We present national and state representative prevalence estimates of modifiable cancer risk factors, preventive behaviors and services, and screening, with a focus on changes during the COVID-19 pandemic. Between 2019 and 2021, current smoking, physical inactivity, and heavy alcohol consumption declined, and human papillomavirus vaccination and stool testing for colorectal cancer screening uptake increased. In contrast, obesity prevalence increased, while fruit consumption and cervical cancer screening declined during the same timeframe. Favorable and unfavorable trends were evident during the second year of the COVID-19 pandemic that must be monitored as more years of consistent data are collected. Yet disparities by racial/ethnic and socioeconomic status persisted, highlighting the continued need for interventions to address suboptimal levels among these population subgroups.

More than 40% of the 609,820 cancer-related deaths expected to occur in 2023 in the United States are attributable to major modifiable cancer risk factors, including cigarette smoking, excess body weight, alcohol intake, physical inactivity, unhealthy diet, and obesity and thus potentially avoidable through lifestyle changes (1, 2). Many more cancer-related deaths are preventable through recommended human papillomavirus (HPV) vaccinations or early detection through regular cancer screenings (1, 2, 3). We have previously published biannual updates on prevalence patterns of major modifiable cancer risk factors and cancer screening. In our last report, we published an update that showed mixed progress; for example, although smoking prevalence reached historic lows and nearly 55 million persons had quit by 2019, obesity levels remained high and screening rates remained suboptimal (4). Most importantly, stark racial/ethnic and socioeconomic disparities were evident in most of these measures.

The onset of the corona virus disease 2019 (COVID-19) pandemic in the United States in early 2020 has influenced the patterns of prevalence and disparities in cancer risk factors, prevention, and screening in the country. Studies have assessed changes in individual measures, including attempts to quit smoking (5), physical inactivity (6), alcohol consumption (7), fruit and vegetable consumption (8), and cancer screening (9–13) during the COVID-19 pandemic. However, none have examined changes in all major cancer risk factors and screening measures concurrently and only a few of these studies addressed the changes in the second year of the pandemic (2021). In this study, we comprehensively examined concurrent changes in cancer risk factors, preventive behaviors and services, and screening between 2019 and 2021, covering the second year of the COVID-19 pandemic.

We used three publicly available surveys to examine the changes in prevalence of major cancer risk factors, preventive behaviors and services, and cancer screening between 2019 and 2021. First, the National Health Interview Survey (NHIS), a weighted nationally representative household survey of noninstitutionalized adults (14, 15), was used to estimate prevalence of cigarette smoking, quit ratio, and breast, cervical, and colorectal cancer screening nationally in adults. The NHIS is typically conducted through face-to-face interviews; however, because of concerns about infection risk and the need for social isolation during the early part of the COVID-19 pandemic, data in the first four months of 2021 were collected through telephone interviews with in-person visits only as a follow-up on nonresponse/nontelephone users (15). By May of 2021, interviewers returned to in-person household interviews but were given flexibility contingent on local COVID-19 conditions (15). Second, the Behavioral Risk Factors Surveillance System (BRFSS), a weighted state-level computer-assisted telephone-based survey, was used to estimate national prevalence of physical inactivity, heavy alcohol consumption, recommended fruit and vegetable consumption, as well as state level smoking, and obesity prevalence (16, 17). National level obesity prevalence, which is typically obtained from the National Health and Nutrition Examination Survey (NHANES) which combines interviews and physical examinations to assess health and nutrition (18), was not available for 2021 at the time this study was conducted. Therefore, we present state level obesity prevalence from the BRFSS. Third, the National Immunization Survey – Teen (NIS-TEEN) was used to estimate national HPV and hepatitis B (HBV) vaccination prevalence for adolescents age 13 to 17 years (19, 20). The NIS-TEEN vaccination data were obtained through a household telephone survey where parents/guardian gave permission to contact the teen's vaccination provider, the provider was then mailed an immunization survey to complete, with some provider's completing by telephone if needed. Response rates across the surveys ranged from 59.1% in 2019 and 50.9% in 2021 in the NHIS, 49.4% in 2019 and 44.0% in 2021 in the BRFSS, and a household response rate of 19.7% in 2019 and 21.0% in 2021 in the NIS-TEEN (14–17, 19, 20). Estimates from the NHIS, BRFSS, and NIS-TEEN were survey weighted for nonresponse and to be either representative of the U.S. population nationally (NHIS or NIS-TEEN) or by state (BRFSS; refs. 14–17, 19, 20).

The variables for the primary outcomes of major cancer risk factors include current adult smoking prevalence, defined as the proportion of adults who smoked at least 100 cigarettes in their lifetime and currently smoke cigarettes every day or somedays, quit ratio was defined as the proportion of adults who have ever smoked who now do not smoke, physical inactivity was defined as reports of no physical activity or exercise during the past 30 days other than for their regular job (16, 17), heavy alcohol consumption was defined as consuming >14 drinks per week for males or >7 drinks per week for females, which translates to, on average, two drinks a day for men and one drink a day for women, during the past 30 days (16, 17, 21), and obesity was defined as having a body mass index (BMI) above 30.0 kg/m2 (16, 17). Preventive behaviors included recommended vegetable consumption defined as ≥ 3 servings of vegetables a day, and recommended fruit consumption defined as ≥ 2 servings of fruit a day (16, 17). Preventive services included receipt of HPV and HBV vaccinations in adolescents. The American Cancer Society (ACS) recommends routine HPV vaccination to occur between ages 9 to 12, with the recommendation that providers begin offering vaccination at ages 9 and 10 (22). Up-to-date (UTD) HPV vaccination among teens ages 13 to 17 was defined as received ≥ 2 doses before age 15 or 3 doses on or after age 15 (19, 20). In 2018, the Advisory Committee on Immunization Practices and the Centers for Disease Control (CDC) recommended HBV vaccination within 12 to 24 hours of birth, and among unvaccinated children and adolescents under the age of 19 (23). UTD HBV vaccination amongst teens ages 13 to 17 years was defined as received ≥ 2 hepatitis B 1.0 mL Recombivax shots or ≥ 3 of any combination hepatitis B—containing shots (19, 20).

Variables for cancer screenings included being UTD for breast, cervical, and colorectal cancer defined according to the U.S. Preventive Services Task Force (USPSTF) recommendations. UTD cancer screening was assessed in this study as it more closely relates with cancer outcomes (2). UTD breast cancer screening was defined as biannual mammography in women ages 50 to 74 years (24). UTD cervical cancer screening was defined as cervical cytology every 3 years in women ages 21 to 29 years; for women ages 30 to 65 years, it was defined as cervical cytology every 3 years, high-risk HPV testing every 5 years, or a combination of cervical cytology and HPV testing (cotesting) every 5 years (25). To allow for comparability of UTD colorectal cancer screening estimates over time, we followed the 2016 USPSTF guidelines, rather than the updated 2021 guideline, defined as receipt of fecal immunochemical test or high-sensitivity guaiac-based fecal occult blood test annually; multitarget stool DNA test every 1 to 3 years; colonoscopy every 10 years; computed tomography colonography or flexible sigmoidoscopy every 5 years; or combined annual fecal immunochemical test and flexible sigmoidoscopy every 10 years in individuals ages 50 to 75 years (26).

National and state level age-standardized prevalence was estimated overall and by sociodemographic characteristics: sex, age, race/ethnicity, sexual orientation, immigration status, education (age ≥ 25 years), and health insurance coverage status. Adjusted prevalence ratios (aPR), comparing prevalence of evaluated outcomes in 2021 versus 2019, were estimated for each socioeconomic category via the ratio of predicted marginal probability of the outcome in logistic regression models adjusting for age, sex, race/ethnicity, geographic region, and educational attainment. In the NIS-TEEN, models were adjusted for age, sex, race/ethnicity, and geographic region, but not for education as the population was all under age 18 years. In addition, population estimates of number of persons reporting evaluated outcomes were estimated as survey weighted counts. All weighted estimates and 95% confidence intervals (CIs) were calculated using SAS-callable SUDAAN accounting for complex survey design. The National Center for Health Statistics criteria for data suppression, denominator sizes < 50 or a relative-SE ≥ 30%, was followed (27, 28).

Data availability

The study data are publicly available at the websites of the NHIS, BRFSS, and NIS-TEEN (TeenVaxView).

Tobacco use - cigarette smoking

Overall cigarette smoking prevalence among adults ages ≥18 years between 2019 and 2021 declined from 14.2% in 2019 to 11.7% in 2021 (aPR, 0.89; 95% CI, 0.85–0.94; Fig. 1; Table 1), which translated to a survey weighted population estimate of 5.7 million fewer adults who currently smoke (Supplementary Table S1). Overall, the quit ratio increased from 57.1% in 2019 to 62.7% in 2021 (aPR, 1.05; 95% CI, 1.02–1.07). The decline in adult smoking prevalence between 2019 and 2021 was observed in all subgroups except in older age groups (age ≥ 45 years), Hispanic and Asian individuals, gay, lesbian, or bisexual identifying persons, foreign-born persons, those with no high school diploma or had some college experience, and uninsured or medicare only insured individuals.

Figure 1.

Major cancer risk factors and screening test use in 2019 and 2021. A, Risk factors and preventive behaviors, included the proportion of individuals who currently smoke, individuals who now do not smoke, individuals who are physically inactive in their leisure-time, individuals who use alcohol heavily, and individuals who met recommended vegetable and fruit consumption in 2019 and 2021. B, Vaccinations, included the proportion of teens (ages 13–17) who were up-to-date with HPV and HBV vaccinations. C, Cancer screening, included the proportion of eligible individuals up-to-date with breast, cervical, and colorectal cancer screening (stool testing and colonoscopy were also displayed separately). aProportion of adults who smoked at least 100 cigarettes in their lifetime and currently smoke cigarettes every day or somedays. Proportion of adults who have ever smoked who now do not smoke. Proportion with no leisure-time physical activity in the past week. Proportion of U.S. adults classified as heavy drinkers (> 14 drinks per week in the past year in males and > 7 drinks per week in past year in females). Proportion consumed three servings of vegetables a day. Proportion consumed two servings of fruit a day. bReceived ≥ 2 doses before age 15 or 3 doses on or after age 15. Received ≥ 2 hepatitis B 1.0 mL Recombivax shots or ≥3 combination hepatitis B—containing shots. cProportion of women ages 50 to 74 who received biannual mammography screening. Proportion of women ages 21 to 29, without a hysterectomy, who had cervical cytology every 3 years, or women ages 30 to 65, without a hysterectomy, who had a cervical cytology every 3 years, a HPV test every 5 years, or cotested every 5 years. Proportion of adults ages 50 to 75 who received either a fecal immunochemical test or high-sensitivity guaiac-based fecal occult blood test annually; multitarget stool DNA test every 1 to 3 years; colonoscopy every 10 years; CT colonography or flexible sigmoidoscopy every 5 years, or combined annual FIT test and flexible sigmoidoscopy every 10 years. Proportion of adults ages 50 to 75 who received a fecal immunochemical test or high-sensitivity guaiac-based fecal occult blood test annually. Proportion of adults ages 50 to 75 who received colonoscopy within the last 10 years. Note: estimates are survey weighted. Prevalence estimates with 95% CI not including 1.0 for the aPR comparing prevalence of evaluated outcomes in 2021 versus 2019 received an asterisk.

Figure 1.

Major cancer risk factors and screening test use in 2019 and 2021. A, Risk factors and preventive behaviors, included the proportion of individuals who currently smoke, individuals who now do not smoke, individuals who are physically inactive in their leisure-time, individuals who use alcohol heavily, and individuals who met recommended vegetable and fruit consumption in 2019 and 2021. B, Vaccinations, included the proportion of teens (ages 13–17) who were up-to-date with HPV and HBV vaccinations. C, Cancer screening, included the proportion of eligible individuals up-to-date with breast, cervical, and colorectal cancer screening (stool testing and colonoscopy were also displayed separately). aProportion of adults who smoked at least 100 cigarettes in their lifetime and currently smoke cigarettes every day or somedays. Proportion of adults who have ever smoked who now do not smoke. Proportion with no leisure-time physical activity in the past week. Proportion of U.S. adults classified as heavy drinkers (> 14 drinks per week in the past year in males and > 7 drinks per week in past year in females). Proportion consumed three servings of vegetables a day. Proportion consumed two servings of fruit a day. bReceived ≥ 2 doses before age 15 or 3 doses on or after age 15. Received ≥ 2 hepatitis B 1.0 mL Recombivax shots or ≥3 combination hepatitis B—containing shots. cProportion of women ages 50 to 74 who received biannual mammography screening. Proportion of women ages 21 to 29, without a hysterectomy, who had cervical cytology every 3 years, or women ages 30 to 65, without a hysterectomy, who had a cervical cytology every 3 years, a HPV test every 5 years, or cotested every 5 years. Proportion of adults ages 50 to 75 who received either a fecal immunochemical test or high-sensitivity guaiac-based fecal occult blood test annually; multitarget stool DNA test every 1 to 3 years; colonoscopy every 10 years; CT colonography or flexible sigmoidoscopy every 5 years, or combined annual FIT test and flexible sigmoidoscopy every 10 years. Proportion of adults ages 50 to 75 who received a fecal immunochemical test or high-sensitivity guaiac-based fecal occult blood test annually. Proportion of adults ages 50 to 75 who received colonoscopy within the last 10 years. Note: estimates are survey weighted. Prevalence estimates with 95% CI not including 1.0 for the aPR comparing prevalence of evaluated outcomes in 2021 versus 2019 received an asterisk.

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Table 1.

Prevalence estimates and aPRs of major modifiable cancer risk factors, adults 18 years and older, U.S. NHIS and BRFSS 2019–2021.

Current smokingaQuit ratiobPhysical inactivitycHeavy alcohol used
Characteristic 2019 (%) 2021 (%) aPR (95% CI) 2019 (%) 2021 (%) aPR (95% CI) 2019 (%) 2021 (%) aPR (95% CI) 2019 (%) 2021 (%) aPR (95% CI) 
Overall 14.2 11.7 0.89 (0.85–0.94) 57.1 62.7 1.05 (1.02–1.07) 25.8 23.3 0.92 (0.91–0.93) 6.6 6.2 0.94 (0.91–0.98) 
Sex             
 Males 15.5 13.3 0.93 (0.86–0.99) 59.5 63.8 1.04 (1.01–1.07) 24.4 21.0 0.88 (0.85–0.9) 7.0 6.4 0.93 (0.88–0.98) 
 Females 13.0 10.1 0.86 (0.8–0.92) 54.0 61.3 1.06 (1.03–1.1) 27.2 25.4 0.96 (0.94–0.98) 6.2 5.9 0.96 (0.91–1.01) 
Age (years) 
 18–24 8.0 5.4 0.64 (0.49–0.84) 39.9 50.3 1.24 (0.99–1.55) 20.1 17.3 0.85 (0.79–0.91) 7.2 5.9 0.82 (0.71–0.94) 
 25–44 16.7 12.6 0.82 (0.76–0.89) 50.8 59.0 1.12 (1.06–1.18) 23.6 20.1 0.86 (0.83–0.88) 7.4 7.3 0.99 (0.93–1.05) 
 45–64 17.0 14.9 0.96 (0.89–1.03) 58.3 62.1 1.04 (1.0–1.09) 28.1 25.4 0.93 (0.9–0.95) 6.5 6.0 0.93 (0.87–0.98) 
 ≥65 8.2 8.3 1.05 (0.94–1.17) 82.5 81.8 0.99 (0.97–1.01) 31.3 31.2 1.02 (0.99–1.04) 4.2 4.2 0.99 (0.92–1.08) 
Race/Ethnicity 
 Hispanic 8.8 7.9 0.9 (0.76–1.06) 59.7 66.1 1.08 (1.0–1.16) 34.4 31.4 0.91 (0.87–0.95) 4.7 4.6 1.0 (0.86–1.16) 
 White only 16.2 13.3 0.92 (0.87–0.97) 58.8 63.7 1.03 (1.01–1.06) 22.8 20.2 0.93 (0.91–0.94) 7.8 7.2 0.93 (0.89–0.96) 
 Black only 14.9 11.7 0.8 (0.69–0.92) 42.4 47.1 1.11 (1.0–1.22) 30.9 28.3 0.93 (0.89–0.97) 5.1 4.9 0.96 (0.84–1.1) 
 Asian only 7.1 5.5 0.8 (0.59–1.1) 58.9 64.7 1.11 (0.98–1.26) 21.0 17.8 0.86 (0.76–0.97) 2.9 2.5 0.94 (0.66–1.32) 
 AIAN only 25.2 18.6 0.75 (0.58–0.98) 45.5 57.4 1.2 (1.0–1.44) 28.2 26.6 0.96 (0.87–1.07) 6.5 8.4 1.29 (0.98–1.71) 
Sexual orientation 
 Gay or lesbian 17.9 14.3 0.82 (0.6–1.12) 50.8 65.7 1.17 (0.98–1.39) 26.5 23.2 0.88 (0.76–1.02) 8.0 8.3 0.95 (0.73–1.24) 
 Straight 14.0 11.5 0.89 (0.85–0.94) 57.2 62.7 1.04 (1.02–1.07) 25.4 23.0 0.94 (0.92–0.96) 6.3 6.1 0.96 (0.91–1.01) 
 Bisexual 19.7 21.2 0.82 (0.63–1.08) 58.8 60.1 1.14 (0.94–1.38) 27.9 25.1 0.91 (0.81–1.03) 11.2 8.9 0.77 (0.63–0.95) 
Immigration status 
 Born in U.S./U.S. territory 15.9 13.0 0.89 (0.85–0.94) 56.5 61.9 1.04 (1.02–1.07) — — — — — — 
 In U.S. < 10 years 7.8 8.2 0.83 (0.55–1.25) 54.3 62.6 1.19 (0.94–1.52) — — — — — — 
 In U.S. 10 years 7.4 6.1 0.91 (0.75–1.1) 62.5 74.1 1.06 (0.99–1.14) — — — — — — 
Education (among individuals aged ≥25 years) 
 No HS diploma 23.9 21.1 0.99 (0.87–1.12) 44.7 48.9 1.02 (0.94–1.11) 44.8 43.3 0.96 (0.93–1.0) 5.3 5.2 1.01 (0.87–1.16) 
 HS/GED 22.0 19.2 0.89 (0.82–0.96) 52.5 58.0 1.08 (1.03–1.13) 33.8 31.0 0.93 (0.91–0.95) 6.6 6.7 1.02 (0.95–1.1) 
 Some college 16.3 15.5 0.97 (0.89–1.05) 61.9 63.1 1.01 (0.97–1.05) 25.0 23.0 0.94 (0.91–0.97) 7.0 6.8 0.96 (0.89–1.03) 
 College graduate 5.8 4.6 0.77 (0.68–0.88) 75.6 80.7 1.05 (1.02–1.08) 14.9 12.7 0.86 (0.83–0.89) 6.5 5.9 0.91 (0.87–0.96) 
Health Insurance coverage 
 Uninsured 22.5 20.0 0.94 (0.83–1.05) 40.2 43.8 1.09 (0.97–1.23) 34.9 30.3 0.84 (0.8–0.89) 8.0 7.4 0.94 (0.83–1.06) 
 Private 10.8 8.5 0.86 (0.8–0.93) 67.2 71.9 1.05 (1.02–1.08) 19.9 17.2 0.86 (0.83–0.9) 6.9 6.7 0.97 (0.9–1.05) 
 Medicaid/Other Public/Dual eligible 24.9 21.6 0.88 (0.81–0.97) 40.0 46.7 1.14 (1.04–1.25) 30.7 29.8 0.97 (0.91–1.02) 5.4 5.6 1.03 (0.88–1.21) 
 Medicare only (age ≥ 65) 8.1 8.4 1.08 (0.91–1.29) 82.0 81.2 0.98 (0.95–1.02) 29.2 32.4 1.04 (1.0–1.09) 4.3 4.4 1.07 (0.93–1.22) 
Current smokingaQuit ratiobPhysical inactivitycHeavy alcohol used
Characteristic 2019 (%) 2021 (%) aPR (95% CI) 2019 (%) 2021 (%) aPR (95% CI) 2019 (%) 2021 (%) aPR (95% CI) 2019 (%) 2021 (%) aPR (95% CI) 
Overall 14.2 11.7 0.89 (0.85–0.94) 57.1 62.7 1.05 (1.02–1.07) 25.8 23.3 0.92 (0.91–0.93) 6.6 6.2 0.94 (0.91–0.98) 
Sex             
 Males 15.5 13.3 0.93 (0.86–0.99) 59.5 63.8 1.04 (1.01–1.07) 24.4 21.0 0.88 (0.85–0.9) 7.0 6.4 0.93 (0.88–0.98) 
 Females 13.0 10.1 0.86 (0.8–0.92) 54.0 61.3 1.06 (1.03–1.1) 27.2 25.4 0.96 (0.94–0.98) 6.2 5.9 0.96 (0.91–1.01) 
Age (years) 
 18–24 8.0 5.4 0.64 (0.49–0.84) 39.9 50.3 1.24 (0.99–1.55) 20.1 17.3 0.85 (0.79–0.91) 7.2 5.9 0.82 (0.71–0.94) 
 25–44 16.7 12.6 0.82 (0.76–0.89) 50.8 59.0 1.12 (1.06–1.18) 23.6 20.1 0.86 (0.83–0.88) 7.4 7.3 0.99 (0.93–1.05) 
 45–64 17.0 14.9 0.96 (0.89–1.03) 58.3 62.1 1.04 (1.0–1.09) 28.1 25.4 0.93 (0.9–0.95) 6.5 6.0 0.93 (0.87–0.98) 
 ≥65 8.2 8.3 1.05 (0.94–1.17) 82.5 81.8 0.99 (0.97–1.01) 31.3 31.2 1.02 (0.99–1.04) 4.2 4.2 0.99 (0.92–1.08) 
Race/Ethnicity 
 Hispanic 8.8 7.9 0.9 (0.76–1.06) 59.7 66.1 1.08 (1.0–1.16) 34.4 31.4 0.91 (0.87–0.95) 4.7 4.6 1.0 (0.86–1.16) 
 White only 16.2 13.3 0.92 (0.87–0.97) 58.8 63.7 1.03 (1.01–1.06) 22.8 20.2 0.93 (0.91–0.94) 7.8 7.2 0.93 (0.89–0.96) 
 Black only 14.9 11.7 0.8 (0.69–0.92) 42.4 47.1 1.11 (1.0–1.22) 30.9 28.3 0.93 (0.89–0.97) 5.1 4.9 0.96 (0.84–1.1) 
 Asian only 7.1 5.5 0.8 (0.59–1.1) 58.9 64.7 1.11 (0.98–1.26) 21.0 17.8 0.86 (0.76–0.97) 2.9 2.5 0.94 (0.66–1.32) 
 AIAN only 25.2 18.6 0.75 (0.58–0.98) 45.5 57.4 1.2 (1.0–1.44) 28.2 26.6 0.96 (0.87–1.07) 6.5 8.4 1.29 (0.98–1.71) 
Sexual orientation 
 Gay or lesbian 17.9 14.3 0.82 (0.6–1.12) 50.8 65.7 1.17 (0.98–1.39) 26.5 23.2 0.88 (0.76–1.02) 8.0 8.3 0.95 (0.73–1.24) 
 Straight 14.0 11.5 0.89 (0.85–0.94) 57.2 62.7 1.04 (1.02–1.07) 25.4 23.0 0.94 (0.92–0.96) 6.3 6.1 0.96 (0.91–1.01) 
 Bisexual 19.7 21.2 0.82 (0.63–1.08) 58.8 60.1 1.14 (0.94–1.38) 27.9 25.1 0.91 (0.81–1.03) 11.2 8.9 0.77 (0.63–0.95) 
Immigration status 
 Born in U.S./U.S. territory 15.9 13.0 0.89 (0.85–0.94) 56.5 61.9 1.04 (1.02–1.07) — — — — — — 
 In U.S. < 10 years 7.8 8.2 0.83 (0.55–1.25) 54.3 62.6 1.19 (0.94–1.52) — — — — — — 
 In U.S. 10 years 7.4 6.1 0.91 (0.75–1.1) 62.5 74.1 1.06 (0.99–1.14) — — — — — — 
Education (among individuals aged ≥25 years) 
 No HS diploma 23.9 21.1 0.99 (0.87–1.12) 44.7 48.9 1.02 (0.94–1.11) 44.8 43.3 0.96 (0.93–1.0) 5.3 5.2 1.01 (0.87–1.16) 
 HS/GED 22.0 19.2 0.89 (0.82–0.96) 52.5 58.0 1.08 (1.03–1.13) 33.8 31.0 0.93 (0.91–0.95) 6.6 6.7 1.02 (0.95–1.1) 
 Some college 16.3 15.5 0.97 (0.89–1.05) 61.9 63.1 1.01 (0.97–1.05) 25.0 23.0 0.94 (0.91–0.97) 7.0 6.8 0.96 (0.89–1.03) 
 College graduate 5.8 4.6 0.77 (0.68–0.88) 75.6 80.7 1.05 (1.02–1.08) 14.9 12.7 0.86 (0.83–0.89) 6.5 5.9 0.91 (0.87–0.96) 
Health Insurance coverage 
 Uninsured 22.5 20.0 0.94 (0.83–1.05) 40.2 43.8 1.09 (0.97–1.23) 34.9 30.3 0.84 (0.8–0.89) 8.0 7.4 0.94 (0.83–1.06) 
 Private 10.8 8.5 0.86 (0.8–0.93) 67.2 71.9 1.05 (1.02–1.08) 19.9 17.2 0.86 (0.83–0.9) 6.9 6.7 0.97 (0.9–1.05) 
 Medicaid/Other Public/Dual eligible 24.9 21.6 0.88 (0.81–0.97) 40.0 46.7 1.14 (1.04–1.25) 30.7 29.8 0.97 (0.91–1.02) 5.4 5.6 1.03 (0.88–1.21) 
 Medicare only (age ≥ 65) 8.1 8.4 1.08 (0.91–1.29) 82.0 81.2 0.98 (0.95–1.02) 29.2 32.4 1.04 (1.0–1.09) 4.3 4.4 1.07 (0.93–1.22) 

Note: All estimates are survey weighted. Estimates are age-adjusted to the 2000 U.S. standard population, excluding for age group and insurance status. Prevalence ratios are adjusted by age, sex, race/ethnicity, region, and education. aPR's with 95% CI not including 1.0 are shown in bold.

