysis,controllingforage,gender,race/ethnicity,andeducation.
3. Results
3.1. Current Cigarette Smoking among Adults
Assessment of the NSDUHS current smoking definition indicated that the overall
prevalence(25.5%,95%CI24.726.2)wassignificantlyhigherthantheNHISoverall
prevalence(20.6%,95%CI19.921.4)(Table1).Thissamepatternwasobservedforall
subpopulationsanalyzedexceptthe5064and 65yearoldagegroups,Asians,and
American Indians/Alaska Natives. Using the NSDUHM current smoking definition,
overall prevalence remained significantly higher (23.6%, 95%CI 22.824.3) than the
NHISoverallprevalence.Thissamepatternwasobservedforthe1825and2634years
agegroups,males,nonHispanicwhites,andcollegegraduates.
Table 1: Current cigarette smoking among adults and daily cigarette
smoking among adults who currently smoke ** by demographic and
current smoking variable definitionNHIS and NSDUH, 2008.
3.2. Daily Cigarette Smoking among Current Smokers
Assessment of smoking frequency using the NSDUHS current smoking definition
indicatedthattheoverallprevalenceofdailysmoking(63.3%,95%CI61.864.8)was
significantlylowerthantheNHISprevalence(79.7%,95%CI78.381.2)(Table1).This
samepatternwasobservedforallsubpopulationsanalyzedexceptthe65yearoldage
group and American Indians/Alaska Natives. Using the NSDUHM current smoking
definition,theprevalenceofdailycigarettesmokingduringthepast30daysremained
significantly lower (68.2%, 95%CI 66.869.6) than the NHIS prevalence. This same
patternwasobservedforallsubpopulationsanalyzedexceptthe2634and65yearold
agegroups,HispanicsorLatinos,Asians,andAmericanIndians/AlaskaNatives.
3.3. <100 Lifetime Cigarettes among Current Smokers
AmongNSDUHScurrentsmokers,youngerrespondentshadsignificantlygreaterodds
ofsmokingfewerthan100cigarettesduringtheirlifetime(Table2).Usingpersonsaged
65yearsasthereferent,1824yearoldshad11.2timesgreaterodds(aOR,95%CI:
4.826.1)and2534yearoldshad3.5timesgreaterodds(aOR,95%CI:1.58.7),of
havingalifetimesmokinglevelof<100cigarettes.Bygender,femaleshad1.2times
greaterodds(aOR,95%CI:1.11.4)thanmalesofhavingalifetimesmokinglevel<100
cigarettes.AscomparedtononHispanicwhites,HispanicorLatinosmokershad4.8
timesgreaterodds(aOR,95%CI:4.25.5)ofhavingalifetimesmokinglevelof<100
cigarettes,followedbyAmericanIndians/AlaskaNatives(aOR,95%CI:3.6,1.87.3),
nonHispanicblacks(aOR,95%CI:2.4,2.02.8),andAsians(aOR,95%CI:2.2,1.5
3.3). By education, smokers who graduated from college had 2.5 times greater odds
(aOR,95%CI:1.93.2),andthosewithsomecollegeeducationhad1.7timesgreater
odds(aOR,95%CI:1.32.1),ofhavingalifetimesmokinglevelof<100cigarettesthan
thosewithlessthanahighschooleducation.
