Reasons for Electronic Nicotine Delivery System use and smoking abstinence at 6†months: a descriptive study of callers to employer and health plan-sponsored quitlines.

OBJECTIVE: Describe cigarette smoking abstinence among employer and health plan-sponsored quitline registrants who were not using Electronic Nicotine Delivery Systems (ENDS), were using ENDS to quit smoking or were using ENDS for other reasons at the time of quitline registration. METHODS: We examined 6029 quitline callers aged ≥18 years who smoked cigarettes at registration, and completed ≥1 counselling calls, baseline ENDS use questions and a 6-month follow-up survey (response rate: 52.4%). 30-day point prevalence smoking quit rates (PPQRs) were assessed at 6-month follow-up (ENDS-only users were considered quit). Data were weighted for non-response bias. Logistic regression analyses controlled for participant characteristics and programme engagement. RESULTS: At registration, 13.8% of respondents used ENDS (7.9% to quit smoking, 5.9% for other reasons). 30-day PPQRs were: 55.1% for callers using ENDS to quit, 43.1% for callers using ENDS for other reasons, and 50.8% for callers not using ENDS at registration. Callers using ENDS for other reasons were less likely to quit than other groups (adjusted ORs=0.65-0.77); quit rates did not significantly differ between non-ENDS users and those using ENDS to quit. Among callers using ENDS to quit at baseline, 40% used ENDS regularly at follow-up. CONCLUSIONS: ENDS users not using ENDS to quit smoking were less successful at quitting at 6-month follow-up compared with callers using ENDS to quit smoking and callers who did not use ENDS at programme registration. Incorporating reasons for ENDS use may be important for future studies examining the role of ENDS in tobacco cessation.

How state counter-industry campaigns help prime perceptions of tobacco industry practices to promote reductions in youth smoking.

OBJECTIVE: This study assessed the impact of state media campaigns that prominently feature counter-industry messages on youth cigarette smoking, beyond the effects of price, secular trends, tobacco control efforts, and the national truth campaign. METHODS: Rates of youth smoking were compared in three groups of states: (1) those with long funded counter-industry campaigns (California, Florida, and Massachusetts); (2) states with more recently funded counter-industry media campaigns (Indiana, Minnesota, Mississippi, and New Jersey); and (3) other states. An analysis was performed for a series of national telephone surveys of 12-17 year olds between 1999 and 2002, controlling for differences in demographic background, the price of cigarettes, and exposure to the national truth campaign. RESULTS: Between 1999 and 2002, rates of current smoking and established smoking decreased significantly faster in states with established or more newly funded counter-industry campaigns than in other states. State counter-industry campaigns appear to prime, or make more salient, negative perceptions about tobacco industry practices. CONCLUSION: Results highlight the value of continued state counter-industry campaigns.

Budapest Student Health Behavior Survey--Budapest, Hungary, 1999. Findings on unintentional and intentional injuries, alcohol use, and sexual activity.

OBJECTIVE: In Hungary, a large proportion of adult morbidity and mortality can be attributed to health risk behaviors that begin in early adolescence. To date, studies examining health risk behaviors among youth have rarely been undertaken in Hungary. In order to expand current research in this area, the Hungarian Metropolitan Institute of State Public Health and Public Health Officer Service and the Office on Smoking and Health at the U.S. Centers for Disease Control and Prevention developed and implemented the Budapest Student Health Behavior Survey. The objective of this study was to examine health behavior risk factors among secondary school students in Budapest in 1999. METHODS: The 1999 Budapest Student Health Behavior Survey is cross-sectional school-based survey A 2-stage cluster sampling design was used to produce a representative sample of secondary students in grades 9-12 in Budapest. Information was collected on unintentional and intentional injuries, alcohol use, and sexual activity. FINDINGS: During the 30 days preceding the survey, 28.7% of students had rarely or never worn a seatbelt and 68.1% drunk alcohol. During the 12 months preceding the survey, 14.5% had been threatened or injured with a weapon, 12.9% experienced dating violence, and 13.5% seriously considered suicide. Of the 44.7% of students who had had sexual intercourse, 29.5% had > or = 4 sex partners. Of sexually active students, 50.4% had not used a condom at last sexual intercourse. CONCLUSION: Many secondary school students in Budapest practice behaviors that place them at risk for serious health problems both in the short and long-term. Programs and policies that adequately address such behaviors among secondary school students are needed to reduce subsequent morbidity and mortality.

