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Patterns of Birth Cohort‒Specific Smoking Histories by Race and Ethnicity in the U.S.

Open AccessPublished:January 15, 2023DOI:https://doi.org/10.1016/j.amepre.2022.06.022

      Introduction

      U.S. smoking prevalence varies greatly by race/ethnicity. However, little is known about how smoking initiation, cessation, and intensity vary by birth cohort and race/ethnicity.

      Methods

      Adult smoking data were obtained from the 1978–2018 National Health Interview Surveys. Age‒period‒cohort models with constrained natural splines were developed to estimate historical smoking patterns among non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian and Pacific Islander, and non-Hispanic American Indian and Alaskan Native individuals. Annual smoking prevalence and probabilities of smoking initiation, cessation, and intensity by age, year, gender, and race/ethnicity were estimated for the 1900 to 2000 birth cohorts. Analysis was conducted in 2020–2021.

      Results

      Smoking initiation probabilities were highest for the American Indian and Alaskan Native population, second highest among the non-Hispanic White population, and lowest among Asian and Pacific Islander and Hispanic populations across birth cohorts. Historically, initiation probabilities among non-Hispanic Black populations were comparable with those among non-Hispanic White populations but have decreased since the 1970 birth cohort. Cessation probabilities were lowest among American Indian and Alaskan Native and non-Hispanic Black populations and highest among non-Hispanic White and Asian and Pacific Islander populations across cohorts and ages. Initiation and cessation probabilities produce observed patterns of smoking where prevalence among American Indian and Alaskan Native populations is highest across all ages and cohorts. Across cohorts, smoking prevalence among non-Hispanic Black populations, particularly males, is lower than among non-Hispanic White populations at younger ages but higher at older ages.

      Conclusions

      There are important and persistent racial/ethnic differences in smoking prevalence, initiation, cessation, and intensity across U.S. birth cohorts. Targeted interventions should address widening smoking disparities by race/ethnicity, particularly for American Indian and Alaskan Native and non-Hispanic Black populations.

      INTRODUCTION

      Smoking prevalence is decreasing across all sociodemographic groups in the U.S., but the prevalence and the magnitude of change vary greatly by race/ethnicity and gender.
      National Center for Chronic Disease Prevention Health Promotion (U.S.)
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      American Indian and Alaskan Native populations have historically had the highest smoking prevalence among racial/ethnic groups in the U.S., with an estimated prevalence of 25.2% (95% CI=14.4, 35.9) in 2018.
      • Creamer MR
      • Wang TW
      • Babb S
      • et al.
      Tobacco product use and cessation indicators among adults – United States, 2018.
      In contrast, Asian and Hispanic populations have the lowest levels of smoking in the U.S., with a reported prevalence of 8.2% (95% CI=6.3, 10.0) and 12.3% (95% CI=10.8, 13.8) in 2018, respectively. In between these extremes lie non-Hispanic Black and non-Hispanic White populations. Historically, these populations have had similar prevalence,
      National Center for Chronic Disease Prevention Health Promotion (U.S.)
      Office on Smoking and Health. The health consequences of smoking-50 years of progress: a report of the Surgeon General.
      with some variation by gender.
      • 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.
      In 2018, smoking prevalence was 17.9% (95% CI=17.1, 18.6) in non-Hispanic White adults and 18.2% (95% CI=16.3, 20.1) in non-Hispanic Black adults.
      • Creamer MR
      • Wang TW
      • Babb S
      • et al.
      Tobacco product use and cessation indicators among adults – United States, 2018.
      Although trends in overall smoking prevalence by year are well characterized, less is known about how smoking prevalence or the rates of smoking initiation, cessation, and intensity (cigarettes smoked per day) vary by birth cohort across various racial and ethnic groups. Previous studies have shown that age-specific smoking patterns for some U.S. populations vary dramatically by birth cohort.
      National Center for Chronic Disease Prevention Health Promotion (U.S.)
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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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      Patterns of birth cohort-specific smoking histories, 1965-2009.
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      2: birth-cohort-specific estimates of smoking behaviors for the U.S. population.
      In particular, Holford et al.
      • Holford TR
      • Levy DT
      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
      estimated historical birth cohort patterns in smoking prevalence, initiation, cessation, and intensity for the U.S. population by gender. They found that smoking patterns vary largely by cohort, with important differences by gender; males had consistent declines in smoking prevalence and initiation since the 1920 birth cohort, whereas female smoking prevalence and initiation increased considerably through the 1940 birth cohort.
      • Holford TR
      • Levy DT
      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
      In a subsequent study of U.S. White versus Black populations, not excluding Hispanic populations, Holford and colleagues
      • 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.
      found that initiation probabilities exhibit higher and earlier age peaks in White than in Black populations and that cessation rates are higher in the White than in Black population across ages. These patterns translate into a higher prevalence in the White population at younger ages but a higher prevalence in the Black population at older ages.
      • 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.
      These differences, together with the lower rates of smoking intensity among Black adults, translate into important differences in pack years and duration, which in turn affect their rates of smoking-related diseases, such as lung cancer.
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      • Haiman CA
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      Earlier studies explored birth cohort patterns in smoking prevalence and initiation among the Hispanic population
      • Escobedo LG
      • Remington PL.
      Birth cohort analysis of prevalence of cigarette smoking among Hispanics in the United States.
      ,
      • Escobedo LG
      • Remington PL
      • Anda RF.
      Long-term secular trends in initiation of cigarette smoking among Hispanics in the United States.
      ,
      • Rodriquez EJ
      • Oh SS
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      • Schroeder SA.
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      and among White, Black, and Asian/Pacific Islander populations.
      • Freedman DM
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      • et al.
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      However, no studies have examined and simultaneously compared cohort and age patterns of smoking prevalence, initiation, cessation, and intensity for multiple racial and ethnic groups.
      Using data from the National Health Interview Survey (NHIS), the age‒period‒cohort approach developed by Holford et al.
      • Holford TR
      • Levy DT
      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
      was used to estimate smoking prevalence and annual probabilities of smoking initiation, cessation, and intensity by age, birth cohort, year, and gender for 5 U.S. racial/ethnic groups: non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, non-Hispanic Asian and Pacific Islander (API), and non-Hispanic American Indian and Alaskan Native (AIAN). These estimates could characterize the differences in smoking outcomes for public health surveillance purposes and also serve as input parameters for computational modeling analyses of smoking and the impact of prevention and control interventions for specific racial and ethnic groups.
      • Jeon J
      • Holford TR
      • Levy DT
      • et al.
      Smoking and lung cancer mortality in the United States from 2015 to 2065: a comparative modeling approach.
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      • et al.
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      METHODS

