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America’s Health Rankings has tracked the prevalence of smoking among US adults since the report was first published in 1990. Obesity was also included in 1990, but was a part of a combined measure called “risk for heart disease.” Obesity was explicitly added to the model in the 2004 edition. To better gauge where the United States is in its recent efforts to reduce the prevalence of smoking and obesity, a five-year trend analysis was conducted using data from the Centers for Disease Control (CDC) and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS). The analysis highlights the variation in prevalence and the annual rate of change [1] for both of these significant public health challenges by state and education levels [2] using data from editions 2012 through 2016.
Obesity is the second-leading cause of preventable death, close behind smoking. Obesity contributes to conditions such as heart disease, stroke, diabetes, and certain cancers [3]. Smoking also contributes to cancer, heart disease, stroke, and respiratory diseases. In addition, smoking has adverse effects on reproductive health, and it impacts treatment of other chronic diseases such as diabetes. The CDC estimates that smoking and secondhand smoke cause more than 480,000 deaths annually, or one in five deaths [4]. Since the publication of the first Surgeon General’s report on smoking and health in 1964, more than 20 million Americans have died from smoking [5].
Smoking has been steadily declining in the United States since the mid-1960s [6]. Since then, states have adopted numerous policies to prevent people--especially youth--from starting to smoke, help people quit smoking, and help reduce death and disability from the effects of smoking. A few examples of state smoking cessation efforts include enacting laws restricting or prohibiting smoking in public places and workplaces, raising the prices of tobacco products through taxation, and implementing telephone quitlines staffed with counselors trained to help smokers quit. In the first edition of America’s Health Rankings, published in 1990, the prevalence of smoking among US adults was 29.5%. Today, 17.5% of adults smoke.
Contrary to smoking, obesity among US adults has been rising. Despite calls to action by the Surgeon General as early as 2001, the prevalence of obesity has nearly tripled from 11.6% in 1990 to 29.8% today [7]. Factors associated with obesity include where people live, environment, culture, attitudes, emotions, stress, dietary habits, sedentary behavior, genes, income, and education [8,9].
Obesity risk and likelihood of being a smoker have been linked to education level. Education has been shown to have a direct and indirect association with the risk of obesity [10]. Higher educational attainment is associated with a decreased likelihood of obesity, especially among women [9]. Lower education level is associated with an increased risk of smoking [11]. Since the negative health effects of smoking became well-known, the prevalence of smoking among college graduates has been significantly lower compared with adults who are less educated [6].
Trends in Smoking Prevalence, 2012 to 2016
Nationally, the prevalence of smoking among US adults aged 18 years and older has decreased over the past four years from 21.2% in 2012 to 17.5% in 2016 (Figure 5), an average annual decrease of -0.89%. Among adults aged 25 years and older, the prevalence of smoking is significantly lower among those who have a college degree compared with those with less than high school, high school or equivalent, and some college (Figure 6).
Smoking prevalence decreased at a faster average rate in 16 states compared with the average rate of change in the United States (-0.89%).

