BACKGROUND: The public health gain from the dramatic reduction in cigarette smoking prevalence in the United States in recent decades has not been evenly distributed geographically. This study examines major socio-demographic and economic factors underlying these disparities.
METHODS: Data came from an online survey of a probability sample of 12300 adults (18+) in 13 high-tobacco burden states (Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, South Carolina, Tennessee, West Virginia), and 4 low-tobacco burden states (California, Illinois, Maryland, Virginia), collected in two cross-sectional waves in April-May 2023 and April-May 2024 by the American Cancer Society. We used threefold Oaxaca-Blinder linear decomposition analysis to examine sources of difference in cigarette smoking prevalence between high- and low-tobacco burden states.
RESULTS: Differences in smoking propensities by population characteristics, holding the population composition constant, accounted for 70.7% of the difference in smoking prevalence between high- and low-tobacco burden states (19.4% vs. 13.4%). The difference was largely driven by significantly higher smoking rates in high-tobacco burden states among adults aged ≥40 years and individuals with Variation in the population composition, holding smoking propensities constant, contributed 11.5% of the difference in smoking prevalence between the two groups of states, driven by the larger proportion of individuals in the lowest income group with a significantly higher smoking rate (28.2% vs. 17.9%) in high-tobacco burden states.
The residual 17.8% is attributable to unmeasured macro-level differences affecting cigarette smoking propensities among population sub-groups, mainly at varying levels of educational attainment.
CONCLUSIONS: Regional disparities in smoking prevalence may be reduced through increased cessation support for adults aged ≥40 years and have less education, as well as income growth at the bottom income stratum and advancement in educational attainment beyond high school.