      Study Sample and Measures

      Publicly available deidentified data were obtained from the 1978–2018 NHIS. The NHIS is an annual nationally representative cross-sectional household survey of the non-institutionalized population of U.S. adults aged ≥18 years.

      About the National Health Interview Survey. National Center for Health Statistics, Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/nhis/about_nhis.htm. Updated March 3, 2022. Accessed October 17, 2022.

      An established model for smoking was used, where individuals who have never smoked may transition to current smoking and then may quit former smoking.
      • 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.
      ,
      • Jeon J
      • Holford TR
      • Levy DT
      • et al.
      Smoking and lung cancer mortality in the United States from 2015 to 2065: a comparative modeling approach.
      ,
      • Holford TR
      • Levy DT
      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
      ,
      • Tam J
      • Levy DT
      • Jeon J
      • et al.
      Projecting the effects of tobacco control policies in the USA through microsimulation: a study protocol.
      ,
      • Moolgavkar SH
      • Holford TR
      • Levy DT
      • et al.
      Impact of reduced tobacco smoking on lung cancer mortality in the United States during 1975-2000.
      Each survey provided data on current, former, or never smoking status, which was used for cross-sectional estimates of ever-smoking prevalence by age and survey year. A subset of surveys collected age at smoking initiation (1978–1980, 1987, 1988, 1992, 1995, 1997–2018), age at cessation (1978–1980, 1983, 1985, 1990, 1992, 1994, 1995, 1997–2018), and cigarettes per day (CPD) smoked as an indicator of smoking intensity (1983, 1985, 1988, 1991–1995, 1997–2018), which were used to retrospectively reconstruct smoking histories until the date of the survey. More details about tobacco-use definitions and the underlying model are provided in the Appendix (available online).
      Before 1978, the NHIS coded respondent race on the basis of the interviewer's observation (White, Black, other), whereas national origin was asked in a single question starting in 1976. Because of the inadequacy of these data, in 1978, the NHIS began asking respondents directly about race and Hispanic origin as 2 separate questions in annual surveys.

      National Health Interview Survey: historical context. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/nhis/rhoi/rhoi_history.htm. Updated November 6, 2015. Accessed December 27, 2021.

      Therefore, 1978–2018 NHIS surveys were used because during this period, data were collected consistently for the racial/ethnic groups included in the analysis. Five racial/ethnic groups were considered: NHW, NHB, Hispanic, API, and AIAN. Individuals reporting multiple races were not included in the analysis. For brevity, the descriptor non-Hispanic was omitted in language describing API and AIAN groups. Data from the 2019 and 2020 NHIS were excluded because of survey design changes that became effective in 2019.

      National Health Interview Survey 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.

