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Nicotine Dependence in the United States
Prevalence, Trends, and Smoking Persistence
Naomi Breslau, PhD;
Eric O. Johnson, PhD;
Eva Hiripi, MS;
Ronald Kessler, PhD
Arch Gen Psychiatry. 2001;58:810-816.
ABSTRACT
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Background The prevalence of smoking in the United States has been closely monitored.
However, little is known about the epidemiology of nicotine dependence. We
studied DSM-III-R nicotine dependence in the United
States, trends across cohorts, and the role of nicotine dependence in smoking
persistence.
Methods The Tobacco Supplement to the National Comorbidity Survey was administered
to a representative subset of 4414 persons aged 15 to 54 years. The World
Health Organization's Composite International Diagnostic Interview was used
to assess nicotine dependence.
Results Lifetime prevalence of nicotine dependence was 24%, nearly half of those
who had ever smoked daily for a month or more. The highest risk for nicotine
dependence occurred in the first 16 years after daily smoking began, at which
point the rate declined and continued at a slower pace for several years.
Nicotine dependence increased the risk of smoking persistence, with an odds
ratio (OR) of 2.2 (95% confidence interval [CI], 1.6-3.0). Members of the
most recent cohort, who were 15 to 24 years of age at the time of the survey,
were the least likely to smoke daily, but those who smoked had the highest
risk of dependence: OR for daily smoking in the most recent vs earliest cohort
was 0.7 (95% CI, 0.5-0.9), and for dependence among smokers, 7.2 (95% CI,
5.0-10.4).
Conclusions Despite evidence that nicotine dependence is the leading preventable
cause of death and morbidity, it remains a common psychiatric disorder. Smoking
cessation and the decline in uptake in recent years varied across subgroups
of the population.
INTRODUCTION
DESPITE scientific evidence that smoking is highly addictive, little
information is available on the epidemiology of nicotine dependence, as distinct
from smoking per se. Robins et al1 reported
on the lifetime prevalence of DSM-III nicotine dependence
based on data from the St Louis, Mo, site of the Epidemiologic Catchment Area
study. Risk factors for nicotine dependence or cohort comparisons were not
reported. Kandel et al2 reported findings on
a proxy measure of the DSM-IV nicotine dependence
from the National Household Survey of Drug Abuse (NHSDA). The report by Kandel
et al is on 12-month prevalence, the only period for which the proxy measure
of nicotine dependence was assessed in the NHSDA; risk factors for becoming
nicotine dependent or trends across cohorts could not be estimated. Data on DSM-III-R nicotine dependence were reported by Breslau
et al,3 based on a representative sample of
young adults in southeast Michigan. Lifetime prevalence of nicotine dependence
was reported by age, sex, race, and educational level. However, trends across
cohorts could not be examined because of the narrow age range of this regional
sample. National data on DSM-III-R nicotine dependence
were gathered in the National Comorbidity Survey (NCS); however, only descriptive
estimates of the associations with sociodemographic characteristics have been
reported to date.4
In this report, we present new information on nicotine dependence based
on the NCS. Our analysis proceeds as follows. First, we describe the cumulative
incidence of daily smoking in the population and the transition from daily
smoking to nicotine dependence. Beyond the general knowledge that smoking
is highly addictive and that multiple exposures are necessary to cross from
intermittent use to dependence,5, 6
no information is available on the period of risk for developing dependence
after the onset of smoking. Second, we examine sociodemographic predictors
of daily smoking and nicotine dependence. Third, we examine trends in smoking
and nicotine dependence across four 10-year birth cohorts represented in the
NCS. Although secular trends in smoking have been reported,7, 8, 9
no such information has been reported on the risk of becoming dependent. Last,
we evaluate the role of nicotine dependence in the persistence of smoking.