Abbreviations: 95% CI, 95% confidence interval; AIAN, American Indian/Alaska Native; HS, high school.

aProportion of adults who smoked at least 100 cigarettes in their lifetime and currently smoke cigarettes every day or somedays.

bProportion of adults who have ever smoked who now do not smoke.

cProportion with no leisure-time physical activity in the past week.

dProportion of U.S. adults classified as heavy drinkers (>14 drinks per week in the past year in males and > 7 drinks per week in past year in females).

By state, smoking prevalence between 2019 and 2021 statistically significantly declined in the District of Columbia and 17 of the 50 states, while prevalence remained unchanged in the remaining states (Supplementary Table S2), contributing to a decline in median smoking prevalence by state from 16.7% in 2019 to 15.0% in 2021. In 2021, smoking prevalence between the highest and lowest prevalence states ranged by three-fold from 7.3% in Utah to 24.1% in West Virginia.

Physical inactivity and alcohol consumption

Overall physical inactivity among adults ages ≥ 18 years declined from 25.8% in 2019 to 23.3% in 2021 (aPR, 0.92; 95% CI, 0.91–0.93), which translates to 3.2 million fewer persons reporting physical inactivity in 2021 versus 2019. The decline between 2019 and 2021 was observed in all population subgroups except among older adults (≥65 years), American Indian Alaska Native (AIAN) persons, gay, lesbian, or bisexual identifying persons, those without a high school diploma, and medicaid/other public/dual eligible or medicare only insured persons.

Heavy alcohol consumption among adults ages ≥18 years also declined from 6.6% in 2019 to 6.2% in 2021 (aPR, 0.94, 95% CI, 0.91–0.98), translating to 1.4 million fewer persons reporting heavy drinking in 2021 compared with 2019. The decline in heavy alcohol consumption occurred in all population subgroups except women, individuals ages 25 to 44 years and ≥ 65 years, all racial/ethnic groups except non-Hispanic (NH) White persons, straight, gay, and lesbian identifying persons, and those without a college degree.

Healthy eating and obesity prevalence

Overall recommended vegetable consumption prevalence among adults ages ≥ 18 years remained statistically unchanged between 2019 (12.2%) and 2021 (12.0%; aPR, 0.97; 95% CI, 0.95–1.0; Fig. 1; Table 2), but there were significantly fewer adults reporting recommended vegetable intake in 2021 (1.1 million).

Table 2.

Prevalence estimates and aPRs of cancer preventive behaviors, adults 18 years and older, U.S. BRFSS 2019–2021.

Recommended vegetable consumptionaRecommended fruit consumptionb
Characteristics2019 (%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)
Overall 12.2 12.0 0.97 (0.95–1.0) 30.0 28.8 0.95 (0.93–0.96) 
Sex 
 Males 9.7 9.7 0.99 (0.95–1.04) 27.2 26.6 0.97 (0.94–0.99) 
 Females 14.6 14.1 0.96 (0.92–0.99) 32.7 30.9 0.93 (0.91–0.95) 
Age (years) 
 18–24 10.3 9.4 0.91 (0.82–1.01) 27.1 25.9 0.95 (0.9–1.01) 
 25–44 13.4 13.2 0.98 (0.93–1.02) 29.8 28.5 0.95 (0.93–0.98) 
 45–64 12.2 12.2 0.98 (0.93–1.02) 29.3 28.6 0.96 (0.93–0.98) 
 ≥65 10.6 10.7 1.0 (0.95–1.05) 33.7 31.5 0.92 (0.9–0.94) 
Race/Ethnicity 
 Hispanic 9.6 10.2 1.05 (0.95–1.17) 32.7 32.4 0.99 (0.94–1.04) 
 White only 12.7 12.1 0.94 (0.92–0.97) 29.0 26.9 0.91 (0.9–0.93) 
 Black only 10.7 11.1 1.03 (0.94–1.12) 29.7 31.1 1.04 (0.99–1.09) 
 Asian only 17.4 17.9 1.02 (0.88–1.18) 32.3 32.6 1.02 (0.92–1.12) 
 AIAN only 12.3 11.0 0.9 (0.72–1.12) 28.9 29.2 0.99 (0.88–1.12) 
Sexual orientation 
 Gay/lesbian 13.6 12.8 0.95 (0.76–1.19) 25.7 27.4 1.03 (0.89–1.18) 
 Straight 12.7 11.2 0.89 (0.85–0.92) 30.1 27.7 0.9 (0.89–0.92) 
 Bisexual 16.2 13.7 0.9 (0.75–1.07) 29.6 27.6 0.92 (0.82–1.03) 
Education (among individuals aged ≥ 25 years) 
 No HS diploma 8.3 8.9 1.05 (0.93–1.2) 30.7 30.7 0.99(0.94–1.05) 
 HS/GED 9.6 10.4 1.07 (1.0–1.14) 27.1 26.8 0.96 (0.93–0.99) 
 Some college 12.9 11.9 0.93 (0.88–0.98) 29.3 27.0 0.92(0.89–0.94) 
 College graduate 15.8 15.4 0.96 (0.93–1.0) 34.3 32.6 0.94 (0.93–0.96) 
Health Insurance coverage 
 Uninsured 10.5 10.6 1.05(0.93–1.17) 29.3 29.7 0.99 (0.94–1.05) 
 Private 13.3 12.4 0.94 (0.89–0.99) 29.9 27.8 0.95 (0.92–0.98) 
 Medicaid/Other public/Dual eligible 10.4 12.1 1.16 (1.03–1.31) 30.9 29.8 1.01 (0.95–1.08) 
 Medicare only (age ≥ 65) 10.8 10.8 1.0 (0.91–1.1) 34.2 30.4 0.92 (0.88–0.96) 
Recommended vegetable consumptionaRecommended fruit consumptionb
Characteristics2019 (%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)
Overall 12.2 12.0 0.97 (0.95–1.0) 30.0 28.8 0.95 (0.93–0.96) 
Sex 
 Males 9.7 9.7 0.99 (0.95–1.04) 27.2 26.6 0.97 (0.94–0.99) 
 Females 14.6 14.1 0.96 (0.92–0.99) 32.7 30.9 0.93 (0.91–0.95) 
Age (years) 
 18–24 10.3 9.4 0.91 (0.82–1.01) 27.1 25.9 0.95 (0.9–1.01) 
 25–44 13.4 13.2 0.98 (0.93–1.02) 29.8 28.5 0.95 (0.93–0.98) 
 45–64 12.2 12.2 0.98 (0.93–1.02) 29.3 28.6 0.96 (0.93–0.98) 
 ≥65 10.6 10.7 1.0 (0.95–1.05) 33.7 31.5 0.92 (0.9–0.94) 
Race/Ethnicity 
 Hispanic 9.6 10.2 1.05 (0.95–1.17) 32.7 32.4 0.99 (0.94–1.04) 
 White only 12.7 12.1 0.94 (0.92–0.97) 29.0 26.9 0.91 (0.9–0.93) 
 Black only 10.7 11.1 1.03 (0.94–1.12) 29.7 31.1 1.04 (0.99–1.09) 
 Asian only 17.4 17.9 1.02 (0.88–1.18) 32.3 32.6 1.02 (0.92–1.12) 
 AIAN only 12.3 11.0 0.9 (0.72–1.12) 28.9 29.2 0.99 (0.88–1.12) 
Sexual orientation 
 Gay/lesbian 13.6 12.8 0.95 (0.76–1.19) 25.7 27.4 1.03 (0.89–1.18) 
 Straight 12.7 11.2 0.89 (0.85–0.92) 30.1 27.7 0.9 (0.89–0.92) 
 Bisexual 16.2 13.7 0.9 (0.75–1.07) 29.6 27.6 0.92 (0.82–1.03) 
Education (among individuals aged ≥ 25 years) 
 No HS diploma 8.3 8.9 1.05 (0.93–1.2) 30.7 30.7 0.99(0.94–1.05) 
 HS/GED 9.6 10.4 1.07 (1.0–1.14) 27.1 26.8 0.96 (0.93–0.99) 
 Some college 12.9 11.9 0.93 (0.88–0.98) 29.3 27.0 0.92(0.89–0.94) 
 College graduate 15.8 15.4 0.96 (0.93–1.0) 34.3 32.6 0.94 (0.93–0.96) 
Health Insurance coverage 
 Uninsured 10.5 10.6 1.05(0.93–1.17) 29.3 29.7 0.99 (0.94–1.05) 
 Private 13.3 12.4 0.94 (0.89–0.99) 29.9 27.8 0.95 (0.92–0.98) 
 Medicaid/Other public/Dual eligible 10.4 12.1 1.16 (1.03–1.31) 30.9 29.8 1.01 (0.95–1.08) 
 Medicare only (age ≥ 65) 10.8 10.8 1.0 (0.91–1.1) 34.2 30.4 0.92 (0.88–0.96) 

Note: All estimates are survey weighted. Estimates are age-adjusted to the 2000 U.S. standard population, excluding for age group and insurance status. Prevalence ratios are adjusted by age, sex, race/ethnicity, region, and education. aPR's with 95% CI not including 1.0 are shown in bold.