      Statistical Analysis

      For each racial/ethnic group, the approach developed by Holford and colleagues
      • Holford TR
      • Levy DT
      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
      was independently applied to estimate the following age-specific (single ages 0–99 years) smoking outcomes by birth cohort (single birth years 1900 to 2000 cohorts), calendar year and gender: smoking initiation and cessation probabilities; prevalence of ever, never, current, and former smoking; and distribution of CPD smoked for current smokers. The following categories of CPD smoked were considered (approximate mean CPD within a category): CPD≤5 (3), 5<CPD≤15 (10), 15<CPD≤25 (20), 25<CPD≤35 (30), 35<CPD≤45 (40), and 45<CPD (60). This framework has been previously applied to obtain estimates of smoking histories for the U.S. population by gender,
      • Jeon J
      • Holford TR
      • Levy DT
      • et al.
      Smoking and lung cancer mortality in the United States from 2015 to 2065: a comparative modeling approach.
      ,
      • Holford TR
      • Levy DT
      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
      for U.S. Black and White populations,
      • 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.
      and for the Canadian population by gender.
      • Manuel DG
      • Wilton AS
      • Bennett C
      • Rohit Dass A
      • Laporte A
      • Holford TR
      Smoking patterns based on birth-cohort-specific histories from 1965 to 2013, with projections to 2041.
      Briefly, age‒period‒cohort weighted-logistic regression models (PROC SURVEYLOGISTIC in SAS 9.4) were used to estimate each of the smoking parameters. Temporal effects (age, period, and cohort) were modeled using constrained natural splines. To resolve the well-known identifiability problem of distinguishing age, period, and cohort, the following measures were taken:
      • 1.
        The period slope was constrained to be zero for estimating initiation probabilities.
      • 2.
        The cohort slope was constrained to be zero for cessation probabilities.
      • 3.
        An age-cohort model was used for estimating ever-smoker prevalence.
      To address recall bias in retrospective self-reported age at smoking initiation and to enforce consistency of the estimates across smoking outcomes, the initiation probabilities by cohort were calibrated to produce predictions of ever-smoking prevalence consistent with estimated ever-smoker prevalence at age 30 years. Information about the specific models used for each sociodemographic/smoking parameter combination, including the number and location of spline knots and other details, are presented in the Appendix (available online).

      RESULTS

      Figure 1 shows age-specific smoking initiation probabilities for each racial/ethnic group and gender combination for selected birth cohorts (1910, 1930, 1950, 1970, 1990). Figures showing patterns for additional cohorts by calendar year are available in the Appendix (Appendix Figure 1, available online). For all racial/ethnic groups, smoking initiation probabilities increased with age during adolescence, peaked in the late teens, and then declined (Figure 1). Among females, initiation probabilities increased from the 1910 to the 1950 birth cohort, except for the API population, and have since decreased for more recent birth cohorts. Among males, initiation probabilities increased from the 1910 to the 1930 birth cohort, except for the Hispanic population, but have likewise declined by cohort. In terms of race/ethnicity, age-specific smoking initiation probabilities were generally highest among the AIAN population, followed by the NHW population, and were lowest among Hispanic and API populations. Initiation probabilities were higher among NHB than among Hispanic and API populations in earlier birth cohorts, but the differences were comparable across the 3 groups in recent birth cohorts. All groups had decreasing initiation by cohort, except for the female AIAN population, which showed increased initiation probabilities in the 1990 birth cohort, the most recent cohort displayed.
      Figure 1
      Figure 1Age-specific smoking initiation probabilities for selected birth cohorts by race/ethnicity and gender (females, top panels; males, bottom panels). Note: Lines represent the initiation probabilities for NHW (red), NHB (orange), Hispanic (sky blue), API (blue), and AIAN (black) populations. An interactive version of this figure's data can be found at http://apps.cisnetsmokingparameters.org/race/. AIAN, American Indian and Alaskan Native; API, Asian and Pacific Islander; NHB, non-Hispanic Black; NHW, non-Hispanic White.
      Figure 2 shows age-specific smoking-cessation probabilities for each racial/ethnic group and gender combination for selected birth cohorts (1910, 1930, 1950, 1970, 1990). Figures showing the patterns for additional cohorts by calendar year are available in the Appendix (Appendix Figure 2, available online). Smoking-cessation probabilities generally increased with age and birth cohort (Figure 2). In terms of race/ethnicity, cessation probabilities were lowest among the NHB population and highest among NHW, Hispanic, and API populations. In general, although cessation rates increased by cohort across racial/ethnic groups, the differences in cessation probabilities between the groups with the highest and lowest rates widened in recent cohorts, particularly at younger ages. Of note, cessation probabilities among all other race/ethnic groups have increased relative to those among the NHB population.
      Figure 2
      Figure 2Age-specific smoking-cessation probabilities for selected birth cohorts by race/ethnicity and gender (females, top panels; males, bottom panels). Note: Lines represent the cessation probabilities for NHW (red), NHB (orange), Hispanic (sky blue), API (blue), and AIAN (black) populations. An interactive version of this figure's data can be found at http://apps.cisnetsmokingparameters.org/race/. AIAN, American Indian and Alaskan Native; API, Asian and Pacific Islander; NHB, non-Hispanic Black; NHW, non-Hispanic White.
      Current smoking prevalence is derived from the smoking initiation and cessation probabilities mentioned earlier, yielding patterns of smoking prevalence by age, birth cohort, year, gender, and race/ethnicity. Figure 3 shows age-specific current smoking prevalence for each racial/ethnic group and gender combination for selected birth cohorts (1910, 1930, 1950, 1970, 1990). Figures showing the patterns for additional cohorts by calendar year are shown in Appendix Figure 3 (available online). Among males, current smoking prevalence decreased by birth cohort since the birth cohort of 1930, but among females, prevalence increased until the 1950 birth cohort and then decreased. In terms of race/ethnicity, current smoking prevalence was generally highest across ages and cohorts among the AIAN population and lowest among Hispanic and API populations. The relatively high smoking prevalence among the AIAN population was driven by higher initiation probabilities and relatively low cessation probabilities. Smoking prevalence among the NHB population, particularly in males, was lower at younger ages but higher at older ages than among the NHW population. These differences result from the lower initiation and cessation probabilities for the NHB population than those for the NHW population.
      Figure 3
      Figure 3Age-specific smoking prevalence (percentage) for selected birth cohorts by race/ethnicity and gender (females, top panels; males, bottom panels). Note: Lines represent the smoking prevalence for NHW (red), NHB (orange), Hispanic (sky blue), API (blue), and AIAN (black) populations. An interactive version of this figure's data can be found at http://apps.cisnetsmokingparameters.org/race/. AIAN, American Indian and Alaskan Native; API, Asian and Pacific Islander; NHB, non-Hispanic Black; NHW, non-Hispanic White.
      Figure 4 shows age-specific mean CPD consumed by smokers for each racial/ethnic group and gender combination for selected birth cohorts (1910, 1930, 1950, 1970, 1990). Figures showing the patterns for additional cohorts by calendar year are shown in Appendix Figure 4 (available online). Age-specific mean CPD among current smokers decreased since the 1930 birth cohort. In terms of age, for older birth cohorts, the mean CPD increased until about age 50 years and then decreased. However, for recent birth cohorts, the mean CPD has been relatively constant or decreasing with age, with no clear peak. In terms of race/ethnicity, the NHW population had the highest mean CPD for both males and females followed by the AIAN and the NHB populations. The Hispanic and API populations had the lowest mean CPD across birth cohorts.
      Figure 4
      Figure 4Age-specific mean cigarettes per day among current smokers for selected birth cohorts by race/ethnicity and gender (females, top panels; males, bottom panels). Note: Lines represent the mean cigarettes per day for NHW (red), NHB (orange), Hispanic (sky blue), API (blue), and AIAN (black) populations. An interactive version of this figure's data can be found at http://apps.cisnetsmokingparameters.org/race/. AIAN, American Indian and Alaskan Native; API, Asian and Pacific Islander; NHB, non-Hispanic Black; NHW, non-Hispanic White.
      Appendix Figure 5 (available online) shows the mean cumulative years of smoking (duration), and Appendix Figure 6 (available online) shows the mean cumulative pack years for selected birth cohorts by race/ethnicity and gender. Across all cohorts, the AIAN female population had the longest smoking duration, followed by the NHW and NHB populations. Among males, smoking duration was similar in the earlier cohorts across groups, except for API, which had a lower smoking duration; however, in later cohorts, AIAN had the longest smoking durations. The NHW and AIAN populations both had the highest levels of pack years, consistent with their higher mean CPD and duration.

