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. Author manuscript; available in PMC: 2025 Aug 1.
Published in final edited form as: Prev Med. 2024 Jun 22;185:108054. doi: 10.1016/j.ypmed.2024.108054

Examining U.S. Disparities in Smoking Among Rural Versus Urban Women of Reproductive Age: 2002–2019

Stephen T Higgins 1,2,3, Tyler Erath 1,2, Fang-Fang Chen 1,2
PMCID: PMC11269002  NIHMSID: NIHMS2005774  PMID: 38914268

Abstract

Objective:

This study is part of a programmatic investigation of rural disparities in cigarette smoking examining disparities in smoking prevalence and for the first-time quit ratios among adult women of reproductive age (18–44 years), a highly vulnerable population due to risk for multigenerational adverse effects.

Methods:

Data came from 18 years (2002–2019) of the U.S. National Survey on Drug Use and Health (NSDUH) among women (n=280,626) categorized by rural-urban residence, pregnancy status, using weighted logistic regression models testing time trends and controlling for well-established sociodemographic predictors of smoking (race/ethnicity, education, income). Concerns regarding changes in survey methods used before 2002 and after 2019 precluded inclusion of earlier and more recent survey years in the present study.

Results:

Overall smoking prevalence across years was greater in rural than urban residents (adjusted odds ratio [AOR]=1.11; 95%CI, 1.07–1.15; P<.001) including those not-pregnant (AOR=1.10; 1.07–1.14; P<.001) and pregnant (AOR=1.29; 1.09–1.52; P<.001). Overall quit ratios across years were lower in rural than urban residents (AOR=0.93; 0.87–0.99; P<.001) including those not-pregnant (AOR=0.93; 0.88–1.00, P=.035) and pregnant (AOR=0.78; 0.62–0.99; P=.039). Interactions of rural versus urban residence with study years for prevalence and quit ratios overall and by pregnancy status are detailed in the main text.

Conclusions:

These results support a longstanding and robust rural disparity in smoking prevalence among women of reproductive age including those currently pregnant and provides novel evidence that differences in smoking cessation contribute to this disparity further underscoring a need for greater access to evidence-based tobacco control and regulatory interventions in rural regions.

Keywords: cigarette smoking, women, reproductive age, pregnancy, prevalence, quit ratios, rural residence, disparities, tobacco control, tobacco regulation

U.S. rural disparities has been a concern since the 1980s. Rural communities on average have greater prevalence of risky health behaviors and worse outcomes than more urban areas with inadequate healthcare access a notable contributor (Leider et al., 2020; Meit et al., 2014). When the landmark 1964 Surgeon General’s report on smoking and cancer was released, cigarette smoking prevalence was lower in rural than urban regions for both men and women. Smoking has decreased considerably in rural and urban regions alike since 1964 (U.S. Department of Health, Education, and Welfare, 1964), but more so among urban residents creating the current rural-urban disparities in smoking prevalence (Higgins, 2021; Leider et al., 2020; Meit et al., 2014).

A programmatic series of studies using the U.S. National Survey on Drug Use and Health (NSDUH) examined these rural-urban smoking disparities in adults (Doogan et al., 2017; Cepeda-Benito et al., 2018; Nighbor et al., 2018; Parker et al., 2022). NSDUH is a nationally representative cross-sectional survey of the U.S. civilian, non-institutionalized population aged 12 years and above that measures prevalence and correlates of substance use. Common methods across these studies included examining current smoking status defined as smoked in the past 30 days and smoked 100 or more cigarettes lifetime among adults (≥18 years) residing in rural versus metropolitan/micropolitan areas based on the 2000 U.S. Census and 2013 classifications from the U.S. Office of Management and Budget. Doogan et al. (2017) reported a growing rural-urban disparity in adult smoking prevalence between 2007 and 2014 that could be accounted for by differences in sociodemographic characteristics in the early but not the later survey years examined. Examining those same survey years, Cepeda-Benito et al. (2017) reported significant sex differences in this rural-urban disparity in smoking prevalence wherein smoking prevalence time trends decreased significantly in urban women and men and rural men but remained flat in rural women and exceeded prevalence levels observed in urban women. Examining survey years 2007–16, Nighbor et al. (2018) demonstrated that these rural-urban disparities were discernible among women of reproductive age including pregnant women raising concerns about their potential for contributing to multigenerational adverse health outcomes. Parker et al. (2022) extended these rural-urban comparisons by demonstrating a disparity between 2010–2020 in quit-ratios (proportion of former smokers among lifetime smokers) with results collapsed across men and women. In the present report, we return to the focus on women of reproductive age and pregnancy status that was the focus of Nighbor et al. (2018) broadening the number of survey years (2002–2019) and analyzing disparities in quit ratios in addition to prevalence. The shared overarching rationale for focusing on smoking in women of reproductive age is concerns about the potential for multi-generational adverse effects.

