Much of the suffering and death from cancer could be prevented by more systematic efforts to reduce tobacco use, improve diet, increase physical activity, reduce obesity, and expand the use of established screening tests. Monitoring the prevalence of cancer risk factors and screening is important to measure progress and strengthen cancer prevention and early detection efforts. In this review article, we provide recent prevalence estimates for several cancer risk factors, including tobacco, obesity, physical activity, nutrition, ultraviolet radiation exposure as well as human papillomavirus and hepatitis B vaccination coverage and cancer screening prevalence in the United States. In 2013, cigarette smoking prevalence was 17.8% among adults nationally, but ranged from 10.3% in Utah to 27.3% in West Virginia. In addition, 15.7% of U.S. high school students were current smokers. In 2011–2012, obesity prevalence was high among both adults (34.9%) and adolescents (20.5%), but has leveled off since 2002. About 20.2% of high school girls were users of indoor tanning devices, compared with 5.3% of boys. In 2013, cancer screening prevalence ranged from 58.6% for colorectal cancer to 80.8% for cervical cancer and remains low among the uninsured, particularly for colorectal cancer screening where only 21.9% of eligible adults received recommended colorectal cancer screening. Cancer Epidemiol Biomarkers Prev; 24(4); 637–52. ©2015 AACR.

Much of the suffering and death from cancer could be prevented by more systematic efforts to reduce tobacco use, improve diet and physical activity, reduce obesity, and expand the use of established screening tests. Avoiding the use of tobacco products and exposure to secondhand smoke (SHS), maintaining a healthy weight, staying physically active throughout life, and consuming a healthy diet can substantially reduce a person's lifetime risk of developing or dying from cancer (1, 2). The American Cancer Society (ACS) estimates that in 2015 about 171,000 cancer deaths will be caused by tobacco smoking alone (3). In addition, approximately one quarter to one third of the 1,658,370 cancer cases expected to occur in 2015 can be attributed to poor nutrition, physical inactivity, overweight, and obesity (1–3). Regular use of cervical and colorectal cancer screening tests can prevent the development of cancer through identification and removal or treatment of premalignant abnormalities (4). Screening tests can also improve survival and decrease mortality by detecting cancer at an early stage when treatment is more effective. In addition, the human papillomavirus (HPV) and hepatitis B (HBV) vaccines prevent potentially carcinogenic infections that may lead to cancer.

Monitoring the prevalence of cancer risk factors, use of vaccines, and screening tests is important to monitor progress and strengthen cancer prevention and early detection efforts. Previous studies have provided prevalence estimates of individual risk factors and screening; however, there are fewer resources with current estimates for major risk factors and screening in one place. In this review article, we provide recent prevalence estimates for major cancer risk factors, including tobacco use, obesity, physical activity, nutrition, ultraviolet radiation (UVR) exposure, and infectious agents, as well as HPV and HBV vaccination and cancer screening prevalence in U.S. adults. We also provide risk factor information for youth as many health behaviors begin at an early age and several risk factors, particularly smoking, are cumulative over time.

We used data from publicly available population-based surveys that are facilitated by the Centers for Disease Control and Prevention. Before releasing the data for public use, the data were weighted to account for the various complex survey designs and allow for generalizability of the survey responses to the population (i.e., state or nation) represented by the sample. All weighted prevalence estimates were generated using SAS-callable SUDAAN release 11.0.1 to account for the complex survey designs.

The 2013 National Health Interview Survey (NHIS) was used to estimate nationwide patterns in tobacco, indoor tanning use, sun-protective behaviors, and cancer screening data. NHIS is an in-person household survey of noninstitutionalized adults ≥18 years and designed to provide national prevalence estimates on sociodemographic and health data in the United States (5). When data were available, NHIS data were used to generate nationwide data as it is an in-person survey (as opposed to telephone based) with higher response rates than state-based surveys discussed below (6).

The 2012 and 2013 Behavioral Risk Factor Surveillance System (BRFSS) data were used to estimate state-level tobacco, obesity, nutrition/physical activity, sun-protective behaviors, and cancer screening prevalence. When nationwide data were not available from NHIS, BRFSS data were used. BRFSS is a monthly, computer-assisted telephone-based survey of adults ≥18 years and is designed to provide state-level estimates for health behaviors (7). The survey methods were generally comparable from state to state. Data on tobacco use, obesity, physical activity, and nutrition for high school students from the Youth Behavioral Risk Survey (YRBS), which is a school-based survey, are also presented (8).

The 1976–2012 National Health and Nutrition Examination Survey (NHANES) was used to estimate the prevalence of overweight and obesity in the United States as height and weight data are collected by trained personnel during physical examinations (9). NHANES includes data on both adults (≥20 years) and children (2–19 years).

We relied on previously published reports utilizing the National Immunization Survey–Teen for HPV and HBV vaccination prevalence (10). Reports using the National Adult Tobacco Survey (NATS) were used for nationwide estimates of cigars, smokeless tobacco, and e-cigarette prevalence (11).

Tobacco use

The year 2014 marked the 50th anniversary of the first Surgeon General's Report on Smoking and Health. This landmark report determined that cigarette smoking caused lung cancer (12), and since then other tobacco products, including cigars and smokeless tobacco, have been causally linked to cancer as well (13). Substantial gains in tobacco control have been made since the first Surgeon General's report, yet, there have been 20 million deaths due to tobacco since 1964, and tobacco use remains the single largest preventable cause of disease and premature death in the United States (13).

Adult tobacco use

Tobacco use increases the risk of cancers of the lung, mouth, larynx, pharynx, esophagus, stomach, colorectum, liver, pancreas, kidney, bladder, uterine cervix, and ovary (mucinous), as well as myeloid leukemia (13, 14). Limited but mounting evidence suggests that long-term, heavy smoking increases the risk of breast cancer, particularly among women who began smoking before giving birth to their first child (15, 16). Exposure to SHS also increases the risk of lung cancer in adults (13, 17).

According to the 2013 NHIS, an estimated 17.8% of adults (men, 20.5%; women, 15.3%) smoked cigarettes (Table 1), compared with 23.5% in 1999 (18). As shown in Fig. 1, smoking prevalence has declined across all education groups, but has decreased more rapidly among persons with undergraduate or graduate degrees. As shown in Table 1, there is wide variation in cigarette use by education. Smoking prevalence also varied by race/ethnicity and was lowest among Asians (9.6%) and highest in American Indians/Alaska Natives (22.7%) (Table 1). People who identified themselves as gay or lesbian (25.8%) or bisexual (28.6%) had higher smoking prevalence than those who identified as straight (17.6%; Table 1). The prevalence of smoking also varies by state, ranging from 27.3% in West Virginia to 10.3% in Utah (Table 2).

Figure 1.

Current cigarette smoking trendsa, adults 25 years and older, by education, NHIS 1999–2013b. aCurrent smoker: ever smoked 100 cigarettes in lifetime and smoking every day or some days at time of survey. bGED, General Educational Development high school equivalency; HS, high school.

Figure 1.

Current cigarette smoking trendsa, adults 25 years and older, by education, NHIS 1999–2013b. aCurrent smoker: ever smoked 100 cigarettes in lifetime and smoking every day or some days at time of survey. bGED, General Educational Development high school equivalency; HS, high school.

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Table 1.

Prevalence (%) of current cigarette smokinga, adults 18 years and older, NHIS 2013

MalesFemalesOverall
Overall 20.5 15.3 17.8 
Age, y 
 18–24 21.9 15.4 18.7 
 25–44 23.3 17.1 20.1 
 45–64 21.9 18.1 19.9 
 65+ 10.6 7.5 8.8 
Race/ethnicity 
 White (non–Hispanic) 21.2 17.9 19.5 
 Black (non–Hispanic) 22.2 15.6 18.5 
 Hispanic 17.3 7.0 12.1 
 American Indian/Alaska Native 25.9 19.7 22.7 
 Asian (non–Hispanic)b 15.0 4.9 9.6 
Educationc 
 <High school diploma 30.6 18.0 24.2 
 GED 42.3 39.7 41.4 
 High school graduate 26.7 17.6 22.0 
 Some college 20.6 18.8 19.7 
 Undergraduate degree 10.4 7.9 9.1 
 Graduate degree 5.7 5.5 5.6 
Sexual orientation 
 Gay or lesbian 25.8 25.7 25.8 
 Straight 20.3 15.0 17.6 
 Bisexual 28.8 28.5 28.6 
Insurance status 
 Uninsured 33.4 24.7 29.3 
 Insured 17.6 13.6 15.5 
MalesFemalesOverall
Overall 20.5 15.3 17.8 
Age, y 
 18–24 21.9 15.4 18.7 
 25–44 23.3 17.1 20.1 
 45–64 21.9 18.1 19.9 
 65+ 10.6 7.5 8.8 
Race/ethnicity 
 White (non–Hispanic) 21.2 17.9 19.5 
 Black (non–Hispanic) 22.2 15.6 18.5 
 Hispanic 17.3 7.0 12.1 
 American Indian/Alaska Native 25.9 19.7 22.7 
 Asian (non–Hispanic)b 15.0 4.9 9.6 
Educationc 
 <High school diploma 30.6 18.0 24.2 
 GED 42.3 39.7 41.4 
 High school graduate 26.7 17.6 22.0 
 Some college 20.6 18.8 19.7 
 Undergraduate degree 10.4 7.9 9.1 
 Graduate degree 5.7 5.5 5.6 
Sexual orientation 
 Gay or lesbian 25.8 25.7 25.8 
 Straight 20.3 15.0 17.6 
 Bisexual 28.8 28.5 28.6 
Insurance status 
 Uninsured 33.4 24.7 29.3 
 Insured 17.6 13.6 15.5 

Abbreviation: GED, General Educational Development high school equivalency.

aEver smoked 100 cigarettes in lifetime and smoking every day or some days at time of survey.

bDoes not include Native Hawaiians or other Pacific Islanders.

cAmong persons aged 25 years or older.