Measuring statewide merchant compliance with tobacco minimum age laws: the Massachusetts experience.

OBJECTIVES: This study evaluated merchant compliance with laws prohibiting the sale of tobacco to minors in Massachusetts. METHODS: Stratified cluster sampling was used to select outlets from which youths aged 13 to 17 years attempted to purchase tobacco. RESULTS: Illegal sales were more common when the youth purchasing the tobacco was older, when the clerk was male, and when tobacco was obtained from a self-service display or unlocked vending machine. Failure to request proof of age was the strongest predictor of illegal sales. CONCLUSIONS: Measured compliance rates are strongly influenced by the age of the youths used to purchase tobacco.

Subgroup-specific effects of questionnaire wording on population-based estimates of mammography prevalence.

OBJECTIVES: This study investigated whether an apparent downturn in prevalence rates of mammography use reported in the 1992 Behavioral Risk Factor Surveillance System (BRFSS) questionnaire resulted from a change in questionnaire wording. METHODS: In a pretest-posttest design (1990-1991 vs 1992), piecewise linear regression analyses were based on monthly prevalence estimates of mammography use among female BRFSS respondents 40 years or older. RESULTS: Self-reported mammography use was lower by 3.5 percentage points (95% confidence interval [CI] = 1.5, 5.5) overall--and lower by 13.6 percentage points (95% CI = 2.6, 24.6) among Black women with less than a high school education--when predicted from 1992 data than when predicted from 1990-1991 data. CONCLUSIONS: A change in questionnaire wording in the BRFSS caused demographic-specific effects in population-based estimates of mammography use.

Factors associated with discrepancies between self-reports on cigarette smoking and measured serum cotinine levels among persons aged 17 years or older: Third National Health and Nutrition Examination Survey, 1988-1994.

The discrepancy between cigarette smoking status reported during an interview and measured level of serum cotinine, a nicotine biomarker, was investigated in a representative sample of the US population aged >/=17 years (N = 15,357). Data were collected from participants in the Third National Health and Nutrition Examination Survey (1988-1994). Among self-reported smokers, 7.5% (95% confidence interval: 6.3, 8.7) had a serum cotinine level less than or equal to 15.0 ng/ml, the selected cutoff point for identifying nonsmokers. Age (p < 0.01), race/ethnicity (p < 0.01), and average number of cigarettes smoked per day (p < 0.01) were associated with these discrepant findings. Among self-reported nonsmokers, 1.4% (95% confidence interval: 1.1, 1.7) had a serum cotinine level greater than 15.0 ng/ml, the selected cutoff point for identifying smokers. Race/ethnicity (p < 0.01), education (p < 0.01), number of household members who smoked in the home (p = 0.03), and self-reported smoking status from an earlier home interview (p < 0.01) were associated with these discrepant findings. Differences in smoking patterns, including the extent of nicotine dosing, may explain most of the discrepancy observed among self-reported smokers, whereas deception regarding smoking status may explain most of the discrepancy among self-reported nonsmokers. This study provides evidence that self-reported smoking status among adult respondents to a population-based survey conducted in a private medical setting is accurate.

Methodological issues in estimating smoking-attributable mortality in the United States.

The authors explored two methodological issues in the estimation of smoking-attributable mortality for the United States. First, age-specific and age-adjusted relative risk, attributable fraction, and smoking-attributable mortality estimates obtained using data from the American Cancer Society's second Cancer Prevention Study (CPS II), a cohort study of 1.2 million participants (1982-1988), were compared with those obtained using a combination of data from the National Mortality Follow-back Survey (NMFS), a representative sample of US decedents in which information was collected from informants (1986), and the National Health Interview Survey (NHIS), a nationally representative household survey (1987). Second, the potential for residual confounding of the disease-specific age-adjusted smoking-attributable mortality estimates was addressed with a model-based approach. The estimated smoking-attributable mortality based on the CPS II for the four most common smoking-related diseases-lung cancer, chronic obstructive pulmonary disease, coronary heart disease, and cerebrovascular disease-was 19% larger than the estimated smoking-attributable mortality based on the NMFS/NHIS, yet the two data sources yielded essentially the same smoking-attributable mortality estimate for lung cancer alone. Further adjustment of smoking-attributable mortality for disease-appropriate confounding factors (education, alcohol intake, hypertension status, and diabetes status) indicated little residual confounding once age was taken into account.