Abbreviations: 95% CI, 95% confidence interval; AIAN, American Indian/Alaska Native; HS, high school.

aProportion consumed 3 servings of vegetables a day.

bProportion consumed 2 servings of fruit a day.

Overall recommended fruit consumption declined from 30.0% in 2019 to 28.8% in 2021 (aPR, 0.95; 95% CI, 0.93–0.96), which translated to a corresponding survey weighted estimate of 4.5 million fewer individuals consuming fruit at least twice daily. The decline in fruit consumption occurred in all population subgroups except younger individuals (age 18–24 years), in all racial/ethnic groups except NH White persons, gay, lesbian, or bisexual identifying persons, persons without a high school diploma, and medicaid/publicly insured/dual eligible or uninsured persons.

Between 2019 and 2021, obesity prevalence by state increased in 17 of the 50 states while prevalence remained unchanged in the remaining states (Supplementary Table S2). This contributed to a median increase in obesity by state from 32.2% in 2019 to 34% in 2021. In 2021, obesity prevalence ranged from 25.1% in Colorado to 41.0% in West Virginia.

HPV and HBV vaccination

Overall UTD HPV prevalence among teens ages 13 to 17 increased from 54.2% in 2019 to 61.7% in 2021 (aPR, 1.14; 95% CI, 1.1–1.18; Fig. 1; Table 3). Amongst individuals ages 13 to 17 years, 1.7 million more were UTD with their HPV vaccination in 2021 than 2019. The increase in UTD HPV vaccination occurred in all subgroups except Hispanic and uninsured persons. UTD HBV prevalence among teens ages 13 to 17 remained stable and high from 91.6% in 2019 to 92.3% in 2021 (aPR, 1.01; 95% CI, 0.99–1.02). In the same age group, the survey weighted population estimate for UTD HBV vaccination was stable between 2019 and 2021 at 19.1 and 19.4 million, respectively.

Table 3.

Prevalence estimates and aPRs for HPV and HBV vaccination, adolescents 13–17 years, U.S. NIS-TEEN 2019–2021.

HPV vaccineaHepatitis B vaccineb
Characteristics2019(%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)
Overall 54.2 61.7 1.14 (1.1–1.18) 91.6 92.3 1.01 (0.99–1.02) 
Sex 
 Males 51.8 59.8 1.16 (1.1–1.22) 91.3 92.8 1.02 (1.0–1.04) 
 Females 56.8 63.8 1.12(1.06–1.18) 91.9 91.7 1.0 (0.98–1.02) 
Age (years) 
 13 45.3 49.4 1.11 (1.04–1.19) 92.1 92.9 1.01 (0.99–1.04) 
 14 52.2 59.4 1.13 (1.07–1.2) 91.6 93.4 1.01 (0.99–1.03) 
 15 58.6 66.2 1.13(1.07–1.19) 92.8 92.9 1.0 (0.98–1.03) 
 16 57.6 65.8 1.16(1.1–1.23) 90.7 91.0 1.0 (0.98–1.03) 
 17 57.1 67.9 1.19 (1.1–1.29) 90.8 91.1 1.0 (0.96–1.03) 
Race/Ethnicity 
 Hispanic 58.1 61.7 1.06(0.97–1.17) 87.3 90.1 1.03 (0.98–1.08) 
 White only 51.6 59.8 1.16(1.12–1.22) 93.8 92.9 0.99 (0.98–1.0) 
 Black only 54.3 65.0 1.19(1.08–1.31) 91.2 92.2 1.01 (0.98–1.05) 
 Other + multiracial 58.7 65.9 1.12(1.01–1.23) 91.4 94.3 1.03 (0.99–1.07) 
Health Insurance coverage 
 Uninsured 36.7 39.6 1.01 (0.76–1.34) 86.5 87.1 0.99 (0.91–1.09) 
 Private (employer/union) 53.1 62.1 1.17(1.12–1.23) 92.5 93.6 1.01 (1.0–1.03) 
 S-chip/Medicaid 59.1 64.1 1.08(1.02–1.15) 91.2 91.3 1.0 (0.97–1.03) 
HPV vaccineaHepatitis B vaccineb
Characteristics2019(%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)
Overall 54.2 61.7 1.14 (1.1–1.18) 91.6 92.3 1.01 (0.99–1.02) 
Sex 
 Males 51.8 59.8 1.16 (1.1–1.22) 91.3 92.8 1.02 (1.0–1.04) 
 Females 56.8 63.8 1.12(1.06–1.18) 91.9 91.7 1.0 (0.98–1.02) 
Age (years) 
 13 45.3 49.4 1.11 (1.04–1.19) 92.1 92.9 1.01 (0.99–1.04) 
 14 52.2 59.4 1.13 (1.07–1.2) 91.6 93.4 1.01 (0.99–1.03) 
 15 58.6 66.2 1.13(1.07–1.19) 92.8 92.9 1.0 (0.98–1.03) 
 16 57.6 65.8 1.16(1.1–1.23) 90.7 91.0 1.0 (0.98–1.03) 
 17 57.1 67.9 1.19 (1.1–1.29) 90.8 91.1 1.0 (0.96–1.03) 
Race/Ethnicity 
 Hispanic 58.1 61.7 1.06(0.97–1.17) 87.3 90.1 1.03 (0.98–1.08) 
 White only 51.6 59.8 1.16(1.12–1.22) 93.8 92.9 0.99 (0.98–1.0) 
 Black only 54.3 65.0 1.19(1.08–1.31) 91.2 92.2 1.01 (0.98–1.05) 
 Other + multiracial 58.7 65.9 1.12(1.01–1.23) 91.4 94.3 1.03 (0.99–1.07) 
Health Insurance coverage 
 Uninsured 36.7 39.6 1.01 (0.76–1.34) 86.5 87.1 0.99 (0.91–1.09) 
 Private (employer/union) 53.1 62.1 1.17(1.12–1.23) 92.5 93.6 1.01 (1.0–1.03) 
 S-chip/Medicaid 59.1 64.1 1.08(1.02–1.15) 91.2 91.3 1.0 (0.97–1.03) 

Note: All estimates are survey weighted. Estimates are age-adjusted to the 2000 U.S. standard population, excluding for age group and insurance status. Prevalence ratios are adjusted by age, sex, race/ethnicity, and region. aPR's with 95% CI not including 1.0 are shown in bold.

Abbreviations: 95% CI, 95% confidence interval.

aReceived ≥2 doses before age 15 or 3 doses on or after age 15.

bReceived ≥2 Hepatitis B 1.0 mL Recombivax shots or ≥3 combination Hepatitis B—containing shots.

Cancer screening

Overall UTD breast cancer screening remained unchanged from 76.4% in 2019 to 75.9% in 2021 (Fig. 1; Table 4). Conversely, cervical cancer screening declined from 74.8% in 2019 to 73.4% in 2021 (aPR, 0.97; 95% CI, 0.95–0.99). The decline in cervical cancer screening was observed in certain population subgroups including AIAN, gay, lesbian, or bisexual identifying persons, U.S. born or foreign-born in the United States < 10 years, and those without private insurance.

Table 4.

Prevalence estimates and aPRs for cancer screening, adults 18 years and older, U.S. NHIS 2019–2021.