Table 2.

Prevalence (%) of current cigarette smoking and use of smokeless tobacco products, adults 18 years and older and high school students, by state, BRFSS and YRBS, 2013

AdultsHigh school studentsc
StateCigarette smokingaSmokeless tobacco usebCigarette smokingdSmokeless tobacco usee
Alabama 21.5 6.1 18.0 14.7 
Alaska 22.6 6.8 10.6 9.1 
Arizona 16.3 3.2 14.1 6.6 
Arkansas 25.9 6.9 19.1 14.8 
California 12.5 1.5 — — 
Colorado 17.7 4.3 — — 
Connecticut 15.5 1.8 13.5 — 
Delaware 19.6 2.2 14.2 7.1 
District of Columbia 18.8 1.5 — 4.3 
Florida 16.8 2.6 10.8 — 
Georgia 18.8 5.0 12.8 9.5 
Hawaii 13.3 1.6 10.4 — 
Idaho 17.2 5.7 12.2 8.0 
Illinois 18.0 2.6 14.1 8.4 
Indiana 21.9 4.9 — — 
Iowa 19.5 4.9 — — 
Kansas 20.0 5.5 10.2 8.1 
Kentucky 26.5 7.0 17.9 13.2 
Louisiana 23.5 5.7 12.1 12.7 
Maine 20.2 2.1 12.8 6.0 
Maryland 16.4 2.5 11.9 7.4 
Massachusetts 16.6 1.5 10.7 4.8 
Michigan 21.4 4.0 11.8 6.9 
Minnesota 18.0 5.0 — — 
Mississippi 24.8 8.5 17.2 10.3 
Missouri 22.1 5.2 14.9 10.4 
Montana 19.0 8.0 15.2 13.4 
Nebraska 18.5 5.3 10.9 7.7 
Nevada 19.4 3.2 10.3 5.0 
New Hampshire 16.2 2.6 13.8 7.3 
New Jersey 15.7 1.7 12.9 — 
New Mexico 19.1 4.3 14.4 8.0 
New York 16.6 2.2 10.6 7.0 
North Carolina 20.3 4.3 15.0 8.5 
North Dakota 21.2 7.6 19.0 13.8 
Ohio 23.4 4.2 15.1 8.6 
Oklahoma 23.7 6.3 18.5 12.1 
Oregon 17.3 4.6 — — 
Pennsylvania 21.0 4.4 — — 
Rhode Island 17.4 1.9 8.0 7.0 
South Carolina 22.0 4.4 16.0 7.8 
South Dakota 19.6 6.6 16.5 11.5 
Tennessee 24.3 4.8 15.4 13.3 
Texas 15.9 4.3 14.1 8.1 
Utah 10.3 2.9 4.4 2.6 
Vermont 16.6 2.8 — 9.1 
Virginia 19.0 4.0 11.1 8.3 
Washington 16.1 3.7 — — 
West Virginia 27.3 9.4 19.6 15.9 
Wisconsin 18.7 4.3 11.8 8.0 
Wyoming 20.6 8.8 17.4 14.2 
AdultsHigh school studentsc
StateCigarette smokingaSmokeless tobacco usebCigarette smokingdSmokeless tobacco usee
Alabama 21.5 6.1 18.0 14.7 
Alaska 22.6 6.8 10.6 9.1 
Arizona 16.3 3.2 14.1 6.6 
Arkansas 25.9 6.9 19.1 14.8 
California 12.5 1.5 — — 
Colorado 17.7 4.3 — — 
Connecticut 15.5 1.8 13.5 — 
Delaware 19.6 2.2 14.2 7.1 
District of Columbia 18.8 1.5 — 4.3 
Florida 16.8 2.6 10.8 — 
Georgia 18.8 5.0 12.8 9.5 
Hawaii 13.3 1.6 10.4 — 
Idaho 17.2 5.7 12.2 8.0 
Illinois 18.0 2.6 14.1 8.4 
Indiana 21.9 4.9 — — 
Iowa 19.5 4.9 — — 
Kansas 20.0 5.5 10.2 8.1 
Kentucky 26.5 7.0 17.9 13.2 
Louisiana 23.5 5.7 12.1 12.7 
Maine 20.2 2.1 12.8 6.0 
Maryland 16.4 2.5 11.9 7.4 
Massachusetts 16.6 1.5 10.7 4.8 
Michigan 21.4 4.0 11.8 6.9 
Minnesota 18.0 5.0 — — 
Mississippi 24.8 8.5 17.2 10.3 
Missouri 22.1 5.2 14.9 10.4 
Montana 19.0 8.0 15.2 13.4 
Nebraska 18.5 5.3 10.9 7.7 
Nevada 19.4 3.2 10.3 5.0 
New Hampshire 16.2 2.6 13.8 7.3 
New Jersey 15.7 1.7 12.9 — 
New Mexico 19.1 4.3 14.4 8.0 
New York 16.6 2.2 10.6 7.0 
North Carolina 20.3 4.3 15.0 8.5 
North Dakota 21.2 7.6 19.0 13.8 
Ohio 23.4 4.2 15.1 8.6 
Oklahoma 23.7 6.3 18.5 12.1 
Oregon 17.3 4.6 — — 
Pennsylvania 21.0 4.4 — — 
Rhode Island 17.4 1.9 8.0 7.0 
South Carolina 22.0 4.4 16.0 7.8 
South Dakota 19.6 6.6 16.5 11.5 
Tennessee 24.3 4.8 15.4 13.3 
Texas 15.9 4.3 14.1 8.1 
Utah 10.3 2.9 4.4 2.6 
Vermont 16.6 2.8 — 9.1 
Virginia 19.0 4.0 11.1 8.3 
Washington 16.1 3.7 — — 
West Virginia 27.3 9.4 19.6 15.9 
Wisconsin 18.7 4.3 11.8 8.0 
Wyoming 20.6 8.8 17.4 14.2 

aSmoked 100 cigarettes in their entire lifetime and are current smokers (regular and irregular).

bReported currently using chewing tobacco, snuff, or snus every day or some days.

cData on high school students previously reported by Kann et al. (27).

dSmoked cigarettes on one or more of the 30 days preceding the survey.

eUsed chewing tobacco, snuff, or dip on one or more of the 30 days preceding the survey.

—, Not all states participated and provided weighted YRBS data in 2013.

Other forms of tobacco

Cigar smoking increases the risk of cancers of the lung, oral cavity, larynx, esophagus, and likely the pancreas (19). While cigarette smoking has declined in the past decade, per capita consumption of loose tobacco and cigars increased 123.1% between 2000 and 2011 (11). According to 2012–2013 NATS, the prevalence of smoking cigars (including cigarillos and filtered little cigars) every day or some days was 2.0% (men, 3.2%; women, 0.7%) among U.S. adults 18 years and older (11). Cigar use (every day or some days) was highest among non–Hispanic blacks (3.7%) and those with household incomes <$20,000 (3.8%) (11).

Smokeless tobacco products, including chewing tobacco and snuff, increase the risk of oral, pancreatic, and esophageal cancer, as well as noncancerous oral conditions (20). The use of smokeless tobacco has remained stable since 2005 (21). According to NATS, in 2012–2013, 2.6% of adults 18 and older (4.8% of men and 0.8% of women) used smokeless products every day or some days (11). Young adults (18–24 years of age, 4.4%) were two times more likely to use smokeless products than older adults (45–65 years of age, 2.1%; 65+ years of age, 1.0%; ref. 11). During the same period, smokeless tobacco use among non–Hispanic whites (3.0%) was higher than among Hispanics (0.6%) and non–Hispanic blacks (1.0%; ref. 11). According to the 2013 BRFSS data, smokeless tobacco use was highest in West Virginia (9.4%) and lowest in California, the District of Columbia, and Massachusetts (1.5%; Table 2).

The health risks of e-cigarettes are not fully known (22, 23), though there is growing concern in the public health community that e-cigarette use will normalize cigarette smoking and lead to the use of other forms of tobacco products with known health risks (22, 24). In 2012–2013, 1.9% of adults were (every day or some days) e-cigarette users (11). The prevalence of ever use of e-cigarettes nearly doubled between 2010 (3.3%) and 2011 (6.1%; ref. 24). Concomitantly, expenditures on e-cigarette advertising have tripled in recent years (25).

Youth tobacco use

Approximately 90% of adults who smoke began smoking before the age of 18 (26). Adolescents are more sensitive to nicotine and appear to become more easily addicted (26). Further, the cumulative increase in the risk of cancer with increased duration of smoking makes youth smoking an important aspect of cancer control (26).