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Annual Rate of Change in Smoking Prevalence by State Between 2012 and 2016 all states experienced an average decrease in smoking prevalence per year (Figure 7).
  • Smoking prevalence decreased at a faster rate on average in 16 states compared with the average rate of change in the United States (-0.89%).
  • Smoking prevalence decreased at the fastest rate in Illinois, with an average decrease in smoking of -1.37% per year. Smoking prevalence decreased at the slowest rate in Tennessee, at -0.29% per year on average.
  • Indiana (23.0%), Oklahoma (23.3%), and Wyoming (20.8%) had a higher five-year average prevalence of smoking relative to other states, and the prevalence has decreased at a faster-than-average rate of -1.11% per year, -1.00% per year, and -1.01% per year, respectively.
  • On the other hand, California (12.7%), Hawaii (14.6%), and Utah (10.3%) had a lower five-year average prevalence of smoking relative to other states and the prevalence decreased at a slower-than-average rate of -0.38% per year, -0.59% per year, and -0.63% per year, respectively.
Annual Rate of Change in Smoking Prevalence by Education Level Interesting differences emerged when smoking was stratified by education level among adults aged 25 years and older between 2012 and 2016 (Figure 8).
  • Nationally, smoking decreased across all education groups over the past four years. The average rate of decrease ranged from -0.39% per year among college graduates to -0.74% per year among adults who did not graduate from high school.
  • In a handful of states, the average annual rate of smoking prevalence increased among adults with a high school degree, some college, or among college graduates. For example, Tennessee increased 1.05% for adults with some college.
  • Despite the average national rate of decline being largest among adults who did not graduate from high school, smoking prevalence increased among this population in 15 states over the same time period, led by South Dakota and Connecticut.
  • Compared with other education levels, there was more variation in smoking prevalence by state among adults who did not graduate from high school.
  • Among adults who did not graduate from high school:
  • Nevada experienced an average decrease of -3.44% per year in smoking prevalence from 2012 to 2016, while South Dakota saw an average increase of 1.76% per year in smoking prevalence over the same five-year period.
  • Relative to other states, Connecticut (24.5%) and Hawaii (23.5%) had a lower five-year average prevalence of smoking, but a faster average rate of increase per year at 1.07% per year and 0.54% per year, respectively.
  • Even though Ohio (41.8%) had a higher average prevalence of smoking relative to other states from 2012 to 2016, the prevalence increased at a rate of 0.04% per year, which is a slower rate than other states over the same time period.
  • Indiana (39.0%), New Hampshire (38.4%), and Vermont (37.9%) had a higher five-year average smoking prevalence relative to other states, but the prevalence in these states decreased at a much faster rate of -1.90% per year, -2.15% per year, and -3.15% per year, respectively.

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Trends in Obesity Prevalence, 2012 to 2016
The prevalence of obesity among US adults has increased 0.60% per year between 2012 and 2016, reaching its highest level in 2016 at nearly 30% of adults aged 18 years and older (Figure 9). Since 2007, the prevalence of obesity among US adults has been above 25%. When stratified by education level, the prevalence of obesity among adults aged 25 years and older was significantly lower among those with a college degree compared with other education levels; however, it was still increasing yearly for each education level (Figure 10).
Obesity prevalence increased at a faster average rate in 21 states compared with the average rate of change in the United States (0.60%).

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Annual Rate of Change in Obesity Prevalence by State
At the state level, all states except Michigan and Colorado experienced an average annual increase in obesity in the same five-year period (Figure 11).
  • Obesity prevalence increased at a faster average rate in 21 states compared with the average rate of change in the United States (0.60%).
  • Obesity prevalence increased at the fastest rate in Wyoming, with an average annual increase of 1.29%.
  • On the opposite end of the spectrum, Michigan and Colorado experienced average annual decreases in obesity prevalence of -0.06% and -0.02%, respectively.
  • Both states decreased even though Michigan (31.2%) had a relatively high average prevalence of obesity and Colorado (20.8%) had the lowest five-year average prevalence. This shows that improvements can occur regardless of a state’s obesity prevalence.
  • While Arizona (27.0%), Oregon (27.7%), and Wyoming (27.2%) had a lower five-year average prevalence of obesity relative to other states, the prevalence increased at a faster average rate at 0.95% per year, 0.74% per year, and 1.29% per year, respectively.
  • Mississippi (35.1%) had the highest five-year average prevalence of obesity relative to other states, but the prevalence was increasing at a slower average rate (0.23% per year) compared with other states.
Annual Rate of Change in Obesity Prevalence by Education Level
Interesting differences emerged when obesity was stratified by education level among adults 25 years and older between 2012 and 2016 (Figure 12):
  • Nationally, obesity increased across all education groups over the past four years. However, the average rate of change per year was 2.5 times higher among high school graduates than college graduates.
  • There was more variation in obesity prevalence by state among those who did not graduate from high school compared with other education levels.
  • Among adults who did not graduate from high school:
  • Seventeen states experienced a negative average annual rate of change in obesity prevalence over the past four years, led by Wisconsin (-2.76% per year) and Indiana (-2.65% per year).
  • Vermont (2.52% per year), Pennsylvania (1.91% per year), and New York (1.78% per year) experienced a dramatic increase in the average rate of obesity prevalence compared with the other education levels.
  • Relative to other states, Nevada (32.7%) and Nebraska (33.3%) had a lower five-year average prevalence of obesity, but the prevalence increased at a much faster rate on average than other states (1.43% per year and 1.32% per year, respectively).
  • Even though Mississippi (38.1%) and California (35.4%) had a higher five-year average prevalence of obesity relative to other states, the prevalence has been decreasing on average (-0.09% per year and -0.08% per year, respectively) unlike most other states.