Breast cancer screeningaCervical cancer screeningbColorectal cancer screeningcStool testingdColonoscopye
Characteristics2019 (%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)
Overall 76.4 75.9 0.99 (0.97–1.01) 74.8 73.4 0.97 (0.95–0.99) 68.0 71.2 1.04 (1.02–1.05) 6.6 10.1 1.53 (1.39–1.68) 62.6 63.4 1.0 (0.98–1.02) 
Sex 
 Males — — — — — — 66.7 70.3 1.04 (1.01–1.07) 6.0 9.6 1.58 (1.36–1.83) 61.4 63.3 1.02 (0.99–1.05) 
 Females — — — — — — 69.3 72.1 1.03 (1.01–1.06) 7.1 10.6 1.49 (1.32–1.69) 63.7 63.4 0.99 (0.96–1.02) 
Age (years) 
 21–24 — — — 56.8 51.5 0.89 (0.78–1.02) — — — — — — — — — 
 25–44 — — — 78.4 77.3 0.98 (0.95–1.0) — — — — — — — — — 
 45–64 — — — 74.0 73.0 0.98 (0.95–1.01) — — — — — — — — — 
 50–64 75.7 75.5 0.99 (0.96–1.02) — — — 62.5 65.6 1.04 (1.01–1.07) 5.4 8.9 1.63 (1.41–1.87) 57.3 58.1 1.0 (0.97–1.03) 
 ≥65 78.1 76.9 0.98 (0.95–1.01) 64.2 61.3 0.98 (0.81–1.17) 79.8 83.0 1.03 (1.01–1.05) 9.1 12.6 1.41 (1.24–1.6) 73.7 74.3 1.0 (0.97–1.03) 
Race/Ethnicity 
 Hispanic 78.5 74.0 0.94 (0.88–1.0) 68.1 66.4 0.96 (0.9–1.02) 55.4 62.5 1.14 (1.05–1.23) 8.2 15.6 1.89 (1.45–2.46) 47.8 52.3 1.11 (1.02–1.21) 
 White only 76.0 76.3 0.99 (0.97–1.02) 78.3 77.9 0.98 (0.96–1.01) 71.0 73.8 1.02 (1.0–1.04) 6.0 8.6 1.42 (1.26–1.59) 66.0 66.3 0.99 (0.97–1.01) 
 Black only 79.1 82.1 1.03 (0.97–1.1) 75.3 72.3 0.94 (0.88–1.0) 69.8 71.7 1.02 (0.97–1.08) 6.8 12.0 1.81 (1.36–2.42) 64.5 64.8 1.0 (0.94–1.07) 
 Asian only 73.9 67.3 0.92 (0.82–1.03) 64.5 61.7 0.95 (0.86–1.04) 57.4 60.2 1.05 (0.94–1.18) 8.4 11.4 1.39 (0.98–1.97) 51.8 51.1 0.98 (0.85–1.13) 
 AIAN only 63.2 58.7 0.94 (0.75–1.18) 71.5 64.7 0.84 (0.73–0.98) 60.8 63.9 1.07 (0.88–1.32) 7.6 10.3 1.56 (0.77–3.17) 54.3 56.9 1.05 (0.81–1.36) 
Sexual orientation 
 Gay/Lesbian 73.7 77.8 1.01 (0.81–1.25) 75.8 69.4 0.92 (0.78–1.08) 78.4 76.8 0.97 (0.86–1.1) 8.7 12.3 1.25 (0.66–2.37) 71.7 68.0 0.96 (0.83–1.1) 
 Straight 76.6 76.3 0.99 (0.97–1.01) 75.5 74.0 0.97 (0.95–0.99) 68.2 71.3 1.03 (1.02–1.05) 6.5 10.1 1.54 (1.4–1.7) 62.8 63.5 1.0 (0.98–1.02) 
 Bisexual f — — 73.2 77.8 0.98 (0.86–1.12) 79.1 69.1 0.87 (0.7–1.09) — — — 70.5 55.4 0.81 (0.63–1.05) 
Immigration status 
 Born in U.S./U.S. territory 76.7 76.7 0.99 (0.97–1.01) 77.5 76.4 0.97 (0.95–1.0) 70.9 73.2 1.02 (1.0–1.04) 6.4 9.4 1.45 (1.31–1.61) 65.6 65.6 0.99 (0.97–1.01) 
 In U.S. < 10 years 58.9 60.0 1.04 (0.76–1.43) 53.9 52.8 0.95 (0.8–1.12) 28.3 36.7 1.31 (0.86–2.0) — — — 22.7 27.9 1.35 (0.82–2.23) 
 In U.S. ≥ 10 years 77.7 74.2 0.95 (0.9–1.01) 71.4 65.5 0.94 (0.89–0.99) 58.6 65.2 1.1 (1.03–1.16) 8.0 13.5 1.73 (1.37–2.17) 52.6 56.0 1.05 (0.97–1.12) 
Education (among individuals ages ≥ 25 years) 
 No HS diploma 69.4 63.9 0.92 (0.84–1.02) 58.2 56.2 0.95 (0.85–1.08) 51.1 58.2 1.14 (1.04–1.24) 8.0 12.7 1.6 (1.19–2.15) 44.7 49.8 1.11 (1.01–1.23) 
 HS/GED 73.2 72.7 0.99 (0.95–1.04) 69.9 66.6 0.96 (0.91–1.02) 64.6 66.4 1.04 (1.0–1.08) 5.9 9.7 1.59 (1.31–1.94) 59.7 58.9 1.0 (0.96–1.04) 
 Some college 75.7 76.8 1.01 (0.97–1.05) 78.2 77.2 0.99 (0.95–1.02) 70.8 72.6 1.03 (0.99–1.06) 6.7 10.4 1.56 (1.33–1.84) 65.0 64.2 0.99 (0.95–1.03) 
 College graduate 82.6 80.8 0.98 (0.95–1.01) 84.1 82.8 0.98 (0.96–1.01) 76.0 77.5 1.02 (0.99–1.05) 6.5 9.4 1.44 (1.24–1.68) 70.8 70.0 0.99 (0.96–1.02) 
Health insurance coverage 
 Uninsured 45.6 42.2 0.93 (0.76–1.14) 56.0 55.4 0.99 (0.9–1.09) 31.4 29.6 0.95 (0.8–1.13) 4.4 4.8 1.15 (0.64–2.06) 27.0 24.0 0.9 (0.74–1.09) 
 Private 80.0 80.0 0.99 (0.97–1.02) 79.3 77.4 0.97 (0.94–0.99) 71.9 74.3 1.03 (1.0–1.05) 5.7 8.9 1.53 (1.34–1.75) 66.7 66.8 1.0 (0.97–1.02) 
 Medicaid/Other public/Dual eligible 72.4 70.6 0.97 (0.9–1.04) 67.9 67.6 0.99 (0.93–1.05) 57.8 60.1 1.03 (0.95–1.12) 8.4 10.9 1.27 (0.94–1.71) 51.7 52.6 1.01 (0.93–1.1) 
 Medicare only (age ≥65) 78.2 75.1 0.96 (0.91–1.01) 63.9 56.7 0.92 (0.68–1.24) 77.8 82.4 1.05 (1.01–1.08) 10.3 14.9 1.47 (1.22–1.78) 71.2 71.9 1.0 (0.96–1.04) 
Breast cancer screeningaCervical cancer screeningbColorectal cancer screeningcStool testingdColonoscopye
Characteristics2019 (%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)2019 (%)2021 (%)aPR (95% CI)
Overall 76.4 75.9 0.99 (0.97–1.01) 74.8 73.4 0.97 (0.95–0.99) 68.0 71.2 1.04 (1.02–1.05) 6.6 10.1 1.53 (1.39–1.68) 62.6 63.4 1.0 (0.98–1.02) 
Sex 
 Males — — — — — — 66.7 70.3 1.04 (1.01–1.07) 6.0 9.6 1.58 (1.36–1.83) 61.4 63.3 1.02 (0.99–1.05) 
 Females — — — — — — 69.3 72.1 1.03 (1.01–1.06) 7.1 10.6 1.49 (1.32–1.69) 63.7 63.4 0.99 (0.96–1.02) 
Age (years) 
 21–24 — — — 56.8 51.5 0.89 (0.78–1.02) — — — — — — — — — 
 25–44 — — — 78.4 77.3 0.98 (0.95–1.0) — — — — — — — — — 
 45–64 — — — 74.0 73.0 0.98 (0.95–1.01) — — — — — — — — — 
 50–64 75.7 75.5 0.99 (0.96–1.02) — — — 62.5 65.6 1.04 (1.01–1.07) 5.4 8.9 1.63 (1.41–1.87) 57.3 58.1 1.0 (0.97–1.03) 
 ≥65 78.1 76.9 0.98 (0.95–1.01) 64.2 61.3 0.98 (0.81–1.17) 79.8 83.0 1.03 (1.01–1.05) 9.1 12.6 1.41 (1.24–1.6) 73.7 74.3 1.0 (0.97–1.03) 
Race/Ethnicity 
 Hispanic 78.5 74.0 0.94 (0.88–1.0) 68.1 66.4 0.96 (0.9–1.02) 55.4 62.5 1.14 (1.05–1.23) 8.2 15.6 1.89 (1.45–2.46) 47.8 52.3 1.11 (1.02–1.21) 
 White only 76.0 76.3 0.99 (0.97–1.02) 78.3 77.9 0.98 (0.96–1.01) 71.0 73.8 1.02 (1.0–1.04) 6.0 8.6 1.42 (1.26–1.59) 66.0 66.3 0.99 (0.97–1.01) 
 Black only 79.1 82.1 1.03 (0.97–1.1) 75.3 72.3 0.94 (0.88–1.0) 69.8 71.7 1.02 (0.97–1.08) 6.8 12.0 1.81 (1.36–2.42) 64.5 64.8 1.0 (0.94–1.07) 
 Asian only 73.9 67.3 0.92 (0.82–1.03) 64.5 61.7 0.95 (0.86–1.04) 57.4 60.2 1.05 (0.94–1.18) 8.4 11.4 1.39 (0.98–1.97) 51.8 51.1 0.98 (0.85–1.13) 
 AIAN only 63.2 58.7 0.94 (0.75–1.18) 71.5 64.7 0.84 (0.73–0.98) 60.8 63.9 1.07 (0.88–1.32) 7.6 10.3 1.56 (0.77–3.17) 54.3 56.9 1.05 (0.81–1.36) 
Sexual orientation 
 Gay/Lesbian 73.7 77.8 1.01 (0.81–1.25) 75.8 69.4 0.92 (0.78–1.08) 78.4 76.8 0.97 (0.86–1.1) 8.7 12.3 1.25 (0.66–2.37) 71.7 68.0 0.96 (0.83–1.1) 
 Straight 76.6 76.3 0.99 (0.97–1.01) 75.5 74.0 0.97 (0.95–0.99) 68.2 71.3 1.03 (1.02–1.05) 6.5 10.1 1.54 (1.4–1.7) 62.8 63.5 1.0 (0.98–1.02) 
 Bisexual f — — 73.2 77.8 0.98 (0.86–1.12) 79.1 69.1 0.87 (0.7–1.09) — — — 70.5 55.4 0.81 (0.63–1.05) 
Immigration status 
 Born in U.S./U.S. territory 76.7 76.7 0.99 (0.97–1.01) 77.5 76.4 0.97 (0.95–1.0) 70.9 73.2 1.02 (1.0–1.04) 6.4 9.4 1.45 (1.31–1.61) 65.6 65.6 0.99 (0.97–1.01) 
 In U.S. < 10 years 58.9 60.0 1.04 (0.76–1.43) 53.9 52.8 0.95 (0.8–1.12) 28.3 36.7 1.31 (0.86–2.0) — — — 22.7 27.9 1.35 (0.82–2.23) 
 In U.S. ≥ 10 years 77.7 74.2 0.95 (0.9–1.01) 71.4 65.5 0.94 (0.89–0.99) 58.6 65.2 1.1 (1.03–1.16) 8.0 13.5 1.73 (1.37–2.17) 52.6 56.0 1.05 (0.97–1.12) 
Education (among individuals ages ≥ 25 years) 
 No HS diploma 69.4 63.9 0.92 (0.84–1.02) 58.2 56.2 0.95 (0.85–1.08) 51.1 58.2 1.14 (1.04–1.24) 8.0 12.7 1.6 (1.19–2.15) 44.7 49.8 1.11 (1.01–1.23) 
 HS/GED 73.2 72.7 0.99 (0.95–1.04) 69.9 66.6 0.96 (0.91–1.02) 64.6 66.4 1.04 (1.0–1.08) 5.9 9.7 1.59 (1.31–1.94) 59.7 58.9 1.0 (0.96–1.04) 
 Some college 75.7 76.8 1.01 (0.97–1.05) 78.2 77.2 0.99 (0.95–1.02) 70.8 72.6 1.03 (0.99–1.06) 6.7 10.4 1.56 (1.33–1.84) 65.0 64.2 0.99 (0.95–1.03) 
 College graduate 82.6 80.8 0.98 (0.95–1.01) 84.1 82.8 0.98 (0.96–1.01) 76.0 77.5 1.02 (0.99–1.05) 6.5 9.4 1.44 (1.24–1.68) 70.8 70.0 0.99 (0.96–1.02) 
Health insurance coverage 
 Uninsured 45.6 42.2 0.93 (0.76–1.14) 56.0 55.4 0.99 (0.9–1.09) 31.4 29.6 0.95 (0.8–1.13) 4.4 4.8 1.15 (0.64–2.06) 27.0 24.0 0.9 (0.74–1.09) 
 Private 80.0 80.0 0.99 (0.97–1.02) 79.3 77.4 0.97 (0.94–0.99) 71.9 74.3 1.03 (1.0–1.05) 5.7 8.9 1.53 (1.34–1.75) 66.7 66.8 1.0 (0.97–1.02) 
 Medicaid/Other public/Dual eligible 72.4 70.6 0.97 (0.9–1.04) 67.9 67.6 0.99 (0.93–1.05) 57.8 60.1 1.03 (0.95–1.12) 8.4 10.9 1.27 (0.94–1.71) 51.7 52.6 1.01 (0.93–1.1) 
 Medicare only (age ≥65) 78.2 75.1 0.96 (0.91–1.01) 63.9 56.7 0.92 (0.68–1.24) 77.8 82.4 1.05 (1.01–1.08) 10.3 14.9 1.47 (1.22–1.78) 71.2 71.9 1.0 (0.96–1.04) 