SUBJECTS AND METHODS
SAMPLE
The sampling scheme of the NCS has been described in detail previously.10 Briefly, the NCS is a stratified multistage area
probability sample of 8098 persons 15 to 54 years of age selected from the
noninstitutionalized population of the United States. Data were gathered between
September 1990 and March 1992. The diagnostic interview used to ascertain
history of psychiatric disorders according to DSM-III-R was a modified version of the World Health Organization's Composite
International Diagnostic Interview,11 a structured
interview designed to be administered by trained lay interviewers. The Tobacco
Supplement, in which diagnostic information on nicotine dependence is covered,
was administered in the second half of the survey to 4414 NCS respondents.
Because the NCS fieldwork was conducted in replicates, each designed to be
a separate national sample, data from the Tobacco Supplement subsample are
representative of the US population.
ASSESSMENT
The DSM-III-R12
adopted a unitary definition of dependence across all psychoactive substances.
The definition reflects the consensus in the field of addiction on the construct
of dependence as a cognitive, behavioral, and physiologic cluster that characterizes
compulsive use of all substances.13, 14, 15
It represents a departure from earlier definitions of dependence as a physiologic
construct characterized by tolerance and withdrawal symptoms upon cessation.
The DSM-III-R diagnosis of nicotine dependence requires
the lifetime occurrence of 3 or more criterion symptoms of dependence, with
some symptoms persisting for a month or more.
The section of the World Health Organization's Composite International
Diagnostic Interview on nicotine dependence begins with a screen question
that inquires whether the respondent had ever smoked daily for a month or
more. Onset of daily smoking is defined as the age
at which daily smoking for a month or more first occurred. Persons who answer
positively to the screen question are asked about the DSM-III-R defining symptoms of nicotine dependence. Information on smoking initiation,
ie, whether the respondent ever smoked a cigarette and age at first cigarette,
is not obtained. Lifetime prevalence of nicotine dependence is defined as the proportion of persons in the sample who have ever
met the criteria up to the time of the interview. The onset
of nicotine dependence is defined by the age at which symptoms of dependence
first occurred in smokers who have ever met the criteria of nicotine dependence.
The Composite International Diagnostic Interview does not inquire about the
age at onset of individual symptoms of dependence. The item on age at onset
inquires about the respondent's age "at which symptoms like that first occurred,"
referring to criterion symptoms of dependence endorsed by the respondent.
Thus, the age at onset of nicotine dependence in the NCS refers to the age
at which multiple symptoms occurred, as opposed to the age at the earliest
symptom. Smoking persistence is defined as smoking
"fairly regularly" in the past 12 months among persons who have ever smoked
daily for a month or more.
STATISTICAL ANALYSIS
The NCS data presented herein were weighted to adjust for variation
in the probabilities of selection and nonresponse, and to approximate the
data to the distribution of the US population on key sociodemographic characteristics.10 The weights ranged from 0.115 to 6.497. To take into
account the complex survey design, the 95% confidence intervals (CIs) of odd
ratios (ORs) and Wald  2 tests in the survival analyses and
the logistic regressions were computed by means of the jackknife repeated
replications method, implemented in user-developed SAS macros.16, 17
Cumulative incidence curves of daily smoking and the transition to nicotine
dependence were obtained by means of Kaplan-Meier survival methods. For the
incidence of daily smoking, time was defined as chronological age. For the
transition to nicotine dependence among daily smokers, time was defined as
the number of years since the onset of daily smoking. We also present the
cumulative incidence curve of nicotine dependence among daily smokers by chronological
age.
The associations of daily smoking or nicotine dependence with sociodemographic
factors were estimated in discrete-time multivariable survival analyses.18 Age at time of interview was subdivided into 4 cohorts:
15 to 24, 25 to 34, 35 to 44, and 45 to 55 years. In these analyses, education
was defined as time varying, ie, number of years of schooling completed at
given ages, rather than as a fixed variable representing the level of education
attained at the time of the interview. Survival analyses of daily smoking
and nicotine dependence were conducted on person-years through age 24 years,
the upper age limit on which members of all 4 cohorts could be compared. In
the survival analysis of nicotine dependence, we excluded persons with onset
of nicotine dependence before or in the year of onset of daily smoking and
persons who began to smoke daily in the year of the interview (n = 66). In
additional survival models, we examined whether sex and race differences varied
across cohorts, by testing interaction terms and estimating models in separate
cohorts, when significant interactions were detected.