Methods

Data Source

Data were obtained from the National Survey on Drug Use and Health (NSDUH, 2002–2019), an annual, multi-year U.S. nationally representative cross-sectional survey (see https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health). Detailed descriptions of survey procedures have been provided previously (e.g., Doogan et al., 2017; Cepeda-Benito et al., 2018; Nighbor et al., 2018; Parker et al., 2022). We used the eighteen years between 2002–2019 as changes in survey methods and administration in 2002 raise validity concern about including earlier years (see https://www.icpsr.umich.edu/web/ICPSR/series/64) and changes from in-person to remote data collection in 2020 in response to the COVID pandemic raised validity concerns regarding comparisons between surveys conducted using in-person versus remote methods (see https://www.datafiles.samhsa.gov/dataset/national-survey-drug-use-and-health-2019-nsduh-2019-ds0001). Data were analyzed based on consecutive two-year periods (e.g., 2002 and 2003; 2004 and 2005) due to the relatively smaller number of rural pregnant women. We limited the sample to reproductive age adults (18–44 years). Population weights were included with the survey data to obtain results representative of the U.S. population by correcting for selection probabilities, non-response, and post-stratification. References to “adjusted” or “unadjusted” models refer to covariate adjustment.

Measures

The first dependent variable, “current smoking,” was defined as self-reported smoking of part or all of at least one cigarette in the past 30 days and at least 100 cigarettes lifetime. The second dependent variable, “quit ratio”, was estimated as the proportion of those meeting lifetime criteria for smoking (i.e., smoked at least 100 cigarettes lifetime) who report no smoking in the past year.

Current smoking and quit ratios were estimated by rural or urban residence annually. Rurality was defined using US Office of Management and Budget Rural-Urban Continuum Codes. For 2010–2014 NSDUH, definitions were based on 2003 metropolitan or nonmetropolitan statistical area county-level groupings; for the 2015–2019 NSDUH, updated 2013 groupings were used.

Statistical Analyses

Eighteen years of NSDUH data with women of reproductive age (18–44 years) were analyzed (2002–2019) (n = 280,626) in two-year bins with population weight applied. Descriptions of the two outcome variables (smoking prevalence and quit ratios) by sociodemographic characteristics were obtained by using the Proc SurveyMeans procedure in SAS. Weighted logistic regression models were used to test linear time trends in smoking prevalence and quit ratios by rural or urban residence and then further by pregnancy status, using the two-year bin as a continuous variable with the Proc SurveyLogistic procedure. The key predictor variables included time (two-year periods), rural-urban residence, and pregnancy status and interactions between those variables. For each analysis, P < .05 (2-tailed) was considered statistically significant. Models were conducted unadjusted and then adjusted for race and ethnicity, educational attainment, and income.

Results

Participants

The analytic sample included 280,626 self-identified female participants of reproductive age (18–44 years) who responded to all necessary survey items (see Table 1). Rural and urban populations included 55,373 (19.73%) and 225,253 (80.27%) participants, respectively. Regarding geographic residence by pregnancy status, the sample included 52,166 (18.59%) rural not-pregnant women, 3,207 (1.14%) rural pregnant women, 214,345 (76.38%) urban not-pregnant women, and 10,908 (3.89%) urban pregnant women.

Table 1.

Population-weighted characteristics of the combined 2002–2019 sample of women of reproductive age, National Survey on Drug Use and Health.