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Annual Rate of Change in Smoking and Obesity
Some states are improving at a faster rate than the nation for prevalence of smoking and obesity, while others are improving at a slower rate than the nation or are stagnant. Ohio, Maryland, Rhode Island, and Indiana are experiencing faster decreases in smoking prevalence and slower increases in obesity prevalence compared with the United States, while Tennessee and Arkansas are experiencing slower decreases in smoking and faster increases in obesity, on average.
Among adults aged 25 years and older who did not graduate from high school, some states are improving at a faster rate than the nation for prevalence of smoking and obesity. Others are improving at a slower rate than the nation or are stagnant. The prevalence of smoking and obesity among adults who did not graduate from high school decreased at a faster rate in Indiana and Wisconsin compared with the nation. Adults in the same population segment living in Nevada or Vermont are experiencing faster declines in smoking prevalence (>=-3.0% per year) compared with other states and the nation; however, they are also challenged with faster increases in obesity than the nation. In Arkansas and Connecticut, smoking and obesity are increasing at rates faster than the national average in this education level. California experienced the slowest rate of change in smoking and obesity prevalence from 2012 to 2016 among those who did not graduate from high school.
Summary
The prevalence of smoking has decreased in the past four years in all 50 states, but these improvements are not consistent across education levels. However, in the past four years obesity prevalence has increased in most states, and the prevalence varies across education levels. In terms of both smoking and obesity prevalence, where one lives matters most for those who did not graduate from high school. States that are reducing the prevalence of smoking and obesity faster than other states may be able to share lessons learned.
Despite success in reducing smoking among adults, there is still work to be done to meet the Department of Health and Human Services Healthy People 2020 target of reducing the prevalence of smoking to 12.0% [12]. At the same time, nearly one-third of US adults struggle with obesity. In the past four years, the nation has experienced a greater than 0.5% increase per year in obesity prevalence among adults, an indication of the uphill battle we face as a nation to prevent obesity and related health conditions.
[1] Average rate of change per year was calculated as the slope of a least-squares fitted line in prevalence over the five-year period of 2011 to 2015 (BRFSS data years). [2] Education levels analyzed were less than high school graduate, high school graduate or equivalent, some college, and college graduate. [3] Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html. Accessed October 26, 2016. [4] Centers for Disease Control and Prevention Fact Sheet. Current cigarette smoking among adults in the US. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm. Accessed October 26, 2016. [5] US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. [6] Trends in higher education: Smoking rates by education level, 1940-2008. The College Board website. https://trends.collegeboard.org/education-pays/figures-tables/smoking-rates-education-level-1940-2008. Accessed October 26, 2016. [7] Office of the Surgeon General (US). The Surgeon General’s Vision for a Healthy and Fit Nation. Rockville (MD). Office of the Surgeon General (US); 2010. Background on Obesity. [8] Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-pro/guidelines/archive/clinical-guidelines-obesity-adults-evidence-report. Accessed October 26, 2016. [9] Cohen AK, Rai M, Rehkopf DH, Abrams B. Educational attainment and obesity: A systematic review. Obesity Reviews : An Official Journal of the International Association for the Study of Obesity. 2013;14(12):989-1005. doi:10.1111/obr.12062. [10] Devaux, M, Sassi F, Church J, Cecchini M, et al. Exploring the relationship between education and obesity. OECD Journal: Economic Studies. 2011;1. http://dx.doi.org/10.1787/eco_studies-2011-5kg5825v1k23. Accessed October 26, 2016. [11] Gilman SE, Martin LT, Abrams DB, Kawachi I, et al. Education attainment and cigarette smoking: a causal association? Int J Epidemiol. 2008; 37(3): 615-624. [12] Healthy People 2020: Tobacco use goals and objectives. https://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use/objectives. Accessed October 26, 2016.

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