      DISCUSSION

      Age- and cohort-specific smoking prevalence and annual probabilities of smoking initiation, cessation, and intensity by gender were estimated for 5 U.S. racial/ethnic groups using historical cross-sectional, nationally representative data. This is the first study to estimate cohort-specific smoking patterns for racial/ethnic subgroups, including the API and AIAN populations. The age‒period‒cohort modeling approach by Holford et al.
      • Holford TR
      • Levy DT
      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
      was applied, which was previously used for analyses of the U.S. population,
      • Jeon J
      • Holford TR
      • Levy DT
      • et al.
      Smoking and lung cancer mortality in the United States from 2015 to 2065: a comparative modeling approach.
      ,
      • Holford TR
      • Levy DT
      • McKay LA
      • et al.
      Patterns of birth cohort-specific smoking histories, 1965-2009.
      the U.S. White and Black populations,
      • 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.
      and the Canadian population.
      • Manuel DG
      • Wilton AS
      • Bennett C
      • Rohit Dass A
      • Laporte A
      • Holford TR
      Smoking patterns based on birth-cohort-specific histories from 1965 to 2013, with projections to 2041.
      The results show important variations in smoking initiation and cessation probabilities by race/ethnicity that shape the differences in age-specific smoking prevalence by calendar year and birth cohort.
      This study's results indicate large reductions in initiation and increases in cessation among recent cohorts for all racial/ethnic groups. However, disparities in all smoking indicators across racial/ethnic groups remain and, in some cases, are even widening by birth cohort. Consequently, racial/ethnic disparities in smoking will likely persist as recent cohorts age, unless efforts are made to further reduce smoking in high-prevalence groups. Across cohorts, the AIAN population consistently had the highest smoking prevalence and initiation probabilities and duration of smoking and pack years and the lowest cessation probabilities. Relatively low cessation probabilities among the NHB population have led to higher prevalence at older ages than among the NHW population, especially for males. NHW and AIAN individuals who currently smoke had higher smoking intensities (CPD), which persisted across birth cohorts. These findings highlight the need for targeted tobacco control interventions for AIAN and NHB populations, such as developing culturally appropriate cessation programs for AIAN populations
      • Santiago-Torres M
      • Mull KE
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      • et al.
      Efficacy and utilization of smartphone applications for smoking cessation among American Indians and Alaska natives: results from the iCanQuit Trial.
      or banning menthol cigarettes and flavored cigars, which have been used to target the NHB population by the tobacco industry.
      National Center for Chronic Disease Prevention Health Promotion (U.S.)
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      Much of the improvement in observed smoking indicators across cohorts reflects the impact of tobacco control policy progress since the 1960s.
      National Center for Chronic Disease Prevention Health Promotion (U.S.)
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      ,
      • Holford TR
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      However, the health gains have not been uniformly distributed across sociodemographic subgroups. In particular, the persistently higher smoking initiation, prevalence, and intensity and lower smoking cessation in the AIAN population can be explained by a variety of factors, including targeting by the tobacco industry, lack of strong tobacco control policies and low tobacco taxes in tribal lands, the use of commercial tobacco for traditional practices, and the relatively disadvantaged state of the AIAN population with lower SES and higher rates of substance use, which correlate with higher smoking prevalence, than in other racial/ethnic groups.
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      • Santiago-Torres M
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      ,
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      Advancing smoke-free policy adoption on the Navajo Nation.