Not-pregnant Women Pregnant Women
Overall (N = 280,626) Urban (N = 214,345) Rural (N = 52,166) Urban (N = 10,908) Rural (N = 3,207)
Sample N % Sample N % Sample N % Sample N % Sample N %
Age
18–25 158345 29.5 119892 29.2 29316 29.4 6828 34.4 2309 48.9
26–34 64060 32.9 48616 32.4 11421 30.8 3276 50.5 747 41.9
35–49 58221 37.6 45837 38.4 11429 39.7 804 15.1 151 9.2
Race
White 166826 59.4 119566 56.4 39401 78.4 5557 55.1 2302 75.4
Black/African Am 38423 13.8 32293 14.5 3936 9.1 1925 14.5 269 11.1
Native Am/ AK Native 4223 0.6 1929 0.4 2010 1.9 102 0.3 182 2.1
Native HI/ Other Pac Isl 1483 0.4 1144 0.5 255 0.3 61 0.4 23 0.3
Asian 12013 6.2 10791 7.0 767 1.3 420 6.7 35 0.8
More than one race 8444 1.5 6498 1.5 1499 1.3 350 1.5 97 1.7
Hispanic 49214 18.1 42124 19.7 4298 7.7 2493 21.4 299 8.6
Education
Less than high school 39402 12.4 28546 11.9 7978 14.9 2219 15.4 659 17.9
High school diploma/GED 81341 25.6 59041 24.4 17726 33.0 3375 24.5 1199 33.8
Some college 94760 31.8 72820 31.7 18102 33.9 2934 25.4 904 29.3
College degree 65123 30.2 53938 32.0 8360 18.2 2380 34.6 445 19.0
Income
Less than $20,000 79161 21.6 58280 20.8 16707 26.7 3083 20.5 1091 30.9
$20,000 – $49,999 97101 32.7 72375 31.9 19379 37.5 4050 31.4 1297 38.6
$50,000 – $74,999 42485 16.8 32620 16.7 7783 17.5 1654 17.5 428 15.6
$75,000 or More 61879 28.9 51070 30.6 8297 18.3 2121 30.6 391 14.8
Current Smoker 1
No 211725 77.0 164791 78.1 35431 67.1 9136 88.0 2367 74.7
Yes 68901 23.0 49554 21.9 16735 32.9 1772 12.0 840 25.3
Quit Ratio 2
18735 25.6 13916 26.5 3675 20.6 864 33.0 280 21.5
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1

Current smoking is defined as smoked part or all of at least 1 cigarette in the past 30 days and 100 cigarettes lifetime.

2

Quit ratio is defined at the proportion of participants who meet criteria for lifetime smoking (i.e., smoked at least 100 cigarettes in lifetime) but report no smoking in the past year.

A total of 95,308 (33.96%) participants met criteria for lifetime smoking, 68,901 (23.01%) for current smoking, and 18,735 (25.62%) for former smoking. Participants varied in age (29.53% were 18–25 years; 32.90%, 26–34 years; 37.57%, 35–44 years), race (59.39% were White; 39.78% Non-Hispanic Black; 18.13% Hispanic), educational attainment (30.16% with a college degree; 31.79% some college; 25.63% high school degree, 12.43% less than high school), and income (28.90% with more than $75,000 annual income; 16.80% between $50,000-$74,999, 32.70% between $20,000-$49,000, and 21.60% with < $20,000).

Smoking Prevalence

Overall smoking prevalence (not-pregnant and pregnant).

There was a significant main effect of residence on smoking prevalence across the 18-year study period, with the adjusted odds of smoking greater in rural than urban residents (adjusted odds ratio [AOR] =1.11; 95% CI, 1.07–1.15; P < .001). Smoking prevalence decreased over time (AOR=0.95; 0.94-.95; P < .001) and interacted with residence (AOR=1.04; 1.03–1.05; P < .001), with smaller decreases in rural (AOR=0.98; 0.97–0.99; P < .001) than urban residents (AOR=0.94; 0.94–0.95; P < .001) (Figure 1).

Figure 1: Smoking prevalence.

Figure 1:

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Upper panel: current cigarette smoking prevalence among rural versus urban women of reproductive age (not-pregnant and pregnant) in 2-year increments with 95%confidence bars. Bottom panels: current cigarette smoking prevalence among rural versus urban women of reproductive age among not-pregnant (left-most panel) and pregnant (right-most panel) in 2-year increments with 95%confidence bars. Estimates are weighted to reflect the U.S. population during the years 2001–2019. Means and SEMs shown in the figure are listed in Supplemental Table 1.

Smoking prevalence by pregnancy status.

Among the larger sample of not-pregnant women, results were consistent with those described above. Adjusted odds of smoking across the study period were greater in rural than urban residents (AOR=1.10; 1.07–1.14; P < .001). Smoking prevalence decreased over time (AOR=0.95; 0.94–0.95, P < .001) and interacted with residence (AOR=1.04; 1.03–1.05; P < .001), with smaller decreases among rural (AOR=0.98; 0.97–0.99; P < .001) than urban women (OR=0.94; 0.94–0.95; P < .001) (Figure 2, left panel).