The associations of sociodemographic predictors with smoking persistence
in the past 12 months were estimated in multiple logistic regressions, adjusting
for number of years since the onset of daily smoking. In this analysis, education
was defined as the level attained at the time of the interview. Persons who
began smoking daily in the year of the interview or in the preceding year
were excluded (n = 38).
RESULTS
DAILY SMOKING AND THE TRANSITION TO NICOTINE DEPENDENCE
The lifetime prevalence (SE) of daily smoking in the sample was 49.5%
(1.3%) and of DSM-III-R nicotine dependence, 24.1%
(1.0%). The onset of daily smoking occurred almost entirely before age 25
years, with an accelerated rate between 15 and 20 years of age (Figure 1). In contrast, the onset of nicotine dependence among daily
smokers continued into the 40s. A comparison of the ages at onset of nicotine
dependence and daily smoking within individuals showed that in only 5.4% of
dependent smokers the onset of nicotine dependence occurred before or in the
same year in which daily smoking began. (These persons were excluded from
the analysis.) Thus, in most cases, the onset of nicotine dependence lagged
by 1 year or more after daily smoking began. The highest rate of becoming
nicotine dependent occurred in the first 16 years from the year after the
onset of daily smoking, at which point the rate of becoming dependent declined
and continued at a lower pace for approximately 10 years (Figure 1).
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Figure 1. Cumulative incidence curves of
daily smoking and nicotine dependence in the National Comorbidity Survey (n
= 4144 for daily smoking and 2136 for nicotine dependence).
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Multivariable survival analyses were used to estimate the risk of ever
becoming a daily smoker and smokers' risk of nicotine dependence across the
4 birth cohorts of the NCS and by sociodemographic characteristics (Table 1). The results for becoming a daily
smoker (Table 1) show that members
of the most recent cohort, ie, those who had reached 15 to 24 years of age
at the time of the survey, had a lower risk of ever smoking daily than members
of earlier cohorts. Females had a lower risk of daily smoking than males,
and nonwhites had a lower risk than whites. The risk of daily smoking was
unrelated to one's educational level at the time at which daily smoking began.
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Table 1. Sociodemographic Predictors of Daily Smoking and Transition
to Nicotine Dependence*
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The lifetime risk of nicotine dependence among those who had ever smoked
daily for a month or more varied across the 4 NCS cohorts and between racial
groups, but not between the sexes or by educational level (Table 1). Compared with members of the earliest cohort, ie, those
45 to 54 years of age at the time of the survey, each successively more recent
cohort of daily smokers had a significantly higher risk of becoming dependent.
The most recent cohort was more than 7-fold more likely to become dependent
than was the earliest cohort. Black smokers had a lower risk of becoming dependent
than did white smokers, whereas other nonwhite smokers did not differ from
white smokers.
TRENDS ACROSS COHORTS
To illustrate more clearly the results on cohort differences, we present
the cumulative incidence curves of daily smoking and the transition to dependence
in the 4 NCS cohorts. Members of the most recent cohort were the least likely
to ever smoke daily, whereas members of the earliest cohort were the most
likely to ever smoke daily, with the 2 intermediate birth cohorts showing
largely overlapping curves (Figure 2).
The intercohort disparity emerges at approximately age 18 years, when members
of the most recent cohort diverge from the earlier cohorts, showing a sharp
decline in the incidence of daily smoking. The differences between the most
recent cohort and each of the earlier cohorts were statistically significant.
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Figure 2. Cumulative incidence of daily
smoking in the 4 National Comorbidity Survey cohorts (n = 4144).
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With respect to the transition to nicotine dependence (Figure 3), we found the opposite trend from the trend of daily smoking.
Specifically, at each year since daily smoking began, each cohort showed a
significantly higher cumulative incidence of nicotine dependence than the
preceding cohort. The most recent cohort, whose members were the least likely
to ever smoke daily, showed the highest risk of dependence among those who
did smoke daily.
