Tobacco Product Use Among Adults – United States, 2021

Commercial cigarette smoking among U.S. adults has declined during the preceding 5 decades (1,2); however, tobacco product use remains the leading cause of preventable disease and death in the United States, and some populations continue to be disproportionately affected by tobacco use (1,2). To assess recent national estimates of commercial tobacco use among U.S. persons aged ≥18 years, CDC, the Food and Drug Administration (FDA), and the National Cancer Institute analyzed 2021 National Health Interview Survey (NHIS) data. In 2021, an estimated 46 million U.S. adults (18.7%) reported currently using any tobacco product, including cigarettes (11.5%), e-cigarettes (4.5%), cigars (3.5%), smokeless tobacco (2.1%), and pipes (including hookah)* (0.9%).^† Among those who used tobacco products, 77.5% reported using combustible products (cigarettes, cigars, or pipes), and 18.1% reported using two or more tobacco products.^§ The prevalence of current use of any tobacco product use was higher among the following groups: men; persons aged <65 years; persons of non-Hispanic other races; non-Hispanic White (White) persons^¶; residents of rural (nonmetropolitan) areas; financially disadvantaged (income-to-poverty ratio = 0–1.99); lesbian, gay, or bisexual (LGB) persons; those uninsured or enrolled in Medicaid; adults whose highest level of education was a general educational development (GED) certificate; who had a disability; and who had serious psychological distress. Continued surveillance of tobacco product use, implementation of evidence-based tobacco control strategies (e.g., hard-hitting media campaigns, smoke-free policies, and tobacco price increases), conducting linguistically and culturally appropriate educational campaigns, and FDA regulation of tobacco products will aid in reducing tobacco-related disease, death, and disparities among U.S. adults (3,4).

NHIS is an annual, nationally representative, household survey of the noninstitutionalized U.S. civilian population.** In 2021, a total of 29,482 adults were surveyed^†† (response rate = 50.9%) (5). Data were weighted to provide nationally representative estimates, adjusting for differences in selection probability and nonresponse. Use of five tobacco products was assessed: cigarettes, cigars (cigars, cigarillos, or filtered little cigars), pipes (regular pipes, water pipes, or hookahs), e-cigarettes, and smokeless tobacco (chewing tobacco, snuff, dip, snus, or dissolvable tobacco). In this report, tobacco use refers to commercial tobacco products and not to tobacco used for medicinal and spiritual purposes by some American Indian communities. Current cigarette smoking was defined as having ever smoked 100 or more cigarettes within one’s lifetime and smoking every day or some days at the time of survey. Current use of all other tobacco products was defined as use of the product every day or some days at the time of survey. Prevalence estimates for current use of any tobacco product, any combustible tobacco product, two or more tobacco products, and quit ratios^§§ were calculated; for 2021, estimates were calculated overall and by sex, age group, race and ethnicity, U.S. Census Bureau region,^¶¶ rural/urban designation,*** educational attainment (among adults aged ≥25 years), marital status, income-to-poverty ratio,^††† sexual orientation,^§§§ health insurance coverage,^¶¶¶ disability,**** and presence of serious psychological distress.^††††

The top five combinations of tobacco products reported among adults who reported use of two or more tobacco prod­ucts were determined. Previous year changes in tobacco product use prevalences were calculated. Changes in cigarette smoking during 2019–2021 by diagnosed depression^§§§§ overall and among racial and ethnic groups were also calculated. SAS-Callable SUDAAN software (version 11.0.3; Research Triangle Institute) was used to conduct all analyses. Chi-square tests were used to test for statistical significance. P-values <0.05 were considered statistically significant. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^¶¶¶¶

Among U.S. adults in 2021, 18.7% (an estimated 46.0 million) currently used any tobacco product, 14.5% (35.6 million) used any combustible tobacco product, and 3.4% (8.3 million) used two or more tobacco products. Nearly two thirds (66.5%) of adults who ever smoked cigarettes reported having quit (Table). Cigarettes were the most used tobacco product (11.5%; 28.3 million). Prevalence of use and estimated number of users of other tobacco products were as follows: e-cigarettes (4.5%; 11.1 million), cigars (3.5%; 8.6 million), smokeless tobacco (2.1%; 5.2 million), and pipes (0.9%; 2.3 million). Among persons who reported current tobacco product use, 77.5% used combustible tobacco products, and 18.1% used two or more tobacco products. During 2020–2021, a decrease in cigarette smoking prevalence from 12.5% to 11.5% was observed (p<0.01); however, the prevalence of e-cigarette use increased from 3.7% to 4.5% (p<0.01). No statistically significant changes in use prevalences were observed for other tobacco products.

