Cancer prevention and early detection efforts are central to reducing cancer burden. Herein, we present estimates of cancer risk factors and screening tests in 2018 and 2019 among US adults, with a focus on smoking cessation. Cigarette smoking reached a historic low in 2019 (14.2%) partly because 61.7% (54.9 million) of all persons who had ever smoked had quit. Yet, the quit ratio was <45% among lower-income, uninsured, and Medicaid-insured persons, and was <55% among Black, American Indian/Alaska Native, lower-educated, lesbian, gay or bisexual, and recent immigrant persons, and in 12 of 17 Southern states. Obesity levels remain high (2017–2018: 42.4%) and were disproportionately higher among Black (56.9%) and Hispanic (43.7%) women. HPV vaccination in adolescents 13 to 17 years remains underutilized and over 40% were not up-to-date in 2019. Cancer screening prevalence was suboptimal in 2018 (colorectal cancer ≥50 years: 65.6%; breast ≥45 years: 63.2%; cervical 21–65 years: 83.7%), especially among uninsured adults (colorectal: 29.8%; breast: 31.1%). This snapshot of cancer prevention and early detection measures was mixed, and substantial racial/ethnic and socioeconomic disparities persisted. However, gains could be accelerated with targeted interventions to increase smoking cessation in under-resourced populations, stem the obesity epidemic, and improve screening and HPV vaccination coverage.

In the United States, cancer death rates have steadily declined since the early 1990s (1). Yet, in 2021, about 608,570 cancer deaths are expected to occur (2), approximately 45% of which are attributable to modifiable risk factors such as cigarette smoking, excess body weight, alcohol intake, physical inactivity, and unhealthy diet (3). Further, appropriate screening adherence can reduce cancer mortality (4). Cigarette smoking specifically accounts for nearly 30% of cancer deaths (3), but the risk of developing and dying from at least 12 cancers can be reduced substantially by quitting smoking (5).

We previously provided an overview of prevalence patterns of major risk factors, cancer screening, and cancer-related vaccinations in the United States through 2017 (6); herein we update with data from 2018 and 2019. We also provide a detailed review of smoking cessation in the United States, given the primacy of this potentially modifiable factor in cancer prevention and control.

Data were from publicly available population-based surveys. National Health Interview Survey (NHIS)—an annual computer-assisted in-person household survey of noninstitutionalized adults ≥18 years—data were used to estimate tobacco use at the national level, including cigarette smoking, e-cigarette use, cigar, pipe, and smokeless tobacco use in 2019, and alcohol consumption and physical inactivity prevalence in 2018. The 2018 and 2019 NHIS response rates were 53.1% and 59.1%, respectively (7, 8). The Behavioral Risk Factor Surveillance System (BRFSS) is a computer-assisted telephone-based survey of adults ≥18 years designed to provide state-level estimates for health behaviors and was used to estimate current cigarette smoking, cessation behaviors (quit ratio; past-year quit attempt; recent successful cessation), and fruit and vegetable intake in 2019; the median response rate for this survey was 49.4% (9). The Tobacco Use Supplement to the Current Population Survey (TUS-CPS)—a telephone and in-person tobacco-related survey of adults ≥18 years—was used to estimate state-level prevalence of receipt and use of clinical cessation interventions in 2018 to 2019 as these measures were not available in BRFSS (10). Only self-respondents were included and response rates ranged from 56.2% to 58.9% (10). The 2017–2018 National Health and Nutrition Examination Survey (NHANES) data were used to estimate the prevalence of overweight and obesity among adults ≥20 years based on physical examination data measured by trained personnel, with a response rate of 48.8% (11). Data on human papillomavirus (HPV) and hepatitis B virus (HBV) vaccination were obtained from the 2019 National Immunization Survey-Teen (NIS-Teen; refs. 12, 13); HPV initiation rates were computed using methods described elsewhere (7, 14).

We examined national and state-level prevalence overall and by selected sociodemographic variables (sex, age-group, race/ethnicity, education level, income level, immigration status, sexual identity, insurance type). Estimates and 95% confidence intervals were generated using SAS-callable SUDAAN release 11.0.1, accounting for the complex survey designs, and weighted to be representative at the national or state level. The Healthy People 2020 criteria for data suppression were followed (15).

Tobacco

Cigarette smoking

In the NHIS 2019 survey, more than 34 million adults (≥18 years, overall: 14.2%, men: 15.5%, women: 13.0%) currently smoked cigarettes (Table 1). Smoking prevalence in males with <high school (HS) education (26.5%) in 2019 was nearly five times the prevalence in female college graduates (5.4%). Among both men and women, smoking prevalence was lowest among Asian persons (11.4% and 3.0%, respectively) and highest among American Indian/Alaskan Native persons (23.7% and 27.0%, respectively; Table 1). Smoking prevalence varied by both sexual orientation and self-reported sex, with prevalence highest among bisexual women (21.4%) and lowest among bisexual men (11.2%) and straight women (12.7%). By state, smoking prevalence from the BRFSS 2019 survey, ranged from <10% in Utah and California to over 20% in West Virginia, Kentucky, Louisiana, Ohio, Mississippi, Alabama, and Arkansas (Supplementary Table S1).

Table 1.

Current cigarette smoking, quit ratio, past-year quit attempt, and recent successful cessation, US adults ≥18 years, NHIS 2018 and 2019.

Current smokinga (2019)Quit ratiob (2019)Past-year quit attemptc (2018)Recent successful cessationd (2018)
MalesFemalesOverallOverallOverallOverall
% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)
Overall 15.5 (14.7–16.3) 13 (12.3–13.7) 14.2 (13.7–14.8) 61.7 (60.6–62.8) 55.2 (53.2–57.1) 7.5 (6.5–8.7) 
Sex 
 Males — — — 63.3 (61.7–64.8) 55.0 (52.4–57.7) 7.9 (6.5–9.7) 
 Females — — — 59.8 (58.2–61.3) 55.3 (52.4–58.1) 7.0 (5.7–8.5) 
Age (years) 
 18–24 7.8 (6.2–9.8) 8.2 (6.5–10.3) 8.0 (6.8–9.4) 39.9 (33.8–46.3) 71.7 (64.1–78.2) 17.8 (11.7–26.2) 
 25–44 19.1 (17.2–21.3) 14.4 (12.7–16.2) 16.8 (15.5–18.1) 50.8 (48.7–52.8) 57.2 (54.1–60.3) 8.7 (7.2–10.6) 
 45–64 18.5 (16.6–20.5) 14.7 (13.1–16.5) 16.6 (15.3–18.0) 58.3 (56.5–60.1) 51.3 (48.4–54.3) 4.0 (2.9–5.4) 
 65–74 17.9 (16.6–19.3) 16.2 (15–17.5) 17.0 (16.1–18) 77.6 (75.7–79.5) 51.1 (46.1–56.1) 7.5 (5.2–10.7) 
 75+ 9.4 (8.4–10.4) 7.3 (6.5–8.3) 8.2 (7.6–8.9) 89.6 (87.6–91.3) 44.2 (36.1–52.6) 9.6 (5.5–16.2) 
Race/ethnicity 
 Hispanic 11.6 (9.9–13.6) 6.1 (5.0–7.4) 8.8 (7.8–9.9) 61.8 (58.1–65.3) 59.2 (52.5–65.7) 6.9 (4.2–11.4) 
 NH White only 16.5 (15.5–17.5) 15.8 (14.9–16.8) 16.1 (15.5–16.9) 63.9 (62.6–65.1) 52.9 (50.7–55.0) 8.1 (6.9–9.5) 
 NH Black only 17.8 (15.4–20.4) 12.8 (11–14.8) 14.9 (13.5–16.5) 47.3 (43.6–51.1) 61.7 (56.2–66.9) 4.9 (3.0–7.7) 
 NH Asian only 11.4 (8.8–14.7) 3.0 (2.0–4.7) 7.1 (5.5–9.0) 60.2 (52.9–67.1) 67.7 (57.0–76.8) 9.8 (5.4–16.9) 
 NH AIAN only or multiple 23.7 (16.6–32.7) 27.0 (18.9–36.9) 25.2 (18.4–33.6) 48.8 (39.7–58.0) 44.2 (30.2–59.1) e 
Sexual orientation 
 Gay or lesbian 18.1 (13.1–24.4) 17.9 (12.4–25.1) 17.9 (14.0–22.6) 52.5 (43.8–61.1) 64.2 (52.3–74.5) e 
 Straight 15.5 (14.7–16.3) 12.7 (12.0–13.4) 14.0 (13.5–14.6) 62.1 (60.9–63.3) 54.8 (52.7–56.8) 7.4 (6.4–8.6) 
 Bisexual 11.2 (6.7–18.1) 21.4 (16.6–27.2) 19.7 (15.6–24.5) 49.5 (41.3–57.7) 72.1 (60.2–81.4) e 
Immigration status 
 Born in US/US territory 16.5 (15.7–17.4) 15.3 (14.5–16.2) 15.9 (15.3–16.6) 61.2 (60.0–62.4) 54.6 (52.6–56.7) 7.8 (6.7–9.0) 
 In US fewer than 10 years 10.8 (7.7–15.0) 4.5 (2.6–7.6) 7.8 (5.8–10.3) 49.9 (39.9–60.0) 58.0 (44.2–70.6) e 
 In US 10+ years 11.2 (9.3–13.5) 3.8 (3.0–4.9) 7.4 (6.3–8.6) 68.5 (64.6–72.1) 60.3 (53.5–66.7) 4.4 (2.5–7.6) 
Education (≥25 years) 
 <HS 26.5 (23.2–30.1) 21.0 (17.9–24.5) 23.9 (21.5–26.5) 52.6 (49.2–55.9) 51.0 (46.3–55.8) 2.8 (1.6–4.8) 
 HS 24.1 (22.3–26.0) 19.8 (18.1–21.5) 22 (20.8–23.4) 55.9 (53.9–57.9) 50.5 (47.3–53.7) 5.9 (4.5–7.7) 
 Some college 17.1 (15.7–18.7) 15.6 (14.3–17.0) 16.3 (15.3–17.3) 63.8 (62.0–65.6) 56.3 (52.8–59.7) 6.8 (5.2–8.8) 
 College graduate 6.2 (5.4–7.1) 5.4 (4.8–6.1) 5.8 (5.3–6.4) 78.1 (76.2–79.8) 59.9 (54.6–64.9) 12.7 (9.7–16.3) 
Income level 
 <100% FPL 26.6 (23.6–29.8) 22.4 (20.1–24.8) 24 (22.1–26) 42.1 (38.7–45.7) 57.3 (52.9–61.7) 5.3 (3.6–7.7) 
 100 to less than 200% FPL 22.9 (20.8–25.2) 19.2 (17.4–21.1) 20.9 (19.5–22.4) 50.6 (48.2–53.1) 55.2 (51.6–58.8) 5.3 (3.9–7.2) 
 ≥200% FPL 12.6 (11.8–13.4) 9.6 (8.9–10.3) 11.1 (10.6–11.7) 68.5 (67.2–69.8) 55.1 (52.5–57.6) 8.9 (7.4–10.6) 
Insurance status 
 Uninsured 24.7 (22.0–27.5) 19.9 (17.4–22.7) 22.5 (20.6–24.5) 40.2 (36.7–43.8) 53.4 (48.9–57.7) 5.8 (4.0–8.5) 
 Private 11.9 (11.1–12.8) 9.7 (9.0–10.4) 10.8 (10.2–11.4) 67.2 (65.7–68.7) 55.7 (52.9–58.4) 9.2 (7.6–11.0) 
 Medicaid/public/dual eligible 26.7 (23.5–30.2) 23.7 (21.5–26.2) 24.9 (23–26.9) 40.0 (37.0–43.0) 58.8 (54.4–63.0) 5.5 (3.6–8.3) 
 Medicare (ages ≥65 years) 9.0 (7.4–10.9) 7.5 (6.3–8.9) 8.1 (7.1–9.3) 82.0 (79.6–84.1) 46.1 (39.6–52.7) 6.4 (3.8–10.8) 
 Other 19.7 (17.1–22.6) 15.0 (12.3–18.1) 17.7 (15.9–19.7) 65.8 (62.3–69.1) 53.7 (47.2–60.1) 6.4 (4.1–9.9) 
Current smokinga (2019)Quit ratiob (2019)Past-year quit attemptc (2018)Recent successful cessationd (2018)
MalesFemalesOverallOverallOverallOverall
% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)
Overall 15.5 (14.7–16.3) 13 (12.3–13.7) 14.2 (13.7–14.8) 61.7 (60.6–62.8) 55.2 (53.2–57.1) 7.5 (6.5–8.7) 
Sex 
 Males — — — 63.3 (61.7–64.8) 55.0 (52.4–57.7) 7.9 (6.5–9.7) 
 Females — — — 59.8 (58.2–61.3) 55.3 (52.4–58.1) 7.0 (5.7–8.5) 
Age (years) 
 18–24 7.8 (6.2–9.8) 8.2 (6.5–10.3) 8.0 (6.8–9.4) 39.9 (33.8–46.3) 71.7 (64.1–78.2) 17.8 (11.7–26.2) 
 25–44 19.1 (17.2–21.3) 14.4 (12.7–16.2) 16.8 (15.5–18.1) 50.8 (48.7–52.8) 57.2 (54.1–60.3) 8.7 (7.2–10.6) 
 45–64 18.5 (16.6–20.5) 14.7 (13.1–16.5) 16.6 (15.3–18.0) 58.3 (56.5–60.1) 51.3 (48.4–54.3) 4.0 (2.9–5.4) 
 65–74 17.9 (16.6–19.3) 16.2 (15–17.5) 17.0 (16.1–18) 77.6 (75.7–79.5) 51.1 (46.1–56.1) 7.5 (5.2–10.7) 
 75+ 9.4 (8.4–10.4) 7.3 (6.5–8.3) 8.2 (7.6–8.9) 89.6 (87.6–91.3) 44.2 (36.1–52.6) 9.6 (5.5–16.2) 
Race/ethnicity 
 Hispanic 11.6 (9.9–13.6) 6.1 (5.0–7.4) 8.8 (7.8–9.9) 61.8 (58.1–65.3) 59.2 (52.5–65.7) 6.9 (4.2–11.4) 
 NH White only 16.5 (15.5–17.5) 15.8 (14.9–16.8) 16.1 (15.5–16.9) 63.9 (62.6–65.1) 52.9 (50.7–55.0) 8.1 (6.9–9.5) 
 NH Black only 17.8 (15.4–20.4) 12.8 (11–14.8) 14.9 (13.5–16.5) 47.3 (43.6–51.1) 61.7 (56.2–66.9) 4.9 (3.0–7.7) 
 NH Asian only 11.4 (8.8–14.7) 3.0 (2.0–4.7) 7.1 (5.5–9.0) 60.2 (52.9–67.1) 67.7 (57.0–76.8) 9.8 (5.4–16.9) 
 NH AIAN only or multiple 23.7 (16.6–32.7) 27.0 (18.9–36.9) 25.2 (18.4–33.6) 48.8 (39.7–58.0) 44.2 (30.2–59.1) e 
Sexual orientation 
 Gay or lesbian 18.1 (13.1–24.4) 17.9 (12.4–25.1) 17.9 (14.0–22.6) 52.5 (43.8–61.1) 64.2 (52.3–74.5) e 
 Straight 15.5 (14.7–16.3) 12.7 (12.0–13.4) 14.0 (13.5–14.6) 62.1 (60.9–63.3) 54.8 (52.7–56.8) 7.4 (6.4–8.6) 
 Bisexual 11.2 (6.7–18.1) 21.4 (16.6–27.2) 19.7 (15.6–24.5) 49.5 (41.3–57.7) 72.1 (60.2–81.4) e 
Immigration status 
 Born in US/US territory 16.5 (15.7–17.4) 15.3 (14.5–16.2) 15.9 (15.3–16.6) 61.2 (60.0–62.4) 54.6 (52.6–56.7) 7.8 (6.7–9.0) 
 In US fewer than 10 years 10.8 (7.7–15.0) 4.5 (2.6–7.6) 7.8 (5.8–10.3) 49.9 (39.9–60.0) 58.0 (44.2–70.6) e 
 In US 10+ years 11.2 (9.3–13.5) 3.8 (3.0–4.9) 7.4 (6.3–8.6) 68.5 (64.6–72.1) 60.3 (53.5–66.7) 4.4 (2.5–7.6) 
Education (≥25 years) 
 <HS 26.5 (23.2–30.1) 21.0 (17.9–24.5) 23.9 (21.5–26.5) 52.6 (49.2–55.9) 51.0 (46.3–55.8) 2.8 (1.6–4.8) 
 HS 24.1 (22.3–26.0) 19.8 (18.1–21.5) 22 (20.8–23.4) 55.9 (53.9–57.9) 50.5 (47.3–53.7) 5.9 (4.5–7.7) 
 Some college 17.1 (15.7–18.7) 15.6 (14.3–17.0) 16.3 (15.3–17.3) 63.8 (62.0–65.6) 56.3 (52.8–59.7) 6.8 (5.2–8.8) 
 College graduate 6.2 (5.4–7.1) 5.4 (4.8–6.1) 5.8 (5.3–6.4) 78.1 (76.2–79.8) 59.9 (54.6–64.9) 12.7 (9.7–16.3) 
Income level 
 <100% FPL 26.6 (23.6–29.8) 22.4 (20.1–24.8) 24 (22.1–26) 42.1 (38.7–45.7) 57.3 (52.9–61.7) 5.3 (3.6–7.7) 
 100 to less than 200% FPL 22.9 (20.8–25.2) 19.2 (17.4–21.1) 20.9 (19.5–22.4) 50.6 (48.2–53.1) 55.2 (51.6–58.8) 5.3 (3.9–7.2) 
 ≥200% FPL 12.6 (11.8–13.4) 9.6 (8.9–10.3) 11.1 (10.6–11.7) 68.5 (67.2–69.8) 55.1 (52.5–57.6) 8.9 (7.4–10.6) 
Insurance status 
 Uninsured 24.7 (22.0–27.5) 19.9 (17.4–22.7) 22.5 (20.6–24.5) 40.2 (36.7–43.8) 53.4 (48.9–57.7) 5.8 (4.0–8.5) 
 Private 11.9 (11.1–12.8) 9.7 (9.0–10.4) 10.8 (10.2–11.4) 67.2 (65.7–68.7) 55.7 (52.9–58.4) 9.2 (7.6–11.0) 
 Medicaid/public/dual eligible 26.7 (23.5–30.2) 23.7 (21.5–26.2) 24.9 (23–26.9) 40.0 (37.0–43.0) 58.8 (54.4–63.0) 5.5 (3.6–8.3) 
 Medicare (ages ≥65 years) 9.0 (7.4–10.9) 7.5 (6.3–8.9) 8.1 (7.1–9.3) 82.0 (79.6–84.1) 46.1 (39.6–52.7) 6.4 (3.8–10.8) 
 Other 19.7 (17.1–22.6) 15.0 (12.3–18.1) 17.7 (15.9–19.7) 65.8 (62.3–69.1) 53.7 (47.2–60.1) 6.4 (4.1–9.9) 