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Figure 3. Cumulative incidence of nicotine
dependence among daily smokers in the 4 National Comorbidity Survey cohorts
(n = 2136).
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CHANGES IN SOCIODEMOGRAPHIC CORRELATES OF DAILY SMOKING AND NICOTINE
DEPENDENCE ACROSS COHORTS
The sex difference in daily smoking was considerably narrower in recent
than in earlier cohorts. The OR for females vs males in the most recent cohort
was 0.8 (95% CI, 0.6-1.1), whereas in the earliest cohort it was 0.5 (95%
CI, 0.4-0.6). In contrast, the gap in daily smoking between whites and blacks
widened over time: in the most recent cohort, the OR for blacks vs whites
was 0.3 (95% CI, 0.2-0.5), whereas in the earliest cohort it was 0.6 (95%
CI, 0.4-1.0). With respect to the transition to nicotine dependence, there
was little evidence of change in sociodemographic correlates.
NICOTINE DEPENDENCE AND PERSISTENCE IN SMOKING
We examined the impact of nicotine dependence on smoking persistence
in the past 12 months among persons who had ever smoked daily for a month
or more, by means of multiple logistic regression. Time from onset of daily
smoking, age, sex, race, and education were included as covariates. Smokers
who had ever been dependent were more likely to smoke in the past 12 months
than smokers who had never been dependent (OR, 2.2; 95% CI, 1.6-3.0).
In addition, nicotine dependence modified the risk of smoking persistence
differentially across subgroups of the population (Table 2). A significant interaction between nicotine dependence
and any of the sociodemographic variables indicates that the relationship
of the variable with smoking persistence differed significantly between dependent
and nondependent smokers. A significant interaction was detected between nicotine
dependence and age. Dependent smokers who were 15 to 24 years of age were
more likely to have continued to smoke in the past 12 months than dependent
smokers in the oldest age group (OR, 6.1; 95% CI, 1.8-20.9). However, nondependent
smokers did not differ significantly across age groups. A significant interaction
was also detected between nicotine dependence and sex, with female smokers
more likely to persist than male smokers if they were dependent, but less
likely to persist if they were nondependent. With respect to race, we found
that among dependent smokers, blacks differed little from whites, whereas
among nondependent smokers, blacks were more likely to persist than whites
(OR, 2.5; 95% CI, 1.4-4.2). Hispanic smokers, dependent and nondependent,
differed little from white smokers, whereas members of the "other" racial
category showed a higher risk of smoking persistence than whites.
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Table 2. Sociodemographic Predictors of Smoking Persistence Among Daily
Smokers With and Without History of Nicotine Dependence*
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In contrast to the interactions of nicotine dependence with age, sex,
and race, education was a strong predictor of smoking persistence in both
dependent and nondependent smokers: smokers with less than 12 years of schooling
had the highest odds of persistence, relative to smokers who completed college.
COMMENT
The key findings of this study are as follows. In the NCS sample of
persons 15 to 54 years of age, the lifetime prevalence of DSM-III-R nicotine dependence was 24%. The risk of daily smoking was
lower in females than in males and in nonwhites than in whites. The onset
of daily smoking rarely occurred after age 25 years. Smokers' transition to
nicotine dependence continued into the 40s. The highest rate of smokers' progression
to nicotine dependence occurred in the first 16 years after the year at which
daily smoking began, and, from that point, the transition to dependence continued
at a lower rate for approximately a decade. The risk of nicotine dependence
in daily smokers did not vary between the sexes or by educational level, but
was lower among black than among white smokers. Dependent smokers were twice
as likely to smoke in the year preceding the interview as were nondependent
smokers. Members of the most recent cohort were the least likely to ever smoke
daily, but those who did smoke daily had the highest risk of becoming dependent,
compared with members of earlier cohorts.
