Using the Past to Understand the Future of U.S. and Global Smoking Disparities: A Birth Cohort Perspective

Abstract

U.S. smoking-related disparities persist, but data evaluating how smoking patterns across diverse populations have changed by birth cohort are lacking. Worldwide, smoking continues to exact harm, especially to low- and middle-income nations with less historical data for smoking analyses. The Cancer Intervention and Surveillance Modeling Network Lung Working Group previously generated smoking histories for the whole U.S. population using an age, period, and birth cohort methodologic framework. These inputs have been used in numerous models to simulate future patterns of smoking and to evaluate the potential impact of policies. However, the absence of detailed model-ready inputs on smoking behaviors for diverse U.S. populations has been a barrier to research evaluating future trends in smoking-related disparities or the projected impacts of policies across sociodemographic groups. This supplement issue provides new estimates of smoking behaviors with detailed historical data by race/ethnicity, by educational attainment, by family income, and for each of the 50 U.S. states and Washington, District of Columbia. All-cause mortality RRs associated with smoking by race/ethnicity and educational attainment are also available for the first time. Finally, the supplement issue presents comprehensive smoking histories for Brazil, showing the application of this methodology to resource-limited settings. Collectively, these data aim to offer insight into future U.S. and global smoking disparities and accelerate research on tobacco control policies that advance health equity. This effort will allow tobacco simulation models to account comprehensively for population diversity, thereby enabling researchers to develop more sophisticated analyses of tobacco use and control interventions. Since the publication of the first Surgeon General's Report on Smoking and Health in 1964,1U.S. Department of Health Education and Welfare. Smoking and health: report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: U.S. Department of Health, Education, and Welfare, Public Health Service. https://www.govinfo.gov/app/details/GPO-SMOKINGANDHEALTH. Published 1964. Accessed October 21, 2022.Google Scholar the U.S. has benefited from major improvements to health and life expectancy, partly owing to decades of progress in tobacco prevention and control that drastically reduced smoking and consequently smoking-related morbidity and mortality in the population.2Holford TR Meza R Warner KE et al.Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964–2012.JAMA. 2014; 311: 164-171https://doi.org/10.1001/jama.2013.285112Crossref PubMed Scopus (203) Google Scholar Social norms around smoking changed dramatically over this time period; as Americans grew to understand the harms of smoking and secondhand smoke exposure, many quit and quit in droves, and many fewer young people started to smoke.1U.S. Department of Health Education and Welfare. Smoking and health: report of the Advisory Committee to the Surgeon General of the Public Health Service. 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State of tobacco control 2022: 20 years proven policies to prevent and reduce tobacco use. Chicago, IL: American Lung Association. https://www.lung.org/getmedia/3c56576e-1be2-4408-a0f4-2dd7674fa32e/sotc-2022-final-report. Published 2022. Accessed September 2, 2022.Google Scholar Although targeted tobacco control interventions have been developed to address smoking disparities,21Drope J Liber AC Cahn Z et al.Who's still smoking? Disparities in adult cigarette smoking prevalence in the United States.CA Cancer J Clin. 2018; 68: 106-115https://doi.org/10.3322/caac.21444Crossref PubMed Scopus (201) Google Scholar including ‘Tips from Former Smokers’ campaigns tailored for racial/ethnic minorities and other priority populations,22Tips from former smokers: real stories. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/stories/index.html. Updated September 5, 2022. Accessed November 18, 2022.Google Scholar,23Kong G Singh N Krishnan-Sarin S. A review of culturally targeted/tailored tobacco prevention and cessation interventions for minority adolescents.Nicotine Tob Res. 2012; 14: 1394-1406https://doi.org/10.1093/ntr/nts118Crossref PubMed Scopus (34) Google Scholar their long-term impact on smoking disparities will need to be evaluated. How sociodemographic differences in cigarette smoking will unfold over the coming decades will depend on accurate information about smoking within and across populations and whether that information is used to inform policy and regulation. Cohort analyses are particularly crucial to understanding the smoking trajectories in U.S. populations. As each birth cohort comes of age, they face their own unique sociocultural and policy environments during key life stages relevant to smoking uptake (adolescence, young adulthood) and cessation (middle and older ages). For instance, an individual born in 1975 was surrounded by a different tobacco product and policy landscape and a different set of social norms surrounding smoking as a teenager during the 1990s from someone born in 1960 who would have been at peak smoking initiation ages during the 1970s and 1980s. Major events, policies, and social changes have defined the lives and influenced the behaviors of entire birth cohorts during the most significant ages of smoking initiation and cessation. Examples are disruptions caused by the 20th century's 2 world wars, during which cigarettes were provided to American soldiers as rations, inducing higher smoking initiation in certain birth cohorts24Bedard K Deschênes O. The long-term impact of military service on health: evidence from world war ii and korean war veterans.Am Econ Rev. 2006; 96: 176-194https://doi.org/10.1257/000282806776157731Crossref Scopus (127) Google Scholar; college education subsidies provided by the G.I. Bill to military veterans improved social mobility and decreased smoking among veterans who used them25Rumery ZR Patel N Richard P. The association between the use of the education benefits from the G.I. Bill and veterans’ health.Mil Med. 2018; 183: e241-e248https://doi.org/10.1093/milmed/usx102Crossref Scopus (3) Google Scholar; and the women's liberation movement whose feminist slogans were co-opted by Philip Morris to market Virginia Slim cigarettes to young women.12Toll BA Ling PM. The Virginia Slims identity crisis: an inside look at tobacco industry marketing to women.Tob Control. 2005; 14: 172-180https://doi.org/10.1136/tc.2004.008953Crossref PubMed Scopus (94) Google Scholar In more recent history, the National Truth campaign, launched in 2000 as a smoking prevention educational campaign, reduced smoking initiation among adolescents born in the 1980s.26Farrelly MC Nonnemaker J Davis KC Hussin A. The Influence of the National truth campaign on smoking initiation.Am J Prev Med. 2009; 36: 379-384https://doi.org/10.1016/j.amepre.2009.01.019Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar Without a cohort lens, researchers may attribute changes in smoking patterns to contemporaneous issues of a given period rather than acknowledging the impact of shifts in the lived experiences of different generations. To understand how public health interventions (or lack thereof) are impacting the smoking behaviors of newer generations, it is necessary to examine and compare changes by birth cohort or generation (e.g., people born in the 2000s versus people born in the 1980s). Researchers have studied smoking trajectories by birth cohort for the U.S. population (Figure 1),27Jeon J Holford TR Levy DT et al.Smoking and lung cancer mortality in the United States from 2015 to 2065: a comparative modeling approach.Ann Intern Med. 2018; 169: 684-693https://doi.org/10.7326/M18-1250Crossref PubMed Scopus (82) Google Scholar,28Holford TR Levy DT McKay LA et al.Patterns of birth cohort-specific smoking histories, 1965–2009.Am J Prev Med. 2014; 46: e31-e37https://doi.org/10.1016/j.amepre.2013.10.022Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar but the cohort perspective has been relatively absent from the smoking disparities literature. This literature has mostly documented trends in cross-sectional prevalence by period (calendar year), but such analyses combine information from multiple birth cohorts into a single metric, usually age-adjusted or crude prevalence, thereby masking trends as they vary across generations within specific subpopulations. Examining changes in prevalence and potential disparities by birth cohort, within advantaged and disadvantaged groups, offers a more accurate assessment. In addition, trend analyses of a specific subpopulation (e.g., people of low SES) by period implicitly assume homogeneity across birth cohorts. Therefore, disaggregating the population by birth cohort provides a more comprehensive view—one that better reflects societal changes. For instance, much larger proportions of recent generations have completed college degrees than those born earlier, reflecting the integration of women and racial/ethnic minorities in higher education institutions as well as changing expectations for future employment.29CPS historical time series tables. U.S. