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Birth Cohort‒Specific Smoking Patterns by Family Income in the U.S.

Open AccessPublished:January 15, 2023DOI:https://doi.org/10.1016/j.amepre.2022.07.019

      Introduction

      In the U.S., low-income individuals generally smoke more than high-income individuals. However, detailed information about how smoking patterns differ by income, especially differences by birth cohort, is lacking.

      Methods

      Using the National Health Interview Survey 1983–2018 data, individual family income was calculated as a ratio of the federal poverty level. Missing income data from 1983 to 1996 were imputed using sequential regression multivariate imputation. Age‒period‒cohort models with constrained natural splines were used to estimate annual probabilities of smoking initiation and cessation and smoking prevalence and intensity by gender and birth cohort (1900–2000) for 5 income groups: <100%, 100%–199%, 200%–299%, 300%–399%, and ≥400% of the federal poverty level. Analysis was conducted in 2020–2021.

      Results

      Across all income groups, smoking prevalence and initiation probabilities are decreasing by birth cohort, whereas cessation probabilities are increasing. However, relative differences between low- and high-income groups are increasing markedly, such that there were greater declines in prevalence among those in high-income groups in more recent cohorts. Smoking initiation probabilities are lowest in the ≥400% federal poverty level group for males across birth cohorts, whereas for females, this income group has the highest initiation probabilities in older cohorts but the lowest in recent cohorts. People living below the federal poverty level have the lowest cessation probabilities across cohorts.

      Conclusions

      Smoking prevalence has been decreasing in all income groups; however, disparities in smoking by family income are widening in recent birth cohorts. Future studies evaluating smoking disparities should account for cohort differences. Intervention strategies should focus on reducing initiation and improving quit success among low-income groups.

      INTRODUCTION

      Cigarette smoking has declined considerably in the U.S. for the general population.
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      However, the decrease in smoking prevalence differed greatly by SES.

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      ,

      SNAP eligibility. Food and Nutrition Service. https://www.fns.usda.gov/snap/recipient/eligibility. Updated October 1, 2021. Accessed October 17, 2022.

      Income furthermore determines eligibility for government social services and benefits, including Medicaid coverage, on the basis of whether individuals are below or above the FPL.

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      Thus, analyses of smoking disparities by income facilitate a more comprehensive understanding of socioeconomic differences in health behaviors and in access to care
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      In particular, the risk of smoking-related diseases, such as lung cancer, chronic obstructive pulmonary disease, and cardiovascular disease, has been declining more rapidly among high-income than among low-income individuals, thereby widening overall tobacco–related health disparities by SES in recent years.
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      showed that cohort patterns in U.S. smoking prevalence, initiation, cessation, and intensity vary considerably by gender
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      and race.
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      Another study by Escobedo and colleagues
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      found variations in smoking prevalence trends by education, with decreases among those with higher educational attainment but not in those with lower educational attainment. Smoking trends may also be determined by birth cohort‒specific smoking patterns by income level, but this has not been examined yet. This study focuses on evaluating gender and birth cohort‒specific smoking patterns by income level in the U.S. population. Using a methodology previously developed by the Cancer Intervention and Surveillance Modeling Network-Lung Working Group investigators,
      • Holford TR
      • Levy DT
      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
      ,
      • Holford TR
      • Levy DT
      • Meza R.
      Comparison of smoking history patterns among African American and White cohorts in the United States born 1890 to 1990.
      age-specific smoking prevalence, initiation probabilities, cessation probabilities, mean CPD, mean smoking duration, and mean pack years were estimated by gender and birth cohort for 5 income groups, categorized by family income relative to the FPL. The resulting smoking parameters facilitate a more in-depth understanding of variations of smoking patterns across income groups and their implications for health disparities when used to inform simulation models of smoking and smoking-related morbidity and mortality.

      METHODS

      Study Sample

      Data were obtained from the National Health Interview Survey (NHIS) for smoking status (i.e., current, former, and never smoking; 1983, 1985, 1987, 1990–1995, 1997–2018), age at which respondents started smoking regularly (1987, 1988, 1992, 1995, 1997–2018), years since quitting smoking (1983, 1985, 1990, 1992, 1994, 1995, 1997–2018), and cigarettes smoked per day (1983, 1985, 1988, 1990–1995, 1997–2018). Individuals who smoked ≥100 cigarettes in their lifetime were classified as current smokers if they currently smoked every day or some days at the time of survey completion and were classified as former smokers if they did not currently smoke at all at the time of the survey. Data from the NHIS

      NHIS (National Health Interview Survey). https://nhis.ipums.org/nhis/. Accessed October 17, 2022.

      ,

      2019 Questionnaire redesign. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/nhis/2019_quest_redesign.htm. Updated March 3, 2022. Accessed October 17, 2022.

      were excluded because the survey design was substantially changed in 2019.

      2019 Questionnaire redesign. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/nhis/2019_quest_redesign.htm. Updated March 3, 2022. Accessed October 17, 2022.

      Family income data were also obtained from the NHIS from 1983 to 2018. To estimate smoking patterns by the level of family income and to avoid issues of rising income and inflation, individuals were categorized according to their family income-to-poverty ratio using the FPL for each year and family composition. The FPL is defined by the Census Bureau as the minimum amount of gross income that a family needs for survival, and it varies by family size and structure (i.e., number of adults and related children aged <18 years).

      Prior HHS poverty guidelines and federal register references. ASPE, HHS. https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/prior-hhs-poverty-guidelines-federal-register-references. Accessed October 17, 2022.

      The FPL is adjusted for inflation annually. For this analysis, 5 categories of family income-to-poverty ratio were used: below poverty (<100% FPL), near poverty (100%–199% FPL), 200%–299% FPL, 300%–399% FPL, and ≥400% FPL.

      Measures

      Detailed family income in the NHIS is often subject to high rates of missing values because of the sensitive nature of income-related questions for survey respondents. To address this shortcoming, the NHIS provides 5 imputed data sets for the family income-to-poverty ratio for 1997–2018. For these, missing continuous family incomes were imputed by NHIS investigators using the sequential regression multivariate imputation method.

      IVEware: imputation and variance estimation software. Survey Research Center. https://www.src.isr.umich.edu/software/iveware/. Updated 2016. Accessed October 17, 2022.

      Before 1997, only categorical family income data were included in the NHIS. Following a similar sequential regression multivariate imputation approach, continuous family income for NHIS years 1982–1996 was imputed by calculating a family income-to-poverty ratio for each survey individual by dividing the continuous family income by the corresponding year FPL, accounting for the individual's family size and structure. Five imputed data sets for family income-to-poverty ratio were generated for the years 1982–1996. Additional details regarding the continuous family income imputation procedure for NHIS 1982‒19962 are provided in Appendix Text 1 (available online).