Note: All estimates are survey weighted. Estimates are age-adjusted to the 2000 U.S. standard population, excluding for age group and insurance status. Prevalence ratios are adjusted by age, sex, race/ethnicity, region, and education. aPR's with 95% CI not including 1.0 are shown in bold.

Abbreviations: AIAN, American Indian/Alaska Native; HS, high school.

aProportion of women aged 50–74 who received bi-annual mammography screening.

bProportion of women aged 21–29, without a hysterectomy, who had cervical cytology every 3 years, or women aged 30–65, without a hysterectomy, who had a cervical cytology every 3 years, a HPV test every 5 years, or co-tested every 5 years.

cProportion of adults aged 50–75 who received either a fecal immunochemical test or high-sensitivity guaiac-based fecal occult blood test annually; multitarget stool DNA test every 1–3 years; colonoscopy every 10 years; computed tomography colonography or flexible sigmoidoscopy every 5 years, or combined annual FIT test and flexible sigmoidoscopy every 10 years.

dProportion of adults aged 50–75 who received a fecal immunochemical test or high-sensitivity guaiac-based fecal occult blood test annually.

eProportion of adults aged 50–75 who received colonoscopy within the last 10 years.

fEstimates suppressed with a sample size < 50 or residual standard error ≥ 0.3.

In contrast to UTD breast and cervical cancer screening, UTD colorectal cancer screening increased from 68% in 2019 to 71.2% in 2021 (aPR, 1.04; 95% CI, 1.02–1.05), which translated to about 3.8 million more individuals being screened nationally. UTD stool-testing increased from 6.6% in 2019 to 10.1% in 2021 (aPR, 1.53; 95% CI, 1.39–1.68), whereas UTD colonoscopy remained unchanged. The increase in UTD colorectal cancer screening was observed in all subgroups except in all racial/ethnic subgroups except Hispanic persons, in gay, lesbian, or bisexual identifying persons, in U.S. born or foreign-born persons living in the United States < 10 years, in those with a high school diploma or further education, and those privately insured, medicaid/publicly insured/dual eligible, or uninsured persons.

Attention to the ramifications of the COVID-19 pandemic on cancer screening began in early 2020 because the initial downturn in screening rates was abrupt and brought on by the nationwide suspension of “nonessential” services broadly (29). Less is known about the impact of the pandemic on major modifiable cancer risk factors and preventive behaviors and services other than screening. In this review, we examined the changes in major modifiable risk factors, receipt of preventive behaviors and services, and cancer screening during the COVID-19 pandemic, and found mixed results. Favorable outcomes that were observed during the first 2 years of the pandemic include declines in prevalence of adult smoking, physical inactivity, and heavy alcohol consumption and increases in quit ratio, HPV vaccination, and stool testing for colorectal cancer screening. In contrast, during the same period, declines in fruit consumption, increases in obesity prevalence, and declines in cervical cancer screening were observed revealing the combination of favorable and unfavorable trends. One reason for these contrasting trends may be the influence of the COVID-19 pandemic on the population distribution of the surveys. Individuals who were at a higher risk for COVID-19 severity and mortality (persons who currently smoke, those classified as overweight or obese, etc.) may no longer be able to participate in these surveys. This change makes it difficult to discern whether the improvements in some measures, like cigarette smoking prevalence, physical inactivity, and alcohol consumption were related to positive improvements or due to a generally healthier surveyed population. Yet, across multiple measures, disparities by racial/ethnic, education, and insurance status persisted during the pandemic.