Among adults reporting the use of two or more tobacco products, the most frequently reported combination was cigarettes and e-cigarettes (31.4%), followed by cigarettes and cigars (21.0%), cigarettes and smokeless tobacco (7.9%), e-cigarettes and cigars (7.0%), and cigarettes and pipes (3.7%); in addition, 29.0% of adults who currently used two or more tobacco products reported use of some other combination, including 14.0% who reported use of three or more products (Figure 1).

During 2019–2021, the prevalence of cigarette smoking among adults who were ever told by a health care provider that they had depression (22.9%, 20.5%, and 19.4% in 2019, 2020, and 2021, respectively) was higher than that among those who had never been told that they had depression (12.3%, 10.9%, and 9.9% in 2019, 2020, and 2021, respectively) (Figure 2). Regardless of diagnosed depression status, statistically significant declines in the prevalence of cigarette smoking during 2019–2021 were noted overall, among non-Hispanic Black or African American (Black); White; and Hispanic adults. During 2019–2021, among adults who ever had diagnosed depression, the prevalence of cigarette smoking was highest among non-Hispanic adults of other races in 2019 and 2020, and highest among Black adults in 2021. Among adults who never had diagnosed depression, cigarette smoking prevalence was similar among Black and White adults and was highest among non-Hispanic American Indian or Alaska Native (AI/AN) adults (in 2020), and non-Hispanic adults of other races (2019 and 2021).

In 2021, the prevalence of any current tobacco product use was higher among men (24.1%) than among women (13.6%) (Table). It was also higher among persons aged 25–44 years (22.1%), 45–64 years (21.1%), and 18–24 years (17.0%) than among those aged ≥65 years (11.0%), and higher among non-Hispanic adults of other races (25.6%) or White (21.2%) adults than among Black (18.1%), Hispanic (12.4%), or non-Hispanic Asian (8.6%) adults. Prevalence was higher among adults living in the Midwest (22.1%) or the South (19.7%) U.S. Census Bureau regions than among those living in the Northeast (16.2%) or West (16.0%), as well as higher among those living in rural areas (26.2%) compared with those in urban areas (17.5%). A larger percentage of adults with a GED certificate (39.0%) reported current tobacco product use than did persons with other levels of education (range = 8.6%–24.4%). In addition, use prevalence was higher among persons who were divorced, separated, or widowed (21.3%) or single, never married, or not living with a partner (20.1%) than among those who were married or living with a partner (17.5%). Other sociodemographic groups with higher prevalences of current tobacco use included persons with low income (24.7%) compared with persons with middle (18.9%) or high income (14.8%), and LGB adults (27.4%) compared with heterosexual/straight adults (18.4%). Higher prevalences of tobacco use were reported by persons who were uninsured (28.4%) or insured by Medicaid (28.1%) than by persons who had some other public insurance (21.6%), private insurance (16.2%), or Medicare only (10.7%); by those with a disability (24.2%) compared with those who did not have a disability (18.2%); and by those who reported serious psychological distress (37.6%) compared with those who did not report serious psychological distress (18.0%).

¹Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; ²Office of Science, Center for Tobacco Products, U.S. Food and Drug Administration, Silver Spring, Maryland; ³Tobacco Control Research Branch, National Cancer Institute, National Institutes of Health, Washington, DC.