      Next legends campaign. Food and Drug Administration. https://www.fda.gov/tobacco-products/public-health-education-campaigns/next-legends-campaign. Updated June 8, 2022. Accessed October 17, 2022.

      Indian Health Service
      IHS announces new mobile messaging tool to help people who want to quit commercial tobacco use.

      About the National Native Network. Keep It Sacred. https://keepitsacred.itcmi.org/. Updated October 14, 2022. Accessed October 17, 2022.

      These efforts should distinguish commercial tobacco from traditional tobacco, which has cultural and spiritual importance to AIAN communities.

      Traditional tobacco use. Keep it Sacred. https://keepitsacred.itcmi.org/tobacco-and-tradition/traditional-tobacco-use/. Accessed October 17, 2022.

      Many studies have examined patterns and trends in smoking prevalence, initiation, and cessation by race/ethnicity,
      National Center for Chronic Disease Prevention Health Promotion (U.S.)
      Office on Smoking and Health. The health consequences of smoking-50 years of progress: a report of the Surgeon General.
      ,
      NIH, U.S
      National Cancer Institute. A socioecological approach to addressing tobacco-related health disparities.
      ,
      • Odani S
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      Prevalence and disparities in tobacco product use among American Indians/Alaska natives – United States, 2010-2015.
      ,
      • Sakuma KK
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      Racial/ethnic disparities across indicators of cigarette smoking in the era of increased tobacco control, 1992-2019.
      • Pérez A
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      Age at initiation of cigarette use in a nationally representative sample of U.S. youth, 2013–2017 [published correction appears in JAMA Netw Open. 2021;4(4):e2110182].
      • Escobedo LG
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      • Remington PL
      • Mast EE.
      Sociodemographic characteristics of cigarette smoking initiation in the United States. Implications for smoking prevention policy.
      but few have focused on variations by cohort in age-specific smoking behaviors. In a previous study, smoking patterns were compared between Black and White cohorts in the U.S. using NHIS data from 1965 to 2012.
      • 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.
      This study updates these estimates by including data through 2018 and disaggregating the Hispanic population as a separate group given their known differences in smoking patterns with NHW and NHB populations.
      National Center for Chronic Disease Prevention Health Promotion (U.S.)
      Office on Smoking and Health. The health consequences of smoking-50 years of progress: a report of the Surgeon General.
      ,
      NIH, U.S
      National Cancer Institute. A socioecological approach to addressing tobacco-related health disparities.
      This study also updates smoking cohort patterns for the Hispanic population. Escobedo and colleagues
      • Escobedo LG
      • Remington PL.
      Birth cohort analysis of prevalence of cigarette smoking among Hispanics in the United States.
      previously analyzed birth cohort patterns in smoking prevalence among Mexican‒Americans, Cuban‒Americans, and Puerto Rican‒Americans using data from the 1982–1983 Hispanic Health and Nutrition Examination Survey. They found that smoking prevalence decreased by birth cohort in males for all Hispanic groups but that the prevalence increased among successive cohorts of Cuban‒American and Puerto‒Rican females. This study updated these analyses and found that smoking prevalence is now also decreasing by cohort among Hispanic females. However, specific Hispanic populations were not analyzed independently. In a subsequent study, Escobedo et al.
      • Escobedo LG
      • Remington PL
      • Anda RF.
      Long-term secular trends in initiation of cigarette smoking among Hispanics in the United States.
      evaluated trends in smoking prevalence at ages 20–24 years as a proxy for smoking initiation. They found differences in initiation rates between Hispanic subgroups, with some having higher rates than NHW individuals in earlier cohorts. However, the rates of initiation generally either declined or leveled off for more recent Hispanic cohorts relative to those for the White population. This updated analysis found that initiation and prevalence remain lower for the Hispanic than the NHW population in recent cohorts.
      A strength of this study is the use of historical NHIS data, a nationally representative survey of the U.S. civilian, non-institutionalized population providing data by race and ethnicity consistently since 1978. The timespan and resolution of the NHIS enabled us to produce detailed age, gender, and cohort-specific smoking patterns for different racial/ethnic groups, including API and AIAN populations who are often missing or aggregated in other analyses owing to small sample sizes. Another strength is the use of a methodology that incorporates cohort as well as age and period trends in smoking initiation and cessation probabilities. These probabilities are estimated jointly with ever, never, current, and former smoking prevalence, thereby ensuring that the resulting estimates are consistent across smoking outcomes. This critical feature guarantees that the estimates can be readily used to parameterize simulation models of smoking trends and generate smoking patterns representative of the studied populations.
      The results highlight the importance of cohort variations when comparing trends in smoking behaviors between different sociodemographic groups. Cohort-based analyses are needed to understand the consequences of the varying tobacco market, tobacco control policy, cessation treatment environments, and other social and environmental factors experienced by different generations. Ignoring cohort patterns could result in misinterpretation of trends and in erroneous projections of future smoking. However, analyses such as this study require a large amount of data from multiple nationally representative surveys covering many years. The long-term surveillance of tobacco-use behaviors across different sociodemographic groups requires continued support for multiple national health surveys, improving and maintaining survey response rates, and limiting changes in survey design and structure to ensure consistent tobacco product measures over time. Although this study did not examine social determinants of health or other structural factors that could influence smoking in the groups analyzed, its findings and parameter estimates can inform future work investigating the causal effects of these contextual factors.
      Simulation models of tobacco use have become important tools to assess the impact of past and potential tobacco control policies and regulations.
      • Jeon J
      • Holford TR
      • Levy DT
      • et al.
      Smoking and lung cancer mortality in the United States from 2015 to 2065: a comparative modeling approach.
      ,
      • Levy DT