      Statistical Analysis

      Using age‒period‒cohort (APC) models with constrained natural splines,
      • Holford TR
      • Levy DT
      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
      ,
      • Holford TR
      • Levy DT
      • Meza R.
      Comparison of smoking history patterns among African American and White cohorts in the United States born 1890 to 1990.
      annual probabilities of smoking initiation, cessation, and intensity (CPD) by gender and cohort (1900–2000 birth cohorts) were estimated separately for each income group. The underlying analysis framework assumes that individuals who never smoked can transition into current smoking status (smoking initiation) and that individuals with current smoking status can then transition into former smoking status (smoking cessation). The estimated rates or probabilities from the APC models were presented, which are identifiable and not affected by the known identifiability issue of these models.
      • Holford TR.
      The estimation of age, period and cohort effects for vital rates.
      Smoking initiation probabilities were estimated using data on respondents’ reported age of initiation. For each gender and birth cohort, age-specific initiation probabilities were estimated as conditional probabilities of smoking initiation among individuals who had never smoked up to the time of the interview. To address differential mortality between individuals who smoked and individuals who did not smoke up to the time of interview as well as recall bias in self-reported age at smoking initiation, the cumulative initiation probabilities by cohort were calibrated to match the estimated ever-smoking prevalence at age 30 years. The latter was obtained by fitting an APC model to ever-smoking data from all surveys. Age-specific cessation probabilities were estimated as conditional probabilities of quitting for individuals who reported current smoking, with the minimum age of quitting set as age 15 years. Smoking cessation is based on having quit for at least 2 years, thereby minimizing the need to account for relapse among recent quitters. The risk of relapse is higher immediately after a quit attempt, but permanent abstinence is high among former smokers who quit >2 years.
      • Herd N
      • Borland R
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      In the NHIS surveys, age is top coded at 85 years, thus the cessation probabilities were set as constant beyond age 85 years.
      For estimating smoking intensity by age for each gender and birth cohort, CPD was classified into 6 categories (approximate mean CPD of each category): CPD≤5 (3), 5<CPD≤15 (10), 15<CPD≤25 (20), 25<CPD≤35 (30), 35<CPD≤45 (40), and 45<CPD (60). Age- and cohort-specific probabilities for each dose category were estimated by a cumulative logistic age‒period‒cohort model using constrained natural splines for temporal effects.
      For each birth cohort, the current smoking prevalence at a given age was estimated by multiplying the ever-smoking prevalence by the cumulative proportion of individuals who smoked in the cohort who had not quit smoking at that age. Former smoking prevalence was estimated by subtracting the proportion of current smoking from the proportion of ever smoking. Never-smoking prevalence was estimated by the complement of ever-smoking prevalence. On the basis of the estimated distribution of smoking initiation, current-smoking prevalence; former-smoking prevalence; and mean CPD, the mean smoking duration and mean pack years, were also estimated by age, gender, and birth cohort.
      All smoking parameters for age, period, and cohort effects were estimated separately for each of the 5 income-to-poverty ratio groups: below poverty (<100% FPL), near poverty (100%–199% FPL), 200%–299% FPL, 300%–399% FPL, and ≥400% FPL using the PROC SURVEYLOGISTIC in SAS 9.4, accounting for sample weights.