Note: All estimates are survey weighted. Estimates are age-adjusted to 2000 standard US population, except for by age-group and insurance status. Estimates for White, Black, AI/AN, Asian persons are among non-Hispanics. Estimate for Asian persons does not include Native Hawaiians or other Pacific Islander persons.

Abbreviations: 95% CI, 95% confidence interval; AI/AN, American Indian/Alaska Native; FPL, federal poverty level; HS, high school.

aCigarette smoking: Ever smoked 100 cigarettes in lifetime and now smoke every day or some days.

bQuit ratio: Percentage of ever smokers who are former smokers.

cPast-Year quit attempt: Current smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying to quit smoking and former smokers who quit during the past year.

dRecent successful cessation: Former smokers who quit smoking for ≥6 months during the past year among current smokers and former smokers who quit during the past year.

eEstimate suppressed due to instability.

Use of other forms of tobacco

In the NHIS 2019 survey, 3.7% (6.4% of men and 1.2% of women) smoked cigars, cigarillos, or little filtered cigars currently and 1.0% were current regular pipe, water pipe, or hookah users. About 2.5% (4.8% of men and 0.3% of women) were current smokeless tobacco (chewing tobacco, snuff, dip, snus, or dissolvable tobacco) users (Supplementary Table S2). About 4.8% of adults currently used electronic cigarettes in 2019, and prevalence declined with age, with the highest prevalence in ages 18 to 24 years (9.3%; Supplementary Table S2). Use of all other forms of tobacco was generally higher among American Indian/Alaska Native and White persons, except for cigar use, which was similar among Black (4.5%), White (4.1%), and American Indian/Alaska Native (4.9%) persons.

Smoking cessation

Population cessation behaviors:

Quit ratio is a broad measure of population smoking cessation and is defined as the percentage of ever smokers (smoked 100 cigarettes in lifetime) who are former smokers (do not now smoke at all). The quit ratio among US adults from the NHIS 2019 survey, was 61.7%, that is, about 54.9 million of the 88.9 million adults who ever smoked have quit (Table 1). However, the quit ratio was <50% in Medicaid insured (40%) or uninsured (40.2%), lower income (<100% federal poverty level: 42.1%), and Black (47.3%) or American Indian/Alaska Native (48.8%) persons (Table 1). Although quit ratios capture historical cessation behaviors, measures such as past-year quit attempts and past-year successful cessation capture contemporary quitting behavior as they include recent timeframes. More than one-half (55.2%) of adult persons who smoked cigarettes in the 2018 NHIS survey had attempted to quit in the past year (Table 1), but only 7.5% had quit successfully for ≥6 months during the past year (Table 1). Younger adults ages 18 to 24 years had higher past-year quit attempt prevalence (71.7%) and successful cessation rate (17.8%) than adults ages ≥ 25 years. Although quit attempt prevalence was generally similar across other sociodemographic factors, the rate of recent successful cessation was lower among Black (4.9%) than White (8.1%) persons, <HS (2.8%) than college educated (12.7%) persons, and uninsured (5.8%) and Medicaid (5.5%) insured than privately insured (9.2%) persons (Table 1).

Across US states, in the 2019 BRFSS survey, substantially higher proportions persons who smoked and lived in the Northeast (quit ratio median: 60.3%) and West (58.9%) had quit smoking compared with persons in the South (53.4%) and Midwest (56.0%; Supplementary Table S2). Conversely, even though quit attempt prevalence was generally similar across US regions (Fig. 1A), successful cessation was lower in Southern (median: 5.0%) and Midwestern (5.2%) states than Northeastern (6.4%) and Western (6.8%) states (Fig. 1B). For example, in 10 of the 17 Southern states quit attempt prevalence was higher than the national median; however, recent successful cessation was higher than the national median in only in five Southern states (DC, South Carolina, Delaware, Texas, and Oklahoma).

Figure 1.

Past-year quit attempt (A), recent successful cessation (B), receipt of medical doctor advice to quit (C), use of effective cessation treatments (D), by state, US adults ≥18 years, BRFSS 2019, TUS-CPS, 2018–2019. aCurrent smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying to quit smoking and former smokers who quit during the past year, estimated from BRFSS 2019. bFormer smokers who quit smoking for ≥6 months during the past year among current smokers and former smokers who quit during the past year, estimated from BRFSS 2019. cWas advised by a medical doctor to stop smoking among those who saw a medical doctor during the past year and were current smokers or former smokers who quit in the past year, estimated from TUS-CPS 2018–2019. dUsed one-on-one in-person counseling; a stop-smoking clinic, class, or support group; a telephone helpline or quit line; used a nicotine patch, gum, lozenge, nasal spray or inhaler; and/or a prescription pill called Chantix, Varenicline, Zyban, Bupropion, or Wellbutrin during the past year among current smokers who tried to quit during the past year or used when they stopped smoking among former smokers who quit during the past 2 years, estimated from TUS-CPS 2018–2019. NOTE: Estimates are survey weighted. Outcome quartiles based on Jenks optimization method to determine natural breaks.

Figure 1.

Past-year quit attempt (A), recent successful cessation (B), receipt of medical doctor advice to quit (C), use of effective cessation treatments (D), by state, US adults ≥18 years, BRFSS 2019, TUS-CPS, 2018–2019. aCurrent smokers who reported that they stopped smoking for >1 day during the past 12 months because they were trying to quit smoking and former smokers who quit during the past year, estimated from BRFSS 2019. bFormer smokers who quit smoking for ≥6 months during the past year among current smokers and former smokers who quit during the past year, estimated from BRFSS 2019. cWas advised by a medical doctor to stop smoking among those who saw a medical doctor during the past year and were current smokers or former smokers who quit in the past year, estimated from TUS-CPS 2018–2019. dUsed one-on-one in-person counseling; a stop-smoking clinic, class, or support group; a telephone helpline or quit line; used a nicotine patch, gum, lozenge, nasal spray or inhaler; and/or a prescription pill called Chantix, Varenicline, Zyban, Bupropion, or Wellbutrin during the past year among current smokers who tried to quit during the past year or used when they stopped smoking among former smokers who quit during the past 2 years, estimated from TUS-CPS 2018–2019. NOTE: Estimates are survey weighted. Outcome quartiles based on Jenks optimization method to determine natural breaks.

Close modal
Receipt and use of clinical cessation interventions:

About two-third (66.1%) of adults who smoked cigarettes in the past year saw a medical doctor in the past 12 months in the 2018 to 2019 TUS-CPS survey, 71.7% of whom received advice to quit (Supplementary Table S3). Receipt of advice to quit from a medical doctor was lower among Hispanic (61.9%) than White (72.9%), Black (72%), and Asian (73.3%) adults (Fig. 2; Supplementary Table S3); among adults 18 to 24 years than adults ≥25 years; and among those with a college degree than those without (Supplementary Table S3).

Figure 2.

Receipt of medical doctor advice to quit and use of effective cessation treatments, by race/ethnicity, US adults ≥18 years, TUS-CPS 2018–2019. aWas advised by a medical doctor to stop smoking among those who saw a medical doctor during the past year and were current smokers or former smokers who quit in the past year. bUnstable estimates [suppressed for American Indian/Alaska Native (AI/AN), Asian persons]. cUsed one-on-one in-person counseling; and/or a stop-smoking clinic, class, or support group; and/or a telephone helpline or quit line among current smokers who tried to quit during the past year or used when they stopped smoking among former smokers who quit during the past 2 years. dUsed a nicotine patch, gum, lozenge, nasal spray or inhaler; and/or a prescription pill called Chantix, Varenicline, Zyban, Bupropion, or Wellbutrin during the past year among current smokers who tried to quit during the past year or used when they stopped smoking among former smokers who quit during the past 2 years. Note: Estimates are survey weighted. Estimates for White, Black, AI/AN, Asian persons are among non-Hispanics. Estimate for Asian persons does not include Native Hawaiians or other Pacific Islander persons.

Figure 2.

Receipt of medical doctor advice to quit and use of effective cessation treatments, by race/ethnicity, US adults ≥18 years, TUS-CPS 2018–2019. aWas advised by a medical doctor to stop smoking among those who saw a medical doctor during the past year and were current smokers or former smokers who quit in the past year. bUnstable estimates [suppressed for American Indian/Alaska Native (AI/AN), Asian persons]. cUsed one-on-one in-person counseling; and/or a stop-smoking clinic, class, or support group; and/or a telephone helpline or quit line among current smokers who tried to quit during the past year or used when they stopped smoking among former smokers who quit during the past 2 years. dUsed a nicotine patch, gum, lozenge, nasal spray or inhaler; and/or a prescription pill called Chantix, Varenicline, Zyban, Bupropion, or Wellbutrin during the past year among current smokers who tried to quit during the past year or used when they stopped smoking among former smokers who quit during the past 2 years. Note: Estimates are survey weighted. Estimates for White, Black, AI/AN, Asian persons are among non-Hispanics. Estimate for Asian persons does not include Native Hawaiians or other Pacific Islander persons.

Close modal

Only about one-third (33.6%) of adults in 2018 to 2019 TUS-CPS survey who tried to quit smoking used recommended cessation treatments, including behavioral counseling and/or medications (Fig. 2; Supplementary Table S3). Use of cessation treatments in 2018 to 2019 was lower among Hispanic (24.8%), Asian (24%), and Black (29.9%) persons than White (36.1%) persons (Fig. 2) and among adults <45 years than among ages ≥45 years. The most used cessation treatment was medication alone (24.9%), followed by behavioral counseling and medication in combination (6.1%), and behavioral counseling alone (2.6%; Supplementary Table S3). Lower proportions of Asian (17%), Hispanic (17.9%), and Black (20.4%) adults used medications alone compared with White (27.4%) adults, but no racial/ethnic differences were observed in use of behavioral counseling alone or combination treatment (Fig. 2).

Across US states, in the 2018 to 2019 TUS-CPS survey, receipt of medical doctor advice to quit ranged from 63% in Colorado to 86.4% in Rhode Island and use of recommended cessation treatments ranged from 24.7% in Nevada to 49.5% in Vermont (Fig. 1C and D respectively; Supplementary Table S1). Although medical doctor advice to quit was generally more evenly distributed across US regions, use of cessation treatments were generally lower in Southern states (median: 31.3%) and higher in Northeastern states (39.8%). For example, in all except 5 of 17 Southern states (Arkansas, Maryland, Oklahoma, South Carolina, and Virginia), the use of recommended treatments was less than the national median, whereas in all but two of nine Northeastern states (Rhode Island, New Jersey) the use of treatments was greater than the national median.

Excess body weight, physical activity, diet, and alcohol

Excess body weight

Among adults ≥20 years in 2017 to 2018, the prevalence of obesity (BMI ≥30 kg/m2) was 42.4% (an estimated 99.14 million adults), and the prevalence of overweight (BMI 25.0–29.9 kg/m2) was 30.7%. By race/ethnicity, Black (56.9%) women had the highest obesity level compared with 43.7% of Hispanic women and 39.8% of White women (Table 2). Differences in obesity levels, however, were not as striking among men (Hispanic: 45.7%, White: 44.7%, Black: 41.1%). Overall, obesity prevalence was lowest among Asian men (17.5%) and women (17.2%).

Table 2.

Excess body weight, physical inactivity, and alcohol consumption, US adults ≥18 years, NHANES 2017–2018 and NHIS 2018.