      • Tam J
      • Sanchez-Romero LM
      • et al.
      Public health implications of vaping in the USA: the smoking and vaping simulation model.
      ,
      • Levy DT
      • Meza R
      • Yuan Z
      • et al.
      Public health impact of a US ban on menthol in cigarettes and cigars: a simulation study.
      • Tam J
      • Jeon J
      • Thrasher JF
      • et al.
      Estimated prevalence of smoking and smoking-attributable mortality associated with graphic health warnings on cigarette packages in the US from 2022 to 2100.
      • Tam J
      • Taylor GMJ
      • Zivin K
      • Warner KE
      • Meza R.
      Modeling smoking-attributable mortality among adults with major depression in the United States.
      • Tam J
      • Levy DT
      • Jeon J
      • et al.
      Projecting the effects of tobacco control policies in the USA through microsimulation: a study protocol.
      ,
      • Holford TR
      • Meza R
      • Warner KE
      • et al.
      Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964-2012.
      • Mendez D
      • Le TTT.
      Consequences of a match made in hell: the harm caused by menthol smoking to the African American population over 1980–2018.
      • Le TT
      • Mendez D.
      An estimation of the harm of menthol cigarettes in the United States from 1980 to 2018.
      • Apelberg BJ
      • Feirman SP
      • Salazar E
      • et al.
      Potential public health effects of reducing nicotine levels in cigarettes in the United States.
      ,
      • Moolgavkar SH
      • Holford TR
      • Levy DT
      • et al.
      Impact of reduced tobacco smoking on lung cancer mortality in the United States during 1975-2000.
      ,
      • Warner KE
      • Mendez D.
      How much of the future mortality toll of smoking can be avoided?.
      • Levy DT
      • Chaloupka F
      • Gitchell J
      • Mendez D
      • Warner KE.
      The use of simulation models for the surveillance, justification and understanding of tobacco control policies.
      • Vugrin ED
      • Rostron BL
      • Verzi SJ
      • et al.
      Modeling the potential effects of new tobacco products and policies: a dynamic population model for multiple product use and harm.
      However, the failure of most available models to consider race/ethnicity is a major gap because policies have differential effects by race/ethnicity, which may result in widening health disparities.
      • Colston DC
      • Xie Y
      • Thrasher JF
      • et al.
      Examining truth and state-sponsored media campaigns as a means of decreasing youth smoking and related disparities in the United States.
      • Titus AR
      • Xie Y
      • Colston DC
      • et al.
      Smoke-free laws and disparities in youth smoking in the U.S., 2001–2018.
      • Fleischer NL
      • Donahoe JT
      • McLeod MC
      • et al.
      Taxation reduces smoking but may not reduce smoking disparities in youth.
      A major challenge to the development of simulation models by sociodemographic group is the lack of data to inform these models, particularly group-specific estimates of smoking initiation and cessation, smoking intensity, absolute and RRs of smoking-related morbidity and mortality, and policy effect sizes. This study estimates aim to address some of these gaps, thereby facilitating the development of simulation models by racial/ethnic status. Preliminary versions of the estimated smoking initiation and cessation probabilities have already been incorporated in a model of smoking and health outcomes from menthol cigarettes among Black populations in the U.S.
      • Mendez D
      • Le TTT.
      Consequences of a match made in hell: the harm caused by menthol smoking to the African American population over 1980–2018.
      The observed differences in smoking intensity and duration by race/ethnicity have implications for the burden of tobacco-related diseases across groups; the risk of lung cancer, other tobacco-related cancers, and chronic obstructive pulmonary disease are known to increase with higher cumulative exposures.
      National Center for Chronic Disease Prevention Health Promotion (U.S.)
      Office on Smoking and Health. The health consequences of smoking-50 years of progress: a report of the Surgeon General.
      ,
      • Tammemagi CM
      • Pinsky PF
      • Caporaso NE
      • et al.
      Lung cancer risk prediction: prostate, lung, colorectal and ovarian cancer screening trial models and validation.
      ,
      • Chang JT
      • Meza R
      • Levy DT
      • Arenberg D
      • Jeon J.
      Prediction of COPD risk accounting for time-varying smoking exposures.
      • Rachet B
      • Siemiatycki J
      • Abrahamowicz M
      • Leffondré K.
      A flexible modeling approach to estimating the component effects of smoking behavior on lung cancer.
      • Di Credico G
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      • et al.
      Joint effects of intensity and duration of cigarette smoking on the risk of head and neck cancer: a bivariate spline model approach.
      The relatively high smoking duration among NHW, NHB, and AIAN populations and high pack years among NHW and AIAN populations across cohorts at least partially explain their correspondingly high rates of smoking-related health conditions. Differences in smoking prevalence and intensity by sociodemographic groups also have implications for lung cancer screening eligibility.
      • Aldrich MC
      • Mercaldo SF
      • Sandler KL
      • Blot WJ
      • Grogan EL
      • Blume JD.
      Evaluation of USPSTF lung cancer screening guidelines among African American adult smokers.
      ,
      • Preventive Services Task Force U.S.
      • Krist AH
      • Davidson KW
      • et al.
      Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement.
      ,
      • Meza R
      • Jeon J
      • Toumazis I
      • et al.
      Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: modeling study for the U.S. Preventive Services Task Force.
      The U.S. Preventive Services Task Force currently recommends screening adults aged 50–80 years with at least 20 pack years of exposure and not >15 years since quitting.
      • Preventive Services Task Force U.S.
      • Krist AH
      • Davidson KW
      • et al.
      Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement.
      Major differences in smoking intensity and duration by race/ethnicity suggest that current racial/ethnic disparities in eligibility for screening
      • Aldrich MC
      • Mercaldo SF
      • Sandler KL
      • Blot WJ
      • Grogan EL
      • Blume JD.
      Evaluation of USPSTF lung cancer screening guidelines among African American adult smokers.
      ,
      • Preventive Services Task Force U.S.
      • Krist AH
      • Davidson KW
      • et al.
      Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement.
      ,
      • Meza R
      • Jeon J
      • Toumazis I
      • et al.
      Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: modeling study for the U.S. Preventive Services Task Force.
      will continue as newer cohorts reach the eligibility age.