Trends in adult cigarette smoking in California compared with the rest of the United States, 1978-1994.

OBJECTIVES: This study compared trends in adult cigarette smoking prevalence in California and the remainder of the United States between 1978 and 1994. METHODS: We used data from National Health Interview Surveys and Behavioral Risk Factor Surveillance System surveys to compare trends in smoking prevalence among persons 18 years and older. RESULTS: In both California and the remainder of the United States, the estimated annual rate of decline in adult smoking prevalence accelerated significantly from 1985 to 1990: to -1.22 percentage points per year (95% confidence interval [CI] = -1.51, -0.93) in California and to -0.93 percentage points per year (95% CI = -1.13, -0.73) in the remainder of the nation. The rate of decline slowed significantly from 1990 to 1994: to -0.39 percentage points per year (95% CI = -0.76, -0.03) in California and to -0.05 percentage points per year (95% CI = -0.34, 0.24) in the remainder of the United States. CONCLUSIONS: The presence of an aggressive tobacco control intervention has supported a significant decline in adult smoking prevalence in California from 1985 to 1990 and a slower but still significant decline from 1990 to 1994, a period in which there was no significant decline in the remainder of the nation. To restore nationwide progress in reducing smoking prevalence, other states should consider similar interventions.

A mutation within the leucine-rich repeat domain of the Arabidopsis disease resistance gene RPS5 partially suppresses multiple bacterial and downy mildew resistance genes.

Recognition of pathogens by plants is mediated by several distinct families of functionally variable but structurally related disease resistance (R) genes. The largest family is defined by the presence of a putative nucleotide binding domain and 12 to 21 leucine-rich repeats (LRRs). The function of these LRRs has not been defined, but they are speculated to bind pathogen-derived ligands. We have isolated a mutation in the Arabidopsis RPS5 gene that indicates that the LRR region may interact with other plant proteins. The rps5-1 mutation causes a glutamate-to-lysine substitution in the third LRR and partially compromises the function of several R genes that confer bacterial and downy mildew resistance. The third LRR is relatively well conserved, and we speculate that it may interact with a signal transduction component shared by multiple R gene pathways.

Racial and ethnic differences in serum cotinine levels of cigarette smokers: Third National Health and Nutrition Examination Survey, 1988-1991.

CONTEXT: Cotinine, a metabolite of nicotine, is a marker of exposure to tobacco smoke. Previous studies suggest that non-Hispanic blacks have higher levels of serum cotinine than non-Hispanic whites who report similar levels of cigarette smoking. OBJECTIVE: To investigate differences in levels of serum cotinine in black, white, and Mexican American cigarette smokers in the US adult population. DESIGN: Third National Health and Nutrition Examination Survey, 1988-1991. PARTICIPANTS: A nationally representative sample of persons aged 17 years or older who participated in the survey. OUTCOME MEASURES: Serum cotinine levels by reported number of cigarettes smoked per day and by race and ethnicity. RESULTS: A total of 7182 subjects were involved in the study; 2136 subjects reported smoking at least 1 cigarette in the last 5 days. Black smokers had cotinine concentrations substantially higher at all levels of cigarette smoking than did white or Mexican American smokers (P<.001). Serum cotinine levels for blacks were 125 nmol/L (22 ng/mL) (95% confidence interval [CI], 79-176 nmol/L [14-31 ng/mL]) to 539 nmol/L (95 ng/mL) (95% CI, 289-630 nmol/L [51-111 ng/mL]) higher than for whites and 136 nmol/L (24 ng/mL) (95% CI, 85-182 nmol/L [15-32 ng/mL]) to 641 nmol/L (113 ng/mL) (95% CI, 386-897 nmol/L [68-158 ng/mL]) higher than for Mexican Americans. These differences do not appear to be attributable to differences in environmental tobacco smoke exposure or in number of cigarettes smoked. CONCLUSIONS: To our knowledge, this study provides the first evidence from a national study that serum cotinine levels are higher among black smokers than among white or Mexican American smokers. If higher cotinine levels among blacks indicate higher nicotine intake or differential pharmacokinetics and possibly serve as a marker of higher exposure to cigarette carcinogenic components, they may help explain why blacks find it harder to quit and are more likely to experience higher rates of lung cancer than white smokers.

Cigarette smoking and smoking cessation among older adults: United States, 1965-94.