According to the 2013 YRBS, current cigarette use (smoked on one or more of the 30 days preceding the survey) among high school students decreased from 36.4% in 1997 to 15.7% in 2013; the decrease was much larger during 1997–2003 (36.4% to 21.9%) than during 2003–2013 (21.9% to 15.7%; Supplementary Fig. S1; refs. 8, 27). In 2013, current smoking was slightly higher among males (16.4%) than among females (15.0%; Supplementary Table S1). Patterns of smoking by race/ethnicity for high school students were different than patterns observed in adults where higher among white high school students (18.6%) than blacks (8.2%) and Hispanics (13.1%) (27). As was observed among adults, current smoking among high school students was highest in West Virginia (19.6%) and lowest in Utah (4.4%; Table 2).

Though cigarettes remain the primary tobacco product regularly used by youth and has declined over time, the use of other forms of tobacco, including cigars, smokeless tobacco products, and hookahs (tobacco water pipes), is becoming relatively common. In 2013, 12.6% of high school students reported current use (defined as using cigar/smokeless tobacco on one or more of the 30 days preceding the survey) of cigars and 8.8% reported current use of smokeless tobacco (Supplementary Table S1; ref. 27). Male high school students had noticeably higher cigar use (16.5%) compared with females (8.7%; ref. 27). Males also had higher prevalence of smokeless tobacco use (14.7%) than females (2.9%) (27). Smokeless tobacco use was particularly high among white males (20.6%) compared with Hispanic (7.7%) and black males (4.4%) (Supplementary Table S1; ref. 27). By state, smokeless tobacco use ranged from 2.6% in Utah to 15.9% in West Virginia (Table 2).

An emerging trend among adolescents and young adults is the use of hookahs. In 2012, about 5% of high school students reported current (past 30 days) hookah use (28). Increasing use of hookah is likely associated with the growing number of hookah “bars” and the misperceptions regarding the relative health hazards of hookah use compared with cigarette smoking (29).

Use of e-cigarettes is also increasing among youth. The prevalence of current e-cigarette use among high school students increased from 1.5% in 2011 to 4.5% in 2013 (28). Ever use of e-cigarettes among high school students has more than doubled over the same time period from 4.7% in 2011 to 11.9% in 2013 (30, 31). The growing prevalence of e-cigarette use is likely due to increased awareness and advertising of e-cigarettes (32). Between 2011 and 2013, there was a 256% increase in youth exposure to e-cigarette advertising (32).

Tobacco cessation in adults and youth

Risk of cancer death decreases with smoking cessation; smokers who quit can expect to live as many as 10 years longer than those who continue to smoke (33). Since 2002, there have been more former smokers than current smokers in the United States. According to the 2013 NHIS, approximately 55.2% (51.9 million) of the 94.1 million Americans who have ever smoked 100 cigarettes in their lifetime are former smokers (5). Most smokers who still smoke have tried to quit; of the 42.1 million Americans who currently smoke, 20.1 million (47.7%) reported having attempted to quit for at least 1 day in the past year (5). In 2013, 48.0% of high school smokers made a quit attempt in the past 12 months (27). Cancer survivors who quit smoking have better health outcomes than those who do not (13). However, it is estimated that approximately 9 years after diagnosis, 1 in 10 cancer survivors reports current (past 30 day) smoking (34).

There are several interventions shown to improve smokers' probability of long-term abstinence (35) that include nicotine replacement therapy (NRT) products, prescription medications other than NRT, or combinations of these medications and counseling (individual, group, or telephone; refs. 35, 36). Utilization of smoking cessation interventions in the United States is low; in a 2010 survey of current smokers who tried to quit or former smokers who successfully quit, only about a third (31.7%) used counseling and/or medication (37).

Obesity, physical inactivity, and poor nutrition are major risk factors for cancer, second only to tobacco use (1, 38, 39). The World Cancer Research Fund estimates that about one quarter to one third of all cancers in the United States can be attributed to diet and insufficient physical activity, as well as overweight and obesity (2).

Overweight and obesity

Being overweight and obese is associated with increased risk for many cancers, including cancers of the breast in postmenopausal women (40), colon and rectum (41), endometrium, kidney, and pancreas (41, 42), as well as adenocarcinoma of the esophagus (39). In addition, obesity likely increases the risk of cancer of the gallbladder (41) and may also increase the risk of cancers of the liver, cervix, and ovary; multiple myeloma; non-Hodgkin lymphoma; and aggressive forms of prostate cancer (43–45). Although knowledge about the relationship between weight loss and cancer risk is limited, studies suggest that losing weight may reduce the risk of postmenopausal breast cancer (46–48).

Obesity prevalence in adults

In 2013, more than two thirds of American adults were overweight or obese (49). As shown in Fig. 2, the prevalence of obesity increased rapidly since 1976, but has stabilized in recent years (between 2002 and 2012) overall and in most age/gender groups. However, obesity among women ≥60 years has increased from 31.5% to 38.1% between 2003–2004 and 2011–2012 (49). According to the most recent NHANES data (2011–2012), among women, blacks had the highest obesity prevalence (57.4%) followed by Hispanic (45.2%), non–Hispanic white (33.3%), and Asian (11.3%) women. Among men, Hispanics had the highest obesity prevalence (40.9%) followed by black (37.5%), non–Hispanic white (32.8%), and Asian men (10.8%). Among non–Hispanic whites, lesbians were more likely to be obese (55.3%) compared with heterosexual women (50.5%), while gay men were less likely to be overweight (56.6%) compared with heterosexual men (69.4%; ref. 50). In 2013, obesity prevalence varied widely by state, ranging from 21.3% in Colorado to 35.1% in Mississippi (Table 3).

Figure 2.

Age-adjusted obesitya prevalence trends, adults 20 to 74 years by gender and race/ethnicity, NHANES 1976–2012b. aBMI of 30.0 kg/m2 or greater. bNH Asian persons for the first time in 2011–12 NHANES and were oversampled.

Figure 2.

Age-adjusted obesitya prevalence trends, adults 20 to 74 years by gender and race/ethnicity, NHANES 1976–2012b. aBMI of 30.0 kg/m2 or greater. bNH Asian persons for the first time in 2011–12 NHANES and were oversampled.

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Table 3.

Prevalence (%) of obesity and physical activity measures, adults 18 years and older and high school students, by state, BRFSS and YRBS, 2013