      RESULTS

      The distribution of U.S. adults across income groups from NHIS 1983–2018 is shown in Appendix Figure 1 (available online). The percentage of the population living below the FPL is quite stable across years in both females and males, approximately 10%. The percentage of the population in the highest income (≥400% FPL) group has been growing over time from 1983 to 2018, increasing from 24% to 40% of females and from 28% to 44% of males.
      Figure 1
      Figure 1Age-specific smoking initiation probabilities (percentage) for selected birth cohorts by family income-to-poverty ratio and gender (females, top panels; males, bottom panels). Note: Lines represent the initiation probabilities for below poverty (<100% FPL, red), near poverty (100%–199% FPL, orange), 200%–299% FPL (sky blue), 300%–399% FPL (blue), and ≥400% FPL (black). An interactive version of this figure's data can be found at http://apps.cisnetsmokingparameters.org/income/. FPL, federal poverty level.
      Figure 1 shows the age-specific initiation probabilities by the family income-to-poverty ratio for 5 selected birth cohorts (1910, 1930, 1950, 1970, 1990) by gender. In general, smoking initiation increases during adolescence and decreases during young adulthood, with very little or no initiation occurring beyond age 30 years. Differences in initiation between income groups were relatively modest in earlier birth cohorts but more prominent in recent cohorts. Among females, the highest income (≥400% FPL) group had the highest initiation probabilities in older birth cohorts but the lowest in recent birth cohorts. By contrast, among males, the ≥400% FPL group has the lowest initiation across all birth cohorts. In earlier birth cohorts, the below poverty (<100% FPL) group had the lowest initiation probabilities than other income groups, but with more recent birth cohorts, this group had the highest or second highest initiation probabilities for both genders. The age at peak initiation increases with the level of family income, where lower-income groups have earlier ages at smoking onset. Appendix Figure 2 (available online) shows age-specific initiation probabilities for additional cohorts by calendar year, comparing each income group with the highest income (≥400% FPL) group. Among females, the initiation probabilities increased through the 1940–1960 birth cohorts before decreasing in later birth cohorts. Conversely, the male initiation probabilities decreased by birth cohort since the early 1900s across all income groups. Initiation probabilities were much higher in males than in females in early birth cohorts but became similar by gender with more recent birth cohorts across all income groups.
      Figure 2
      Figure 2Age-specific smoking-cessation probabilities (percentage) for selected birth cohorts by family income-to-poverty ratio and gender (females, top panels; males, bottom panels). Note: Lines represent the initiation probabilities for below poverty (<100% FPL, red), near poverty (100%–199% FPL, orange), 200%–299% FPL (sky blue), 300%–399% FPL (blue), and ≥400% FPL (black). An interactive version of this figure's data can be found at http://apps.cisnetsmokingparameters.org/income/. FPL, federal poverty level.
      In general, smoking-cessation probabilities increased with age and declined slightly at older ages. For both genders, there was a clear positive gradient in age-specific cessation probabilities by the level of family income, especially in recent birth cohorts: cessation probabilities were highest in the ≥400% FPL group and lowest in the below-poverty group (Figure 2). Differences in cessation probabilities by income group became larger with more recent birth cohorts. Figure 2 shows that males in the ≥400% FPL group generally have higher cessation probabilities than females in the same income group across birth cohorts. However, there were no major gender differences in cessation for each of the other income groups except in the 1910 birth cohort. Cessation probabilities increased by birth cohort across all income groups in both females and males (Appendix Figure 3, available online).
      Figure 3