OBJECTIVE: To characterise patterns of cigarette smoking and smoking cessation among older adults in the United States. DESIGN: Data from the National Health Interview Surveys (NHIS) 1965-94 were analysed. The NHIS is a cross-sectional survey using a representative national sample. SETTING: In most cases interviews were conducted in the home; telephone interviews were conducted when respondents could not be interviewed in person. PARTICIPANTS: Participants were from a representative sample of the American civilian, non-institutionalised population aged 18 and older. Sample sizes for the years analysed ranged from n = 19,738 to n = 138,988 overall, and n = 3806 to n = 12,491 for those aged 65 years and older. MAIN OUTCOME MEASURES: Using the NHIS data from 1965-94, trends in current smoking and the prevalence of smoking cessation by demographic characteristics among older adults (65 years and older) were assessed and compared with trends among younger adults. A logistic regression analysis was conducted to determine the demographic characteristics of former smokers compared with current smokers among those aged 65 and older. RESULTS: The prevalence of current smoking among 65 year olds and older declined from 1965 to 1994 (17.9% to 12.0%). Although smoking prevalence was lower among older adults than younger adults (aged 18-64), the rate of decline in smoking was slower among older adults. Among older adults, the prevalence of cessation rose with increasing educational attainment, and was consistently higher for men than for women and for whites compared with blacks. After adjustment for demographic factors among older adults who had ever smoked, increasing age and educational attainment were strongly related to the likelihood of being a former smoker. Although there were no racial differences among women, older white (OR = 2.6) and Hispanic (OR = 3.67) men were significantly more likely to be former smokers than older black men. Also, the gender difference in smoking cessation was noted only for whites. CONCLUSIONS: Given the projected increase in the elderly population, the medical and economic consequences of smoking will become a greater burden in the next decades. Therefore, focusing attention on cessation among the elderly is an immediate and urgent priority for public health professionals and clinicians.

State smoking prevalence estimates: a comparison of the Behavioral Risk Factor Surveillance System and current population surveys.

OBJECTIVES: This study examined whether there are systematic differences between the Behavioral Risk Factor Surveillance System (BRFSS) and the Current Population Survey (CPS) for state cigarette smoking prevalence estimates. METHODS: BRFSS telephone survey estimates were compared with estimates from the US Census CPS tobacco-use supplements (the CPS sample frame includes persons in households without telephones). Weighted overall and sex- and race-specific BRFSS and CPS state estimates of adults smoking were analyzed for 1985, 1989, and 1992/1993. RESULTS: Overall estimates of smoking prevalence from the BRFSS were slightly lower than estimates from CPS (median difference: -2.0 percentage points in 1985, -0.7 in 1989, and -1.9 in 1992/1993; P < .05 for all comparisons), but there was variation among states. Differences between BRFSS and CPS estimates were larger among men than among women and larger among Blacks than among Hispanics or Whites; for most states, these differences were not significant. CONCLUSIONS: The BRFSS generally provides state estimates of smoking prevalence similar to those obtained from CPS, and these are appropriate for ongoing state surveillance of smoking prevalence.

Predictors of tobacco sales to minors.

BACKGROUND: Our purpose was to determine which characteristics of buyers, stores, and store clerks predicted successful tobacco sales to minors. METHODS: Seventeen minors visited randomly selected retail outlets in the Austin, Texas, area and attempted to purchase tobacco products. We used logistic regression modeling to determine independent predictors of successful purchase attempts. RESULTS: Overall, 101 of 165 attempts (61.2%) were successful. Although legally required, only 25.3% of stores posted warning signs about underage purchase of tobacco, and stores with signs were no less likely to sell to minors than stores without signs. Successful attempts were more common from vendors in metropolitan locations and from vendors with no alcohol products. Only 8.1% of attempts succeeded when buyers were questioned (usually about age), compared with 95.6% of attempts when no questions were asked (P < 0.001). The best predictor of a successful purchase attempt was failure to question buyers (adjusted odds ratio = 1,850; P < 0.001). CONCLUSIONS: Warning signs had no effect on vendors' compliance with the state minors' access law, and failure to question minors about their age substantially increased the odds of a successful purchase. Laws prohibiting tobacco sales to minors should be enforced by requiring vendors to obtain proof of buyers' ages for persons who appear to be < 30 years of age.

The relationship between cigarette smoking and education revisited: implications for categorizing persons' educational status.

