Indicators of Nicotine Addiction Among Women-United States, 1991 to 1992

An estimated 22 million US women were current smokers in 1993; of these, 73% wanted to quit smoking [1]. However, attempts to quit smoking and to remain abstinent are hindered by nicotine(Drug information on nicotine) addiction and by the subsequent effects of nicotine withdrawal [2]. To assess the prevalence of selected indicators of nicotine addiction among U.S. women, Centers for Disease Control (CDC) analyzed data from the National Household Survey on Drug Abuse (NHSDA) in 1991 and 1992 [3]. This report presents the findings of the analysis.

The NHSDA is a household survey of a nationally representative sample of the civilian, noninstitutionalized U.S. population. Combined data from the 1991 and 1992 surveys (n = 7,137) were used to estimate the prevalences of four indicators of nicotine addiction among women who smoke. Information about these indicators was based on responses to four questions; current smokers (defined as persons who had ever smoked 100 cigarettes and had smoked during the 30 days preceding the survey) were asked whether, during the 12 months preceding the survey, they:

1. Felt they needed or were dependent on cigarettes

2. Needed larger amounts (more cigarettes) to get the same effect

3. Felt unable to cut down on their use even though they tried

4. Had withdrawal symptoms, that is, felt sick because they stopped or cut down on cigarette use.

The analysis of "unable to cut down" (n = 4,422) and "felt sick" (n = 4,646) was restricted to persons who reported trying to reduce their use of cigarettes during the preceding 12 months. In addition, for the indicator "unable to cut down," because of the question design, respondents who reported not trying to reduce any drug use during the preceding 12 months (n = 224) also were excluded. Because the likelihood of daily smoking and the intensity of smoking (ie, number of cigarettes smoked per day) varies directly with age, respondents were classified into two age groups: 12- to 24-year-olds and 25-year-olds and older.

Among female smokers in both age groups, 75% reported feeling dependent on cigarettes. The prevalence of feeling dependent varied directly with intensity of smoking; among those who smoked 6 to 15 cigarettes per day, 80.6% of those aged 12 to 24 years, and 76.1% of those aged 25 years and older reported feeling dependent on cigarettes. Female smokers aged 12 to 24 years were more likely to report needing more cigarettes to attain the same effect than were those aged 25 years and older (18.0% vs 13.2%). Among those who had tried to reduce smoking during the preceding 12 months, 81.5% of 12- to 24-year-olds, and 77.8% of 25-year-olds and older reported being unable to do so. Even among those who smoked 6 to 15 cigarettes per day, inability to reduce smoking was reported by 82.6% of 12- to 24-year-olds, and 73.8% of the 25-year-olds and older. Of all female smokers aged 12 years and older, 35.4% reported withdrawal symptoms (ie, feeling sick) when they tried to reduce their smoking.

Females in both the younger and older age groups were equally likely to report at least one of the four indicators of nicotine addiction (81.2% and 79.4%, respectively). Even among females who smoked five or fewer cigarettes per day, 63.1% of those aged 12 to 24 years, and 53% of those aged 25 years and older reported one or more of these indicators.

Editorial Note from the CDC: In 1990, an estimated 61,000 U.S. women aged 35 years and older died from cardiovascular diseases attributable to cigarette smoking [4]. Because the risk for myocardial infarction can be reduced by 50% after 1 year of abstaining from smoking, [5] interventions to encourage smoking cessation are an important strategy to reduce cardiovascular mortality. Although most women smokers want to quit smoking, only 2.5% of all smokers successfully quit each year [6]. The finding in this report that approximately 80% of female smokers reported symptoms of nicotine addiction underscores the importance of measures to increase women's access to cessation interventions, including adjunctive nicotine-replacement therapy.

The findings in this report are subject to at least two limitations:

First, the NHSDA indicators are not comprehensive measures of nicotine addiction, and do not include all symptoms of nicotine withdrawal (eg, anxiety, irritability, anger, difficulty concentrating, hunger, or cravings for cigarettes)2; as a result, the NHSDA data may underestimate the proportion of smokers who report at least one indicator of nicotine addiction.

Second, these findings are based on self-reported data, and perceptions of nicotine addiction were not validated. However, in previous studies, self-reported symptoms of nicotine addiction have been confirmed by observer rating [2].

Although manifestations of cardiovascular disease occur primarily during adulthood, related high-risk behaviors, such as tobacco use, often are initiated during adolescence; an estimated 87% of female daily smokers began smoking at 18 years or younger of age (CDC, unpublished data, 1991). Young persons often try using tobacco with a belief that they can quit. However, of adolescent smokers who have intended to not be smoking in 5 to 6 years, 73% still smoked 5 years later [7]. The 1991 and 1992 NHSDA data suggest that an important reason for young smokers' failure to quit smoking is a prevalence of addiction similar to that among older smokers. Because of the difficulty in achieving abstinence, and the strength and early onset of nicotine addiction, interventions to prevent smoking initiation are important.

School-based programs, combined with community interventions, have been effective in preventing smoking initiation [7]. Other measures that can prevent smoking initiation, onset of nicotine addiction, and subsequent morbidity and mortality associated with cardiovascular diseases include enforcement of laws that prohibit sales to minors, counteradvertising campaigns that "deglamorize" smoking to youth, and increases in the real price of cigarettes.