AdultsStudents
StateObeseaNo leisure-time physical activity in past 30 daysMet recommended levels of aerobic activitybObesecAttend PE dailyMet recommended levels of physical activityd
Alabama 32.4 31.5 44.7 17.1 35.7 24.8 
Alaska 28.4 22.3 55.0 12.4 16.0 20.9 
Arizona 26.8 25.2 51.0 10.7 23.0 21.7 
Arkansas 34.6 34.4 40.3 17.8 23.0 27.5 
California 24.1 21.4 56.0 — — — 
Colorado 21.3 17.9 59.5 — — — 
Connecticut 25.0 24.9 50.2 12.3 — 26.0 
Delaware 31.1 27.8 48.9 14.2 13.1 23.7 
District of Columbia 22.9 19.5 57.8 14.8 — 16.4 
Florida 26.4 27.7 49.4 11.6 24.2 25.3 
Georgia 30.3 27.2 50.1 12.7 33.6 24.7 
Hawaii 21.8 22.1 59.1 13.4 7.3 22.0 
Idaho 29.6 23.7 53.9 9.6 22.4 27.9 
Illinois 29.4 25.1 51.2 11.5 63.6 25.4 
Indiana 31.8 31.1 43.7 — — — 
Iowa 31.3 28.5 46.1 — — — 
Kansas 30.0 26.5 48.3 12.6 27.9 28.3 
Kentucky 33.2 30.2 45.8 18.0 19.3 22.5 
Louisiana 33.1 32.2 44.5 13.5 33.6 — 
Maine 28.9 23.3 53.4 11.6 4.5 22.3 
Maryland 28.3 25.3 48.0 11.0 18.2 21.6 
Massachusetts 23.6 23.5 53.6 10.2 16.7 23.0 
Michigan 31.5 24.4 52.4 13.0 26.8 26.7 
Minnesota 25.5 23.5 52.1 — — — 
Mississippi 35.1 38.1 36.5 15.4 28.7 25.9 
Missouri 30.4 28.3 47.4 14.9 30.9 27.2 
Montana 24.6 22.5 56.9 9.4 34.9 27.7 
Nebraska 29.6 25.3 49.5 12.7 34.9 32.3 
Nevada 26.2 23.7 52.4 11.4 25.9 24.0 
New Hampshire 26.7 22.4 54.6 11.2 18.2 22.9 
New Jersey 26.3 26.8 50.0 8.7 45.2 27.6 
New Mexico 26.4 24.3 54.4 12.6 25.1 31.1 
New York 25.4 26.7 47.1 10.6 18.9 25.7 
North Carolina 29.4 26.6 48.1 12.5 — 25.9 
North Dakota 31.0 27.6 45.1 13.5 — 24.7 
Ohio 30.4 28.5 48.9 13.0 — 25.9 
Oklahoma 32.5 33.0 43.0 11.8 32.2 38.5 
Oregon 26.5 18.6 63.2 — — — 
Pennsylvania 30.0 26.3 47.5 — — — 
Rhode Island 27.3 26.9 48.5 10.7 25.7 23.2 
South Carolina 31.7 26.9 48.2 13.9 — 23.8 
South Dakota 29.9 23.9 53.2 11.9 18.5 27.7 
Tennessee 33.7 37.2 37.0 16.9 22.3 25.4 
Texas 30.9 30.1 41.7 15.7 38.3 30.0 
Utah 24.1 20.6 54.4 6.4 18.6 19.7 
Vermont 24.7 20.5 58.5 13.2 14.5 25.4 
Virginia 27.2 25.5 51.3 12.0 13.3 23.8 
Washington 27.2 20.0 55.7 — — — 
West Virginia 35.1 31.4 47.1 15.6 30.7 31.0 
Wisconsin 29.8 23.8 52.3 11.6 39.4 24.0 
Wyoming 27.8 25.1 53.6 10.7 23.7 28.2 
AdultsStudents
StateObeseaNo leisure-time physical activity in past 30 daysMet recommended levels of aerobic activitybObesecAttend PE dailyMet recommended levels of physical activityd
Alabama 32.4 31.5 44.7 17.1 35.7 24.8 
Alaska 28.4 22.3 55.0 12.4 16.0 20.9 
Arizona 26.8 25.2 51.0 10.7 23.0 21.7 
Arkansas 34.6 34.4 40.3 17.8 23.0 27.5 
California 24.1 21.4 56.0 — — — 
Colorado 21.3 17.9 59.5 — — — 
Connecticut 25.0 24.9 50.2 12.3 — 26.0 
Delaware 31.1 27.8 48.9 14.2 13.1 23.7 
District of Columbia 22.9 19.5 57.8 14.8 — 16.4 
Florida 26.4 27.7 49.4 11.6 24.2 25.3 
Georgia 30.3 27.2 50.1 12.7 33.6 24.7 
Hawaii 21.8 22.1 59.1 13.4 7.3 22.0 
Idaho 29.6 23.7 53.9 9.6 22.4 27.9 
Illinois 29.4 25.1 51.2 11.5 63.6 25.4 
Indiana 31.8 31.1 43.7 — — — 
Iowa 31.3 28.5 46.1 — — — 
Kansas 30.0 26.5 48.3 12.6 27.9 28.3 
Kentucky 33.2 30.2 45.8 18.0 19.3 22.5 
Louisiana 33.1 32.2 44.5 13.5 33.6 — 
Maine 28.9 23.3 53.4 11.6 4.5 22.3 
Maryland 28.3 25.3 48.0 11.0 18.2 21.6 
Massachusetts 23.6 23.5 53.6 10.2 16.7 23.0 
Michigan 31.5 24.4 52.4 13.0 26.8 26.7 
Minnesota 25.5 23.5 52.1 — — — 
Mississippi 35.1 38.1 36.5 15.4 28.7 25.9 
Missouri 30.4 28.3 47.4 14.9 30.9 27.2 
Montana 24.6 22.5 56.9 9.4 34.9 27.7 
Nebraska 29.6 25.3 49.5 12.7 34.9 32.3 
Nevada 26.2 23.7 52.4 11.4 25.9 24.0 
New Hampshire 26.7 22.4 54.6 11.2 18.2 22.9 
New Jersey 26.3 26.8 50.0 8.7 45.2 27.6 
New Mexico 26.4 24.3 54.4 12.6 25.1 31.1 
New York 25.4 26.7 47.1 10.6 18.9 25.7 
North Carolina 29.4 26.6 48.1 12.5 — 25.9 
North Dakota 31.0 27.6 45.1 13.5 — 24.7 
Ohio 30.4 28.5 48.9 13.0 — 25.9 
Oklahoma 32.5 33.0 43.0 11.8 32.2 38.5 
Oregon 26.5 18.6 63.2 — — — 
Pennsylvania 30.0 26.3 47.5 — — — 
Rhode Island 27.3 26.9 48.5 10.7 25.7 23.2 
South Carolina 31.7 26.9 48.2 13.9 — 23.8 
South Dakota 29.9 23.9 53.2 11.9 18.5 27.7 
Tennessee 33.7 37.2 37.0 16.9 22.3 25.4 
Texas 30.9 30.1 41.7 15.7 38.3 30.0 
Utah 24.1 20.6 54.4 6.4 18.6 19.7 
Vermont 24.7 20.5 58.5 13.2 14.5 25.4 
Virginia 27.2 25.5 51.3 12.0 13.3 23.8 
Washington 27.2 20.0 55.7 — — — 
West Virginia 35.1 31.4 47.1 15.6 30.7 31.0 
Wisconsin 29.8 23.8 52.3 11.6 39.4 24.0 
Wyoming 27.8 25.1 53.6 10.7 23.7 28.2 

Abbreviation: PE, physical education.

aObese defined as BMI 30 kg/m2 or greater.

bIncludes 150 minutes of moderate intensity activity or 75 minutes of vigorous intensity activity each week.

cBMI at or above 95th percentile of age- and sex-specific 2000 CDC growth chart.

dPhysical activity that increased heart rate and made breathing difficult some of the time for a total of at least 60 minutes/day on all 7 days preceding the survey.

Obesity prevalence in youth

Between 1976 and 2002, there were rapid increases in obesity prevalence among adolescents (ages 12–19 years), from 5.0% to 16.0%, and this trend was observed across all race/ethnicities and genders (Fig. 3; ref. 51). Since 2002, obesity prevalence has remained stable in adolescents overall, though a recent study observed declining obesity in 2 to 5-year-olds from 13.9% in 2003–2004 to 8.4% in 2011–2012 (49). During 2011–2012, the prevalence of obesity among all children and adolescents ages 2 to 19 years was 16.7% among boys and 17.2% among girls (49). Among girls 12 to 19 years, obesity prevalence was lowest among non–Hispanic Asians (7.3%) and highest among non–Hispanic blacks (22.7%) in 2011–2012 (Fig. 3; ref. 49). Among boys 12 to 19 years, obesity prevalence was lowest among non–Hispanic Asians (14.8%) and highest in Hispanics (23.9%) in 2011–2012. The percentage of U.S. high school students who were obese in 2013 varied widely across states, ranging from about 6% in Utah to 18% in Kentucky (Table 3).

Figure 3.

Obesitya prevalence trends, youth 12 to 19 years, by gender and race/ethnicity, NHANES 1976–2012b. aBMI at or above the sex- and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMI-for-age CDC growth charts. bNH Asian persons for the first time in 2011–12 NHANES.

Figure 3.

Obesitya prevalence trends, youth 12 to 19 years, by gender and race/ethnicity, NHANES 1976–2012b. aBMI at or above the sex- and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMI-for-age CDC growth charts. bNH Asian persons for the first time in 2011–12 NHANES.

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Physical activity

Physical activity acts in a variety of ways to reduce the risk of several types of cancer, including cancers of the breast, colon, and endometrium (38). In addition, regular physical activity helps maintain a healthy body weight by increasing energy expenditure.

Physical activity in adults

In 2013, 30.5% of adults reported no leisure-time physical activity during an average week (Supplementary Table S2). About one half (50.1%) of adults reported meeting recommended levels of aerobic activity (at least 150 minutes of moderate or 75 minutes of vigorous activity per week; men, 54.3%; women, 46.2%; Supplementary Table S2). Oregon (63.2%) had the highest proportion of adults who reported meeting recommended levels of aerobic activity, whereas Mississippi (36.5%) had the lowest (Table 3).

Physical activity in youth

In 2013, 27.1% of U.S. high school students met recommended levels of physical activity and 29.4% attended physical education classes daily (Supplementary Table S3). The proportion of high school students meeting recommended physical activity levels varied by state, ranging from 16.4% in the District of Columbia to 38.5% in Oklahoma. Daily physical education class attendance ranged from 4.5% in Maine to 63.6% in Illinois (Table 3).

Nutrition

Fruit and vegetable intake.

Higher consumption of non-starchy vegetables and fruits is associated with lower risk of mouth, pharynx, larynx, esophageal, and stomach cancers (52). Recent evidence also suggests that consuming non-starchy vegetables lowers the risk of estrogen receptor–negative breast tumors (53).

In 2013, the prevalence of consuming three or more servings of vegetables among adults ranged from 10.6% in Oklahoma to 22.7% in California, with a national median of 15.1% (Table 4). A median of 29.8% of adults reported eating two or more servings of fruits daily in 2013, ranging from 17.6% in Tennessee to 39.8% in California. In 2013, 15.7% of high school students reported consuming vegetables three or more times per day, with the lowest proportion in South Carolina (9.7%) and the highest in New Mexico (17.5%; Table 4). In 2013, about 1 in 3 (33.2%) high school students consumed 100% fruit juice or fruit two or more times a day, ranging from 24.0% in Alabama to 34.3% in Utah.

Table 4.

