Understanding the Sources of Subnational Disparities in Cigarette Smoking Prevalence: Findings From a Multi-State Rapid-Response Survey in the U.S., 2023-2024.

Abstract

Cigarette smoking prevalence among U.S. adults varies widely across states. This study examines major sociodemographic and economic factors underlying subnational smoking disparities. Data were from a rapid-response online survey of a probability sample of 12,300 adults (aged ≥18 years) in 13 high-tobacco-burden states (Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, South Carolina, Tennessee, and West Virginia) and 4 low-tobacco-burden comparison states (California, Illinois, Maryland, and Virginia), conducted in 2023 and 2024 and analyzed in 2024. Threefold Oaxaca-Blinder linear decomposition analysis was used to identify sources of disparities in cigarette smoking prevalence between high- and low-tobacco-burden states. Differences in smoking propensities by population characteristics (population composition held constant) accounted for 56.7% of the subnational disparity in smoking prevalence. This was largely driven by higher smoking prevalence in high-tobacco-burden states among older adults (aged 40-65 years) and individuals with less than a high-school education. Convergence of smoking prevalence of college graduates and those aged 18-20 years partially offset the difference. Variation in population composition (smoking propensities held constant) contributed 22.9% of the difference, driven by larger proportions of individuals in the group with less than college education in high-tobacco-burden states with significantly higher smoking rates. The residual 20.4% was attributable to unmeasured macrolevel differences simultaneously affecting individual smoking propensities and population composition by educational status. The mitigation of subnational smoking disparities requires concerted tobacco control efforts tailored to smoking cessation among older adults and persons with less than college education and population-level advancement in educational attainment.