      Figure 3Age-specific smoking prevalence (percentage) for selected birth cohorts by family income-to-poverty ratio and gender (females, top panels; males, bottom panels). Note: Lines represent the initiation probabilities for below poverty (<100% FPL, red), near poverty (100%–199% FPL, orange), 200%–299% FPL (sky blue), 300%–399% FPL (blue), and ≥400% FPL (black). An interactive version of this figure's data can be found at http://apps.cisnetsmokingparameters.org/income/. FPL, federal poverty level.
      Across all income groups, smoking prevalence increased through young adulthood and gradually declined with age for both females and males. For both genders, there was a clear negative gradient in age-specific current smoking prevalence by income group in all selected birth cohorts, except in the 1910 birth cohort (Figure 3); across birth cohorts and ages, smoking prevalence is highest in the below-poverty group, followed by near poverty, 200%–299% FPL, and 300%–399% FLP and lowest in the ≥400% FPL group. In Appendix Figure 4 (available online), similar to initiation trends, smoking prevalence in females increased through the 1940–1960 birth cohorts, then decreased with later birth cohorts, with modest variation by income group. For males across all income groups, prevalence has been decreasing by birth cohort since the early 1900s birth cohorts. Smoking prevalence was much higher among males than among females in early birth cohorts, but gender differences in smoking prevalence have decreased in recent birth cohorts.
      Figure 4
      Figure 4Age-specific mean cigarettes per day among current smokers for selected birth cohorts by family income-to-poverty ratio and gender (females, top panels; males, bottom panels). Note: Lines represent the initiation probabilities for below poverty (<100% FPL, red), near poverty (100%–199% FPL, orange), 200%–299% FPL (sky blue), 300%–399% FPL (blue), and ≥400% FPL (black). An interactive version of this figure's data can be found at http://apps.cisnetsmokingparameters.org/income/. FPL, federal poverty level.
      Figure 4 shows age-specific mean CPDs among individuals who currently smoke by income group and gender for 5 selected birth cohorts. In early birth cohorts, the mean CPDs were highest in the ≥400% FPL group and lowest in the below-poverty group. However, in recent birth cohorts, the mean CPDs were lowest in the ≥400% FPL group and highest in the below-poverty and near-poverty groups. In early birth cohorts (1910 and 1930), the mean CPDs increased until around age 55 years and decreased thereafter. In contrast, for the 1950 birth cohort, the peak occurred around age 40 years. Mean CPDs became relatively flat, slightly decreasing by age, in recent birth cohorts. This pattern was consistent across all income groups and genders. In general, mean CPDs decreased by birth cohort for both genders and were higher in males than in females in all income groups (Appendix Figure 5, available online).
      Across all selected birth cohorts except for the 1910 birth cohort, there was a negative gradient in the age-specific mean smoking duration by the level of family income, where smoking duration was shorter with higher income (Appendix Figure 6, available online); the mean smoking duration was longest in the below-poverty group, followed by near-poverty, 200%–299% FPL, and 300%–399% FLP group and shortest in the ≥400% FPL group. Appendix Figure 6 (available online) shows that in general, the mean smoking duration has been decreasing by birth cohort in all income groups and that males had higher mean smoking duration than females in early birth cohorts, but differences by gender have narrowed with recent birth cohorts.
      Appendix Figure 7 (available online) shows a negative gradient in age-specific mean pack years by the level of family income in relatively recent birth cohorts for both genders. Similar to patterns in smoking duration, mean pack years decreased by birth cohort in all income groups and for both genders, with males having higher mean pack years than females in early birth cohorts but reaching similar levels in recent birth cohorts (Appendix Figure 7, available online).