Consumption (%) of fruits and vegetables, adults 18 years and older and high school students, by state, BRFSS and YRBS, 2013

AdultsStudents
State≥2 Fruit servings per day≥ 3 Vegetable servings per dayaFruit or 100% fruit juice ≥2 times per dayAte vegetables ≥3 times per dayb
Alabama 20.3 12.4 24.0 11.0 
Alaska 30.5 19.5 29.3 15.5 
Arizona 27.8 17.7 — — 
Arkansas 22.4 13.0 25.7 13.8 
California 39.8 22.7 — — 
Colorado 33.5 18.1 — — 
Connecticut 34.4 15.7 31.0 14.6 
Delaware 30.2 14.3 34.1 — 
District of Columbia 35.2 18.5 29.1 13.6 
Florida 31.7 16.8 34.1 15.1 
Georgia 26.0 16.0 29.1 11.4 
Hawaii 29.1 18.3 27.1 — 
Idaho 30.6 17.6 28.4 13.1 
Illinois 34.5 16.9 32.6 12.4 
Indiana 27.2 13.2 — — 
Iowa 27.5 11.8 — — 
Kansas 24.2 14.2 26.8 12.4 
Kentucky 22.8 11.7 25.7 11.6 
Louisiana 20.9 11.3 — — 
Maine 34.3 17.9 32.0 — 
Maryland 30.9 16.1 31.9 13.8 
Massachusetts 33.8 16.9 — — 
Michigan 30.1 13.8 29.2 11.9 
Minnesota 30.2 14.3 — — 
Mississippi 21.7 10.9 25.4 14.4 
Missouri 25.2 13.2 24.6 11.5 
Montana 28.9 16.5 28.2 13.2 
Nebraska 29.8 14.2 26.4 11.7 
Nevada 30.7 17.6 29.4 11.6 
New Hampshire 32.7 17.0 — — 
New Jersey 31.3 15.1 30.8 11.8 
New Mexico 28.3 17.8 29.9 17.5 
New York 34.1 16.2 33.2 — 
North Carolina 23.6 12.7 27.1 12.5 
North Dakota 28.1 11.7 28.9 12.0 
Ohio 26.4 12.9 30.1 12.0 
Oklahoma 19.0 10.6 24.1 11.2 
Oregon 34.6 19.7 — — 
Pennsylvania 30.1 13.4 — — 
Rhode Island 32.9 14.9 32.6 13.8 
South Carolina 25.5 12.5 27.5 9.7 
South Dakota 26.4 11.6 30.5 12.5 
Tennessee 17.6 11.2 27.5 12.3 
Texas 23.5 14.9 29.4 10.8 
Utah 33.4 17.2 34.3 14.2 
Vermont 34.7 18.1 — — 
Virginia 31.3 16.4 31.4 12.9 
Washington 28.3 16.4 — — 
West Virginia 19.0 11.7 31.2 15.3 
Wisconsin 31.0 13.0 33.9 — 
Wyoming 27.3 16.3 31.3 16.4 
United Statesc 29.8 15.1 33.2 15.7 
AdultsStudents
State≥2 Fruit servings per day≥ 3 Vegetable servings per dayaFruit or 100% fruit juice ≥2 times per dayAte vegetables ≥3 times per dayb
Alabama 20.3 12.4 24.0 11.0 
Alaska 30.5 19.5 29.3 15.5 
Arizona 27.8 17.7 — — 
Arkansas 22.4 13.0 25.7 13.8 
California 39.8 22.7 — — 
Colorado 33.5 18.1 — — 
Connecticut 34.4 15.7 31.0 14.6 
Delaware 30.2 14.3 34.1 — 
District of Columbia 35.2 18.5 29.1 13.6 
Florida 31.7 16.8 34.1 15.1 
Georgia 26.0 16.0 29.1 11.4 
Hawaii 29.1 18.3 27.1 — 
Idaho 30.6 17.6 28.4 13.1 
Illinois 34.5 16.9 32.6 12.4 
Indiana 27.2 13.2 — — 
Iowa 27.5 11.8 — — 
Kansas 24.2 14.2 26.8 12.4 
Kentucky 22.8 11.7 25.7 11.6 
Louisiana 20.9 11.3 — — 
Maine 34.3 17.9 32.0 — 
Maryland 30.9 16.1 31.9 13.8 
Massachusetts 33.8 16.9 — — 
Michigan 30.1 13.8 29.2 11.9 
Minnesota 30.2 14.3 — — 
Mississippi 21.7 10.9 25.4 14.4 
Missouri 25.2 13.2 24.6 11.5 
Montana 28.9 16.5 28.2 13.2 
Nebraska 29.8 14.2 26.4 11.7 
Nevada 30.7 17.6 29.4 11.6 
New Hampshire 32.7 17.0 — — 
New Jersey 31.3 15.1 30.8 11.8 
New Mexico 28.3 17.8 29.9 17.5 
New York 34.1 16.2 33.2 — 
North Carolina 23.6 12.7 27.1 12.5 
North Dakota 28.1 11.7 28.9 12.0 
Ohio 26.4 12.9 30.1 12.0 
Oklahoma 19.0 10.6 24.1 11.2 
Oregon 34.6 19.7 — — 
Pennsylvania 30.1 13.4 — — 
Rhode Island 32.9 14.9 32.6 13.8 
South Carolina 25.5 12.5 27.5 9.7 
South Dakota 26.4 11.6 30.5 12.5 
Tennessee 17.6 11.2 27.5 12.3 
Texas 23.5 14.9 29.4 10.8 
Utah 33.4 17.2 34.3 14.2 
Vermont 34.7 18.1 — — 
Virginia 31.3 16.4 31.4 12.9 
Washington 28.3 16.4 — — 
West Virginia 19.0 11.7 31.2 15.3 
Wisconsin 31.0 13.0 33.9 — 
Wyoming 27.3 16.3 31.3 16.4 
United Statesc 29.8 15.1 33.2 15.7 

aVegetables included cooked or canned beans, dark green vegetables, orange colored vegetables or other vegetables (excludes fried potatoes).

bVegetables include green salad, potatoes (excluding French fries, fried potatoes, or potato chips), carrots, or other vegetables, during the 7 days preceding the survey.

cFor adults, the median fruit/vegetable consumption are presented. For high school students, nationwide fruit/vegetable consumption estimates are presented.

Other dietary factors.

There are several other dietary factors that protect against or increase the risk of developing certain cancers. Although evidence for an association between whole-grain foods and different types of cancer is limited, a recent meta-analysis found that for every 10 grams of daily fiber consumed, the risk of colorectal cancer was reduced by 10% (54). Total grain consumption in the United States is higher than recommended levels, but most of this is attributed to the overconsumption of refined grains. In 2007–2010, the average daily consumption of whole grains represented only 12% of the total grains consumed (6.46 ounces), which was well below the U.S. Department of Agriculture recommendation that at least half of grains consumed should be whole grains (55).

High intake of processed or red meat has been convincingly associated with increased risk of colorectal cancer (56) but limited and suggestive evidence for increased risk of pancreatic cancer (57). Red meat consumption has decreased since the 1970s and declined from 105 grams/capita/day in 1970 to 85 grams/capita/day in 2007, but remains the most common type of meat consumed in the United States (58% of the total meat intake) (58). Alcohol consumption is an established cause of cancers of the mouth, pharynx, larynx, esophagus, liver, colorectum, and female breast, and there is some evidence of an association with pancreatic cancer (38, 39, 59, 60). Combined with tobacco use, alcohol consumption increases the risk of cancers of the mouth, larynx, and esophagus far more than the independent effect of either drinking or smoking (38). Breast cancer risk increases with increasing intake of alcohol (61). According to 2012 nationwide data, the prevalence of heavier drinking (defined as 2 or more drinks per day for men and 1 or more for women) was around 5% for adults ages 18 years and older (51).

UVR is a risk factor for skin cancer, including, basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma (62, 63). Incidence of BCC and SCC is difficult to estimate as cancer registries do not require reporting of nonmelanoma skin cancers, though a study using Medicare claims data estimated 2.2 million people were diagnosed with BCC and SCC in 2006 (64). An estimated 73,870 people will be diagnosed and 9,940 will die from melanoma in 2015 (3). The incidence of melanoma in the United States has been increasing in the past 30 years, in part, due to changes in behavior that have resulted in increased exposure to solar UVR, use of indoor tanning devices by young adult white women, and increased awareness and detection practices (65–67).

Prevalence of skin-protective behaviors

Studies show that most adults and adolescents in the United States do not regularly protect themselves against exposure to UVR when outdoors on sunny days (68). In 2010, national data showed that 32.1% of adults reported always or often using sunscreen when outside for an hour or more on a warm, sunny day in the past 12 months, and 37.1% reported seeking shade, while fewer adults reported clothing protection behaviors, including wearing hats (12.8%) or long-sleeved shirts (11.5%) (69). In 2013, only 10.1% of U.S. high school students reported using sunscreen routinely (27).

Indoor tanning devices

Exposure to artificial UVR occurs through the use of indoor tanning booths or lamps. The International Agency for Research on Cancer (IARC) lists UV-emitting indoor tanning devices as carcinogenic to humans (65). In 2013, 4.4% of U.S. adults reported using an indoor tanning device in the past year; use was highest among women (6.9%), non–Hispanic whites (6.6%), ages 18 to 29 years (8.6%), and those living in the Midwest (7.5%; Supplementary Table S4). In the 2013 YRBS, 20.2% and 5.3% of high school girls and boys reported using an indoor tanning device in the previous year, respectively (Supplementary Table S4). Because UVR exposure in childhood and teenage years is particularly detrimental, policy makers in some states are regulating the use of tanning devices by minors (70).

