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2005). As discussed in Chapter 5, it is likely that variations in the levels of tobacco control activities among the states also account for some of these variations in smoking prevalence. It is widely accepted that California’s lower prevalence is attributable at least in part to the intensity of tobacco control efforts in that state (CDC 1996). Kuiper and colleagues (2005) present evidence that comprehensive state programs reduce the prevalence of smoking among adults and adolescents at the state and national levels. Jemal and colleagues (2003) examined comprehensive smoking cessation programs among 33 states and found that the intensity of the program had a very large negative correlation with the prevalence of current smoking (r = −0.81, p < 0.0001) and a large positive correlation with the quit rate (r = 0.82, p < 0.0001) among adults ages 30 to 39 years. The impact of comprehensive state tobacco control programs is discussed in more detail in Chapter 5 of this report.

States with a high prevalence of smoking among adults also have high rates of smokers who made no attempt to change their behavior in the last year (Burns and Warner 2003), suggesting that environment plays a role in sustaining smoking behavior or promoting cessation efforts.

Comorbidity

Several recent studies have documented a relationship between mental illness and smoking among adults and adolescents (Black et al. 1999; Lasser et al. 2000; Upadhyaya et al. 2002). As used by Lasser and colleagues (2000), the term “mental illness” in this context is defined very broadly to include major depression, bipolar disorder, dysthymia, panic disorder, agoraphobia, social phobia, simple phobia, generalized anxiety disorder, alcohol abuse, alcohol dependence, drug abuse, drug dependence, antisocial personality, conduct disorder, or nonaffective psychosis (Lasser et al. 2000). Adults who currently experience symptoms of these disorders smoke more than 44 percent of the cigarettes consumed in the United States (Lasser et al. 2000). Lasser and colleagues also found that adults with a lifetime history of mental illness (broadly defined as above) were more likely to be current smokers than adults with no history of mental illness. Adults with mental illnesses manifesting within the past month were the most likely to smoke and the least likely to quit. Figure 1-16 compares the smoking prevalence and cessation rates by mental illness status. The study also revealed that those with a larger number of mental illness comorbidities have a greater likelihood of smoking and a greater tendency to smoke heavily.

EMERGING CHALLENGES

Although the prevalence of smoking among adults continues a 40-year decline, some recent trends suggestive of a flattening in rates of adult smok-



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