Several limitations in this study warrant comment. First, because NCS
data are based on retrospective reports, inferences regarding cohort effects
should take into account the possibility of differential recall or reporting
bias across age groups. However, our finding of a lower risk of daily smoking
in members of the most recent cohort is consistent with the trends of "ever
smoking" and "regular smoking" in the 1991 to 1993 NHSDA.7
It is also consistent with the trend in daily smoking in high school seniors
up to 1992, the year of the NCS, based on the Monitoring the Future Study.8, 9 Furthermore, the closing of the sex
difference and the widening of the race difference in daily smoking in recent
cohorts, observed in this study, have been found among high school seniors
in the Monitoring the Future Study.8, 9
Data from Monitoring the Future do not rely on retrospective reports.
Second, the NCS Tobacco Supplement did not gather information on smoking
initiation; consequently, we could not estimate the risk of nicotine dependence
among persons who had ever smoked. Nonetheless, the NCS data allowed us to
chart important aspects in the course of tobacco use. We found that nicotine
dependence is distinctly a later stage than daily smoking: in most dependent
smokers (95%), the onset of nicotine dependence lagged by at least 1 year
after the onset of daily smoking. Furthermore, the transition to nicotine
dependence slowed down only after 16 years following the year in which daily
smoking began. The data also allowed us to examine important factors in this
transition, as described above. In the absence of information on smoking initiation,
we could not determine whether the observed lower risk of daily smoking in
members of the most recent cohort reflects a lower risk of initiation or a
lower risk of the transition to daily smoking among those who ever smoked,
or both. To address this question, we examined cohort differences in smoking
initiation in the NHSDA.19 Analysis of the
1992 (the year of the NCS) NHSDA public use data, subdivided to correspond
to the NCS cohorts, showed a lower prevalence of ever smoking among persons
15 to 24 years of age than among earlier cohorts, 61.5% (in 15- to 24-year-olds)
vs 74.5% (in 25- to 34-year-olds), 78.1% (in 35- to 44-year-olds), and 80.9%
(in 45- to 54-year-olds). These cohort differences in smoking initiation might
account in part for the cohort differences in daily smoking observed in this
study.
Finally, the NCS data are based on DSM-III-R,
and, strictly speaking, direct inferences on nicotine dependence according
to the current definition in DSM-IV cannot be drawn. DSM-IV requires the clustering of 3 or more dependence
symptoms within a 1-year period, a requirement that theoretically might reclassify
some DSM-III-R dependent smokers as nondependent
according to DSM-IV. However, the available evidence
suggests that the differences between the 2 diagnostic systems have little
influence on prevalence estimates of nicotine dependence and on the classification
of smokers as dependent vs nondependent.20, 21
The estimate of the lifetime prevalence of DSM-III-R nicotine dependence in the NCS is similar to the estimate reported
by Breslau et al,3 24% and 20%, respectively.
The higher figure reported by Robins et al1
from the St Louis site of the Epidemiologic Catchment Area study (36.6%) might
be due to the use of the DSM-III in that study. Evidence
suggesting that the DSM-III definition of nicotine
dependence might be overinclusive has been reported.22
Studies on 12-month prevalence of nicotine dependence yielded discrepant results.2, 23 Sex and race differences observed
in the NCS are also in accord with those reported by Breslau et al3 and Andreski and Breslau24
and by Kandel and Chen using NHSDA data.25
The results on the role of nicotine dependence in the persistence of
smoking are in accord with previous reports.21, 26, 27
In addition, they shed new light on 2 points. First, the study clarifies previous
findings on race differences in smokers' potential for quitting. According
to previous reports (reviewed by Giovino et al28),
black smokers are less successful than white smokers in their efforts to quit.
The extent to which the race difference in quitting is due to a greater likelihood
of black smokers' becoming dependent has not been previously examined. Our
analysis showed that the greater persistence of black smokers is not due to
a higher rate of dependence in black vs white smokers. In fact, black smokers
are less likely than white smokers to become dependent. Furthermore, among
dependent smokers, blacks do not differ from whites in the potential for quitting.
Instead, it is only among nondependent smokers that blacks are at a relative
disadvantage.