      Limitations

      Limitations of the study include the use of self-reported data, which is subject to underreporting, particularly in more recent years when smoking became less socially accepted. Similarly, NHIS response rates have decreased in recent years,
      • Keyes KM
      • Rutherford C
      • Popham F
      • Martins SS
      • Gray L.
      How healthy are survey respondents compared with the general population?: using survey-linked death records to compare mortality outcomes.
      ,
      National Center for Health Statistics
      Centers for Disease Control and Prevention. National Health Interview Survey, 2019. Public-use data file and documentation.
      which could result in higher nonresponse bias among recent cohorts. The analysis also relies on self-reported retrospective data on the age of smoking initiation and cessation, which are subject to recall bias. However, these data are essential for analyzing earlier birth cohorts and are critical to understanding long-term use trends. The calibration process aimed to address this limitation (Appendix, available online).
      This study did not consider further variations within racial/ethnic subgroups. There are important differences in smoking patterns within Hispanic populations. In particular, Cuban-Americans and Puerto Ricans have a higher smoking prevalence than Mexican Americans.
      National Center for Chronic Disease Prevention Health Promotion (U.S.)
      Office on Smoking and Health. The health consequences of smoking-50 years of progress: a report of the Surgeon General.
      ,
      NIH, U.S
      National Cancer Institute. A socioecological approach to addressing tobacco-related health disparities.
      ,
      • Escobedo LG
      • Remington PL.
      Birth cohort analysis of prevalence of cigarette smoking among Hispanics in the United States.
      ,
      • Blanco L
      • Garcia R
      • Pérez-Stable EJ
      • et al.
      National trends in smoking behaviors among Mexican, Puerto Rican, and Cuban men and women in the United States.
      There is considerable heterogeneity in Asian American populations as well. For example, Filipino Americans have a considerably higher smoking prevalence than Asian Indians and Chinese Americans.
      • Rao M
      • Bar L
      • Yu Y
      • et al.
      Disaggregating Asian American cigarette and alternative tobacco product use: results from the National Health Interview Survey (NHIS) 2006-2018.
      Factors such as country of origin, level of acculturation, duration of U.S. residence, and other socioeconomic factors as well as temporal changes in the composition of the population because of in and out migration translate into important variations across race/ethnicity groups.
      NIH, U.S
      National Cancer Institute. A socioecological approach to addressing tobacco-related health disparities.
      ,
      • Gorman BK
      • Lariscy JT
      • Kaushik C.
      Gender, acculturation, and smoking behavior among U.S. Asian and Latino immigrants.
      ,
      • Mattingly DT
      • Hirschtick JL
      • Fleischer NL.
      Unpacking the non-Hispanic other category: differences in patterns of tobacco product use among youth and adults in the United States, 2009–2018.
      There are also important differences in the rates of commercial tobacco use and in ceremonial traditional tobacco practices across different AIAN subpopulations.