Figure 2: Quit ratios.

Figure 2:

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Upper panel: smoking quit ratios among rural versus urban women of reproductive age (not-pregnant and pregnant) in 2-year increments with 95%confidence bars. Bottom panels: Smoking quit ratios among rural versus urban women of reproductive age who are not-pregnant (left panel) and pregnant (right panel) 2-year increments with 95%confidence bars. Quit ratios represent the proportion of women who reported no smoking in the past 30 days among those who reported having smoked 100 or more cigarettes lifetime. Estimates are weighted to reflect the U.S. population during the years 2001–2019.

Among pregnant women, adjusted odds of smoking across the study period were also greater among rural than urban residents (AOR=1.29; 1.09–1.52; P < .001). Smoking prevalence decreased over time (AOR=0.97; 0.94–0.99; P < .001) but did not interact significantly with residence (AOR=1.06; 1.00–1.12; ns). In exploratory analyses, there was no significant decrease in adjusted odds of current smoking across years among rural women (AOR=1.01; 0.96–1.06; ns) but a significant decrease among urban residents (AOR=0.96; 0.93–0.99; P < .010) (Figure 2, right panel).

Quit Ratios

Overall quit ratios.

Quit ratios across the study period were significantly lower among rural than urban residents (AOR=0.93; 0.87–0.99; P<.001). Quit ratios increased over time (AOR=1.02; 1.01–1.03; P< 001) although they did not interact significantly with residence (AOR=0.99; 0.96–1.01; ns). Exploratory analyses showed that adjusted odds failed to increase significantly over time among rural residents (AOR=1.01; 0.99–1.03; ns) but did among urban residents (AOR=1.03; 1.01–1.04; P < .001) (Figure 3).

Quit ratio by pregnancy status.

Among not-pregnant women, quit ratios across the study period were significantly lower among rural than urban residents (AOR=0.93; 0.88–1.00, P=.035). Adjusted odds of quitting increased over time (AOR=1.02; 1.01–1.03; P <.001) although the increase did not interact significantly with residence (AOR=0.98; 0.96–1.01; ns). Consistent with the overall pattern described above, exploratory analyses indicated that quit ratios failed to increase significantly over time among rural women (AOR=1.01; 0.99–1.03; ns) but did among urban women (AOR=1.03; 1.02–1.04; P < .001) (Figure 4, left panel).

Among pregnant women, quit ratios across the study period were significantly lower among rural than urban women (AOR=0.78; 0.62–0.99; P=.039). Adjusted odds of quitting did not increase over time (AOR=1.03; 0.99–1.07; ns). The interaction between time and rural residence was not significant (AOR=1.01; 0.92–1.10; ns). Exploratory analyses failed to show significant increases in adjusted odds over time in rural (AOR=1.04; 0.96–1.13; ns) or urban women (AOR=1.03; 0.98–1.08; ns) (Figure 4, right panel).

Discussion

This study contributes further empirical evidence from a nationally representative sample demonstrating a robust and longstanding U.S. rural disparity in smoking prevalence and, to our knowledge, novel evidence demonstrating that lower quit ratios (i.e., smoking cessation) contribute to these disparities in women (Cepeda-Benito et al., 2018; Nighbor et al., 2018). More specifically, the present results demonstrate that these disparities in prevalence and smoking cessation are evident among women of reproductive age including those who are pregnant. These data replicate prevalence disparities previously reported for women of reproductive age (Nighbor et al., 2018) and extend them across a greater time period and to disparities in smoking cessation. Similarly, the disparities in quit ratios reported here extend those previously reported for adults of both sexes (Parker et al., 2022) to women of reproductive age and across a greater time period. Importantly, the disparities in the present and prior studies were not fully accounted for by differences in key sociodemographic risk factors strongly suggesting that differences in access to evidence-based smoking cessation and other tobacco control and regulatory interventions and policies are at least in part contributors.