The IARC has classified 11 infectious agents as carcinogenic to humans, including select strains of HPV, HBV, hepatitis C virus (HCV), human immunodeficiency virus type 1 (HIV), human T-cell lymphotrophic virus type-1, Epstein–Barr virus (EBV), Kaposi sarcoma herpesvirus, Heliobacter pylori (H. pylori), Clonorchis sinensis, Opisthorchis viverrini, and Schistosoma haematobium (71). In this review, we provide data on five of these infectious agents (HPV, HBV, HCV, HIV, and H. pylori), which are responsible for the majority of cancers associated with infectious agents in the United States (72).

HPV

HPV is the most common sexually transmitted infection in the United States, with approximately 14 million people becoming newly infected annually (73). Virtually all cervical cancers are causally related to persistent HPV infections. Further, persistent infection with HPV causes 90% of all anal cancers, about 60% of SCCs in the oropharynx and 40% of vaginal, vulvar, and penile cancers (74). Three vaccines have now been approved by the U.S. Food and Drug Administration (FDA) for the prevention of HPV infection. Two of the vaccines provide protection against HPV types causing 70% of cervical cancers (75). The most recently approved vaccine offers protection against nine types of HPV and prevention of approximately 90% of cervical, vulvar, vaginal and anal cancers (76).

In 2013, 37.6% of U.S. girls ages 13 to 17 years received the complete three-dose HPV vaccination series in 2013, up from 5.9% in 2007; among adolescent boys, complete vaccination increased from 1.3% in 2011 to 13.9% in 2013 (Supplementary Table S5; ref. 77). Approximately 57.3% of girls and 34.6% of boys ages 13 to 17 years have initiated the HPV vaccine (at least 1 of the 3-dose series; Supplementary Table S5). Initiation of HPV vaccination for adolescent girls ranged from 39.9% in Kansas to 76.6% in Rhode Island and from 11.0% in Utah to 69.3% in Rhode Island among boys in 2013. (Supplementary Table S5). Despite the increases in HPV vaccination uptake among adolescents in the United States, HPV vaccination coverage is considerably lower than countries with national screening programs, including the UK and Portugal, where ≥80% of adolescent girls have received all 3 doses of the HPV vaccine (78).

HBV

Chronic infection with HBV causes liver cancer (79). It accounts for 58% and 23% of liver cancers in developing and developed countries, respectively (80). HBV is also increasingly recognized as a risk factor for non-Hodgkin lymphoma (81). Approximately 700,000 to 2.2 million people are living with chronic HBV infection in the United States, and an estimated 38,000 people are newly infected each year (82–84). Most new HBV cases (95%) in the United States are among people who immigrated from countries where HBV infection is more common (85). Vaccination against HBV has been the primary prevention strategy in reducing prevalence of the virus (82, 86). According to the 2013 National Immunization Survey—Teen, 93.2% of adolescents ages 13 to 17 years received at least 3 HBV vaccine doses (Supplementary Table S5); HBV vaccination did not vary across poverty levels, but was slightly lower among Asians (87.8%) compared with other racial/ethnic groups (non–Hispanic whites 93.8%, non–Hispanic black 93.2%, Hispanic 92.8%; ref. 10).

HCV

Chronic infection with HCV also causes cirrhosis and liver cancer and may increase risk of non-Hodgkin lymphoma (71, 87). Liver cancer incidence has increased in the United States in recent years, and HCV-related mortality is also increasing (88). These trends have been attributed to the HCV epidemic that began in the late 1960s, primarily as a result of increased injection drug use (89). In 2013, the United States Preventive Services Task Force (USPSTF) updated their recommendations to include one-time screening among men and women born between 1945 and 1965 because people born during this time period represent about three fourths of the HCV infections in the United States (90). In contrast with HBV infection, there is no vaccine to protect against HCV infection. Until recently, HCV was treated with a combination of drugs that initiated the body's immune response and helped prevent HCV replication; however, these drugs cured only a fraction of HCV infections and required patients to receive weekly injections for up to 48 weeks (91, 92). In the past 5 years, the treatments available for HCV have rapidly changed and the FDA has approved several direct-acting antivirals that have higher cure rates of HCV, and only require 12 weeks of treatment (91–94, 95). However, there is some concern about the affordability and accessibility of these drugs, which may cost $64,000–84,000 for a course of treatment (96, 97).

According to the 2003–2010 NHANES data, 3.6 million Americans, or 1.3% of the noninstitutionalized U.S. population, had past or present HCV infection and 2.7 million, or 1.0%, had chronic HCV infection (98). HCV infection was more common among males, non–Hispanic blacks, and those with lower socioeconomic status (98). HCV prevalence was higher in certain subgroups, including the homeless (22.2%–52.5%), the incarcerated (23.1%–41.2%), and veterans (5.4%–10.7%; ref. 99).

HIV

HIV infection increases the risk of several cancers. There are several acquired immunodeficiency syndrome (AIDS)–defining cancers, including Kaposi sarcoma, certain types of lymphoma (diffuse large B-cell, B-cell immunoblastic, and small-cell cleaved lymphomas), and cervical cancer (100). People infected with HIV are at an increased risk for other cancer-causing infectious agents (such as HCV, HBV, HPV, and EBV) and have higher incidence of cancers (including liver, anal cancer, oropharyngeal and Hodgkin lymphoma) associated with these infectious agents (101–103).

In 2010, there were an estimated 1.1 million people ages 13 years and older living with HIV in the United States (104). Since the mid-1990s, although incidence has remained stable, the prevalence of HIV infection has increased due to improvements in survival among those with HIV as highly active antiretroviral therapy became available (104, 105). In 2011, the majority of people living with HIV infection in the United States were males (75.9%) and males who have sex with males (65.7%; ref. 104). Compared with non–Hispanic whites, prevalence rates were 8 times higher among blacks and 2.5 times higher among Hispanics (104). Further, HIV prevalence varies by geographic region, with higher concentration in urban areas and higher prevalence in the South compared with other parts of the country (106).

H. pylori

Chronic infection with the bacterium H. pylori causes stomach cancer and gastric lymphoma (107, 108). Stomach cancer was a leading cause of cancer-related deaths in the United States in the early part of the 20th century; however, stomach cancer is not even among the top 10 causes of cancer-related death currently. This large decline in stomach cancer incidence is thought to be related to improvements in hygiene and changes in dietary patterns (increased consumption of fresh fruits and vegetables as opposed to preserved foods; refs. 109–111). In other parts of the world, particularly in low- and middle-income countries, stomach cancer is still one of the leading causes of cancer deaths (112). According to the 1999–2000 NHANES data, approximately 30.7% of adults in the United States were seropositive for H. pylori (113). H. pylori infection is higher among Mexican Americans (64.0%) and non–Hispanic blacks (52.0%), compared with non–Hispanic whites (21.2%; ref. 113). H. pylori prevalence is higher among those who recently immigrated to the United States (114). In 2014, IARC recommended that countries with high gastric cancer incidence (including China and Japan) should incorporate H. pylori screening and treatment into their cancer control programs (115). In the United States, there is no recommendation to screen asymptomatic people for H. pylori because of the low gastric cancer incidence among Americans.

Breast cancer screening

In the United States, female breast cancer death rates have been declining since 1989, due to early detection by mammography screening and improvements in treatment (3). Mammography screening reduces breast cancer mortality by detecting cancers at an earlier stage (116). Despite the relatively high prevalence of mammography screening in the United States, studies suggest that many women are initiating mammography later than recommended, are not having mammography at recommended intervals (117), or are not receiving appropriate follow-up of abnormal results (118–120).

According to the 2013 NHIS, 51.3% and 65.9% of women 40 years of age and older reported having a mammogram within the past year and in the past 2 years, respectively (Table 5). The percentage of women 40 years of age and older who reported having a mammogram within the past 2 years increased from 29% in 1987 to 70% in 2000, although this percentage declined by 3.4% between 2000 and 2005 and has remained relatively stable since then (121). In 2013, the prevalence of a mammogram in the past year was similar among white, black, and Asian women (50%–52%), but was slightly lower in Hispanic (45.9%) (Table 5). The lowest prevalence of mammography use in the past year was reported among women who lack health insurance (22.3%), followed by recent immigrants (living in the United States <10 years; 27.0%; ref. Table 5). According to the 2012 BRFSS, the percentage of women 40 years of age and older who reported having a mammogram in the past year ranged from 47.3% in Wyoming to 72.1% in Massachusetts (Table 6).

Table 5.