Cigarette smoking is the leading risk factor for at least 13 cancers (30–32) and smoking cessation reduces the risk of all cancers associated with smoking (30, 33). The decline in smoking prevalence between 2019 and 2021 during the 2nd year of the COVID-19 pandemic, observed in both the NHIS and the BRFSS data, follows a long-term trend of improvements in population smoking levels (4, 34). Yet, studies from the 1st year of the COVID-19 pandemic, showed that other measures of smoking worsened (35, 36). For example, 2020 was the only year since 2011 where attempts to quit smoking in the past year decreased (35) and cigarette consumption increased by 14% more than expected (36). Clearly, more years of consistent data on different smoking measures are needed to ascertain trends further into the COVID-19 pandemic. One finding, however, is consistent from prior years, that is, persons with high smoking prevalence (e.g., lower educated persons) did not experience any changes in smoking prevalence or quit ratio, further entrenching persistent socioeconomic disparities in smoking.

Overall, physical inactivity declined among adults during the COVID-19 pandemic. The decline reported here was unique as there were no reported declines prior to the pandemic (37). Although we did not measure physical inactivity amongst youths, a global meta-analysis assessing changes during the COVID-19 pandemic reported an estimated 17 minute per day decline in moderate-to-vigorous physical activity in children 18 years and younger (38). More recent studies have reported that a sedentary lifestyle was a risk factor for COVID-19 mortality and hospitalization irrespective of other factors, while sufficient (150 minutes a week of moderate or 75 minutes a week of vigorous intensity) physical activity was associated with a lower prevalence of COVID-19 associated hospitalization and improvements in other health conditions (39–43). To mitigate cancer risk, further attention is needed towards the physical activity of older adults and persons with lower educational attainment.

Although studies from the 1st year of the pandemic were largely mixed in terms of alcohol consumption trends (44), we observed an overall decline in prevalence of heavy alcohol consumption during the second year of the pandemic in 2021. Yet, the decline was not uniform across sociodemographic factors. Prevalence of heavy drinking declined in NH White persons and college graduates but remained unchanged in other racial ethnic groups and individuals with lower education, indicating heavy alcohol consumption in vulnerable populations may reflect stress-related coping during the COVID-19 pandemic (45, 46).

Consumption of vegetables and fruits are associated with a reduced risk of cancer and cardiovascular disease, as well as cancer and all-cause mortality (47–49). Prior research reported declines in consumption of any fruit daily from 1999 to 2018, but no changes in consumption of any vegetables daily (50). The trends observed in our study mimic these trends, with a significant decline in fruit consumption (50) and a stable vegetable consumption (50) trend between 2019 and 2021. Dietary shifts were observed during the early phase of the COVID-19 pandemic in the United States with more frequent consumption of unhealthy snacks, desserts, and sugar-sweetened beverages (51). Declines in fruit consumption could at least partially be attributed to the lack of availability and high price for perishable goods because of the COVID-19 pandemic (52).

Unfavorable dietary patterns, at least in part, potentially influenced the observation of an increase in median obesity prevalence across U.S. states, and an increase in 17 of 50 U.S. states, in 2021 compared with 2019. Although this study showed an increase in obesity prevalence between 2019 to 2021, this could be a continuation of a secular increasing trend since before 1976 (37). Many studies reported that prevalence of overweight and obesity increased among adults during the COVID-19 pandemic (53–57). Although we did not analyze youth obesity prevalence, other studies indicate it rose sharply during the COVID-19 pandemic (58, 59). Apart from being a major risk factor for cancer outcomes, obesity is associated with mortality in patients with COVID-19 and can be an independent risk factor for disease severity (60, 61). To mitigate cancer risk during a pandemic, and even after, attention is needed to support a healthy diet, promote physical activity, and weight management.

Although HPV vaccination increased in the NIS-TEEN in 2021 versus 2019 (62–63), continuing an increasing trend in HPV vaccination starting in 2016 (62–64), other studies report reduced vaccination coverage among age-eligible adolescents during the COVID-19 pandemic, including in a cohort study of eight large United States healthcare systems (65). A modeling study additionally found reduced HPV vaccination coverage before versus after the pandemic, which could potentially translate to meaningful increases in rates of HPV-related cancers and its disease precursors in the future unless catch-up vaccination occurs (66). It is important to track NIS-TEEN data in future years as children 11 to 12 years (those eligible for HPV vaccinations during the pandemic) become eligible to be surveyed.

In a recently published study, past-year screening declined for breast, cervical, and prostate cancer screening in 2021 compared with 2019, potentially exacerbating declining trends already observed in breast and cervical cancer screening (37), although past-year colorectal cancer screening remained stable (13). In our analysis, we show that these declines extended to not only past-year screening but also to UTD cervical cancer screening. Although UTD breast cancer screening did not decline, in relation to the declines seen in past year screening (13), this may be indicative of the longer time periods individuals can remain UTD for breast cancer screening. Many women only need to be screened biennially to be UTD with breast cancer screening. This is pertinent because it indicates that there is still an opportunity to intervene and increase screening into 2022 and 2023 to prevent declines in UTD screening. The same can potentially be said for other cancer screenings, such as for lung cancer, where there were reported declines in certain populations during the pandemic (67, 68). Without intervention, there is a risk of declines in past year screening feeding into declines in future years of UTD screening, which is particularly concerning as UTD cancer screening is most closely related to long-term health outcomes.

The increase in UTD colorectal cancer screening between 2019 and 2021 was primarily due to the large increase in stool testing and was consistent with previous findings (9, 13, 37). UTD colonoscopy remained unchanged, however, as colonoscopy is only recommended every 10 years. The adoption of stool-based testing during the pandemic has highlighted the importance of home-based screening, where possible, as an alternative to clinically invasive initial screening during a health care disruption (9, 13, 69, 70). However, further attention is needed regarding follow-up of a suspicious stool-based test during and after the COVID-19 pandemic. A recent study showing data from 2017 to 2020 reported an overall follow-up colonoscopy rate of 56.1% within one year of any type of positive stool-based test among an average-risk insured population (71). Disparities in follow-up colonoscopy were also found by race, insurance type, smoking status, prior stool testing and stool test type, and presence of comorbidities (71). In addition, follow-up colonoscopy was significantly lower during the first year of the COVID-19 pandemic, 2020, compared to 2019 in receipt of follow-up colonoscopy at 90, 180, and 360 days (71). This is of particular concern as positive results on stool-based tests require follow-up with colonoscopy to receive the benefits of screening (26, 72).

Limitations

Our study has several limitations. For both the NHIS and the BRFSS, data were self-reported and nonresponse bias was a concern. In addition, there is a concern regarding how representative surveys are of the U.S. population during the COVID-19 pandemic. Individuals who complete surveys are generally healthier, have higher socioeconomic status, and are also more likely to participate in cancer screening and preventive behaviors as they are more able to take advantage of new health promoting opportunities (73–75). This issue is particularly relevant during the COVID-19 pandemic, as healthier or higher socioeconomic status persons may be more likely to respond, as participation may be lower among individuals who had severe COVID-19 or who died from it, particularly in those who had other risk factors for severe disease. Although we do not know the extent to which COVID-19 severity and mortality associated with risk factors may have impacted the results, all estimates presented here accounted for nonresponse biases via use of survey weights and change estimates (aPRs) adjusted by a combination of age, sex, race/ethnicity, region, and educational status, but this does not fully account for all nonresponse biases. In addition, NHIS survey changes in administration mode (in-person vs. telephone-based) and nonresponse adjustment and calibration methods in 2021 may impact comparisons of weighted survey estimates to prior years (14, 15).

Conclusion

During the second year of the COVID-19 pandemic, we found both favorable and unfavorable changes in major cancer risk factors, preventive behaviors and services, and cancer screening. On one hand, prevalence of cigarette smoking, alcohol consumption, and physical inactivity declined, and HPV vaccination and stool testing for colorectal cancer screening increased. On the other hand, prevalence of recommended fruit consumption and cervical cancer screening declined, and obesity prevalence increased. Although it is yet unclear whether these contrasting trends reflect true changes in behavior and services or are an artifact of changes in survey methods or underlying population compositions during the COVID-19 pandemic, particular attention will be needed to address persisting disparities by racial/ethnic and socioeconomic status.

F. Islami reports all authors were employed by the ACS, 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.

The publication costs of this article were defrayed in part by the payment of publication fees. Therefore, and solely to indicate this fact, this article is hereby marked “advertisement” in accordance with 18 USC section 1734.

Note: Supplementary data for this article are available at Cancer Epidemiology, Biomarkers & Prevention Online (http://cebp.aacrjournals.org/).

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