References

1. CDC. Smoking & tobacco use. Smoking cessation: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://www.cdc.gov/tobacco/sgr/2020-smoking-cessation/index.html
2. Martell BN, Garrett BE, Caraballo RS. Disparities in adult cigarette smoking—United States, 2002–2005 and 2010–2013. MMWR Morb Mortal Wkly Rep 2016;65:753–8. https://doi.org/10.15585/mmwr.mm6530a1 PMID:27491017
3. CDC. Best practices for comprehensive tobacco control programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. https://www.cdc.gov/tobacco/stateandcommunity/guides/pdfs/2014/comprehensive.pdf
4. King BA, Graffunder C. The tobacco control vaccine: a population-based framework for preventing tobacco-related disease and death. Tob Control 2018;27:123–4. https://doi.org/10.1136/tobaccocontrol-2018-054276 PMID:29475955
5. National Center for Health Statistics. National Health Interview Survey: 2021 survey description. Hyattsville, MD: US Department of Health and Human Services, CDC; National Center for Health Statistics; 2022. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2021/srvydesc-508.pdf
6. Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco product use among adults—United States, 2020. MMWR Morb Mortal Wkly Rep 2022;71:397–405. https://doi.org/10.15585/mmwr.mm7111a1 PMID:35298455
7. Han B, Volkow ND, Blanco C, Tipperman D, Einstein EB, Compton WM. Trends in prevalence of cigarette smoking among US adults with major depression or substance use disorders, 2006–2019. JAMA 2022;327:1566–76. https://doi.org/10.1001/jama.2022.4790 PMID:35471512
8. CDC. Best practices user guides: health equity in tobacco prevention and control. Atlanta: US Department of Health and Human Services, CDC; 2015. https://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-health-equity.pdf
9. Purnell JQ, Peppone LJ, Alcaraz K, et al. Perceived discrimination, psychological distress, and current smoking status: results from the Behavioral Risk Factor Surveillance System Reactions to Race Module, 2004-2008. Am J Public Health 2012;102:844–51. https://doi.org/10.2105/AJPH.2012.300694 PMID:22420821
10. Binnie V, McHugh S, Macpherson L, Borland B, Moir K, Malik K. The validation of self-reported smoking status by analysing cotinine levels in stimulated and unstimulated saliva, serum and urine. Oral Dis 2004;10:287–93. https://doi.org/10.1111/j.1601-0825.2004.01018.x PMID:15315646

Abbreviations: AI/AN = American Indian or Alaska Native; CHIP = Children’s Health Insurance Program; e-cigarettes = electronic cigarettes; GED = general educational development certificate; NCHS = National Center for Health Statistics; NHIS = National Health Interview Survey.
* Smoking and tobacco product use refers to use of commercial tobacco products and not to tobacco used for medicinal and spiritual purposes by some American Indian communities.
^† 95% Korn-Graubard CIs. NCHS data presentation standards. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf
^§ Any tobacco use was defined as use either “every day” or “some days” of at least one tobacco product. For cigarettes, users were defined as adults who reported use either “every day” or “some days” and had smoked ≥100 cigarettes during their lifetime.
^¶ Any combustible tobacco use was defined as use either “every day” or “some days” of at least one combustible tobacco product: cigarettes; cigars, cigarillos, filtered little cigars; pipes, water pipes, or hookah. For cigarettes, users were defined as adults who reported use either “every day” or “some days” and had smoked 100 or more cigarettes during their lifetime.
** Current cigarette smoking was defined as smoking 100 or more cigarettes during a person’s lifetime and now smoking cigarettes “every day” or “some days.”
^†† Current cigar smoking was defined as smoking cigars, cigarillos, or little filtered cigars at least once during a person’s lifetime and now smoking at least one of these products “every day” or “some days.”
^§§ Current pipe smoking was defined as smoking tobacco in a regular pipe, water pipe, or hookah at least once during a person’s lifetime and now smoking at least one of these products “every day” or “some days.”
^¶¶ Current e-cigarette use was defined as using e-cigarettes at least once during a person’s lifetime and now using e-cigarettes “every day” or “some days.”
*** Current smokeless tobacco product use was defined as using chewing tobacco, snuff, dip, snus, or dissolvable tobacco at least once during a person’s lifetime and now using at least one of these products “every day” or “some days.”
^††† Current multiple tobacco product use was defined as use “every day” or “some days” for two or more of the following tobacco products: cigarettes (100 or more cigarettes during a person’s lifetime); cigars, cigarillos, filtered little cigars; pipes, water pipes, or hookah; e-cigarettes; or smokeless tobacco products.
^§§§ Quit ratio is the percentage of persons who ever smoked (100 or more cigarettes during their lifetime) who have quit smoking.
^¶¶¶ Hispanic persons could be of any race. All other groups were non-Hispanic. The following four non-Hispanic single-race categories were available for sampled adults in the 2021 NHIS public use files: 1) AI/AN; 2) Asian; 3) Black or African American; and 4), White. The “non-Hispanic, other” category includes those adults who were categorized as “non-Hispanic AI/AN and any other group” or “other single and multiple races.”
**** Based on NCHS data presentation standards, estimates were statistically unreliable (https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf). SAS MACRO used to suppress criteria check. https://www.sas.com/content/dam/SAS/support/en/sas-global-forum-proceedings/2019/3659-2019.pdf
^†††† https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf
^§§§§ Urbanization level (termed metropolitan statistical area in a previous report) is based on the 2013 NCHS Urban-Rural Classification Scheme for Counties (https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf). Note that the original variable for urbanization level in the NHIS public use data files is four levels; for this report, the four-level variable has been reduced to a dichotomous variable.
^¶¶¶¶ Ratio of family income to poverty threshold for family size based on the imputed family income to poverty threshold variable (29,482).
***** Private coverage: adults who had any comprehensive private insurance plan (including health maintenance organizations and preferred provider organizations). Medicaid: adults aged <65 years; includes those who did not have private coverage but had Medicaid or other state-sponsored health plans, including CHIP. For adults aged ≥65 years, those who did not have any private coverage but had Medicare and Medicaid or other state-sponsored health plans were categorized as having Medicaid. Medicare only: adults aged ≥65 years who only had Medicare coverage. Other coverage: adults who did not have private insurance, Medicaid, or other public coverages, but who had any type of military coverage, coverage from other government programs, or Medicare (adults aged <65 years). Uninsured: adults who did not indicate at the time of interview that they were covered under private health insurance, Medicare, Medicaid, CHIP, a state-sponsored health plan, other government programs, or military coverage. Insurance coverage is “as of time of survey.”
^{†††††} Disability was defined based on self-reported presence of selected limitations including vision, hearing, mobility, remembering or concentrating, self-care, and communication. Respondents who indicated “A lot of difficulty” or “Cannot do at all/unable to do” to at least one of the following six questions: “Do you have difficulty seeing, even when wearing glasses?,” “Do you have difficulty hearing, even when using a hearing aid?,” “Do you have any difficulty walking or climbing steps?,” “Using your usual language, do you have difficulty communicating, for example, understanding or being understood?,” “Do you have difficulty remembering or concentrating?,” or “Do you have difficulty with self-care, such as washing all over or dressing?” were coded as living with a disability; those who responded “no difficulty” or “some difficulty” to all six questions were coded as no disability. These six questions are based on the short set of questions recommended by the Washington Group on Disability Statistics. https://www.cdc.gov/nchs/washington_group/index.htm
^§§§§§ Serious psychological distress was assessed using a set of questions from the six-item Kessler (K6) scale (https://pubmed.ncbi.nlm.nih.gov/22351472/) that asks sampled adults to assess the frequency of six characteristics (sadness, nervousness, restlessness, hopelessness, feeling that everything was an effort, and worthlessness) experienced within the previous 30 days. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2021/srvydesc-508.pdf