Overweight (BMI 25.0–29.9 kg/m2), ≥20 years, NHANES 2017–2018Obese (BMI ≥30.0 kg/m2), ≥20 years, NHANES 2017–2018No Physical Activity, ≥18 years, NHIS 2018Alcohol Consumption (heavier)a, ≥18 years, NHIS 2018
MalesFemalesOverallMalesFemalesOverallMalesFemalesOverallMalesFemalesOverall
% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)
Overall 34.1 (30.4–38.1) 27.5 (25.5–29.6) 30.7 (28.4–33.2) 43 (37.5–48.7) 41.9 (37.7–46.2) 42.4 (38.7–46.3) 23.1 (21.8–24.4) 27.9 (26.5–29.2) 25.6 (24.5–26.7) 5.1 (4.6–5.6) 5.2 (4.7–5.7) 5.1 (4.8–5.5) 
Age (years) 
 18–24 — — — — — — 15.4 (12.7–18.6) 19.7 (16.6–23.1) 17.5 (15.3–19.9) 3.1 (2.1–4.5) 4.5 (3.1–6.4) 3.8 (2.9–4.8) 
 20–24 26.1 (16.4–38.7) 19.2 (11.3–30.7) 22.8 (16.1–31.1) 32.9 (18.5–51.5) 34.2 (26.2–43.3) 33.5 (24.1–44.5)       
 25–44 31.3 (26.5–36.6) 27.1 (23.4–31.1) 29.2 (27.1–31.5) 43.9 (37.4–50.6) 41.9 (35.9–48.3) 42.9 (38.8–47.2) 20 (18.2–21.9) 23.9 (22–25.9) 22 (20.5–23.5) 5.8 (5–6.7) 5.7 (4.9–6.5) 5.7 (5.2–6.4) 
 45–64 37.1 (31.7–42.7) 27 (23.4–30.9) 31.8 (28.7–35.2) 45.9 (38.8–53.2) 44.2 (38.2–50.3) 45 (40.6–49.5) 24.4 (22.6–26.3) 29 (27.1–30.9) 26.8 (25.3–28.3) 5.6 (4.8–6.5) 5.5 (4.8–6.4) 5.6 (5–6.2) 
 65–74 40.1 (26.2–55.6) 35.9 (27.7–45.0) 37.9 (28.8–47.8) 44.8 (32.7–57.6) 43.9 (34.0–54.4) 44.4 (36.6–52.4) 29.3 (26.8–31.9) 33.3 (31–35.6) 31.4 (29.6–33.3) 5 (4–6.3) 5.1 (4.2–6.2) 5.1 (4.4–5.9) 
 75+ 38.2 (31.9–45.0) 33.6 (28.6–39.0) 35.5 (31.7–39.6) 33.8 (27.1–41.3) 38.8 (30.9–47.3) 36.7 (31.2–42.6) 40.9 (37.6–44.3) 51.2 (48.2–54.1) 46.9 (44.5–49.3) 1.8 (1.1–2.8) 3.3 (2.4–4.4) 2.6 (2.1–3.4) 
Race/ethnicity 
 Hispanic 42.4 (38.0–47.0) 34.8 (31.9–37.9) 38.7 (35.7–41.8) 45.7 (41.9–49.6) 43.7 (39.4–48.0) 44.8 (41.4–48.2) 31.8 (28.6–35.2) 36.5 (33.4–39.6) 34.3 (31.8–36.8) 4 (2.9–5.4) 1.4 (1–1.9) 2.6 (2–3.3) 
 White 30.6 (25.3–36.4) 26.3 (22.8–30.1) 28.4 (24.7–32.3) 44.7 (37.0–52.7) 39.8 (33.9–46.1) 42.2 (37.0–47.7) 20.3 (18.9–21.7) 23.2 (21.8–24.7) 21.8 (20.7–23) 6 (5.4–6.6) 7.1 (6.4–7.9) 6.6 (6.1–7.1) 
 Black 30.6 (25.5–36.3) 23.4 (20.4–26.8) 26.8 (23.8–30.1) 41.1 (36.4–45.9) 56.9 (52.8–61.0) 49.6 (46.5–52.8) 26.6 (23.3–30.1) 40.6 (36.9–44.3) 34.3 (31.7–37.1) 3.4 (2.4–4.8) 3.1 (2.3–4.2) 3.2 (2.5–4.1) 
 Asian 47.2 (41.9–52.5) 30.8 (25.5–36.8) 38.4 (34.5–42.4) 17.5 (13.4–22.4) 17.2 (14.5–20.2) 17.4 (14.8–20.3) 18.8 (15.3–23) 23.8 (19.6–28.6) 21.4 (18.3–24.9) 2.7 (1.5–4.7) b 2 (1.3–3.1) 
 AI/AN — — — — — — 23.7 (15.8–34) 22.9 (14.8–33.7) 22.9 (16.2–31.4) b b b 
Educational attainment (≥25 years) 
 <HS 36.1 (30.4–42.2) 30.2 (22.6–39.1) 33.3 (27.8–39.3) 39.8 (34.1–45.7) 45.2 (36.7–53.9) 42.4 (36.7–48.3) 46.3 (42.2–50.4) 49.9 (46.3–53.5) 48.2 (45.2–51.1) 5.9 (4.4–8) 2.4 (1.6–3.6) 4.2 (3.2–5.3) 
 HS 29.3 (24.9–34.2) 29.3 (24.2–34.9) 29.4 (26.1–33.0) 47.7 (40.3–55.2) 49.3 (44.4–54.1) 48.4 (43.9–52.9) 33.3 (30.9–35.8) 38 (35.3–40.8) 35.6 (33.7–37.6) 7.1 (6–8.4) 5 (4.1–6) 6.1 (5.4–7) 
 Some college 32.3 (27.0–38.2) 28.8 (24.6–33.3) 30.2 (26.4–34.3) 50.3 (45.3–55.3) 48.1 (42.5–53.8) 49.5 (46.1–52.9) 23.6 (21.6–25.6) 29.5 (27.4–31.6) 26.7 (25.2–28.2) 5.3 (4.3–6.4) 5.2 (4.5–6.1) 5.2 (4.6–5.9) 
 College graduate 43.3 (34.2–53.0) 27.1 (23.0–31.6) 34.9 (29.6–40.6) 36.3 (26.5–47.3) 32.6 (27.6–38.1) 34.3 (28.6–40.5) 11.8 (10.5–13.2) 16.9 (15.5–18.4) 14.5 (13.4–15.6) 4.2 (3.5–5) 6.4 (5.7–7.3) 5.4 (4.8–5.9) 
Sexual orientation 
 Gay or lesbian — — — — — — 19.5 (14.3–26) 22 (15.9–29.8) 20.9 (16.4–26.4) 3.1 (1.6–6) 12.6 (7.6–20.1) 6.7 (4.5–10) 
 Straight — — — — — — 23.1 (21.8–24.4) 27.9 (26.5–29.3) 25.6 (24.5–26.7) 5.1 (4.6–5.6) 5.1 (4.6–5.6) 5.1 (4.7–5.4) 
 Bisexual — — — — — — 13.9 (8.1–22.9) 21.8 (14.7–31.1) 19.5 (14.1–26.2) 7.8 (2.8–19.9) 7.5 (4.5–12.2) 7.8 (4.6–12.8) 
Health Insurance 
 Uninsured 33.8 (26.1–42.6) 28.8 (23.9–34.2) 31.8 (27.0–37.0) 34.8 (26.8–43.7) 43.1 (36.2–50.3) 38.1 (31.8–44.9) 31.9 (28.5–35.4) 37.2 (33.2–41.4) 34.2 (31.6–37) 7 (5.6–8.8) 4.2 (3.1–5.7) 5.8 (4.8–7) 
 Private 35.5 (30.7–40.6) 27.6 (25.1–30.3) 31.4 (28.5–34.5) 45.6 (39.1–52.3) 41.4 (36.4–46.5) 43.4 (38.9–48.1) 17.6 (16.4–18.9) 22.3 (20.9–23.6) 20 (19–21.1) 4.9 (4.3–5.5) 6.1 (5.5–6.7) 5.5 (5.1–5.9) 
 Medicaid/public/dual eligible 33.5 (27.5–40.2) 28.8 (24.7–33.3) 30.7 (27.3–34.4) 39.3 (31.7–47.4) 45.2 (38.1–52.4) 42.8 (37.4–48.4) 36 (32.4–39.9) 42.2 (39.1–45.4) 39.9 (37.3–42.5) 4.6 (3.4–6.1) 3.4 (2.6–4.4) 3.8 (3.2–4.6) 
 Medicare (ages ≥65 years) 31.8 (23.1–42.0) 35.8 (26.5–46.1) 33.7 (27.5–40.5) 45.3 (32.8–58.5) 39.4 (29.0–50.8) 42.5 (37.0–48.1) 33.1 (29.6–36.7) 41.9 (39–44.7) 38.2 (35.9–40.6) 3.8 (2.8–5.3) 4.4 (3.4–5.7) 4.2 (3.4–5.1) 
 Other 28.2 (17.5–42.1) b 26.3 (15.7–40.5) 48 (35.7–60.6) 38.3 (25.2–53.3) 43.1 (33.7–53.1) 35.4 (31.8–39.2) 35.1 (30.9–39.6) 35.3 (32.4–38.3) 4.7 (3.4–6.4) 2.8 (1.9–4.2) 3.9 (3–5.1) 
Income 
 <100% FPL 31.3 (25.4–37.9) 24.6 (20.1–29.9) 27.5 (23.6–31.8) 39.7 (32.0–47.9) 49.6 (43.0–56.2) 45.4 (40.3–50.5) 37.5 (33.8–41.4) 43.3 (39.9–46.8) 41 (38.3–43.8) 6.2 (4.7–8.3) 2.7 (2–3.6) 4.1 (3.3–5) 
 100 to less than 200% FPL 34.3 (27.8–41.4) 24.8 (20.6–29.5) 29.2 (25.8–32.9) 38.3 (31.9–45.1) 47.5 (40.4–54.8) 43.2 (38.3–48.4) 32.8 (30–35.7) 38.3 (35.6–41.1) 35.6 (33.6–37.8) 3.5 (2.6–4.7) 3.6 (2.8–4.6) 3.5 (2.9–4.2) 
 ≥200% FPL 35.5 (30.4–41.1) 27.9 (25.1–31.0) 31.9 (28.6–35.3) 45.3 (38.4–52.4) 39.4 (34.3–44.7) 42.4 (38.1–46.9) 19 (17.7–20.3) 22.4 (21–23.8) 20.7 (19.6–21.8) 5.3 (4.8–6) 6.1 (5.5–6.8) 5.7 (5.3–6.2) 
Immigration status 
 Born in the US 30.3 (25.9–35.1) 24.8 (22.4–27.4) 27.5 (24.8–30.3) 46.5 (40.5–52.5) 44.3 (39.7–49.0) 45.4 (41.4–49.4) 21.8 (20.5–23.1) 26.2 (24.8–27.6) 24.1 (22.9–25.2) 5.8 (5.3–6.4) 6.2 (5.6–6.8) 6 (5.6–6.4) 
 In US fewer than 10 years 59.1 (47.9–69.5) 39.3 (29.3–50.3) 47.7 (38.8–56.7) 15 (8.1–26.2) 29.8 (21.3–39.9) 24.6 (20.2–29.7) 35.2 (28.2–42.9) 40.3 (33.4–47.6) 36.7 (31.8–41.9) b b b 
 In US, 10+ years 48.9 (43.0–54.9) 37.5 (32.8–42.4) 43.1 (38.6–47.7) 32.6 (27.3–38.3) 33.8 (28.7–39.3) 33.2 (28.9–37.9) 26.3 (23.2–29.6) 31.6 (28.7–34.7) 29.2 (26.9–31.6) 2.6 (1.8–3.7) 1.7 (1.1–2.6) 2.1 (1.6–2.8) 
Overweight (BMI 25.0–29.9 kg/m2), ≥20 years, NHANES 2017–2018Obese (BMI ≥30.0 kg/m2), ≥20 years, NHANES 2017–2018No Physical Activity, ≥18 years, NHIS 2018Alcohol Consumption (heavier)a, ≥18 years, NHIS 2018
MalesFemalesOverallMalesFemalesOverallMalesFemalesOverallMalesFemalesOverall
% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)
Overall 34.1 (30.4–38.1) 27.5 (25.5–29.6) 30.7 (28.4–33.2) 43 (37.5–48.7) 41.9 (37.7–46.2) 42.4 (38.7–46.3) 23.1 (21.8–24.4) 27.9 (26.5–29.2) 25.6 (24.5–26.7) 5.1 (4.6–5.6) 5.2 (4.7–5.7) 5.1 (4.8–5.5) 
Age (years) 
 18–24 — — — — — — 15.4 (12.7–18.6) 19.7 (16.6–23.1) 17.5 (15.3–19.9) 3.1 (2.1–4.5) 4.5 (3.1–6.4) 3.8 (2.9–4.8) 
 20–24 26.1 (16.4–38.7) 19.2 (11.3–30.7) 22.8 (16.1–31.1) 32.9 (18.5–51.5) 34.2 (26.2–43.3) 33.5 (24.1–44.5)       
 25–44 31.3 (26.5–36.6) 27.1 (23.4–31.1) 29.2 (27.1–31.5) 43.9 (37.4–50.6) 41.9 (35.9–48.3) 42.9 (38.8–47.2) 20 (18.2–21.9) 23.9 (22–25.9) 22 (20.5–23.5) 5.8 (5–6.7) 5.7 (4.9–6.5) 5.7 (5.2–6.4) 
 45–64 37.1 (31.7–42.7) 27 (23.4–30.9) 31.8 (28.7–35.2) 45.9 (38.8–53.2) 44.2 (38.2–50.3) 45 (40.6–49.5) 24.4 (22.6–26.3) 29 (27.1–30.9) 26.8 (25.3–28.3) 5.6 (4.8–6.5) 5.5 (4.8–6.4) 5.6 (5–6.2) 
 65–74 40.1 (26.2–55.6) 35.9 (27.7–45.0) 37.9 (28.8–47.8) 44.8 (32.7–57.6) 43.9 (34.0–54.4) 44.4 (36.6–52.4) 29.3 (26.8–31.9) 33.3 (31–35.6) 31.4 (29.6–33.3) 5 (4–6.3) 5.1 (4.2–6.2) 5.1 (4.4–5.9) 
 75+ 38.2 (31.9–45.0) 33.6 (28.6–39.0) 35.5 (31.7–39.6) 33.8 (27.1–41.3) 38.8 (30.9–47.3) 36.7 (31.2–42.6) 40.9 (37.6–44.3) 51.2 (48.2–54.1) 46.9 (44.5–49.3) 1.8 (1.1–2.8) 3.3 (2.4–4.4) 2.6 (2.1–3.4) 
Race/ethnicity 
 Hispanic 42.4 (38.0–47.0) 34.8 (31.9–37.9) 38.7 (35.7–41.8) 45.7 (41.9–49.6) 43.7 (39.4–48.0) 44.8 (41.4–48.2) 31.8 (28.6–35.2) 36.5 (33.4–39.6) 34.3 (31.8–36.8) 4 (2.9–5.4) 1.4 (1–1.9) 2.6 (2–3.3) 
 White 30.6 (25.3–36.4) 26.3 (22.8–30.1) 28.4 (24.7–32.3) 44.7 (37.0–52.7) 39.8 (33.9–46.1) 42.2 (37.0–47.7) 20.3 (18.9–21.7) 23.2 (21.8–24.7) 21.8 (20.7–23) 6 (5.4–6.6) 7.1 (6.4–7.9) 6.6 (6.1–7.1) 
 Black 30.6 (25.5–36.3) 23.4 (20.4–26.8) 26.8 (23.8–30.1) 41.1 (36.4–45.9) 56.9 (52.8–61.0) 49.6 (46.5–52.8) 26.6 (23.3–30.1) 40.6 (36.9–44.3) 34.3 (31.7–37.1) 3.4 (2.4–4.8) 3.1 (2.3–4.2) 3.2 (2.5–4.1) 
 Asian 47.2 (41.9–52.5) 30.8 (25.5–36.8) 38.4 (34.5–42.4) 17.5 (13.4–22.4) 17.2 (14.5–20.2) 17.4 (14.8–20.3) 18.8 (15.3–23) 23.8 (19.6–28.6) 21.4 (18.3–24.9) 2.7 (1.5–4.7) b 2 (1.3–3.1) 
 AI/AN — — — — — — 23.7 (15.8–34) 22.9 (14.8–33.7) 22.9 (16.2–31.4) b b b 
Educational attainment (≥25 years) 
 <HS 36.1 (30.4–42.2) 30.2 (22.6–39.1) 33.3 (27.8–39.3) 39.8 (34.1–45.7) 45.2 (36.7–53.9) 42.4 (36.7–48.3) 46.3 (42.2–50.4) 49.9 (46.3–53.5) 48.2 (45.2–51.1) 5.9 (4.4–8) 2.4 (1.6–3.6) 4.2 (3.2–5.3) 
 HS 29.3 (24.9–34.2) 29.3 (24.2–34.9) 29.4 (26.1–33.0) 47.7 (40.3–55.2) 49.3 (44.4–54.1) 48.4 (43.9–52.9) 33.3 (30.9–35.8) 38 (35.3–40.8) 35.6 (33.7–37.6) 7.1 (6–8.4) 5 (4.1–6) 6.1 (5.4–7) 
 Some college 32.3 (27.0–38.2) 28.8 (24.6–33.3) 30.2 (26.4–34.3) 50.3 (45.3–55.3) 48.1 (42.5–53.8) 49.5 (46.1–52.9) 23.6 (21.6–25.6) 29.5 (27.4–31.6) 26.7 (25.2–28.2) 5.3 (4.3–6.4) 5.2 (4.5–6.1) 5.2 (4.6–5.9) 
 College graduate 43.3 (34.2–53.0) 27.1 (23.0–31.6) 34.9 (29.6–40.6) 36.3 (26.5–47.3) 32.6 (27.6–38.1) 34.3 (28.6–40.5) 11.8 (10.5–13.2) 16.9 (15.5–18.4) 14.5 (13.4–15.6) 4.2 (3.5–5) 6.4 (5.7–7.3) 5.4 (4.8–5.9) 
Sexual orientation 
 Gay or lesbian — — — — — — 19.5 (14.3–26) 22 (15.9–29.8) 20.9 (16.4–26.4) 3.1 (1.6–6) 12.6 (7.6–20.1) 6.7 (4.5–10) 
 Straight — — — — — — 23.1 (21.8–24.4) 27.9 (26.5–29.3) 25.6 (24.5–26.7) 5.1 (4.6–5.6) 5.1 (4.6–5.6) 5.1 (4.7–5.4) 
 Bisexual — — — — — — 13.9 (8.1–22.9) 21.8 (14.7–31.1) 19.5 (14.1–26.2) 7.8 (2.8–19.9) 7.5 (4.5–12.2) 7.8 (4.6–12.8) 
Health Insurance 
 Uninsured 33.8 (26.1–42.6) 28.8 (23.9–34.2) 31.8 (27.0–37.0) 34.8 (26.8–43.7) 43.1 (36.2–50.3) 38.1 (31.8–44.9) 31.9 (28.5–35.4) 37.2 (33.2–41.4) 34.2 (31.6–37) 7 (5.6–8.8) 4.2 (3.1–5.7) 5.8 (4.8–7) 
 Private 35.5 (30.7–40.6) 27.6 (25.1–30.3) 31.4 (28.5–34.5) 45.6 (39.1–52.3) 41.4 (36.4–46.5) 43.4 (38.9–48.1) 17.6 (16.4–18.9) 22.3 (20.9–23.6) 20 (19–21.1) 4.9 (4.3–5.5) 6.1 (5.5–6.7) 5.5 (5.1–5.9) 
 Medicaid/public/dual eligible 33.5 (27.5–40.2) 28.8 (24.7–33.3) 30.7 (27.3–34.4) 39.3 (31.7–47.4) 45.2 (38.1–52.4) 42.8 (37.4–48.4) 36 (32.4–39.9) 42.2 (39.1–45.4) 39.9 (37.3–42.5) 4.6 (3.4–6.1) 3.4 (2.6–4.4) 3.8 (3.2–4.6) 
 Medicare (ages ≥65 years) 31.8 (23.1–42.0) 35.8 (26.5–46.1) 33.7 (27.5–40.5) 45.3 (32.8–58.5) 39.4 (29.0–50.8) 42.5 (37.0–48.1) 33.1 (29.6–36.7) 41.9 (39–44.7) 38.2 (35.9–40.6) 3.8 (2.8–5.3) 4.4 (3.4–5.7) 4.2 (3.4–5.1) 
 Other 28.2 (17.5–42.1) b 26.3 (15.7–40.5) 48 (35.7–60.6) 38.3 (25.2–53.3) 43.1 (33.7–53.1) 35.4 (31.8–39.2) 35.1 (30.9–39.6) 35.3 (32.4–38.3) 4.7 (3.4–6.4) 2.8 (1.9–4.2) 3.9 (3–5.1) 
Income 
 <100% FPL 31.3 (25.4–37.9) 24.6 (20.1–29.9) 27.5 (23.6–31.8) 39.7 (32.0–47.9) 49.6 (43.0–56.2) 45.4 (40.3–50.5) 37.5 (33.8–41.4) 43.3 (39.9–46.8) 41 (38.3–43.8) 6.2 (4.7–8.3) 2.7 (2–3.6) 4.1 (3.3–5) 
 100 to less than 200% FPL 34.3 (27.8–41.4) 24.8 (20.6–29.5) 29.2 (25.8–32.9) 38.3 (31.9–45.1) 47.5 (40.4–54.8) 43.2 (38.3–48.4) 32.8 (30–35.7) 38.3 (35.6–41.1) 35.6 (33.6–37.8) 3.5 (2.6–4.7) 3.6 (2.8–4.6) 3.5 (2.9–4.2) 
 ≥200% FPL 35.5 (30.4–41.1) 27.9 (25.1–31.0) 31.9 (28.6–35.3) 45.3 (38.4–52.4) 39.4 (34.3–44.7) 42.4 (38.1–46.9) 19 (17.7–20.3) 22.4 (21–23.8) 20.7 (19.6–21.8) 5.3 (4.8–6) 6.1 (5.5–6.8) 5.7 (5.3–6.2) 
Immigration status 
 Born in the US 30.3 (25.9–35.1) 24.8 (22.4–27.4) 27.5 (24.8–30.3) 46.5 (40.5–52.5) 44.3 (39.7–49.0) 45.4 (41.4–49.4) 21.8 (20.5–23.1) 26.2 (24.8–27.6) 24.1 (22.9–25.2) 5.8 (5.3–6.4) 6.2 (5.6–6.8) 6 (5.6–6.4) 
 In US fewer than 10 years 59.1 (47.9–69.5) 39.3 (29.3–50.3) 47.7 (38.8–56.7) 15 (8.1–26.2) 29.8 (21.3–39.9) 24.6 (20.2–29.7) 35.2 (28.2–42.9) 40.3 (33.4–47.6) 36.7 (31.8–41.9) b b b 
 In US, 10+ years 48.9 (43.0–54.9) 37.5 (32.8–42.4) 43.1 (38.6–47.7) 32.6 (27.3–38.3) 33.8 (28.7–39.3) 33.2 (28.9–37.9) 26.3 (23.2–29.6) 31.6 (28.7–34.7) 29.2 (26.9–31.6) 2.6 (1.8–3.7) 1.7 (1.1–2.6) 2.1 (1.6–2.8) 