      DISCUSSION

      This is the first study to provide a comprehensive analysis of smoking behaviors by family income for U.S. birth cohorts. Previous studies have looked at birth cohort smoking patterns by gender,
      U.S. HHS
      The health consequences of smoking-50 years of progress: a report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
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      • Harris JE.
      Cigarette smoking among successive birth cohorts of men and women in the United States during 1900-1980.
      ,
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      • Peddicord JP.
      Smoking prevalence in U.S. birth cohorts: the influence of gender and education.
      ,
      • Holford TR
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      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
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      race,
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      or education
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      in the U.S. population; however, income group differences in smoking patterns by birth cohort have not been studied. This study extends the CISNET age, period, cohort modeling methodology to estimate smoking behaviors—smoking initiation, cessation, and intensity—by family income level in the U.S. Smoking prevalence and initiation probabilities have been decreasing by birth cohort starting with the early 1900s cohorts in males and with the 1940–1960 cohorts in females, although the extent of decrease varied across income groups. Cessation probabilities have been increasing by birth cohort in all income groups, especially in young adult males and females. For all income groups, mean CPD, smoking duration, and pack years have been decreasing by birth cohort. However, differences in smoking initiation and cessation probabilities between income groups have been widening in more recent birth cohorts, resulting in increasing disparities in smoking prevalence by income level. These findings are consistent with other studies showing differences in smoking prevalence and cessation probability by income level to be widening in recent years.
      • Jamal A
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      Current cigarette smoking among adults–United States, 2005-2014.
      ,
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      ,
      • Babb S
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      • Schauer G
      • Asman K
      • Jamal A.
      Quitting smoking among adults–United States, 2000-2015.
      ,
      • Vijayaraghavan M
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      • et al.
      Income disparities in smoking cessation and the diffusion of smoke-free homes among U.S. smokers: results from two longitudinal surveys [published correction appears in PLoS One. 2018;13(11):e0208153].
      Findings from this study illustrate the social transition of smoking behaviors from high- to low-income groups as it varies by gender.
      • Fleischer NL
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      The second epidemiologic transition from an epidemiologist's perspective.
      Although males from the lowest income group had the highest smoking levels since early cohorts covered in this analysis, females’ smoking progressively shifted from higher-income to lower-income groups with increasing time/birth cohorts. This social transition increases smoking disparities and progressively concentrates the disproportionate burden of smoking-related morbidity and mortality on the lowest income population. It is particularly problematic because low-income groups have the least access to healthcare resources and are most vulnerable to housing and food insecurity, all of which exacerbate risks to health.
      • Gundersen C
      • Ziliak JP.
      Food insecurity and health outcomes.
      ,
      • Hernández D
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      Housing as a platform for health and equity: evidence and future directions.
      It is plausible that a similar cohort transition of smoking behaviors from higher-income to lower-income groups also would have been observed among males if data from even earlier cohorts were available.
      In this study, the NHIS imputation methods were used and extended to fill in gaps in historical income data, addressing the absence of continuous income data before 1997. This allowed using NHIS data from NHIS 1983–2018. Future researchers that wish to use this imputation methodology to analyze the relationship between family income and other NHIS outcomes and behaviors besides smoking can refer to the Appendix (available online) for details. Another methodologic strength is the use of the Cancer Intervention and Surveillance Modeling Network-Lung Working Group approach, which jointly estimates historical age‒period‒cohort‒specific initiation and cessation probabilities with the prevalence of ever, never, current, and former smoking, resulting in consistent estimates across smoking behaviors.
      Cohort-specific smoking patterns may reflect changes in both the tobacco control policy and tobacco product landscapes over time. People born in 1950 versus in 1990 were exposed to very different sets of social norms and public health policies during key life stages for initiation (adolescence, young adulthood) and cessation (middle age, older adulthood). For instance, the strong decreases in smoking initiation and prevalence across income groups since the 1950 birth cohort likely reflects the continuous impact of strengthened tobacco control policies and regulations implemented since the 1964 Surgeon General's Report.
      Estimates of age-specific initiation and cessation probabilities and the distribution of CPD by birth cohort for the overall U.S. population have been used as input parameters for simulation models of smoking.
      • Holford TR
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      • et al.
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      ,
      • Holford TR
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      ,
      • Jeon J
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      5: Actual and counterfactual smoking prevalence rates in the U.S. population via microsimulation.
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      An estimation of the harm of menthol cigarettes in the United States from 1980 to 2018.
      These models have been used to examine the potential impact of health intervention strategies such as tobacco policies on smoking and lung cancer,
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      Smoking and lung cancer mortality in the United States from 2015 to 2065: a comparative modeling approach.
      ,
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      Potential public health effects of reducing nicotine levels in cigarettes in the United States.
      • Levy DT
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      Public health implications of vaping in the USA: the smoking and vaping simulation model.
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      the benefits and harms of different cancer screening strategies on health outcomes,
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      Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the U.S. Preventive Services Task Force.
      • Meza R
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      Meza R, Jeon J, Toumazis I, et al. Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: a collaborative modeling study for the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality (U.S.). https://www.ncbi.nlm.nih.gov/books/NBK568586/. Published 2021. Accessed October 17, 2022.