OBJECTIVE: This study sought to reassess the relationship between cigarette smoking and education. METHODS: Data from the 1983 to 1991 National Health Interview Survey for participants aged 25 years and older were used to plot the prevalence of current smoking, ever smoking, heavy smoking, and smoking cessation, as well as the adjusted log odds ratios, by years of education. RESULTS: The "less than high school graduate" category consisted of two groups with distinct smoking patterns: persons with 0 to 8 years and persons with 9 to 11 years of education. The latter were the most likely to be current, ever, and heavy smokers and the least likely to have quit smoking, whereas the former were similar to persons having 12 years of education. After 11 years of education, the likelihood of smoking decreased and that of smoking cessation increased with each successive year of education. These results persisted after the statistical adjustment for age, sex, ethnicity, poverty status, employment status, marital status, geographic region, and year of survey. CONCLUSIONS: The relationship between smoking and education is not monotonic. Thus, when evaluating smoking in relation to education, researchers should categorize years of education as follows: 0 to 8, 9 to 11, 12, 13 to 15, and 16 or more years.

Trends in smokeless tobacco use among men in four states, 1988 through 1993.

OBJECTIVES: Trends in smokeless tobacco use were examined for men in Indiana, Iowa, Montana, and West Virginia from 1988 through 1993. METHODS: State survey data from the Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. RESULTS: Demographic characteristics associated with smokeless tobacco use included age less than 35 years, a high school education or less, and rural residence. Overall, there was little change in smokeless tobacco use among men in these states (range = -0.4-0.4 percentage points annually); only West Virginia had a significant decline. CONCLUSIONS: Reasons for the overall lack of decline may include increased advertising and promotional expenditures or substitution of smokeless tobacco for cigarettes. Increased prevention and cessation efforts are needed.

Cigarette smoking and self-reported health problems among U.S. high school seniors, 1982-1989.

PURPOSE: To estimate the independent effect of cigarette smoking on respiratory tract symptoms and health status indicators among high school seniors. DESIGN: Consolidated data sets from one-time cross-sectional survey designs. SETTING: High schools in the United States, 1982-1989. SAMPLE: A total of 26,504 high school seniors, with an 83% response rate. MEASURES: Odds ratios for respiratory tract symptoms and health status indicators for cigarette smokers compared with nonsmokers, while controlling for sex, socioeconomic status, and use of other drugs. RESULTS: High school seniors who were regular cigarette smokers and who began smoking by grade nine were significantly more likely than never smokers to report shortness of breath when not exercising (adjusted odds ratio [OR] = 2.7), coughing spells (OR = 2.1), productive cough (OR = 2.4), and wheezing or gasping (OR = 2.6). These smokers were also more likely to have seen a doctor or other health professional for an emotional or psychologic complaint (OR = 3.0) and to rate their overall health as poorer than average (OR = 2.4). We found strong dose-response relationships for most outcome measures. CONCLUSIONS: Cigarette smoking among high school seniors is associated with respiratory tract symptoms and poorer overall physical health and may be a marker for underlying mental health problems. Smoking prevention activities directed at adolescents should include information on the early adverse health consequences of cigarette smoking.

The association between veteran status and cigarette-smoking behaviors.

Although the prevalence of smoking has decreased since 1980 among active duty military personnel, it remains higher than among the adult civilian population; among military veterans, the prevalence of smoking has not been well described. The objectives of this study were to describe patterns of cigarette smoking behaviors among United States veterans and nonveterans and to examine the association between military veteran status and cigarette smoking. We analyzed data from a cross-sectional survey from a national probability sample of the civilian, noninstitutionalized adult population (National Health Interview Survey supplements). We estimated the prevalence of ever, current, and former smoking, as well as crude and adjusted odds ratios (AORs) of each outcome measure among veterans and nonveterans, by gender. The prevalence of ever smoking was 74.2% (+/- 0.7%) among veterans and 48.4% (+/- 0.5%) among nonveterans; current smoking prevalence was 33.9% (+/- 1.0%) among veterans and 27.7% (+/- 0.5%) among nonveterans. Among those who had not initiated smoking before the age of 18 years, veterans were more likely than nonveterans to report ever smoking (AOR = 1.8 for men and 1.9 for women) and current smoking (AOR = 1.9 for both men and women). After statistical adjustment, no difference was seen in cessation behavior. We concluded that the prevalence of ever and current smoking was higher among U.S. military veterans. The association was the strongest among veterans who had not initiated smoking before the age of 18 years. These findings are consistent with the hypothesis that military service is a risk factor for cigarette smoking, and they support the military's current prevention and cessation efforts.