Second, previous studies have consistently reported marked differences
in the rates of smoking cessation across educational levels.26, 28
However, the possibility that nicotine dependence might modify this relationship
has not been previously tested. Our results show that smokers who completed
college, dependent and nondependent, were far less likely to have persisted
in smoking in the year preceding the interview than were smokers with lower
education.
A potential explanation of our findings that members of the most recent
cohort had the lowest risk of smoking but the highest conditional risk of
dependence might be the following. The growing awareness of the addictive
potential of smoking and its adverse health effects has resulted in declining
numbers who take up smoking. Those in recent cohorts who do take up smoking
might be more deviant than smokers in earlier cohorts with respect to personality
traits that influence smoking and the progression to nicotine dependence (eg,
risk taking, impulsivity). A similar interpretation was suggested by Heath
et al29 for the observation of no heterogeneity
in the relative magnitude of genetic and environmental influences on smoking
across birth cohorts, despite the declining prevalence of smoking in recent
cohorts. It should be noted that, since 1992, when the NCS was completed,
smoking prevalence has been rising slowly among adolescents, a reversal of
the trend in the previous decade.30 The implication
of the rise in smoking for the conditional risk of nicotine dependence in
these new cohorts is unclear.
A closer examination of sociodemographic predictors of smoking across
cohorts showed that the sex gap in the risk of daily smoking that characterized
earlier cohorts has nearly closed in recent cohorts, whereas the racial gap
has widened during the same period. These findings are consistent with previous
reports.31, 32, 33
Changing social norms about sex differences in a wide range of behaviors might
be reflected in the closing sex difference in smoking. A similar trend has
been reported with respect to the sex difference in alcohol use.7
The widening racial differences in recent cohorts is difficult to explain.
The findings on the relationship between level of educational attainment
and the persistence of smoking in the year preceding the interview are consistent
with previous reports on the increasing inequality in daily smoking across
educational levels.34, 35, 36
Our finding that the risk of daily smoking was unrelated to educational level
at the time of onset of daily smoking might appear at first glance to conflict
with studies that reported an inverse relationship between smoking and education.31, 33, 36 However, these studies
did not estimate the risk of smoking by level of education at the time of
smoking onset, but at the time of the interview.
The growing availability of scientific information on the adverse health
effects of smoking has been followed by dramatic reductions in the overall
prevalence of smoking in the population. However, changes in daily smoking,
nicotine dependence, and smoking persistence have varied across subgroups
of the population, as shown herein. Further research is needed to elucidate
the biological and sociocultural bases of these variations.
AUTHOR INFORMATION
Accepted for publication December 21, 2000.
This study was supported in part by grant RO1 48802 from the National
Institutes of Mental Health, Bethesda, Md (Dr Breslau).
The data reported herein come from the NCS. The NCS is a collaborative
epidemiologic investigation of the prevalence, causes, and consequences of
psychiatric morbidity and comorbidity supported by the National Institute
of Mental Health (grants R01 MH46376, R01 MH49098, and R01 MH52861), with
supplemental support from the National Institute on Drug Abuse, Bethesda (through
a supplement to grant MH46376) and the W. T. Grant Foundation, New York, NY
(90135190), R. C. Kessler, PhD, principal investigator. Preparation for this
report was also supported by National Institute of Mental Health grant K05
MH00507.
A complete list of NCS publications, along with abstracts, study documentation,
interview schedules, and the raw NCS public use data files, can be obtained
directly from the NCS Homepage at http://www.hcp.med.harvard.edu/ncs/.
From the Departments of Psychiatry, Henry Ford Health System, Detroit,
Mich (Drs Breslau and Johnson), Case Western Reserve University School of
Medicine, Cleveland, Ohio (Dr Breslau), and University of Michigan School
of Medicine, Ann Arbor (Dr Breslau); and the Department of Health Care Policy,
Harvard Medical School, Boston, Mass (Ms Hiripi and Dr Kessler).
Corresponding author and reprints: Naomi Breslau, PhD, Henry Ford
Health System, One Ford Place, 3A, Detroit, MI 48202-3450 (e-mail:
nbresla1{at}hfhs.org).
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