The disparities in quit ratios underscore the need to increase access to evidence-based smoking-cessation interventions for rural women. Of course, greater services should be made available to women of all ages, but the added concern of protecting against the adverse effects of maternal smoking on infants and children cannot be ignored. Smoking during pregnancy is associated with catastrophic pregnancy outcomes as well as all-cause and cause-specific infant death (Anderson et al., 2019; Cnattingius, 2004). Importantly, these associations are (a) dose dependent and (b) less likely in those who smoked in the first trimester but quit in the second or third trimester compared to women who smoked throughout the pregnancy (Anderson et al., 2019; Cnattingius, 2004; Higgins et al., 2022). The positive impact of quitting smoking during pregnancy on sudden unexpected infant death (SUID) (Anderson et al., 2019) is particularly important to underscore as it is the category that contributes most to rural disparities in infant death (Mohamoud et al., 2023; Sun et al., 2023). While these adverse effects underscore the need to increase access to effective smoking-cessation interventions to protect maternal and infant health, there are also sound reasons for doing the same to protect women’s health more generally. Rural women are at greater risk than urban women for smoking-related chronic disease and premature death, including cardiovascular disease and smoking-related cancers (Abrams et al., 2022; Nechuta & Wallace, 2023; Womack et al., 2020). As such, increasing access to evidence-based treatment for smoking cessation across rural women of all ages represents an important opportunity to improve maternal and infant health, reduce smoking-related chronic disease, and increase longevity and quality of life.

Recent advances in digital health offer promise for bringing evidence-based smoking cessation to rural women. For example, a randomized clinical trial (RCT) out of our group (Kurti et al., 2022) demonstrated that adding a smartphone-based contingency-management (CM) intervention for pregnant women who smoke in combination with a state quit-line referral increased late-pregnancy cessation rates several-fold above outcomes achieved with a state quit line referral alone. Those cessation differences were maintained through a 24-week postpartum assessment conducted 12 weeks after discontinuation of the CM intervention. That trial was not conducted exclusively with rural residents, but further examining trial outcomes by rural compared to urban residence for purposes of the present report show that 23% (21) of the 90 trial participants were rural residents. Results in that subsample were encouraging with 50%, 30%, and 30% of those who received the CM plus quitline intervention were abstinent at late-pregnancy, 12-, and 24-week postpartum assessments, respectively, compared to 10%, 10%, and 10% among those who received only the quitline referral. While encouraging, RCTs explicitly examining reach and efficacy of the intervention among rural pregnant women are needed. We also see no reason why a modified version of that same smartphone model could not be extended to not-pregnant rural women considering its efficacy postpartum in the Kurti et al. trial and the larger body of evidence supporting CM’s efficacy in promoting smoking cessation in adults generally (Halpern et al., 2015; Volpp et al., 2009). Again, though, RCTs specifically addressing reach and efficacy in these rural populations are needed as are RCTs examining the efficacy of other digital health interventions examining other behavioral and frontline pharmacological smoking-cessation interventions among rural women.

Limitations

This study shares limitations with those noted in prior reports in this series on rural smoking disparities (Cepeda-Benito et al., 2018; Doogan et al., 2017; Nighbor et al., 2018; Parker et al., 2018). NSDUH is a cross-sectional observational study that cannot support causal inferences. While NSDUH uses a valid method for classifying geographic residence there are other methods and results on rural-urban health disparities can vary (Hirko et al., 2022). Additional studies examining rural disparities in women of reproductive age using longitudinal surveys and other geographic identifiers may help to extend the current findings. Another limitation of the present study is the absence of data beyond 2019 including the impact of the COVID-19 pandemic which impacted smoking prevalence (e.g., Gaffney et al., 2022; Kegler et al. 2023). Future studies examining U.S. rural-urban smoking disparities beyond 2019 would be helpful.

Conclusions

These results further document a longstanding and robust rural disparity in smoking prevalence among women of reproductive age including those who are currently pregnant and provides novel and similarly longstanding and robust evidence that differences in smoking cessation contribute to this disparity. These findings further underscore prior calls for additional and more effective national and local tobacco control and regulatory efforts to reduce smoking among rural women of reproductive age especially but certainly not only those who are pregnant.

Supplementary Material

1

Highlights.

Rural disparities in smoking extend to women of reproductive age.

These disparities are evident throughout the 18-year study period (2002–2019).

The disparities are evident across analyses of smoking prevalence and quit ratios.

Lower rates of quitting among rural women contribute to these disparities.

Greater access to effective smoking cessation for rural women should be prioritized.

Funding Sources

Tobacco Centers of Regulatory Science (TCORS) award U54DA036114 from the National Institute on Drug Abuse and Food and Drug Administration. National Institute of General Medical Sciences Center of Biomedical Research Excellence Award P30GM149331; National Institute on Drug Abuse Institutional Training Award T32DA007242. Funders had no role in the study.

Footnotes

Declaration of competing interests: The authors have no competing interests to declare relating to this study and report.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Supplementary Materials

1
NIHMS2005774-supplement-1.docx (23KB, docx)

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