4. Discussion
In comparisons between NHIS and NSDUH, NSDUH consistently yielded higher
nationaloverallandsubpopulationestimatesofcurrentcigarettesmokingamongadults
thanNHISand,amongcurrentsmokers,lowerestimatesofdailysmoking.However,
withtheuseofthemodifiedNSDUHMcurrentsmokingvariabledefinitionthat,likethe
NHISdefinition,isrestrictedtorespondentswithlifetimecigaretteuse100cigarettes,
estimatesgenerallyshiftedclosertoNHISestimates,andseveralsubgroupsdifferences
that were statistically significant for NHIS versus NSDUHSbecame comparable for
NHISversusNSDUHM.Specifically,estimatecomparabilityoccurredforthecurrent
smokingvariableamong3549yearolds,females,nonHispanicblackrespondents,and
thosewith<highschool,highschoolgraduate,orsomecollegeeducationallevel,and,for
the daily smoking variable, among 2634 year olds and Asian respondents. Among
Hispanicrespondents,comparabilityoccurredforboththecurrentsmokingvariableand
thedailysmokingvariable.Intheseinstances,enoughNSDUHrespondentswhoreported
smokingduringthepast30dayshadsmokedfewer than100lifetimecigarettes(i.e.,
NSDUHM) to negate the significant differences originally observed when level of
lifetimecigaretteusewasnottakenintoaccount(i.e.,NSDUHS).The100cigarette
prerequisiteappearedtoimpactcurrentsmokingestimatesmuchmoreextensivelythanit
did smoking frequency estimates; that is, inclusion of the prerequisite produced
comparabilityinestimatesextensivelyacrossallfourdemographiccategoriesforcurrent
smoking,whereascomparabilityoccurredonlyminimallyfordailysmoking.
Subpopulationsmostimpactedbytherestrictionofthecurrentsmokervariabledefinition
torespondentswithlifetimecigaretteuse100cigarettesappeartobeyoungeradultsand
racial/ethnicminorities.Thecurrentsmokingestimatecomparabilitythatoccurredwith
use of the NSDUHM current smoking definition represents a loss of significant
differencesoriginallyobservedbetweenNHISandNSDUHSforthe3549yearsage
group, females, nonHispanic blacks, Hispanics, and the <high school, high school
graduate,andsomecollegeeducationallevels.Thedailysmokingestimatecomparability
that occurred represents a loss of significant differences originally observed between
NHISandNSDUHSforthe2634yearsagegroup,Asians,andHispanics.Withinthis,
Hispanicsmokingprevalenceappearedtobethemostsensitivetodifferencesinsmoking
variabledefinitionsasthiswastheonlygroupforwhichestimatecomparabilityoccurred
acrossbothcurrentsmokinganddailysmoking.
Thesefindingsareconsistentwithotherstudiesshowingrestrictionoftheadultcurrent
smokingdefinitiontorespondentswithlifetimecigaretteuse 100cigarettesleadsto
lowerprevalenceestimates[10,12,13],especiallyamongminorities[46].Theyare
alsoconsistentwithpreviousstudiesthatspecificallyfoundHispanicsmokersweremost
likelytobenondailysmokersandtosmokefewerdayspermonththannonHispanic
respondents[18,19,2124,31,47].Itwasthetobaccoindustryitself,however,that
showedforesightintotherelevanceofsuchnuancesandthesubsequentopportunities
affordedbywhatittermedoccasionalsmokers,andduringthe1990stookaninterestin
this group. Indeed, tobacco industry workshop materials from 1996 explained that
occasional smokers may or may not selfidentify as a smoker [47]. Data collection
effortsbyPhilipMorristhattookplaceinthelate1990sspecificallyfocusedonthose
whodidnotidentifyasasmokeranddefinedoccasionalsmokerssimplytobepeople
whoreferredtothemselvesasnonsmokers,respondedyeswhenaskediftheysmoked
oneormorecigarettesinthepastyear,andrespondednowhenaskediftheypresently
smokeatleastapackaweek[48].Internalcommunicationssummarizingtheresulting
datanotedthatHispanicsrepresentsubstantiallymorethantheirfairshareofoccasional
smokers[49].