Abbreviations: 95% CI, 95% confidence interval; AI/AN, American Indian/Alaska Native; BMI, body mass index.

FPL, federal poverty level; HS, high school; —, Not Available.

Note: All estimates are survey weighted. Estimates are age-adjusted to 2000 standard US population, except by age-group and insurance status. Estimates for White, Black, AI/AN, Asian persons are among non-Hispanics. Estimate for Asian persons does not include Native Hawaiians or other Pacific Islander persons.

a12+ drinks in lifetime, and (male) >14 drinks per week in past year OR (female) >7 drinks per week in past year.

bEstimate not provided due to instability.

Physical activity

Over a quarter (25.6%) of adults reported no leisure time physical activity in 2018, with higher levels in females (27.9%) than males (23.1%; Table 2). The disparity by education was vast, ranging from nearly half (48.2%) of people with <HS education compared with 14.5% of college graduates. The proportions of adults meeting physical activity recommendations (defined as 150 minutes of moderate intensity activity or 75 minutes of vigorous intensity activity each week) in 2019 was 54.3% (Supplementary Table S4).

Diet

Vegetables and fruits:

In 2019, 12.3% of adults reported consuming ≥3 servings of vegetables per day and 26.2% of adults reported eating ≥2 servings of fruit daily (Supplementary Table S5). Variations by race/ethnicity and education were wider among women than men, and especially for vegetable consumption. For example, Asian (18.8%) and White (15.6%) women were between 1.3 and 1.9 times more likely to report consuming ≥3 servings of vegetables per day than Hispanic (10%) or Black (11.8%) women.

Alcohol:

In 2018, an estimated 5.1% of adults were classified as heavier drinkers (defined as 12+ drinks in lifetime and >14 drinks per week in the past year in males and >7 drinks per week in the past year in females), with similar prevalence across sex (Table 2). Heavier alcohol consumption increased with higher levels of education among women (<HS: 2.4%, college graduate: 6.4%), whereas among men prevalence was highest in HS (7.1%) and lowest among college educated (4.2%).

Infectious agents

HPV

The American Cancer Society's 2020 HPV vaccination guidelines recommend routine vaccination of both girls and boys between 9 and 12 years of age (16). Vaccination is also recommended for teenagers and adults through the age of 26 who have not been adequately vaccinated according to the Advisory Committee on Immunization Practices (17). In 2019, 56.8% of girls and 51.8% of boys ages 13 to 17 years were up-to-date with HPV vaccination. In addition, 37.4% of girls and 32.9% of boys were up-to-date (≥2 doses) by their 13th birthday, and 62.3% and 60.1% respectively had initiated their vaccination series by that age (Supplementary Table S6). In 2019, 52% of women and 31.7% of men ages 19 to 26 years reported ever having received ≥1 dose of HPV vaccine.

HBV

The CDC recommends that infants, unvaccinated youth <19 years, and high-risk unvaccinated adults be vaccinated against HBV as a primary prevention strategy (18). In 2019, 91.6% of adolescents had received ≥3 HBV vaccine doses (Supplementary Table S6).

Cancer screening

Breast cancer screening

In 2015, the American Cancer Society updated its recommendations stating that women ≥45 years be screened annually or biennially depending on age, including shared decision making with their healthcare provider; women 40 to 44 years should have the opportunity to begin annual mammography (19). In 2018, 63.2% of women ages ≥45 years reported being up-to-date with mammography screening, with about 53% of women ages 45 to 54 years receiving a past year mammogram and 72.9% to 75.0% of women ages 55 to 74 years receiving a mammogram in the past 2 years (Table 3). The United States Preventive Services Task Force recommends biennial mammography in women age 50 to 74 years; 72.8% in this age group reported receiving a mammogram in the past 2 years in 2018 (Table 3; ref. 20). Asian (54.6%), uninsured (31.1%), and recent immigrant (42.8%) women reported the lowest prevalence of up-to-date mammography use (Table 3). Similar patterns were observed when United States Preventive Services Task Force recommendations were examined, though the overall prevalence was higher, the gap between Asian and other racial/ethnic groups was narrower.

Table 3.

Utilization of breast, cervical, colorectal, and prostate cancer screening tests, US adults, NHIS 2018.

