Reply: Trends in Smoking Prevalence and the Continuing Imperative of Tobacco Control.

From the Authors:

We appreciate Dr. Lang’s thoughtful comments on our article (1). He notes, and we agree, that our finding of a steeper fall in cigarette smoking prevalence in 2020 relative to prior trends could be consistent with an increase in e-cigarette use, which we did not examine. Moreover, his concern that reductions in visits to physicians who commonly provide smoking cessation care may have led to reductions in quit efforts is well taken.

More recent analyses put our study’s finding into fuller context. A study from the Centers for Disease Control and Prevention (CDC) (2), which used a different national survey (the National Health Interview Survey), supports our central finding: like us, they identified a modest reduction in adult smoking prevalence in 2020. Notably, the CDC also found a reduction in e-cigarette use and no increase in the quantity of cigarettes consumed by smokers. However, these trends should be interpreted cautiously: in contrast to our analysis, the CDC study did not adjust for previous trends (the 2019 change in the National Health Interview Survey design would have impeded such an analysis), and cigarette consumption was assessed only in broad categories in their study.

In contrast, another recent analysis identified a 14.1% increase in cigarette sales in the United States with the onset of the pandemic (3), a finding that suggests that current smokers may indeed have increased their consumption of cigarettes even if overall smoking prevalence slightly decreased. This could reflect the disproportionate psychosocial strain that the coronavirus disease (COVID-19) pandemic imposed on disadvantaged groups, who are also more likely to use tobacco.

Putting aside the question of pandemic-related impacts, the devastating and deadly reality is that about 30 million Americans still smoke cigarettes (2) and that the burden of tobacco—as we and many others have observed (4, 5)—increasingly falls on low-income, less-educated, and rural Americans. Our findings do provide some support for the notion that job loss need not necessarily increase smoking prevalence, as was seen to some extent in the Great Recession (6). However, they also underscore the imperative of tobacco control. Well-established evidence-based policies—including bans on promotion, smoking restrictions in public spaces, cigarette taxes, and universal accessibility of smoking cessation therapies—need to be far more widely deployed, although these steps will require confrontation with the tobacco industry. Moreover, in the United States, access to care for smokers must be improved for efficacious medical treatments to actually be delivered to those who need them. With more than 30 million Americans uninsured and 41 million underinsured (7), many who could benefit from pharmacotherapy and counseling are undoubtedly avoiding it because of cost.

Finally, widening social disparities in smoking underscore the fact that arduous, indeed oppressive, conditions help drive this unhealthy habit. Hence, although policies focused on behavioral change are important, broader reforms to address the underlying inequitable social conditions themselves will likely be needed to combat the scourge of the cigarette.