Age-adjusted prevalence (%) of cancer screening test utilization, adults, NHIS 2013

Breast cancer screening among women ≥40 yearsCervical cancer screening among women 21–65 yearsaColorectal cancer screening among men and women ≥50 yearsProstate cancer screening among men≥50 years
Mammogram in past yearMammogram in past 2 yearsPap test in past 3 yearsFOBT in past yearEndoscopybFOBT and/or endoscopycPSA in past year
Overall 51.3 65.9 80.8 7.8 55.9 58.6 34.5 
Gender 
 Males — — — 7.8 56.1 58.8 — 
 Females — — — 7.7 55.8 58.6 — 
Age, y 
 40–49 46.6 59.6 — — — — — 
 50–64 55.8 71.4 — — — — — 
 65+ 51.7 66.9 — — — — — 
 21–30 — — 79.9 — — — — 
 31–40 — — 83.1 — — — — 
 41–50 — — 82.2 — — — — 
 51–65 — — 77.6 — — — — 
 50–64 — — — 6.8 50.4 53.1 26.6 
 65+ — — — 8.8 62.3 65.1 43.9 
Race/ethnicity 
 Non–Hispanic white 52.1 66.4 82.8 7.4 58.0 60.5 36.5 
 Non–Hispanic black 52.6 66.1 82.3 8.5 56.5 59.4 32.9 
 Hispanic 45.9 61.6 77.1 8.4 41.5 44.9 24.3 
 American Indian/Alaska Native 48.5 63.0 80.7 f 45.0 48.0 f 
 Asian (non–Hispanic)d 50.3 66.9 70.6 10.9 48.6 53.2 26.3 
Educatione 
 <HS 38.7 52.7 68.5 6.8 40.0 43.1 23.7 
 HS or GED 47.7 61.4 75.7 7.3 52.6 55.2 28.6 
 Some college 51.9 67.3 83.4 8.6 58.0 60.7 35.7 
 College graduate 59.5 74.8 87.3 7.9 65.4 68.0 43.1 
Sexual orientation 
 Gay/lesbian 56.8 71.1 72.9 10.7 69.4 73.8 54.3 
 Straight 51.4 65.9 81.1 7.8 55.8 58.5 34.3 
 Bisexual f f 65.7 f f f f 
Insurance status 
 Uninsured 22.3 38.0 60.6 2.2 20.3 21.9 20.2 
 Insured 54.8 69.6 85.2 8.1 58.8 61.6 36.2 
Immigration status 
 Born in the United States 51.8 66.1 82.5 7.8 57.7 60.4 35.4 
 Born in U.S. territory 47.2 59.3 76.8 11.1 49.4 55.0 37.2 
 In the United States fewer than 10 years 27.0 39.9 65.9 f 17.3 20.2 25.3 
 In the United States 10+ years 50.0 66.0 76.0 7.7 47.2 50.4 29.2 
Breast cancer screening among women ≥40 yearsCervical cancer screening among women 21–65 yearsaColorectal cancer screening among men and women ≥50 yearsProstate cancer screening among men≥50 years
Mammogram in past yearMammogram in past 2 yearsPap test in past 3 yearsFOBT in past yearEndoscopybFOBT and/or endoscopycPSA in past year
Overall 51.3 65.9 80.8 7.8 55.9 58.6 34.5 
Gender 
 Males — — — 7.8 56.1 58.8 — 
 Females — — — 7.7 55.8 58.6 — 
Age, y 
 40–49 46.6 59.6 — — — — — 
 50–64 55.8 71.4 — — — — — 
 65+ 51.7 66.9 — — — — — 
 21–30 — — 79.9 — — — — 
 31–40 — — 83.1 — — — — 
 41–50 — — 82.2 — — — — 
 51–65 — — 77.6 — — — — 
 50–64 — — — 6.8 50.4 53.1 26.6 
 65+ — — — 8.8 62.3 65.1 43.9 
Race/ethnicity 
 Non–Hispanic white 52.1 66.4 82.8 7.4 58.0 60.5 36.5 
 Non–Hispanic black 52.6 66.1 82.3 8.5 56.5 59.4 32.9 
 Hispanic 45.9 61.6 77.1 8.4 41.5 44.9 24.3 
 American Indian/Alaska Native 48.5 63.0 80.7 f 45.0 48.0 f 
 Asian (non–Hispanic)d 50.3 66.9 70.6 10.9 48.6 53.2 26.3 
Educatione 
 <HS 38.7 52.7 68.5 6.8 40.0 43.1 23.7 
 HS or GED 47.7 61.4 75.7 7.3 52.6 55.2 28.6 
 Some college 51.9 67.3 83.4 8.6 58.0 60.7 35.7 
 College graduate 59.5 74.8 87.3 7.9 65.4 68.0 43.1 
Sexual orientation 
 Gay/lesbian 56.8 71.1 72.9 10.7 69.4 73.8 54.3 
 Straight 51.4 65.9 81.1 7.8 55.8 58.5 34.3 
 Bisexual f f 65.7 f f f f 
Insurance status 
 Uninsured 22.3 38.0 60.6 2.2 20.3 21.9 20.2 
 Insured 54.8 69.6 85.2 8.1 58.8 61.6 36.2 
Immigration status 
 Born in the United States 51.8 66.1 82.5 7.8 57.7 60.4 35.4 
 Born in U.S. territory 47.2 59.3 76.8 11.1 49.4 55.0 37.2 
 In the United States fewer than 10 years 27.0 39.9 65.9 f 17.3 20.2 25.3 
 In the United States 10+ years 50.0 66.0 76.0 7.7 47.2 50.4 29.2 

Abbreviations: GED, General Educational Development high school equivalency; HS, high school.

aAmong women with intact uteri.

bSigmoidoscopy within the past five years or a colonoscopy within the past 10 years.

cFOBT and/or sigmoidoscopy within the past five years or a colonoscopy within the past 10 years.

dDoes not include Native Hawaiians or other Pacific Islanders.

eEstimates for Pap testing are among persons aged 25 years or older.

fEstimate not provided due to instability.

Table 6.

Prevalence (%) of cancer screening test utilization, adults, by state, BRFSS 2012

Breast cancer screening among women ≥40 yearsCervical cancer screening among women 21–65 yearsColorectal cancer screening among men and women ≥50 years
StateMammogram in the past yearPap test in the past 3 yearsFOBT in past yearEndoscopyaCombined FOBT/endoscopyb
Alabama 59.0 84.0 9.7 63.6 66.6 
Alaska 53.6 83.5 6.8 54.6 56.8 
Arizona 53.0 78.8 9.9 56.9 60.0 
Arkansas 49.8 79.0 9.1 56.3 59.5 
California 58.5 85.6 19.5 59.9 68.6 
Colorado 52.3 85.5 10.0 61.2 65.8 
Connecticut 65.9 88.0 10.8 70.1 72.8 
Delaware 67.6 88.9 7.8 71.2 72.6 
District of Columbia 62.6 88.1 14.9 65.4 69.1 
Florida 59.0 80.4 13.6 63.8 68.0 
Georgia 62.1 84.4 12.3 65.1 68.5 
Hawaii 58.6 82.2 13.1 57.8 64.2 
Idaho 49.1 74.6 7.7 59.9 62.2 
Illinois 57.7 85.7 6.9 60.0 62.2 
Indiana 52.4 80.4 9.0 57.8 61.1 
Iowa 61.0 87.0 9.0 64.8 67.3 
Kansas 60.0 84.8 11.1 62.6 66.2 
Kentucky 57.3 81.6 9.0 61.6 64.3 
Louisiana 60.0 85.0 10.8 58.3 62.3 
Maine 65.0 87.9 9.0 71.0 73.2 
Maryland 64.8 88.2 11.8 68.3 71.2 
Massachusetts 72.1 89.6 10.9 72.8 75.8 
Michigan 59.2 86.2 9.6 67.3 69.6 
Minnesota 63.4 87.8 5.3 69.4 71.2 
Mississippi 52.4 80.9 11.4 56.5 59.5 
Missouri 58.4 82.3 8.0 61.7 64.9 
Montana 50.4 82.2 6.4 54.7 57.5 
Nebraska 54.4 83.9 7.5 59.3 62.2 
Nevada 49.6 77.4 12.6 55.3 59.5 
New Hampshire 64.6 86.9 8.0 73.2 75.2 
New Jersey 61.2 84.9 8.4 61.2 63.6 
New Mexico 49.9 83.0 8.6 56.0 59.3 
New York 62.0 82.6 8.7 68.0 70.3 
North Carolina 61.5 86.3 11.6 66.5 69.9 
North Dakota 58.2 84.3 8.3 56.5 59.4 
Ohio 60.3 84.5 9.4 60.6 64.2 
Oklahoma 52.4 81.0 7.9 57.1 60.3 
Oregon 53.9 80.3 10.1 61.6 66.0 
Pennsylvania 59.8 83.2 9.2 64.3 67.6 
Rhode Island 67.0 88.7 8.9 71.3 73.8 
South Carolina 54.3 82.1 7.5 63.6 65.8 
South Dakota 61.5 86.7 8.4 60.8 63.5 
Tennessee 56.5 85.8 10.9 63.7 66.4 
Texas 53.6 80.6 8.8 57.2 60.3 
Utah 50.1 79.1 3.5 66.9 68.3 
Vermont 61.2 86.8 8.6 68.8 71.6 
Virginia 64.3 87.4 9.5 66.0 68.4 
Washington 55.6 83.0 10.4 64.8 68.5 
West Virginia 58.3 80.9 12.9 59.7 63.8 
Wisconsin 63.4 85.2 7.2 70.0 72.6 
Wyoming 47.3 79.9 5.4 55.2 57.4 
Breast cancer screening among women ≥40 yearsCervical cancer screening among women 21–65 yearsColorectal cancer screening among men and women ≥50 years
StateMammogram in the past yearPap test in the past 3 yearsFOBT in past yearEndoscopyaCombined FOBT/endoscopyb
Alabama 59.0 84.0 9.7 63.6 66.6 
Alaska 53.6 83.5 6.8 54.6 56.8 
Arizona 53.0 78.8 9.9 56.9 60.0 
Arkansas 49.8 79.0 9.1 56.3 59.5 
California 58.5 85.6 19.5 59.9 68.6 
Colorado 52.3 85.5 10.0 61.2 65.8 
Connecticut 65.9 88.0 10.8 70.1 72.8 
Delaware 67.6 88.9 7.8 71.2 72.6 
District of Columbia 62.6 88.1 14.9 65.4 69.1 
Florida 59.0 80.4 13.6 63.8 68.0 
Georgia 62.1 84.4 12.3 65.1 68.5 
Hawaii 58.6 82.2 13.1 57.8 64.2 
Idaho 49.1 74.6 7.7 59.9 62.2 
Illinois 57.7 85.7 6.9 60.0 62.2 
Indiana 52.4 80.4 9.0 57.8 61.1 
Iowa 61.0 87.0 9.0 64.8 67.3 
Kansas 60.0 84.8 11.1 62.6 66.2 
Kentucky 57.3 81.6 9.0 61.6 64.3 
Louisiana 60.0 85.0 10.8 58.3 62.3 
Maine 65.0 87.9 9.0 71.0 73.2 
Maryland 64.8 88.2 11.8 68.3 71.2 
Massachusetts 72.1 89.6 10.9 72.8 75.8 
Michigan 59.2 86.2 9.6 67.3 69.6 
Minnesota 63.4 87.8 5.3 69.4 71.2 
Mississippi 52.4 80.9 11.4 56.5 59.5 
Missouri 58.4 82.3 8.0 61.7 64.9 
Montana 50.4 82.2 6.4 54.7 57.5 
Nebraska 54.4 83.9 7.5 59.3 62.2 
Nevada 49.6 77.4 12.6 55.3 59.5 
New Hampshire 64.6 86.9 8.0 73.2 75.2 
New Jersey 61.2 84.9 8.4 61.2 63.6 
New Mexico 49.9 83.0 8.6 56.0 59.3 
New York 62.0 82.6 8.7 68.0 70.3 
North Carolina 61.5 86.3 11.6 66.5 69.9 
North Dakota 58.2 84.3 8.3 56.5 59.4 
Ohio 60.3 84.5 9.4 60.6 64.2 
Oklahoma 52.4 81.0 7.9 57.1 60.3 
Oregon 53.9 80.3 10.1 61.6 66.0 
Pennsylvania 59.8 83.2 9.2 64.3 67.6 
Rhode Island 67.0 88.7 8.9 71.3 73.8 
South Carolina 54.3 82.1 7.5 63.6 65.8 
South Dakota 61.5 86.7 8.4 60.8 63.5 
Tennessee 56.5 85.8 10.9 63.7 66.4 
Texas 53.6 80.6 8.8 57.2 60.3 
Utah 50.1 79.1 3.5 66.9 68.3 
Vermont 61.2 86.8 8.6 68.8 71.6 
Virginia 64.3 87.4 9.5 66.0 68.4 
Washington 55.6 83.0 10.4 64.8 68.5 
West Virginia 58.3 80.9 12.9 59.7 63.8 
Wisconsin 63.4 85.2 7.2 70.0 72.6 
Wyoming 47.3 79.9 5.4 55.2 57.4 

