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Abstract

Objectives. To compare prevalence estimates and assess issues related to the


measurementofadultcigarettesmokingintheNationalHealthInterviewSurvey(NHIS)
andtheNationalSurveyonDrugUseandHealth(NSDUH).Methods.2008dataon
currentcigarettesmokingandcurrentdailycigarettesmokingamongadults 18years
were compared. The standard NHIS current smoking definition, which screens for
lifetime smoking 100 cigarettes, was used. For NSDUH, both the standard current
smokingdefinition,whichdoesnotscreen,andamodifieddefinitionapplyingtheNHIS
currentsmokingdefinition(i.e.,withscreen)wereused.Results.NSDUHconsistently
yieldedhighercurrentcigarettesmokingestimatesthanNHISandlowerdailysmoking
estimates. However, with use of the modified NSDUH current smoking definition, a
notable number of subpopulation estimates became comparable between surveys.
Youngeradultsandracial/ethnicminoritiesweremostimpactedbythelifetimesmoking
screen, with Hispanics being the most sensitive to differences in smoking variable
definitionsamongallsubgroups.Conclusions.Differencesincurrentcigarettesmoking
definitions appear to have a greater impact on smoking estimates in some sub
populationsthanothers.Surveymodedifferencesmayalsolimitintersurveycomparisons
andtrendanalyses. Investigators arecautionedtouse data mostappropriate fortheir
specificresearchquestions.

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.

2. Materials and Methods


2.1. Surveys
Weuseddatafromthe2008NHISand2008NSDUHpublicdatafilesforprevalence
comparisonsbetweensurveys.Combined20062008NSDUHpublicdatafileswereused
toexaminesubpopulationcharacteristicsofrespondentswhohadsmokedduringthepast
30daysbutdidnotmeetthe100lifetimecigarettescriterion.
2.2. NHIS
TheNHISisamultipurposenationalhealthsurveyconductedbytheNationalCenterfor
HealthStatistics(NCHS)attheCentersforDiseaseControlandPrevention(CDC)andis
designed to provide information about a wide range of health topics for the
noninstitutionalizedUShouseholdpopulationaged18yearsandolder.Thesurveyuses
multistage,clustersampling.Itisprimarilyadministeredasadirectinpersoninterview,
withinterviewsthateithercannotbeconductedorfullycompletedinpersonadministered
bytelephone.Thepercentageofcompleted2008NHISsampleadultinterviewsthatwere
administeredeitherinpartorinwholebytelephonewas25%(S.Jack,NCHS,personal
communication,Oct.19,2011).Interviewsareconductedbyfieldrepresentativesusing
computerassisted personal interviewing (CAPI). The CAPI data collection method
employscomputersoftwarethatpresentsthequestionnaireonacomputerscreenand
guides the interviewer through the questionnaire, automatically routing them to
appropriatequestionsbasedonanswerstopreviousquestions.Interviewersentersurvey
responsesdirectlyintothecomputer,andtheCAPIprogramdeterminesiftheselected
response is within an allowable range, checks it for consistency against other data
collected during the interview, and saves the responses into a survey data file. The
nationallyrepresentativesurveysampleandsubsequentdataweightingpermitcalculation
ofnationalestimates.In2008,thedesignoversamplednonHispanicblack,Hispanic,and
Asian populations to allow for more precise estimates in these groups. The 2008
householdresponseratewas84.9%,andtheinterviewresponseratewas74.2%,yielding

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).

Figure 1: Standard NHIS current cigarette smoking variable definition.


2.5.2. NSDUH
OuranalysisusedtwodifferentdefinitionsofcurrentsmokingforNSDUH:thestandard
currentsmokingdefinition(NSDUHS)establishedin1993andamodifieddefinition
(NSDUHM) constructed to be comparable to the NHIS definition. The NSDUHS
currentsmokingdefinitionusestwoquestionstomeasuresmokingprevalence[44].The
first, askedofallrespondents, is have youeversmokedpartorallofacigarette?
Respondentsansweringyesareclassifiedaseversmokers,andthosewhoanswerno
areclassifiedasneversmokers.Eversmokersarethenaskedasecondquestion:during
thepast30days,haveyousmokedpartorallofacigarette?Respondentswhoanswer
yesareclassifiedascurrentsmokers(Figure2).
Figure 2: Standard NSDUH current cigarette smoking variable definition
(NSDUH-S).
WhileNSDUHalsocontainsthequestionhaveyousmokedatleast100cigarettesin
yourentirelife?identicaltotheNHISandisaskedofNSDUHeversmokers,itisnot
usedtodefinecurrentsmoking.Weconstructedthesecond,modifiedNSDUHMcurrent
smokingdefinitionthatincludesthe100cigarettelifetimeusequestion,withNSDUHM
currentsmokersdefinedasNSDUHeversmokerswhobothreportedsmokingpartorall
ofacigaretteduringthe30daysprecedingthesurveyandreportedlifetimecigaretteuse
100cigarettes(Figure3).
Figure 3: Modified NSDUH current cigarette smoking variable definition
(NSDUH-M).
2.6. Daily Smoking
For NHIS, daily smoking among current smokers was defined primarily using the
question do you now smoke cigarettes every day, some days, or not at all?, and
secondarily using the question on how many of the past 30 days did you smoke a
cigarette? which is asked of some day smokers only. Respondents who answered
everydaytothefirstquestionwereclassifiedasdailysmokers,aswererespondents
whoansweredsomedaystothefirstquestionbutforthesecondreportedsmokinga
cigaretteonallofthepreceding30days.ForNSDUHSandNSDUHM,thisvariable
wasdefinedusingthequestionduringthepast30days,thatis,since[DATE],onhow
manydaysdidyousmokepartorallofacigarette?Respondentswhoansweredthat
theysmokedonallofthepreceding30dayswereclassifiedasdailysmokers.
2.7. Lifetime Cigarette Use

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.

Table 2: Level of lifetime cigarette use* <100 cigarettes among adults


who currently smoke cigarettes, by demographicNSDUH 20062008.

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.