Breast cancer screeningCervical cancer screeningColorectal CancerProstate cancer screening
Up-to-date aPast YearBiannualBiannualPap test in past 3 yearsPap test and HPV test in past 5 yearsUp-to-date bUp-to-date CRC Screening cUp-to-date CRC ScreeningUp-to-date CRC ScreeningPSA test in the past year d
≥45 years≥40 years≥40 years50–74 years21–65 years30–65 years21–65 yearsMen and Women, ≥45 yearsMen and Women, ≥50 yearsMen and Women, 50–75 yearsMen ≥50 years
% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)
Overall 63.2 (61.8–64.5) 50.1 (48.8–51.5) 66.1 (64.8–67.3) 72.8 (71.3–74.2) 80.8 (79.6–81.9) 44.7 (42.9–46.4) 83.7 (82.5–84.7) 56.3 (55.3–57.3) 65.6 (64.5–66.6) 66.8 (65.7–68) 35.2 (33.7–36.8) 
Age (years) 
 21–29 — — — — 74.4 (71.1–77.4) — 74.4 (71.1–77.4) — — — — 
 30–39 — — — — 86.6 (84.8–88.1) 53.2 (50.3–56.2) 90 (88.3–91.4) — — — — 
 40–54 — 48.8 (46.6–51.1) 64.2 (62.2–66.2) — — — — — — — — 
  40–49 — — —  85.0 (82.8–87.0) 48.1 (44.7–51.4) 88.5 (86.5–90.3) — — — — 
  45–49 — — — — — — — 20.7 (18.4–23.1) — — — 
  45–54 53.4 (50.7–56.2) 53.4 (50.7–56.2) — — — — — — — — — 
 50–65 — — — — 76 (73.9–77.9) 33 (30.6–35.6) 79.7 (77.7–81.6) — — — — 
  50–54 — — — — — — — 47.8 (45.1–50.5) — — — 
  50–64 — — — — — — — — 61.3 (59.8–62.8) 61.9 (60.4–63.4) 30.2 (28.1–32.4) 
  55–64 72.9 (70.8–75.0) 55.3 (52.9–57.6) 72.9 (70.8–75.0) 71.8 (70.0–73.6) — — — 68.2 (66.3–70.0) — — — 
 65+/65–75 — — — — — — — — 70.6 (69.3–71.9) 77.1 (75.6–78.6) 41.1 (38.8–43.4) 
  65–74 75 (72.7–77.2) 57.5 (54.9–60) 75 (72.7–77.2) 75 (72.7–77.2) — — — 75.8 (74.2–77.3) — — — 
 75+ 50.7 (48–53.4) 37.6 (35–40.2) 50.7 (48–53.4) — — — — 62.9 (60.7–65.1) — — — 
Race/ethnicity 
 White 64.2 (62.7–65.8) 52 (50.4–53.5) 67.6 (66.1–69) 73.1 (71.4–74.7) 81.6 (80.2–82.9) 46 (43.8–48.1) 84.8 (83.5–86) 58.3 (57.1–59.4) 67.6 (66.4–68.8) 69.2 (67.9–70.5) 36.7 (35–38.5) 
 Black 66 (62–69.8) 52 (47.9–56) 68.3 (64.4–71.9) 73.8 (69.1–77.9) 85.3 (82.2–87.8) 48.4 (43.4–53.4) 86.9 (84–89.4) 57.2 (54.2–60.1) 65 (61.8–67.9) 65.6 (62.2–68.8) 33.3 (28.7–38.3) 
 Hispanic 60.1 (55.9–64.2) 45.7 (41.9–49.5) 62.7 (59.1–66.2) 71.4 (66.4–75.8) 79.4 (76.2–82.3) 41.5 (37.3–45.8) 81.7 (78.5–84.6) 49.5 (46.5–52.4) 59.2 (55.6–62.6) 59 (55.1–62.8) 29.8 (24.3–35.8) 
 American Indian/Alaska Native 63.8 (52.6–73.7) 51.1 (38.9–63.1) 63.6 (51–74.6) 65.6 (48–79.7) 73.4 (64.6–80.7) 61.8 (48.8–73.2) 79.9 (69.9–87.2) 48.4 (39.8–57.1) 58.9 (48.6–68.5) 56 (45.5–66.1) e 
 Asian 54.6 (48.6–60.5) 41 (35.4–46.7) 58.1 (52.6–63.4) 71.4 (63.7–78.1) 72.1 (66.9–76.7) 36.6 (30.4–43.4) 74.6 (69.6–79.1) 47.1 (42.7–51.6) 55 (49.8–60) 57.9 (52.2–63.4) 30.2 (24–37.2) 
Sexual orientation 
 Gay/lesbian 70.3 (58.9–79.6) 56.4 (43.7–68.3) 71.5 (60.2–80.6) 79.1 (64.9–88.6) 65.9 (54.7–75.6) 33.5 (22.9–46) 66.4 (55.1–76) 64.4 (57.9–70.5) 75.6 (67.8–82.1) 75.6 (67.7–82.1) 43.4 (34–53.2) 
 Straight 63.3 (61.9–64.7) 50.1 (48.7–51.5) 66.2 (64.9–67.4) 73 (71.5–74.4) 81.3 (80.1–82.4) 44.8 (43–46.6) 84.1 (83–85.2) 56.3 (55.2–57.3) 65.6 (64.5–66.6) 66.8 (65.6–68) 35.1 (33.5–36.7) 
 Bisexual e 49.4 (35.3–63.5) 59.3 (43.8–73.2) e 79.9 (70.9–86.6) 47.4 (37.4–57.6) 84.8 (76.6–90.5) 53.1 (38.4–67.3) 57.9 (40.2–73.9) e e 
Immigration status 
 Born in US/US Territory 64.1 (62.6–65.5) 51.6 (50.2–53) 67.3 (65.9–68.6) 73 (71.4–74.5) 82.2 (81–83.3) 46.7 (44.8–48.5) 85.3 (84.2–86.3) 58.5 (57.4–59.5) 67.9 (66.8–69) 69.1 (67.9–70.3) 36.3 (34.7–37.9) 
 In US fewer than 10 years 42.8 (29.9–56.7) 25.1 (17.1–35.3) 42.5 (31.1–54.7) 53.6 (39–67.5) 61.3 (54.1–68.1) 24 (17.3–32.4) 62.9 (55.3–69.8) 22.1 (15–31.4) 25.7 (17.1–36.7) 29.6 (19.3–42.4) e 
 In US 10+ years 61.2 (57.4–64.9) 46.7 (43.3–50) 64.2 (61.2–67.2) 73.8 (69.4–77.8) 77.7 (74–81) 41.2 (37.2–45.3) 80 (76.3–83.1) 48.1 (45.6–50.5) 56.3 (53.5–59.2) 58.2 (55–61.4) 29.9 (25.7–34.4) 
Education 
 Some high school or less 52.4 (48.3–56.5) 40.2 (36.4–44.1) 53.5 (49.8–57.1) 63.4 (58.3–68.2) 71.6 (67–75.7) 32.2 (27.2–37.6) 74 (69.3–78.2) 44.1 (41.2–46.9) 51.7 (48.4–54.9) 53.2 (49.6–56.7) 23.8 (19.6–28.5) 
 High school diploma 61.1 (58.3–63.7) 47 (44.1–49.8) 62.4 (59.5–65.2) 69.2 (66.1–72) 77.5 (74.7–80.1) 39.3 (35.8–42.8) 80.6 (77.8–83.1) 53.3 (51.4–55.2) 61.8 (59.7–63.7) 63.4 (61.2–65.6) 30.8 (28.1–33.7) 
 Some college 64.1 (61.6–66.4) 50.9 (48.4–53.3) 66.8 (64.4–69.1) 72 (69.4–74.4) 82.9 (80.8–84.8) 48.8 (45.8–51.9) 86.2 (84.3–87.9) 58 (56.4–59.6) 67.5 (65.8–69.2) 67.7 (65.8–69.6) 34.9 (32.3–37.7) 
 College graduate 69.5 (67.3–71.6) 56.5 (54.3–58.6) 73.4 (71.4–75.3) 80.5 (78.2–82.6) 87.2 (85.6–88.7) 48 (45.3–50.7) 90.1 (88.6–91.4) 62.1 (60.6–63.5) 72.6 (71–74.2) 73.4 (71.7–75.1) 43.1 (40.4–45.9) 
Income level 
 <100% FPL 50.6 (46.3–54.8) 36.9 (33–40.9) 50.6 (46.4–54.8) 59.1 (53.9–64.1) 69 (64.9–72.8) 36.3 (31.7–41.3) 71.4 (67.3–75.2) 46.4 (43.3–49.6) 54.7 (51.3–58) 57.2 (53.4–60.9) 25.3 (20.8–30.4) 
 100 to less than 200% FPL 53 (49.3–56.6) 41.5 (38.1–44.9) 56.1 (52.8–59.3) 61.8 (57.7–65.7) 74.9 (71.9–77.6) 38.8 (34.8–43) 78 (75–80.7) 48.9 (46.4–51.4) 55.3 (52.5–58) 57 (53.9–60) 23.2 (19.3–27.5) 
 ≥200% FPL 67.1 (65.5–68.7) 54.1 (52.5–55.7) 70.6 (69.2–72) 76.5 (74.8–78) 83.7 (82.4–84.8) 47.8 (45.7–49.8) 86.6 (85.4–87.7) 59.5 (58.4–60.6) 69.6 (68.4–70.8) 70.1 (68.8–71.4) 38.8 (37–40.5) 
Insurance status 
 Uninsured 31.1 (26.2–36.4) 21.9 (18–26.2) 37.7 (33–42.7) 40.1 (33.7–46.8) 61.7 (57.5–65.7) 33.4 (28.9–38.2) 64.8 (60.6–68.9) 23.6 (20.4–27.3) 29.8 (25.4–34.6) 30.3 (25.8–35.1) 8.7 (5.5–13.5) 
 Private 68.7 (67–70.3) 56.2 (54.7–57.8) 72.4 (71–73.8) 77.5 (75.8–79.1) 83.7 (82.3–84.9) 46.2 (44.1–48.4) 86.5 (85.2–87.6) 59.5 (58.2–60.8) 67.9 (66.5–69.3) 68.6 (67.1–70) 38.6 (36.5–40.7) 
 Medicaid/public/dual eligible 54.3 (49.9–58.6) 44.4 (40.6–48.3) 56.9 (52.9–60.8) 63.3 (58.5–67.8) 78.8 (75.5–81.7) 40.7 (36.7–44.9) 81 (77.7–83.8) 52.2 (49.2–55.2) 57.6 (54.4–60.8) 60.9 (57.4–64.3) 23.4 (18.8–28.7) 
 Medicare (ages ≥65 years) 63.3 (60.6–66) 47.1 (44.4–49.8) 63.3 (60.6–66) 73.5 (69.6–77) 69.9 (55–81.5) 43.6 (29.3–59) 74.2 (59.3–85.1) 69.4 (67.2–71.4) 69.4 (67.2–71.4) 76.7 (74.3–78.9) 36.3 (32.9–39.9) 
 Other 65.2 (60.1–69.9) 46.1 (41.2–51.1) 67.4 (62.5–72) 72.7 (66.4–78.2) 80.4 (75.1–84.8) 43.6 (36.2–51.4) 81.9 (76.6–86.3) 68.4 (65.3–71.4) 71.7 (68.6–74.6) 75.7 (72.2–78.9) 35.8 (31.6–40.3) 
Breast cancer screeningCervical cancer screeningColorectal CancerProstate cancer screening
Up-to-date aPast YearBiannualBiannualPap test in past 3 yearsPap test and HPV test in past 5 yearsUp-to-date bUp-to-date CRC Screening cUp-to-date CRC ScreeningUp-to-date CRC ScreeningPSA test in the past year d
≥45 years≥40 years≥40 years50–74 years21–65 years30–65 years21–65 yearsMen and Women, ≥45 yearsMen and Women, ≥50 yearsMen and Women, 50–75 yearsMen ≥50 years
% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)% (95% CI)
Overall 63.2 (61.8–64.5) 50.1 (48.8–51.5) 66.1 (64.8–67.3) 72.8 (71.3–74.2) 80.8 (79.6–81.9) 44.7 (42.9–46.4) 83.7 (82.5–84.7) 56.3 (55.3–57.3) 65.6 (64.5–66.6) 66.8 (65.7–68) 35.2 (33.7–36.8) 
Age (years) 
 21–29 — — — — 74.4 (71.1–77.4) — 74.4 (71.1–77.4) — — — — 
 30–39 — — — — 86.6 (84.8–88.1) 53.2 (50.3–56.2) 90 (88.3–91.4) — — — — 
 40–54 — 48.8 (46.6–51.1) 64.2 (62.2–66.2) — — — — — — — — 
  40–49 — — —  85.0 (82.8–87.0) 48.1 (44.7–51.4) 88.5 (86.5–90.3) — — — — 
  45–49 — — — — — — — 20.7 (18.4–23.1) — — — 
  45–54 53.4 (50.7–56.2) 53.4 (50.7–56.2) — — — — — — — — — 
 50–65 — — — — 76 (73.9–77.9) 33 (30.6–35.6) 79.7 (77.7–81.6) — — — — 
  50–54 — — — — — — — 47.8 (45.1–50.5) — — — 
  50–64 — — — — — — — — 61.3 (59.8–62.8) 61.9 (60.4–63.4) 30.2 (28.1–32.4) 
  55–64 72.9 (70.8–75.0) 55.3 (52.9–57.6) 72.9 (70.8–75.0) 71.8 (70.0–73.6) — — — 68.2 (66.3–70.0) — — — 
 65+/65–75 — — — — — — — — 70.6 (69.3–71.9) 77.1 (75.6–78.6) 41.1 (38.8–43.4) 
  65–74 75 (72.7–77.2) 57.5 (54.9–60) 75 (72.7–77.2) 75 (72.7–77.2) — — — 75.8 (74.2–77.3) — — — 
 75+ 50.7 (48–53.4) 37.6 (35–40.2) 50.7 (48–53.4) — — — — 62.9 (60.7–65.1) — — — 
Race/ethnicity 
 White 64.2 (62.7–65.8) 52 (50.4–53.5) 67.6 (66.1–69) 73.1 (71.4–74.7) 81.6 (80.2–82.9) 46 (43.8–48.1) 84.8 (83.5–86) 58.3 (57.1–59.4) 67.6 (66.4–68.8) 69.2 (67.9–70.5) 36.7 (35–38.5) 
 Black 66 (62–69.8) 52 (47.9–56) 68.3 (64.4–71.9) 73.8 (69.1–77.9) 85.3 (82.2–87.8) 48.4 (43.4–53.4) 86.9 (84–89.4) 57.2 (54.2–60.1) 65 (61.8–67.9) 65.6 (62.2–68.8) 33.3 (28.7–38.3) 
 Hispanic 60.1 (55.9–64.2) 45.7 (41.9–49.5) 62.7 (59.1–66.2) 71.4 (66.4–75.8) 79.4 (76.2–82.3) 41.5 (37.3–45.8) 81.7 (78.5–84.6) 49.5 (46.5–52.4) 59.2 (55.6–62.6) 59 (55.1–62.8) 29.8 (24.3–35.8) 
 American Indian/Alaska Native 63.8 (52.6–73.7) 51.1 (38.9–63.1) 63.6 (51–74.6) 65.6 (48–79.7) 73.4 (64.6–80.7) 61.8 (48.8–73.2) 79.9 (69.9–87.2) 48.4 (39.8–57.1) 58.9 (48.6–68.5) 56 (45.5–66.1) e 
 Asian 54.6 (48.6–60.5) 41 (35.4–46.7) 58.1 (52.6–63.4) 71.4 (63.7–78.1) 72.1 (66.9–76.7) 36.6 (30.4–43.4) 74.6 (69.6–79.1) 47.1 (42.7–51.6) 55 (49.8–60) 57.9 (52.2–63.4) 30.2 (24–37.2) 
Sexual orientation 
 Gay/lesbian 70.3 (58.9–79.6) 56.4 (43.7–68.3) 71.5 (60.2–80.6) 79.1 (64.9–88.6) 65.9 (54.7–75.6) 33.5 (22.9–46) 66.4 (55.1–76) 64.4 (57.9–70.5) 75.6 (67.8–82.1) 75.6 (67.7–82.1) 43.4 (34–53.2) 
 Straight 63.3 (61.9–64.7) 50.1 (48.7–51.5) 66.2 (64.9–67.4) 73 (71.5–74.4) 81.3 (80.1–82.4) 44.8 (43–46.6) 84.1 (83–85.2) 56.3 (55.2–57.3) 65.6 (64.5–66.6) 66.8 (65.6–68) 35.1 (33.5–36.7) 
 Bisexual e 49.4 (35.3–63.5) 59.3 (43.8–73.2) e 79.9 (70.9–86.6) 47.4 (37.4–57.6) 84.8 (76.6–90.5) 53.1 (38.4–67.3) 57.9 (40.2–73.9) e e 
Immigration status 
 Born in US/US Territory 64.1 (62.6–65.5) 51.6 (50.2–53) 67.3 (65.9–68.6) 73 (71.4–74.5) 82.2 (81–83.3) 46.7 (44.8–48.5) 85.3 (84.2–86.3) 58.5 (57.4–59.5) 67.9 (66.8–69) 69.1 (67.9–70.3) 36.3 (34.7–37.9) 
 In US fewer than 10 years 42.8 (29.9–56.7) 25.1 (17.1–35.3) 42.5 (31.1–54.7) 53.6 (39–67.5) 61.3 (54.1–68.1) 24 (17.3–32.4) 62.9 (55.3–69.8) 22.1 (15–31.4) 25.7 (17.1–36.7) 29.6 (19.3–42.4) e 
 In US 10+ years 61.2 (57.4–64.9) 46.7 (43.3–50) 64.2 (61.2–67.2) 73.8 (69.4–77.8) 77.7 (74–81) 41.2 (37.2–45.3) 80 (76.3–83.1) 48.1 (45.6–50.5) 56.3 (53.5–59.2) 58.2 (55–61.4) 29.9 (25.7–34.4) 
Education 
 Some high school or less 52.4 (48.3–56.5) 40.2 (36.4–44.1) 53.5 (49.8–57.1) 63.4 (58.3–68.2) 71.6 (67–75.7) 32.2 (27.2–37.6) 74 (69.3–78.2) 44.1 (41.2–46.9) 51.7 (48.4–54.9) 53.2 (49.6–56.7) 23.8 (19.6–28.5) 
 High school diploma 61.1 (58.3–63.7) 47 (44.1–49.8) 62.4 (59.5–65.2) 69.2 (66.1–72) 77.5 (74.7–80.1) 39.3 (35.8–42.8) 80.6 (77.8–83.1) 53.3 (51.4–55.2) 61.8 (59.7–63.7) 63.4 (61.2–65.6) 30.8 (28.1–33.7) 
 Some college 64.1 (61.6–66.4) 50.9 (48.4–53.3) 66.8 (64.4–69.1) 72 (69.4–74.4) 82.9 (80.8–84.8) 48.8 (45.8–51.9) 86.2 (84.3–87.9) 58 (56.4–59.6) 67.5 (65.8–69.2) 67.7 (65.8–69.6) 34.9 (32.3–37.7) 
 College graduate 69.5 (67.3–71.6) 56.5 (54.3–58.6) 73.4 (71.4–75.3) 80.5 (78.2–82.6) 87.2 (85.6–88.7) 48 (45.3–50.7) 90.1 (88.6–91.4) 62.1 (60.6–63.5) 72.6 (71–74.2) 73.4 (71.7–75.1) 43.1 (40.4–45.9) 
Income level 
 <100% FPL 50.6 (46.3–54.8) 36.9 (33–40.9) 50.6 (46.4–54.8) 59.1 (53.9–64.1) 69 (64.9–72.8) 36.3 (31.7–41.3) 71.4 (67.3–75.2) 46.4 (43.3–49.6) 54.7 (51.3–58) 57.2 (53.4–60.9) 25.3 (20.8–30.4) 
 100 to less than 200% FPL 53 (49.3–56.6) 41.5 (38.1–44.9) 56.1 (52.8–59.3) 61.8 (57.7–65.7) 74.9 (71.9–77.6) 38.8 (34.8–43) 78 (75–80.7) 48.9 (46.4–51.4) 55.3 (52.5–58) 57 (53.9–60) 23.2 (19.3–27.5) 
 ≥200% FPL 67.1 (65.5–68.7) 54.1 (52.5–55.7) 70.6 (69.2–72) 76.5 (74.8–78) 83.7 (82.4–84.8) 47.8 (45.7–49.8) 86.6 (85.4–87.7) 59.5 (58.4–60.6) 69.6 (68.4–70.8) 70.1 (68.8–71.4) 38.8 (37–40.5) 
Insurance status 
 Uninsured 31.1 (26.2–36.4) 21.9 (18–26.2) 37.7 (33–42.7) 40.1 (33.7–46.8) 61.7 (57.5–65.7) 33.4 (28.9–38.2) 64.8 (60.6–68.9) 23.6 (20.4–27.3) 29.8 (25.4–34.6) 30.3 (25.8–35.1) 8.7 (5.5–13.5) 
 Private 68.7 (67–70.3) 56.2 (54.7–57.8) 72.4 (71–73.8) 77.5 (75.8–79.1) 83.7 (82.3–84.9) 46.2 (44.1–48.4) 86.5 (85.2–87.6) 59.5 (58.2–60.8) 67.9 (66.5–69.3) 68.6 (67.1–70) 38.6 (36.5–40.7) 
 Medicaid/public/dual eligible 54.3 (49.9–58.6) 44.4 (40.6–48.3) 56.9 (52.9–60.8) 63.3 (58.5–67.8) 78.8 (75.5–81.7) 40.7 (36.7–44.9) 81 (77.7–83.8) 52.2 (49.2–55.2) 57.6 (54.4–60.8) 60.9 (57.4–64.3) 23.4 (18.8–28.7) 
 Medicare (ages ≥65 years) 63.3 (60.6–66) 47.1 (44.4–49.8) 63.3 (60.6–66) 73.5 (69.6–77) 69.9 (55–81.5) 43.6 (29.3–59) 74.2 (59.3–85.1) 69.4 (67.2–71.4) 69.4 (67.2–71.4) 76.7 (74.3–78.9) 36.3 (32.9–39.9) 
 Other 65.2 (60.1–69.9) 46.1 (41.2–51.1) 67.4 (62.5–72) 72.7 (66.4–78.2) 80.4 (75.1–84.8) 43.6 (36.2–51.4) 81.9 (76.6–86.3) 68.4 (65.3–71.4) 71.7 (68.6–74.6) 75.7 (72.2–78.9) 35.8 (31.6–40.3) 