aSigmoidoscopy in the past 5 years or colonoscopy in the past 10 years.

bFOBT in the past year, sigmoidoscopy in the past 5 years, or colonoscopy in the past 10 years.

Cervical cancer screening

Cervical cancer incidence and mortality rates have decreased by more than 50% over the past three decades, with most of the reduction attributed to screening with the Papanicolaou (Pap) test, which can detect both cervical cancer and precancerous lesions (122, 123). Women diagnosed with localized cervical cancer also have a high 5-year survival rate (91%) (122). However, almost half of all cervical cancers are diagnosed at a regional or distant stage for which the 5-year survival rates are 57.4% and 16.1%, respectively (122). Most (60%–80%) women diagnosed at these later stages have not had a Pap test in the past 5 years (124).

According to the 2013 NHIS, 80.8% of women 21 to 65 years of age reported having had a Pap test within the past three years (Table 5). The prevalence of Pap test use was similar among non–Hispanic whites, non–Hispanic blacks, and Native Americans (80.7%–82.8%), but lower among Hispanic (77.1%) and Asian (70.6%) women (Table 5). Prevalence was also low among women with no health insurance (60.6%) and recent immigrants (living in the United States <10 years; 65.9%; Table 5). According to the 2012 BRFSS, uptake of recent Pap testing among women 21 to 65 years of age ranged from 74.6% in Idaho to 89.6% in Massachusetts (Table 6).

Colorectal cancer screening

Colorectal cancer screening can both prevent cancer, through the identification and removal of precancerous polyps, and detect malignancy at an early stage (125, 126). However, only 40% of cases are diagnosed when the cancer is localized, for which the relative 5-year survival rate is 90% (122). The decrease in colorectal cancer incidence and death rates over the past several decades has been attributed to screening uptake, risk-factor reduction (e.g., declining tobacco use), and improved treatments (127).

Although colorectal cancer screening increased rapidly since the 2000s (from 38.6% in 2000 to 54.5% in 2008, primarily through increased use of colonoscopy; ref. 128), screening prevalence has stabilized in recent years and still lags behind that for breast and cervical cancers (Table 5). According to the 2013 NHIS, 58.6% of adults 50 years and older were up-to-date with screening [either a fecal occult blood test (FOBT) within the past year or a sigmoidoscopy within the past 5 years or a colonoscopy within the past 10 years; Table 5]. Endoscopic screening, primarily colonoscopy, was much more common (55.9%) than fecal tests (home-based FOBT or FIT; 7.8%). In 2013, screening prevalence was highest among non–Hispanic blacks and whites (59.4%–60.5%), followed by Asians (53.2%), American Indian/Alaska Natives (48.0%), and Hispanics (44.9%; Table 5). According to 2012 BRFSS data, the percentage of adults 50 years of age and older who were up-to-date with screening ranged from 56.8% in Alaska to 75.8% in Massachusetts (Table 6).

Prostate cancer screening

Among U.S. men, cancer of the prostate is the most common type of cancer (other than skin cancer) and the second leading cause of cancer death (3). Mortality trends for prostate cancer have been declining, which is thought to be, in part, due to early detection using the prostate-specific antigen (PSA) test. However, the results of three large clinical trials designed to determine the efficacy of PSA testing were not in agreement and further studies are under way (129–131). Most experts agree that the current evidence is insufficient to recommend for or against routine testing for early prostate cancer detection given concerns about frequent overdiagnosis and substantial risk for serious side effects from prostate cancer treatment (132–134). Informed decisions on whether or not a man should receive PSA testing is encouraged by some public health organizations; however, studies have shown that informed and shared decision-making measures are inconsistently utilized in clinical practice (135). According to the 2013 NHIS, the prevalence of having a PSA test within the past year was 34.5% in men 50 years of age and older (Table 5). Those who had no health insurance, Hispanic men, those with less than a high school education, and recent immigrants (living in the United States <10 years) were the least likely to have had a recent PSA test.

Lung cancer screening

Among U.S. men and women, lung cancer is the leading cause of cancer death, with an estimated 158,040 deaths in 2015 (3). Whereas lung cancer incidence and mortality rates have been declining over the past two decades in men, rates only recently began to decrease after a long period of increasing in women. These trends reflect historical differences in smoking initiation and cessation (13). The initial National Lung Cancer Screening Trial results published in 2011 showed 20% fewer lung cancer deaths in the group that received an invitation to low-dose helical computed tomography (LDCT) screening compared with the group invited to receive annual chest X-ray group after 8 years of follow-up (136). Following these results, several public health organizations began recommending lung cancer screening with LDCT for healthy patients ages 55 to 74 years (ACS; USPSTF recommendation is for ages 55–80 years) with at least a 30 pack-year history of smoking who currently smoke or have quit within the past 15 years (137–140). Approximately 8.6 million former and current smokers are eligible for lung cancer screening, and an estimated 12,250 lung cancer deaths could be averted annually if this population adopted ACS's lung cancer screening guidelines (141). In 2010, a national survey estimated that 1.8% of high-risk smokers (those with a smoking history of 30 or more pack-years) and 4.4% of high-risk former smokers had undergone LDCT for lung cancer screening within the past year (142).

Although there have been many improvements in cancer control with reductions in cigarette smoking prevalence and progress in cancer screening utilization in the past several decades, about 18% of Americans still smoke and smoking prevalence remains high (>25%) among certain populations, including lower socioeconomic persons. In addition, the use of other forms of tobacco, including cigars and e-cigarettes, has increased in recent years. Obesity prevalence is high among both adults and adolescents, particularly among black women with nearly 60% of this population obese. About 1 in 5 young women continues to use indoor tanning devices despite the known harms related to use of these devices. Furthermore, preventive health services, such as HPV vaccination, remain low with only 37.6% and 13.9% of adolescent girls and boys receiving vaccination, respectively. Receipt of recommended cancer screening varies from 80% for cervical cancer to 59% for colorectal cancer, and regardless of the cancer type, people without insurance have markedly lower cancer screening uptake; for example, 21.9% of uninsured receive recommended colorectal cancer screening. These prevalence estimates provide a summary of risk factors and early detection methods for major cancer sites and highlight the populations most in need of cancer control efforts and interventions.

No potential conflicts of interest were disclosed.

This work was supported by the American Cancer Society's Intramural Research Department.

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