FIGURE 1. Percentage of persons aged ≥18 years who reported use of two or more tobacco products, by the top five product combinations — United States, 2021*^,†,§

Abbreviation: e-cigarettes = electronic cigarettes.

* Smoking and tobacco product use refers to use of commercial tobacco products and not to tobacco used for medicinal and spiritual purposes by some American Indian communities.

^† Current smokeless tobacco product use was defined as using chewing tobacco, snuff, dip, snus, or dissolvable tobacco at least once during a person’s lifetime and now using at least one of these products “every day” or “some days.”

^§ “All other combinations” refers to use of other combinations of two or more products.

FIGURE 2. Prevalence* of cigarette smoking^† among persons aged ≥18 years, by race and ethnicity and depression diagnosis history^§ — United States, 2019–2021^¶,**^,††,§§

Abbreviations: AI/AN = American Indian or Alaska Native; NCHS = National Center for Health Statistics; NH = non-Hispanic.

* With 95% CIs indicated by error bars.

^† Smoking and tobacco product use refers to use of commercial tobacco products and not to tobacco used for medicinal and spiritual purposes by some American Indian communities.

^§ Depression was defined using the question, “Have you ever been told by a doctor or other health professional that you had … any type of depression?” Those responding “Yes” were classified as having ever had depression in their lifetime. Those responding “No” were classified as never having had depression in their lifetime.

^¶ Among adults who ever had diagnosed depression, statistically significant (p<0.05) trends during 2019–2021 were observed for the following groups: all races; Black or African American, NH; White, NH; and Hispanic adults.

**Among adults who never had diagnosed depression, statistically significant (p<0.05) trends during 2019–2021 were observed for the following groups: all races; Black or African American, NH; White, NH; and Hispanic adults.

^†† Among adults who ever had diagnosed depression, estimates were statistically unreliable for AI/AN, NH; and Asian, NH adults during 2019–2021 and are not presented based on NCHS data presentation standards (https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf). SAS MACRO used to suppress criteria check. https://support.sas.com/resources/papers/proceedings19/3659-2019.pdf

^§§ Among adults who never had diagnosed depression, estimates were statistically unreliable for AI/AN, NH adults in 2019 and 2021 and are not presented based on NCHS data presentation standards (https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf). SAS MACRO used to suppress criteria check. https://support.sas.com/resources/papers/proceedings19/3659-2019.pdf