Note: All estimates are survey weighted. Estimates are age adjusted to the 2000 US standard population, except by age-group and insurance status. Estimates for White, Black, AI/AN, Asian persons are among non-Hispanics. Estimate for Asian persons does not include Native Hawaiians or other Pacific Islander persons.

Abbreviations: 95% CI, 95% confidence interval; AI/AN, American Indian/Alaska Native; HS, high school; PSA, prostate-specific antigen.

aUp-to-date breast cancer screening: Mammogram within the past year (ages 45–54 years) or past two years (ages ≥55 years).

bAmong women with intact uteri. Up-to-date cervical cancer screening: Pap test in the past 3 years among women 21 to 65 years OR Pap test and HPV test within the past 5 years among women 30 to 65 years.

cUp-to-date CRC screening: For ages ≥45 and ≥50 years: FOBT/FIT, sigmoidoscopy, colonoscopy, CT colonography, OR sDNA test in the past 1, 5, 10, 5 and 3 years, respectively. For ages 50–75 years: FOBT/FIT, sigmoidoscopy, colonoscopy, CT colonography, OR sDNA test in the past 1, 5, 10, 5 and 3 years, respectively, OR sigmoidoscopy in past 10 years with FOBT/FIT in past 1 year.

dAmong men who have not been diagnosed with prostate cancer.

eEstimate not provided due to instability.

Cervical cancer screening

In 2018 and 2020, the United States Preventive Services Task Force and American Cancer Society updated their cervical cancer screening guidelines respectively to include primary HPV testing every 5 years as a screening strategy, along with Pap-testing every 3 years or co-testing every 5 years (21, 22). In 2018, 80.8% of women 21 to 65 years reported having a Pap test within the past 3 years and 83.7% reported being up-to-date with cervical cancer screening, which incorporates HPV co-testing (Table 3; ref. 23). Prevalence of up-to-date cervical cancer screening among women 21 to 65 years was lowest among Asian (74.6%), gay/lesbian (66.4%), uninsured (64.8%), and recent immigrant (62.9%) women. In 2020, the American Cancer Society also increased the recommended age to begin screening from 21 to 25 years and according to the 2018 NHIS, 86% of women 25 to 65 were screened for cervical cancer (7, 9).

Colorectal cancer screening

Colorectal cancer incidence and mortality has been increasing among people born since 1950, prompting the American Cancer Society to recommend that screening begin at age 45 (24, 25). In October 2020, the United States Preventive Services Task Force issued a draft statement also recommending screening initiation at age 45 for those at average risk (26). Among those ≥45 years, overall colorectal cancer screening prevalence was 56.3%, and was lowest in 45- to 49-year old (20.7%), recent immigrant (22.1%), uninsured (23.6%), <HS educated (44.1%), and Asian (47.1%) persons (Table 3). Among those ≥50 years, up-to-date colorectal cancer screening was 65.6% in 2018 (Table 3). The 2018 screening prevalence based on the United States Preventive Services Task Force screening recommendations (ages 50–75) was 66.8% (7, 20).

Prostate cancer screening

Since 2010, the American Cancer Society has recommended that PSA testing should only occur in men at average-risk beginning at age 50 after a process of shared decision making (discussing the advantages, disadvantages, and uncertainity) with a healthcare provider (27). This guideline generally aligns with other groups' recommendations, including those from the United States Preventive Services Task Force, which endorses shared decision making for PSA-testing among men ages 55 to 69 years after a brief period (2012–2016) when routine screening was not recommended for any age (28). In 2018, about a third (35.2%) of men ≥50 years reported having a PSA test within the past year (Table 3). Uninsured (8.7%), Medicaid insured (23.4%), and <HS educated (23.8%) men were among the least likely to have had a recent PSA test.

This contemporary review of major modifiable cancer risk factors and preventive measures in the United States found smoking prevalence is at a historic low—partly driven by long-term improvements in population cessation levels. However, obesity levels remain high and use of cancer screening tests and HPV vaccination are suboptimal. Importantly, socially vulnerable and less-resourced groups tended to have disproportionately worse outcomes across most measures studied.

Tobacco use

In addition to lung cancer, cigarette smoking increases the risk of cancers of the oral cavity and pharynx, larynx, esophagus, pancreas, uterine cervix, kidney, bladder, stomach, colorectum, liver, acute myeloid leukemia (29), mucinous ovarian cancer, and perhaps fatal prostate cancer (29, 30). About 82% of lung cancer cases and 19% of all cancer cases in the United States are attributable to cigarette smoking (3). Quitting smoking reduces the risk of developing all cancers caused by smoking (5). Smoking cessation reduces lung cancer risk by half within 10 to 15 years of cessation compared with people who continue to smoke, and evidence also suggests that cessation reduces all-cause mortality in cancer survivors who currently smoke (5). Historical declines in smoking prevalence have been noted in the United States since the mid-1960s (5), partly a result of nearly two-thirds of US persons (54.9 million) who have ever smoked having quit. This progress is reflected in continuous declines in overall cancer mortality since the early-1990s, and steep declines in lung cancer mortality over the past decade (2). Yet, 14.2% (34 million) of adults still smoke cigarettes. Among those who ever smoked, persons who are Black, American Indian/Alaska Native, lower socioeconomic status, bisexual, gay or lesbian, and residents of Southern states had lower quit ratios. Persons who smoke in many of these same subgroups (Black, American Indian/Alaska Native, Southern residents) also have lower levels of recent successful cessation, despite having similar or higher quit attempt levels.

Low cessation success in general, and among specific subpopulations, may be related to lower receipt of recommended clinical cessation interventions (5). Physician screening for tobacco use, advice to quit, and assistance in quitting has shown to increase quit attempts and cessation success, (5, 31). Although successful cessation often requires multiple attempts to quit, FDA approved cessation medications including nicotine replacement therapy, prescription medications (e.g., bupropion and varenicline), and behavioral counseling (individual, group, or telephone) improve the chances of long-term cessation among adults, especially when used in combination (5). Despite being recommended as clinical cessation interventions since the late-1990s (31), receipt of healthcare provider advice to quit and cessation counseling/medication use remain low among persons who smoke, with significantly lower levels among those who were Hispanic, younger, and Southern residents. Only 72% reported medical doctor advice to quit based on the estimates reported here from the TUS-CPS 2018–2019 survey, and estimates of healthcare provider advice to quit from other national surveys were even lower at between 57% and 65% (32, 33). In addition, just about one-in-three used evidence-based recommended treatments for tobacco dependence in 2018 to 2019, similar to estimates reported in other national surveys (32, 33).

An important factor that contributes to low overall use and disparities in use of recommended cessation treatments is healthcare access to effective aids. Comprehensive, widely promoted insurance coverage of cessation treatments that is free of barriers (copays, prior authorizations, etc.) increases usage, improves cessation outcomes, and is cost-effective (5). Although provisions in Affordable Care Act of 2010 (ACA) mandated coverage of clinical cessation treatments for most health insurance plans, substantial coverage barriers remain, especially in Medicaid programs. Only 14 states had comprehensive coverage that includes individual and group counseling, and all seven FDA-approved tobacco cessation medications to their traditional Medicaid enrollees as of 2020 (34), and only 11 states offered comprehensive coverage to their Medicaid expansion enrollees as of 2019 (35). The proportion of persons who smoke that are covered by Medicaid has increased in the United States, particularly post-ACA (23% in 2019 vs. 14% in 2013 among ages 18–64 years; refs. 8, 36, 37). However, the quit ratio and successful cessation rate are about 40% lower in this group than those privately insured in 2018, even though their quit attempt prevalence are similar, a trend that has continued from the late-1990s (38). These data therefore highlight the critical importance of expanding tobacco cessation coverage in state Medicaid programs.

Other actionable avenues to promote cessation include state-level population tobacco control policies, including cigarette price increases, comprehensive smoke-free policies, mass media campaigns, pictorial health warning requirements, and comprehensive statewide tobacco control programs (5). Price increases and targeted cessation programs are considered particularly equitable, as they have been shown to reduce disparities in smoking by promoting cessation among lower socioeconomic status groups (39). This study documented that Southern states, in general, had lower quit ratios, recent successful cessation, and use of recommended cessation treatments. These geographic disparities are potentially related to the inequitable distribution of healthcare access, cessation coverage policies, and evidence-based tobacco control policies. For example, only 2 of 17 state Medicaid programs in the South cover all recommended cessation treatments for their traditional Medicaid enrollees versus six of nine states in the Northeast (34). Importantly, geographic disparities in cessation outcomes translate to cancer disparities. For example, each of the top 10 ranked metropolitan and micropolitan statistical areas and seven of the top 10 ranked states for smoking-attributable cancer were located in the South (40, 41). Eliminating these disparities will therefore require equitable implementation of effective policies both across US states and within states across health disparate populations.

Excess body weight, physical activity, diet, and alcohol

Approximately 18% of cancer cases in the United States can be attributed to a combination of excess body weight (overweight and obesity), insufficient physical activity, unhealthy diet, and consumption of alcoholic beverages (3). The American Cancer Society nutrition and physical activity guidelines provide recommendations for individuals and communities for healthy eating and active living behaviors. Studies have demonstrated that adults who most closely follow these guidelines (42) are less likely to be diagnosed with and die from cancer (43). These guidelines were updated in 2020 (Supplementary Table S7; ref. 44).

Physical activity can decrease the risk of colon (but not rectal), breast, kidney, endometrial, bladder, esophageal (adenocarcinoma), stomach (cardia), and possibly lung cancer (45–47). Unhealthy dietary patterns are associated with a higher risk of developing cancer (primarily colon; ref. 48), whereas diets with an emphasis on a variety of fruits and vegetables, whole grains, and fish or poultry, and less red or processed meats, added sugars, and highly processed foods is associated with reduced cancer risk (49, 50). Physical inactivity and unhealthy dietary patterns account for an estimated 3% and 4% to 5% of US cancer cases, respectively (3). We found that levels of both modifiable risk factors were suboptimal. About one-quarter of adults in 2018 reported no leisure time physical activity and just over one-half reported recommended physical activity levels. Similarly, just over one-in-four and one-in-ten adults consumed fruits and vegetables respectively at recommended levels in 2019. Prior studies show that time trends in these behaviors varied across specific dietary and physical activity measures. Although leisure time physical activity and adherence to recommended levels increased in the past decade (51, 52), sedentary sitting time increased (53). Recent dietary trends were also mixed; although fruit consumption declined and vegetable and processed meat consumption remained steady (54, 55), positive gains were also noted with a decline in sugar-sweetened beverage consumption (56, 57) and improvement in whole grain consumption (58). Alongside these mixed trends, significant disparities persisted, with lower levels of healthy diet and physical activity among Hispanic and Black persons than White or Asian persons, and among lower income than higher income persons (54, 56–61).

Apart from an unhealthy diet and physical inactivity, an estimated additional 6% of cancer cases can be attributed to alcohol consumption (3), which increases the risk for cancers of the mouth, pharynx, larynx, esophagus, liver, colorectum, and female breast (45). In 2018, heavy alcohol drinking was about 5% among both males and females. However, other studies show that time trends differed by sex—whereas heavy and/or binge alcohol drinking remained stable or declined over time among males, levels have increased over time for women in middle-adulthood, and particularly among higher-educated women (52, 62, 63). These trends are reflected in the distinct and diverging socioeconomic gradients in heavy alcohol drinking by sex reported in our study—heavier drinking was more common among higher educated and higher income females, whereas heavier drinking was more common among lower educated and lower income men.

Possibly reflecting these mixed gains in healthy eating and active living behaviors, obesity rates continued to climb through 2017 to 2018 to when 42.4% of US adults ≥20 years had a BMI in the obese category compared with 22.9% in 1988 to 1994 (64). In addition, obesity levels were strikingly higher among Black and Hispanic women versus White women. Excess body weight increases the risk for cancers of the uterine corpus (endometrium), esophagus (adenocarcinoma), liver, stomach (cardia), kidney (renal cell), pancreas, colorectum, gallbladder, ovary, female breast (postmenopausal), and thyroid, as well as meningioma and multiple myeloma (65), and may also be associated with an increased risk of mouth, pharynx, and larynx, non-Hodgkin lymphoma (diffuse large B-cell lymphoma), male breast cancer, and fatal prostate cancer (65, 66). In 2014, about 7% of cancer cases could be attributed to excess body weight (3). Evidence of increases in obesity-related cancer incidence in successively younger generations suggests that, unless addressed, the burden of obesity-related cancers is likely to substantially increase in the future (3, 67).