Trends in cigarette smoking and physicians' advice to quit smoking among people with diabetes in the U.S.

OBJECTIVE: This study describes changes in the distribution of cigarette smoking and in physicians' advice to quit smoking among the U.S. population with and without diabetes from the mid-1970s to 1990. RESEARCH DESIGN AND METHODS: Data on self-reported smoking status, physicians' advice to quit smoking, history of diabetes, and demographic characteristics were obtained from the 1974, 1985, and 1990 National Health Interview Surveys. We examined the age-adjusted prevalence of smoking and physicians' advice to quit smoking by race, sex, and educational level among individuals with diabetes and those without diabetes. RESULTS: The prevalence of smoking decreased 9.8 percentage points from 1974 to 1990 among individuals with diabetes (from 35.6 to 25.8%, P < 0.01) and 11.7 percentage points among those without diabetes (from 37.3 to 25.6%, P < 0.01). For all years, younger individuals, men, and people with less than a high school education were more likely to smoke, regardless of diabetes status. Among individuals who had ever smoked, those with diabetes were more likely to have received advice to quit than those without diabetes; from 1974 to 1990, the percentage advised to quit smoking by a physician increased from 35.1 to 58.4% for smokers with diabetes and from 26.8 to 46.0% for smokers without diabetes. CONCLUSIONS: Despite decreases in smoking prevalence over time, people with diabetes are still as likely to smoke as those without diabetes. More than 40% of smokers with diabetes currently report never having received advice from a physician to quit smoking. Health care providers should increase their efforts to reduce smoking among people with diabetes.

Trends in cigarette smoking among US adolescents, 1974 through 1991.

OBJECTIVES: The purpose of this study was to determine national trends in adolescent cigarette smoking prevalence. METHODS: We conducted trend analyses based on 1974 through 1991 current smoking prevalence data among persons aged 12 through 19 years from the National Household Surveys on Drug Abuse, High School Seniors Surveys, and National Health Interview Surveys. RESULTS: Overall smoking prevalence declined much more rapidly from 1974 through 1980 (1.9 percentage points annually among younger adolescents; the range among surveys of older adolescents was 0.2 to 2.0 percentage points annually) than from 1985 through 1991 (0 to 0.5 percentage points annually among all adolescents). Since 1980, smoking has generally declined at a slightly faster rate among older female adolescents than among male adolescents. Smoking among Black adolescents of all ages declined in nearly every survey population during each study period (range among surveys: 1974-1985 = 1.0 to 2.9 percentage points; 1985-1991 = 0.7 to 1.5 percentage points annually); for White adolescents, only minimal declines in smoking have occurred since 1985. CONCLUSIONS: Since 1974, major changes in adolescent smoking patterns have occurred, especially among Blacks. The overall slowing rate of decline in smoking prevalence since 1985 may indicate success of increased tobacco advertising and promotional activities targeted at adolescents or inadequate antitobacco education efforts.

Trends in cigarette smoking among US physicians and nurses.

OBJECTIVE: To determine trends in cigarette smoking prevalence among physicians, registered nurses, and licensed practical nurses since 1974. DESIGN: Analyses of data on smoking prevalence among persons 20 years of age and older using combined National Health Interview Survey data sets from 1974, 1976, and 1977; 1978, 1979, and 1980; 1983 and 1985; 1987 and 1988; and 1990 and 1991. MAIN OUTCOME MEASURES: Prevalence of cigarette smoking and average annual change in smoking prevalence. RESULTS: Based on the data for 1990 and 1991, there were an estimated 18,000 physicians, 322,000 registered nurses, and 128,000 licensed practical nurses who smoked cigarettes in the United States. Compared with 1974, 1976, and 1977, by 1990 and 1991 cigarette smoking prevalence had declined from 18.8% to 3.3% among physicians (average annual decline of 1.15 percentage points); from 31.7% to 18.3% among registered nurses (average annual decline of 0.88 percentage point); and from 37.1% to 27.2% among licensed practical nurses (average annual decline of 0.62 percentage point). CONCLUSION: Since 1974, cigarette smoking has declined most rapidly among physicians, at an intermediate rate among registered nurses, and at a lower rate among licensed practical nurses. Because of their important roles as exemplars and health educators, persons in these occupations should not smoke.