      as well as their effectiveness and cost-effectiveness.
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      This study provides smoking parameters for various income groups, which facilitates similar analyses to examine the impact of prevention strategies on health outcomes by income level.
      Income-based analysis of smoking disparities is important because of vulnerability to smoking and related morbidity and mortality in low-income populations. Research has revealed tobacco industry targeting low-income individuals
      • Brown-Johnson CG
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      and the larger presence of tobacco advertising and tobacco product availability in low-income neighborhoods.
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      High rates of smoking initiation and low rates of quitting among low-income groups are especially concerning. Targeted interventions, such as cell phone‒delivered counseling, have shown promise for improving quit success for smokers living in poverty.
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      Efforts to reduce tobacco retailer density may have the potential to address smoking among low-income youth who are disproportionately exposed to both tobacco advertising and retail outlets in their neighborhoods.
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      This study highlights persistent disparities by income and changing trends by birth cohort. The adoption of effective smoking intervention strategies specifically for low-income groups will be important to reduce tobacco–related health disparities.

      Limitations

      This study has some limitations. The analysis used a simplifying assumption that categorized recent quitters as current smokers unless they had quit for at least 2 years. Consequently, more complex smoking trajectories, such as repeated quitting and relapse back to smoking in a lifetime, are not evaluated. The smoking parameters were estimated for age, gender, and birth cohort, separately for each income group, without adjusting for additional potential confounding factors, such as race/ethnicity, education, or U.S. region.
      U.S. HHS
      The health consequences of smoking-50 years of progress: a report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
      ,
      • Omole T
      • McNeel T
      • Choi K.
      Heterogeneity in past-year smoking, current tobacco use, and smoking cessation behaviors among light and/or non-daily smokers.
      ,
      • Ni K
      • Wang B
      • Link AR
      • Sherman SE.
      Does smoking intensity predict cessation rates? A study of light-intermittent, light-daily, and heavy smokers enrolled in two telephone-based counseling interventions.
      The analysis focuses on national data and trends; however, smoking patterns are a reflection of policy environments shaped at the state and local levels and therefore vary geographically. Although both family income and educational attainment are different aspects of SES, they are also highly correlated.
      • Daly MC
      • Duncan GJ
      • McDonough P
      • Williams DR.
      Optimal indicators of socioeconomic status for health research [published correction appears in Am J Public Health. 2002;92(8):1212].
      ,
      • Geyer S
      • Hemström O
      • Peter R
      • Vågerö D.
      Education, income, and occupational class cannot be used interchangeably in social epidemiology. Empirical evidence against a common practice.
      Another limitation is that the analysis focused exclusively on cigarette smoking, but the landscape of tobacco use has changed dramatically with the emergence of E-cigarettes in recent years.
      U.S. HHS
      The health consequences of smoking-50 years of progress: a report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.
      Recent changes in smoking initiation or cessation that may be associated with rising E-cigarette use are still not fully captured by the NHIS data, including potentially different changes by income level. Nonetheless, this analysis found considerable decreases in smoking initiation in recent cohorts, particularly for high-income groups, which could be related to replacement of cigarette smoking by E-cigarettes among youth and young adults.
      • Gentzke AS
      • Wang TW
      • Jamal A
      • et al.
      Tobacco product use among middle and high school students–United States, 2020.
      ,
      • Meza R
      • Jimenez-Mendoza E
      • Levy DT.
      Trends in tobacco use among adolescents by grade, sex, and race, 1991-2019.
      Variations in the use of other tobacco products by income, particularly cigars and cigarillos, might also be contributing to differences in cigarette smoking patterns and trends across income groups.
      • Corey CG
      • Holder-Hayes E
      • Nguyen AB
      • et al.
      U.S. adult cigar smoking patterns, purchasing behaviors, and reasons for use according to cigar type: findings from the Population Assessment of Tobacco and Health (PATH) study, 2013-2014.
      Finally, this analysis defined income levels according to the census federal poverty line, which ignores geographic differences in cost of living and purchasing power across regions, states, and localities.

      CONCLUSIONS

      Smoking prevalence has been decreasing in all income groups, but disparities in smoking by family income are widening in recent birth cohorts. These trends are shaped by the social transition of harmful smoking behaviors from high-income groups in earlier cohorts to low-income groups in recent cohorts. Future studies evaluating smoking disparities should take into account these differences by birth cohort. Intervention strategies should focus on decreasing initiation and improving quit success among low-income groups.
      The authors also acknowledge support from NCI grant U54CA229974.

      ACKNOWLEDGMENTS

      The study sponsor of this study had no role in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.
      No financial disclosures were reported by the authors of this paper.

      CREDIT AUTHOR STATEMENT

      Jihyoun Jeon: Conceptualization, Formal analysis, Methodology, Supervision, Visualization, Writing – original draft. Pianpian Cao: Conceptualization, Data curation, Formal analysis, Writing – review & editing. Nancy L. Fleischer: Conceptualization, Writing – review & editing. David T. Levy: Conceptualization, Funding acquisition, Writing – review & editing. Theodore R. Holford: Conceptualization, Funding acquisition, Methodology, Writing – review & editing. Rafael Meza: Conceptualization, Formal analysis, Funding acquisition, Methodology, Software, Visualization. Jamie Tam: Conceptualization, Formal analysis, Writing – review & editing.

      SUPPLEMENT NOTE

      This article is part of a supplement entitled Patterns of Birth Cohort-Specific Smoking Histories by Sociodemographic Group in the U.S., which is sponsored by the National Cancer Institute (NCI) Grants U01CA199284 and U01CA253858. Authors also acknowledge support from NCI grant U54CA229974. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of NCI.

      Appendix. SUPPLEMENTAL MATERIAL

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