Curtailing future cancer burden will require collaborative community and governmental action at the national, state, and local levels to develop and implement efforts to increase access to affordable, nutritious foods; provide safe, enjoyable, and accessible opportunities for physical activity; and regulate alcohol access (Supplementary Table S7; ref. 44). These efforts must be culturally appropriate and equitable as groups that have been historically marginalized have fewer opportunities to modify behaviors to improve health. An example of such an effort would be to address built environmental barriers to healthy eating and active living behaviors, such as the higher prevalence of food deserts (i.e., areas with limited access to a variety of healthy and affordable food) and safe greenspaces in communities with a larger proportion of racial/ethnic minority groups and low socioeconomic status residents (68, 69).

Primary prevention of HPV

Persistent HPV infection causes almost all cervical cancers, 90% of anal cancers, about 70% of oropharyngeal cancers, and 60% to 70% of vaginal, vulvar, and penile cancers (70). The HPV vaccine currently used in the United States protects against nine HPV types and has the potential to avert about 90% of HPV-caused cancers (70), and receipt of the HPV vaccination before the age of 17 years has recently been shown to lower the risk of cervical cancer by 90% (71). Despite a steep increase in HPV vaccination rates in boys that narrowed the previously wide gender gap (72), our study found that about 43% of girls and 48% of boys ages 13 to 17 years were not up-to-date with HPV vaccination in 2019. In addition, almost 40% had also not initiated their vaccination series by their 13th birthday. The promise of preventing multiple types of cancers will be fully realized only if high coverage with HPV vaccine is achieved in adolescents. Recommended strategies for increasing rates of HPV vaccination in the United States include improving provider recommendation, parental awareness, and increasing vaccination access via removal of administrative and financial barriers to vaccination (73, 74).

Cancer screening

Early detection of cancer through screening reduces breast, uterine cervix, colorectum, prostate, and lung cancer mortality. Colorectal and cervical cancers screening can also prevent these cancers by identifying precancerous lesions that can be removed (27). Since 2000, colorectal cancer screening prevalence improved (2018, ≥50 years: 66%; refs. 27, 75); breast (≥45 years: 63.2%) and cervical cancer (21–65 years: 83.7%) screening prevalence remained stable (76, 77); and prostate cancer screening (≥50 years: 35.2%) declined (78, 79). However, screening rates for all these cancers remain suboptimal, especially for people who are uninsured, among whom <50% were up-to-date for most types of cancer screening. Improving cancer screening and reducing screening disparities will require multicomponent interventions that equitably increase demand, access, and delivery, at the patient, provider, and system levels (80). For example, recent healthcare reforms that have expanded insurance access and reduced financial barriers among lower socioeconomic groups, including the ACA Medicaid expansions and elimination of cost-sharing for screenings, have shown promise in reducing population-level screening disparities (81, 82).

In 2013, recommendations were issued for annual lung cancer screening with low-dose spiral computed tomography for healthy individuals ages 55 to 74 years by the American Cancer Society (27) or for ages 55 to 80 years by the United States Preventive Services Task Force (83) who currently smoke or formerly smoked (and quit within the past 15 years) with at least a 30 pack-year smoking history. In 2021, the United States Preventive Services Task Force, expanded their recommended eligibility criteria by lowering the age to begin screening to 50 years and pack-year threshold to 20 (84). According to prior published estimates using registry and survey data, rates of lung cancer screening with low-dose spiral computed tomography among eligible adults has recently risen (85). However, only about 5% to 6% were screened nationally and screening rates ranged from <4% in several Southern and Western states (Arkansas, West Virginia, Florida, California, and Nevada) to 10% to 15% in Kentucky as well as several Northeastern states (85). Recommendations also state that patients should be involved in shared decision making about the benefits, harms, and limitations of lung cancer screening, yet such discussions may be lacking (86). Lung cancer screenings also provide a teachable moment to promote cessation among current longtime persons who smoke (an estimated 8.0 million adults were eligible in 2018; ref. 85), and there is sufficient evidence that screening can trigger quit attempts, cessation treatment uptake, increase cessation, and potentially yield significant mortality benefits than lung cancer screening alone (5, 87).

Limitations

Limitations of this review include the use of national and state-based surveys with variable response rates, though analyses were weighted to mitigate non-response biases (88). In addition, most estimates were based on self-reports, which may be influenced by recall and social desirability bias, although some measures are reasonably accurate according to validation studies (89–91). For example, the 2015 NHIS estimate of health professional advice to quit was 57% compared with the TUS-CPS 2014 to 2015 estimate of 71%, differences that are potentially related to the differences in mode of administration (telephone-based surveys vs. in-person surveys), nature of the survey (social desirability bias in tobacco specific vs. general health surveys), and questionnaires (5, 92). Our review contains the most contemporary estimates, but it does not cover recent data during the COVID-19 pandemic that began in early 2020. For example, an Electronic Medical Record company report estimated an 80% to 90% decline in breast, colorectal, and cervical cancer screening in March to April of 2020 compared with March to April of 2017 to 2019 and a 30% decline in June 2020 compared with prior years (93, 94). Finally, this report did not present information on excessive ultraviolet radiation exposure—estimated to cause 91% of US melanoma cases (95)—because of a lack of availability of updated surveillance data.

This snapshot reported a mixed picture with historic lows in smoking prevalence but suboptimal obesity, cancer screening, and HPV vaccination levels. In addition, racial/ethnic and socioeconomic status disparities persisted across most outcomes. Substantial progress can still be achieved by promoting smoking cessation among health disparate populations. In addition, focused efforts to stem rising obesity levels and improve screening and HPV vaccination levels are also necessary to accelerate progress and avoid reversing gains achieved thus far in reducing overall cancer burden.

A.K. Minihan reports personal fees from Epidemiology Research & Methods, LLC outside the submitted work. R.L. Siegel reports employment with American Cancer Society, which receives grants from private and corporate foundations, including foundations associated with companies in the health sector for research outside of the submitted work. S.A. Fedewa reports employment with American Cancer Society, which receives grants from private and corporate foundations, including foundations associated with companies in the health sector for research outside of the submitted work. No disclosures were reported by the other authors.

We would like to thank Dr. Liora Sahar for her assistance with map creation and methodology. This work was supported by the American Cancer Society's Surveillance & Health Equity Science Department.