      Commercial tobacco use. Keep it Sacred. https://keepitsacred.itcmi.org/tobacco-and-tradition/commercial-tobacco/. Accessed October 17, 2022.

      Future study is warranted to disaggregate Asian, Hispanic, and AIAN groups. Individuals from other racial groups or who reported multiple races were not included in the analysis; however, these groups also constitute a small fraction of the whole sample. Although small sample sizes create challenges, leveraging data from multiple nationally representative surveys may enable analyses for smaller subpopulations.

      Holford TR, McKay L, Tam J, Jeon J, Levy DT, Meza R. State-specific temporal trends in cigarette smoking histories in the U.S., 1993-2018. Am J Prev Med. In press.

      Finally, although a comprehensive analysis of cohort patterns of cigarette smoking by race and ethnicity was conducted, these analyses did not consider other relevant nicotine delivery products, such as the use of E-cigarettes, cigars, and smokeless tobacco, which also vary by race and ethnicity and may affect cigarette smoking trends owing to substitution effects or dual use.
      National Center for Chronic Disease Prevention Health Promotion (U.S.)
      Office on Smoking and Health. The health consequences of smoking-50 years of progress: a report of the Surgeon General.
      ,
      NIH, U.S
      National Cancer Institute. A socioecological approach to addressing tobacco-related health disparities.
      ,
      • Hirschtick JL
      • Mattingly DT
      • Cho B
      • et al.
      Exclusive, dual, and polytobacco use among U.S. adults by sociodemographic factors: results from 3 nationally representative surveys.
      • Cho B
      • Hirschtick JL
      • Usidame B
      • et al.
      Sociodemographic patterns of exclusive, dual, and polytobacco use among U.S. High school students: a comparison of three nationally representative surveys.
      • Chang JT
      • Levy DT
      • Meza R.
      Examining the transitions between cigarette and smokeless tobacco product use in the United States using the 2002-2003 and 2010-2011 longitudinal cohorts.
      In addition, menthol and nonmenthol cigarette smoking were not distinguished in the analysis. Menthol smoking is known to be an important determinant of smoking initiation and cessation, with high rates of use among NHB populations.
      • Mattingly DT
      • Hirschtick JL
      • Meza R
      • Fleischer NL.
      Trends in prevalence and sociodemographic and geographic patterns of current menthol cigarette use among U.S. adults, 2005-2015.
      ,
      • Brouwer AF
      • Jeon J
      • Cook SF
      • et al.
      The impact of menthol cigarette flavor in the U.S.: cigarette and ENDS transitions by sociodemographic group.
      ,
      • Villanti AC
      • Johnson AL
      • Halenar MJ
      • et al.
      Menthol and mint cigarettes and cigars: initiation and progression in youth, young adults and adults in waves 1-4 of the PATH study, 2013-2017.

      CONCLUSIONS

      This study of smoking patterns by race/ethnicity in the U.S. identifies important differences not only in prevalence but also in cohort- and age-specific initiation and cessation probabilities and smoking intensity. These differences merit strong consideration in developing comprehensive tobacco control strategies, especially those that aim to address tobacco-related health disparities. Among the groups analyzed, the AIAN population remains the group with the highest smoking prevalence and initiation and the lowest cessation probabilities and should therefore be prioritized for targeted policy intervention. Similarly, the NHB population's lower cessation rates translate into longer durations and higher prevalence at older ages, emphasizing the need for policies that promote their smoking cessation.

      CREDIT AUTHOR STATEMENT

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

      ACKNOWLEDGMENTS

      The study sponsor 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.

      Appendix. SUPPLEMENTAL MATERIAL

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