Husten (2009) [14] states that the stability of the behavior within any definitional
categoryorcategoriesofoccasionaluseisanimportantconsiderationindetermininga
definitionoftheterm.Wetakethislineofthoughtastepfurtherbyapplyingstability
criteriawithinaparticularvariabledefinitionandacrossmultiplesubpopulations.The
current analysis indicates that WHOs call for the provision of overall as well as
demographic subpopulation data [6] may not be accurately met if a single current
smokingdefinitionisutilizedforallsubgroupswhenthosesamegroupsareknownto
differonakeycomponentofthevariablesdefinition(i.e.,occasionaluse).LikeHusten,
wereasonthatlevelsofconsumptionmaybebestleftascontinuousvariablesratherthan
presumptivecutpoints,astheredonotseemtobeclearconsumptionlevelsthatcorrelate
withtheonsetofdependenceorhealthrisk.Asnoted,datathatdefinitionallyinclude
rather than exclude lower consumption patterns have significant implications for the
understanding of tobacco use and addiction and the development of prevention and
cessationstrategiessuchastheextenttowhichinterventionmessagesdoversusdonot
addressnondailysmoking[20],healthrisksofanysmoking[31],motivationsother
thanhealtheffects[20],beliefsaboutabilitytoquit[23],situationaltriggers[31],social
and cultural forces [23], and attitude changes [50]especially for racial/ethnic
minorities.
Measuresrelevanttooccasionalsmokersareneededtobeabletoadequatelymonitorand
describetheircigaretteuse,motivations,nicotinedependence,andcessationbehaviors
[50], underscoring the importance for national surveillance systems to use multiple
comparableprevalencemeasurestocapturediversesmokingbehaviors,especiallyamong
subgroups.Considerationmustbetakenwithregards,butnotlimitedto,anyscreener
questions,skippatterns,orcloseddataeditsthatresultinacompletedropofcertain
respondentssuchthattheyareunabletobeaddedbackinwhencalculatingprevalence
estimates. An assumption of dropping respondents from certain questions is that the
answerstothesequestions,hadtheybeenasked,wouldinmostcaseshavebeennoor
not applicable [15]. Much could thus be gained by maintaining one or two key
smokingbehaviorquestionsacrosssurveys,allowingresearcherstoretainratherthan
relinquishtheabilitytotestthisassumption[15]andsubsequentlycapture,assess,and
usethesedatatotheirfullestcapacity.Furtherinvestigationofassociationsbetweenthe
knowledge,attitudes,andbehaviorsoftrueneversmokers(i.e.,lifetimesmokinglevel=
0) and graded levels of lifetime cigarette use >0 may provide additional help in
determiningwhetherajudiciouscutpointexistsforcategorizingarespondentasanever
smokerversusaneversmokerand,subsequently,indefiningcurrentsmokers.Inthe
meantime,investigatorsshouldusedatamostappropriateforaddressingtheirspecific
research questions and subgroups of interest (e.g., relevant consumption levels, age
group,racial/ethnicminoritystatus,etc.).
4.1. Limitations
ThispaperhasdescribedhowtheuseofamodifiedNSDUHcurrentsmokingvariable
definition that, like the NHIS definition, is restricted to respondents with lifetime
cigaretteuse100cigarettesnegatesanotablenumberofsignificantdifferencesamong
subpopulationotherwiseobservedbetweenthetwosurveys.However,thereareother
centralmethodologicaldifferencesinadditiontoquestionwordingthatwerenotassessed
inthecurrentanalysissuchassurveymode,setting,context,andincentivesthatmay
alsocontributetodiscrepanciesincurrentsmokingestimates.In1994,NSDUHchanged
from an interviewer administered survey mode for the tobacco questions to a self
administered survey mode for these questions. Findings from a random split sample
conducted to measure the impact suggest that the selfadministered mode may have
resulted in higher reporting of current smoking behavior [51,52]. NHIS tobacco
questions,ontheotherhand,remainintervieweradministered.Further,NHISinterviews
that either cannot be conducted or fully completed in person are administered by
telephone,whereasNSDUHinterviewmodeisstrictlyinperson.Inastudycomparing
telephone versus facetoface interviewing of national probability samples, findings
suggest telephone respondents to be more likely to present themselves in socially
desirablewaysthanwerefacetofacerespondents[53].MorechangesintheNSDUH
mode of administration took place in 1999 when it shifted from paper and pencil
interviewstoACASI.ACASIisthoughttoproviderespondentswithanenhancedsense
ofprivacy,thusincreasingtheirwillingnesstotruthfullyreporttheirhealthbehaviors.
Indeed,a2004studycomparingthe1999and2001NSDUHandBRFSSprevalence
estimatesofadultbingedrinkingreportedthathavingruledoutotherexplanationssuch
asdifferencesinsurveydesign,sampling,responseratesandquestionwordingACASI
mayhavebeenresponsiblefortheNSDUHestimatesthatwere2.4to9.2percentage
pointshigherthanBRFSSestimates[54].
NHISandNSDUHalsodifferintermsofoverallsurveycontextandquestionplacement,
whichmayinfluencerespondentsperceptionsofsmokingitself[10].NHISprimarily
focuses on participants health status with limited attention given to related licit
substanceuse(cigaretteandalcoholuse),whereasNSDUHfocusesalmostentirelyon
substanceusebehaviors,coveringbothlicitandillicitsubstances,includingmarijuana,
cocaine,crack,hallucinogens,inhalants,andnonmedicaluseofprescriptiondrugs.Inthe
NHIScontextwherecigaretteuseisoneofthemostserioushealthbehaviorsonecan
reportrespondentsmayperceivesmokingtobeoneofthemoreundesirablebehaviors
theyarebeingaskedabout,whichmayleadtounderreporting[35,55].Conversely,in
theNSDUHcontextrespondentsmayperceivesmokingtocomparativelybeoneofthe
moresociallyacceptablebehaviorstheyarebeingaskedaboutandthusmaybemore
comfortableacknowledgingthattheysmoke[10].
In2002,theNSDUHbeganpayingrespondentsa$30incentiveuponcompletionofthe
survey, whereas the NHIS remains uncompensated. Although the results of a 2001
experimentindicatedthattheincentivewouldhavenoappreciableimpactonprevalence
estimates [56], reality dictated otherwise according to a SAMHSA report [57].
SAMHSAreportspresentingNSDUHssummaryoffindingsin2001and2002revealed
increasedprevalenceestimatesacrossthemajorityofsubstancesqueriedinthesurvey
[57],includingcigarettes,alcohol,anyillicitdruguse,marijuana,andcocaine[58].
Lastly,inadditiontosurveymode,setting,context,andincentives,thereareotherfactors
thatmayaffectprevalenceestimatesthatalsofelloutsidethescopeofthecurrentstudy,
such as construct validity and differences in target populations, sampling methods,
adjustments for nonresponse, and weighting. While all of the preceding may help
explainobserveddifferencesinsmokingprevalenceestimates,moreresearchinthese
areasisneeded[10,35].
5. Conclusions
Ourstudyprovidesfurtherinformationonhowdifferentsmokingdefinitionsbetween
two national surveys may impact the overall and subpopulation prevalence estimates
observed for some smoking behaviors. Our findings can be used to further inform
tobaccocontrolresearchandsurveillancewithregardstomeasurementofadultsmoking
behavior,includingcurrentuseandfrequencyofuse.Moreover,thesefindingsmayalso
informhowandwhyestimatesdifferbydemographicsubpopulation.Evidencebased,
statewidetobaccocontrolprogramsthatarecomprehensive,sustained,andaccountable
havebeenshowntoreducesmokingrates,tobaccorelateddeaths,anddiseasescausedby
smoking,withtobaccousemonitoringcriticaltoensuringthatprogramrelatedeffects
can be clearly measured [7]. Further research on methodological issues related to
differing smoking prevalence estimates across tobacco control monitoring systems is
needed,inparticulartoenhancethecapacityoftobaccocontrolsurveillancetoevaluate
progressandfurthertobaccocontrolefforts.Betterunderstandingofwhyestimatesmay
varyacrossdatasystemsandamongspecificsubpopulations,coupledwithcontinued
surveillanceefforts,permitsmoreaccurateassessmentofadultsmokingprevalenceand
tobaccousebehaviors.