1.
Siegel
RL
,
Jemal
A
,
Wender
RC
,
Gansler
T
,
Ma
J
,
Brawley
OW
. 
An assessment of progress in cancer control
.
CA Cancer J Clin
2018
;
68
:
329
39
.
2.
Siegel
RL
,
Miller
KD
,
Fuchs
HE
,
Jemal
A
. 
Cancer statistics, 2021
.
CA Cancer J Clin
2021
;
71
:
7
33
.
3.
Islami
F
,
Goding Sauer
A
,
Miller
KD
,
Siegel
RL
,
Fedewa
SA
,
Jacobs
EJ
, et al
Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States
.
CA Cancer J Clin
2018
;
68
:
31
54
.
4.
Smith
RA
,
Andrews
KS
,
Brooks
D
,
Fedewa
SA
,
Manassaram-Baptiste
D
,
Saslow
D
, et al
Cancer screening in the United States, 2019: a review of current American Cancer Society guidelines and current issues in cancer screening
.
CA Cancer J Clin
2019
;
69
:
184
210
.
5.
US Department of Health and Human Services
.
Smoking cessation. a report of the surgeon general
.
Atlanta, GA
:
Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health
; 
2020
.
6.
Goding Sauer
A
,
Siegel
R
,
Jemal
A
,
Fedewa
SA
. 
Current prevalence of major cancer risk factors and screening test use in the United States: disparities by education and race/ethnicity
.
Cancer Epidemiol Biomarkers Prev
2019
;
28
:
629
42
.
7.
National Center for Health Statistics
. 
2019 2018 National Health Interview Survey data and documentation
.
8.
National Center for Health Statistics
.
2020 September 23
. 
2019 National Health Interview Survey data and documentation
.
Available from:
https://www.cdc.gov/nchs/nhis/2019nhis.htm.
Accessed 2020 September 23
.
9.
Center for Disease Control and Prevention
.
2019 September 11
. 
Behavioral risk factor surveillance system survey data, 2018
.
Available from:
https://www.cdc.gov/brfss/annual_data/annual_data.htm.
Accessed 2020 September 11
.
10.
US Department of Commerce CB
.
2020 September 4
. 
National Cancer Institute and Food and Drug Administration co-sponsored tobacco use supplement to the current population survey, 2018–2019
.
Available from:
https://cancercontrol.cancer.gov/brp/tcrb/tus-cps/.
Accessed 2020 September 4
.
11.
National Center for Health Statistics
.
2017–2018 February 27
. 
National Health and Nutrition Examination Survey Data
.
Available from:
https://wwwn.cdc.gov/nchs/nhanes/Default.aspx.
Accessed 2020 February 27
.
12.
US Department of Health and Human Services
.
2020 February 25
. 
NIS-Teen data and documentation for 2015 to present
.
National Center for Immunization and Respiratory Diseases, Center for Disease Control and Prevention
.
Available from:
https://www.cdc.gov/vaccines/imz-managers/nis/datasets-teen.html.
Accessed 2021 February 25
.
13.
US Department of Health and Human Services
.
2021 March 4
. 
TeenVaxView
.
Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases
,
Available from:
https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/index.html.
Accessed 2021 March 4
.
14.
Fedewa
SA
,
Preiss
AJ
,
Fisher-Borne
M
,
Goding Sauer
A
,
Jemal
A
,
Saslow
D
. 
Reaching 80% human papillomavirus vaccination prevalence by 2026: how many adolescents need to be vaccinated and what are their characteristics?
Cancer
2018
;
124
:
4720
30
.
15.
Klein
R
,
Proctor
SE
,
Boudreault
MA
,
Turczyn
KM
.
Health People 2010 criteria for data suppression
.
Hyattsville, MD
:
Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics
; 
2002
.
16.
Saslow
D
,
Andrews
KS
,
Manassaram-Baptiste
D
,
Smith
RA
,
Fontham
ETH
,
American Cancer Society Guideline Development G
. 
Human papillomavirus vaccination 2020 guideline update: American Cancer Society guideline adaptation
.
CA Cancer J Clin
2020
;
70
:
274
80
.
17.
Meites
E
,
Szilagyi
PG
,
Chesson
HW
,
Unger
ER
,
Romero
JR
,
Markowitz
LE
. 
Human papillomavirus vaccination for adults: updated recommendations of the advisory committee on immunization practices
.
MMWR Morb Mortal Wkly Rep
2019
;
68
:
698
702
.
18.
Schillie
S
,
Vellozzi
C
,
Reingold
A
,
Harris
A
,
Haber
P
,
Ward
JW
, et al
Prevention of hepatitis B virus infection in the United States: recommendations of the advisory committee on immunization practices
.
MMWR Recomm Rep
2018
;
67
:
1
31
.
19.
Oeffinger
KC
,
Fontham
ET
,
Etzioni
R
,
Herzig
A
,
Michaelson
JS
,
Shih
YC
, et al
Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society
.
JAMA
2015
;
314
:
1599
614
.
20.
White
A
,
Thompson
TD
,
White
MC
,
Sabatino
SA
,
de Moor
J
,
Doria-Rose
PV
, et al
Cancer screening test use - United States, 2015
.
MMWR Morb Mortal Wkly Rep
2017
;
66
:
201
6
.
21.
Fontham
ETH
,
Wolf
AMD
,
Church
TR
,
Etzioni
R
,
Flowers
CR
,
Herzig
A
, et al
Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society
.
CA Cancer J Clin
2020
;
70
:
321
46
.
22.
U. S. Preventive Services Task Force
.
2018 October 17
. 
Cervical cancer: screening
.
Available from:
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening.
Accessed 2020 October 17
.
23.
Saslow
D
,
Solomon
D
,
Lawson
HW
,
Killackey
M
,
Kulasingam
SL
,
Cain
J
, et al
American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer
.
CA Cancer J Clin
2012
;
62
:
147
72
.
24.
Siegel
RL
,
Fedewa
SA
,
Anderson
WF
,
Miller
KD
,
Ma
J
,
Rosenberg
PS
, et al
Colorectal cancer incidence patterns in the United States, 1974–2013
.
J Natl Cancer Inst
2017
;
109
:
djw322
.
25.
Wolf
AMD
,
Fontham
ETH
,
Church
TR
,
Flowers
CR
,
Guerra
CE
,
LaMonte
SJ
, et al
Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society
.
CA Cancer J Clin
2018
;
68
:
250
81
.
26.
U. S. Preventive Services Task Force
.
2020 December 4
. 
Draft recommendation statement colorectal cancer: screening
.
Available from:
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening.
Accessed 2020 December 4
.
27.
Smith
RA
,
Andrews
KS
,
Brooks
D
,
Fedewa
SA
,
Manassaram-Baptiste
D
,
Saslow
D
, et al
Cancer screening in the United States, 2018: a review of current American Cancer Society guidelines and current issues in cancer screening
.
CA Cancer J Clin
2018
;
68
:
297
316
.
28.
U. S. Preventive Services Task Force
,
Grossman
DC
,
Curry
SJ
,
Owens
DK
,
Bibbins-Domingo
K
,
Caughey
AB
, et al
Screening for prostate cancer: US Preventive Services Task Force Recommendation Statement
.
JAMA
2018
;
319
:
1901
13
.
29.
US Department of Health and Human Services
.
The health consequences of smoking-50 years of progress. A report from the surgeon general
.
Atlanta, GA; USA
:
Department of Health and Human Services
.
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion
; 
2014
.
30.
Secretan
B
,
Straif
K
,
Baan
R
,
Grosse
Y
,
El Ghissassi
F
,
Bouvard
V
, et al
A review of human carcinogens. Part E: tobacco, areca nut, alcohol, coal smoke, and salted fish
.
Lancet Oncol
2009
;
10
:
1033
4
.
31.
U. S. Preventive Services Task Force
.
2020 October 17
. 
Tobacco smoking cessation in adults, including pregnant persons: interventions
.
Available from:
https://uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions.
Accessed 2020 October 17
.
32.
Babb
S
,
Malarcher
A
,
Schauer
G
,
Asman
K
,
Jamal
A
. 
Quitting smoking among adults—United States, 2000–2015
.
MMWR Morb Mortal Wkly Rep
2017
;
65
:
1457
64
.
33.
Tibuakuu
M
,
Okunrintemi
V
,
Jirru
E
,
Echouffo Tcheugui
JB
,
Orimoloye
OA
,
Mehta
PK
, et al
National trends in cessation counseling, prescription medication use, and associated costs among US adult cigarette smokers
.
JAMA Netw Open
2019
;
2
:
e194585
.
34.
Center for Disease Control and Prevention
.
2020 December 21
. 
STATE system medicaid coverage of tobacco cessation treatments fact sheet
.
Available from:
https://www.cdc.gov/statesystem/factsheets/medicaid/Cessation.html.
Accessed 2020 December 21
.
35.
American Lung Association
.
2019 March 19
. 
Medicaid expansion: state tobacco cessation coverage
.
Available from:
https://www.lung.org/getmedia/b546b74a-671d-44f3-94e8-9f284a5158b8/medicaid-expansion-state.pdf.pdf.
Accessed 2021 March 19
.
36.
National Center for Health Statistics
.
2013 September 23
. 
2013 National Health Interview Survey data and documentation
.
Available from:
https://www.cdc.gov/nchs/nhis/nhis_2018_data_release.htm.
Accessed 2020 September 23
.
37.
Zhu
SH
,
Anderson
CM
,
Wong
S
,
Kohatsu
ND
. 
The growing proportion of smokers in medicaid and implications for public policy
.
Am J Prev Med
2018
;
55
:
S130
S7
.
38.
Zhu
SH
,
Anderson
CM
,
Zhuang
YL
,
Gamst
AC
,
Kohatsu
ND
. 
Smoking prevalence in Medicaid has been declining at a negligible rate
.
PLoS One
2017
;
12
:
e0178279
.
39.
Smith
CE
,
Hill
SE
,
Amos
A
. 
Impact of population tobacco control interventions on socioeconomic inequalities in smoking: a systematic review and appraisal of future research directions
.
Tob Control
2020 Sep 29 [Epub ahead of print]
.
40.
Islami
F
,
Bandi
P
,
Sahar
L
,
Ma
J
,
Drope
J
,
Jemal
A
. 
Cancer deaths attributable to cigarette smoking in 152 U.S. metropolitan or micropolitan statistical areas, 2013–2017
.
Cancer Causes Control
2021
;
32
:
311
6
.
41.
Lortet-Tieulent
J
,
Goding Sauer
A
,
Siegel
RL
,
Miller
KD
,
Islami
F
,
Fedewa
SA
, et al
State-level cancer mortality attributable to cigarette smoking in the United States
.
JAMA Intern Med
2016
;
176
:
1792
8
.
42.
Kushi
LH
,
Doyle
C
,
McCullough
M
,
Rock
CL
,
Demark-Wahnefried
W
,
Bandera
EV
, et al
American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity
.
CA Cancer J Clin
2012
;
62
:
30
67
.
43.
Kabat
GC
,
Matthews
CE
,
Kamensky
V
,
Hollenbeck
AR
,
Rohan
TE
. 
Adherence to cancer prevention guidelines and cancer incidence, cancer mortality, and total mortality: a prospective cohort study
.
Am J Clin Nutr
2015
;
101
:
558
69
.
44.
Rock
CL
,
Thomson
C
,
Gansler
T
,
Gapstur
SM
,
McCullough
ML
,
Patel
AV
, et al
American Cancer Society guideline for diet and physical activity for cancer prevention
.
CA Cancer J Clin
2020
;
70
:
245
71
.
45.
World Cancer Research Fund and American Institute for Cancer Research
.
Continuous update project 3rd ed
.
London, UK
:
World Cancer Research Fund and American Institute for Cancer Research
; 
2018
.
46.
2018 Physical Activity Guidelines Advisory Committee
.
2018 Physical activity guidelines advisory committee scientific report
.
Washington, DC
:
U.S. Department of Health and Human Services
; 
2018
.
47.
Patel
AV
,
Friedenreich
CM
,
Moore
SC
,
Hayes
SC
,
Silver
JK
,
Campbell
KL
, et al
American college of sports medicine roundtable report on physical activity, sedentary behavior, and cancer prevention and control
.
Med Sci Sports Exerc
2019
;
51
:
2391
402
.
48.
Grosso
G
,
Bella
F
,
Godos
J
,
Sciacca
S
,
Del Rio
D
,
Ray
S
, et al
Possible role of diet in cancer: systematic review and multiple meta-analyses of dietary patterns, lifestyle factors, and cancer risk
.
Nutr Rev
2017
;
75
:
405
19
.
49.
Schwingshackl
L
,
Bogensberger
B
,
Hoffmann
G
. 
Diet quality as assessed by the healthy eating index, alternate healthy eating index, dietary approaches to stop hypertension score, and health outcomes: an updated systematic review and meta-analysis of cohort studies
.
J Acad Nutr Diet
2018
;
118
:
74
100
.
50.
Schwingshackl
L
,
Schwedhelm
C
,
Galbete
C
,
Hoffmann
G
. 
Adherence to mediterranean diet and risk of cancer: an updated systematic review and meta-analysis
.
Nutrients
2017
;
9
:
1063
.
51.
National Cancer Institute
.
2020 October 17
. 
Physical activity
.
Available from:
https://progressreport.cancer.gov/prevention/physical_activity.
Accessed 2020 October 17
.
52.
Henley
SJ
,
Thomas
CC
,
Lewis
DR
,
Ward
EM
,
Islami
F
,
Wu
M
, et al
Annual report to the nation on the status of cancer, part II: progress toward Healthy People 2020 objectives for 4 common cancers
.
Cancer
2020
;
126
:
2250
66
.
53.
Yang
L
,
Cao
C
,
Kantor
ED
,
Nguyen
LH
,
Zheng
X
,
Park
Y
, et al
Trends in sedentary behavior among the US population, 2001–2016
.
JAMA
2019
;
321
:
1587
97
.
54.
Ansai
N
,
Wambogo
EA
. 
Fruit and vegetable consumption among adults in the United States, 2015–2018
.
NCHS Data Brief
2021
;
397
:
1
8
.
55.
Zeng
L
,
Ruan
M
,
Liu
J
,
Wilde
P
,
Naumova
EN
,
Mozaffarian
D
, et al
Trends in processed meat, unprocessed red meat, poultry, and fish consumption in the United States, 1999–2016
.
J Acad Nutr Diet
2019
;
119
:
1085
98
.
56.
Marriott
BP
,
Hunt
KJ
,
Malek
AM
,
Newman
JC
. 
Trends in intake of energy and total sugar from sugar-sweetened beverages in the United States among children and adults, NHANES 2003–2016
.
Nutrients
2019
;
11
:
2004
.
57.
Kit
BK
,
Fakhouri
TH
,
Park
S
,
Nielsen
SJ
,
Ogden
CL
. 
Trends in sugar-sweetened beverage consumption among youth and adults in the United States: 1999–2010
.
Am J Clin Nutr
2013
;
98
:
180
8
.
58.
Ahluwalia
N
,
Herrick
KA
,
Terry
AL
,
Hughes
JP
. 
Contribution of whole grains to total grains intake among adults aged 20 and over: United States, 2013–2016
.
NCHS Data Brief
2019
;
341
:
1
8
.
59.
Shan
Z
,
Rehm
CD
,
Rogers
G
,
Ruan
M
,
Wang
DD
,
Hu
FB
, et al
Trends in dietary carbohydrate, protein, and fat intake and diet quality among US adults, 1999–2016
.
JAMA
2019
;
322
:
1178
87
.
60.
Fryar
CD
,
Hughes
JP
,
Herrick
KA
,
Ahluwalia
N
. 
Fast food consumption among adults in the United States, 2013–2016
.
NCHS Data Brief
2018
;
322
:
1
8
.
61.
Center for Disease Control and Prevention
.
2020 October 12
. 
Adult physical inactivity prevalence maps by race/ethnicity
.
Available from:
https://www.cdc.gov/physicalactivity/data/inactivity-prevalence-maps/index.html.
Accessed 2020 October 12
.
62.
Keyes
KM
,
Jager
J
,
Mal-Sarkar
T
,
Patrick
ME
,
Rutherford
C
,
Hasin
D
. 
Is there a recent epidemic of women's drinking? A critical review of national studies
.
Alcohol Clin Exp Res
2019
;
43
:
1344
59
.
63.
Dwyer-Lindgren
L
,
Flaxman
AD
,
Ng
M
,
Hansen
GM
,
Murray
CJ
,
Mokdad
AH
. 
Drinking patterns in US counties from 2002 to 2012
.
Am J Public Health
2015
;
105
:
1120
7
.
64.
Fryar
CD
,
Carroll
MD
,
Afful
J
. 
Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: United States, 1960–1962 through 2017–2018
.
National Center for Health Statistics Health E-Stats
2020
.
65.
Lauby-Secretan
B
,
Scoccianti
C
,
Loomis
D
,
Grosse
Y
,
Bianchini
F
,
Straif
K
. 
Body fatness and cancer—viewpoint of the IARC Working Group
.
N Engl J Med
2016
;
375
:
794
8
.
66.
World Cancer Research Fund/American Institute for Cancer Research
. 
Continuous update project expert report 2018
.
Body fatness and weight gain and the risk of cancer
.
London, UK
:
World Cancer Research Fund/American Institute for Cancer Research
; 
2018
.
67.
Sung
H
,
Siegel
RL
,
Rosenberg
PS
,
Jemal
A
. 
Emerging cancer trends among young adults in the USA: analysis of a population-based cancer registry
.
Lancet Public Health
2019
;
4
:
e137
e47
.
68.
Rhone
A
,
Ver Ploeg
M
,
Dicken
C
,
Wiliams
R
,
Breneman
V
.
2017 October 27
. 
Low-income and low-supermarket-access census tracts, 2010–2015
.
Available from:
https://www.ers.usda.gov/webdocs/publications/82101/eib-165.pdf?v=8590.7.
Accessed 2020 October 27
.
69.
Rigolona
A
,
Browninga
M
,
Jennings
V
. 
Inequities in the quality of urban park systems: an environmental justice investigation of cities in the United States
.
Landsc Urban Plan
2018
;
178
:
156
69
.
70.
Saraiya
M
,
Unger
ER
,
Thompson
TD
,
Lynch
CF
,
Hernandez
BY
,
Lyu
CW
, et al
US assessment of HPV types in cancers: implications for current and 9-valent HPV vaccines
.
J Natl Cancer Inst
2015
;
107
:
djv086
.
71.
Lei
J
,
Ploner
A
,
Elfstrom
KM
,
Wang
J
,
Roth
A
,
Fang
F
, et al
HPV vaccination and the risk of invasive cervical cancer
.
N Engl J Med
2020
;
383
:
1340
8
.
72.
Walker
TY
,
Elam-Evans
LD
,
Yankey
D
,
Markowitz
LE
,
Williams
CL
,
Mbaeyi
SA
, et al
National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years - United States, 2017
.
MMWR Morb Mortal Wkly Rep
2018
;
67
:
909
17
.
73.
National Vaccine Advisory Committee
. 
Overcoming barriers to low HPV vaccine uptake in the United States: recommendations from the National Vaccine Advisory Committee: approved by the National Vaccine Advisory Committee on June 9, 2015
.
Public Health Rep
2016
;
131
:
17
25
.
74.
Kessels
SJ
,
Marshall
HS
,
Watson
M
,
Braunack-Mayer
AJ
,
Reuzel
R
,
Tooher
RL
. 
Factors associated with HPV vaccine uptake in teenage girls: a systematic review
.
Vaccine
2012
;
30
:
3546
56
.
75.
Klabunde
CN
,
Cronin
KA
,
Breen
N
,
Waldron
WR
,
Ambs
AH
,
Nadel
MR
. 
Trends in colorectal cancer test use among vulnerable populations in the United States
.
Cancer Epidemiol Biomarkers Prev
2011
;
20
:
1611
21
.
76.
Breen
N
,
Gentleman
JF
,
Schiller
JS
. 
Update on mammography trends: comparisons of rates in 2000, 2005, and 2008
.
Cancer
2011
;
117
:
2209
18
.
77.
Watson
M
,
Benard
V
,
King
J
,
Crawford
A
,
Saraiya
M
. 
National assessment of HPV and Pap tests: changes in cervical cancer screening, National Health Interview Survey
.
Prev Med
2017
;
100
:
243
7
.
78.
Jemal
A
,
Fedewa
SA
,
Ma
J
,
Siegel
R
,
Lin
CC
,
Brawley
O
, et al
Prostate cancer incidence and PSA testing patterns in relation to USPSTF screening recommendations
.
JAMA
2015
;
314
:
2054
61
.
79.
Jiang
C
,
Fedewa
SA
,
Wen
Y
,
Jemal
A
,
Han
X
. 
Shared decision making and prostate-specific antigen based prostate cancer screening following the 2018 update of USPSTF screening guideline
.
Prostate Cancer Prostatic Dis
2021
;
24
:
77
80
.
80.
Community Preventive Services Task Force
.
2021 March 18
. 
CPSTF findings for cancer prevention and control
.
Available from:
https://www.thecommunityguide.org/content/task-force-findings-cancer-prevention-and-control.
Accessed 2021 March 18
.
81.
Fedewa
SA
,
Yabroff
KR
,
Smith
RA
,
Goding Sauer
A
,
Han
X
,
Jemal
A
. 
Changes in breast and colorectal cancer screening after medicaid expansion under the affordable care act
.
Am J Prev Med
2019
;
57
:
3
12
.
82.
Fedewa
SA
,
Goodman
M
,
Flanders
WD
,
Han
X
,
Smith
RA
,
M Ward
E
, et al
Elimination of cost-sharing and receipt of screening for colorectal and breast cancer
.
Cancer
2015
;
121
:
3272
80
.
83.
Moyer
VA
,
US Preventive Services Task Force
. 
Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement
.
Ann Intern Med
2014
;
160
:
330
8
.
84.
U. S. Preventive Services Task Force
.
2021 March 18
. 
Final recommendation statement lung cancer: screening
.
Available from:
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening.
Accessed 2021 March 18
.
85.
Fedewa
SA
,
Kazerooni
EA
,
Studts
JL
,
Smith
R
,
Bandi
P
,
Sauer
AG
, et al
State variation in low-dose CT scanning for lung cancer screening in the United States
.
J Natl Cancer Inst
2020 Nov 12 [Epub ahead of print]
.
86.
Brenner
AT
,
Malo
TL
,
Margolis
M
,
Elston Lafata
J
,
James
S
,
Vu
MB
, et al
Evaluating shared decision making for lung cancer screening
.
JAMA Intern Med
2018
;
178
:
1311
6
.
87.
Cao
P
,
Jeon
J
,
Levy
DT
,
Jayasekera
JC
,
Cadham
CJ
,
Mandelblatt
JS
, et al
Potential impact of cessation interventions at the point of lung cancer screening on lung cancer and overall mortality in the United States
.
J Thorac Oncol
2020
;
15
:
1160
9
.
88.
Czajka
JL
,
Beyler
A
. 
Background paper - declining response rates in federal surveys: trends and implications
.
Mathematica Policy Research
; 
2016
.
89.
de Leeuw
ED
,
Desiree
E
. 
Data Quality in Mail, Telephone, and Face to Face Surveys
.
Amsterdam
:
TT-Publications
; 
1992
.
90.
Rauscher
GH
,
Johnson
TP
,
Cho
YI
,
Walk
JA
. 
Accuracy of self-reported cancer-screening histories: a meta-analysis
.
Cancer Epidemiol Biomarkers Prev
2008
;
17
:
748
57
.
91.
Burgess
DJ
,
Powell
AA
,
Griffin
JM
,
Partin
MR
. 
Race and the validity of self-reported cancer screening behaviors: development of a conceptual model
.
Prev Med
2009
;
48
:
99
107
.
92.
National Cancer Institute
.
2020 December 11
. 
2014–15 TUS-CPS data, table 5: various unique items
.
Available from:
https://cancercontrol.cancer.gov/brp/tcrb/tus-cps/results/2014-2015/table-5.
Accessed 2020 December 11
.
93.
Epic Health Research Network
.
2020 November 8
. 
Delayed cancer screenings
.
Available from
: https://www.ehrn.org/articles/delays-in-preventive-cancer-screenings-during-covid-19-pandemic/.
Accessed 2020 November 8
.
94.
Epic Health Research Network
.
2020 November 8
. 
Delayed cancer screenings—a second look
.
Available from:
https://www.ehrn.org/articles/delayed-cancer-screenings-a-second-look/.
Accessed 2020 November 8
.
95.
Islami
F
,
Sauer
A
,
Miller
KD
,
Fedewa
SA
,
Minihan
AK
,
Geller
AC
, et al
Cutaneous melanomas attributable to ultraviolet radiation exposure by state
.
Int J Cancer
2020
;
147
:
1385
90
.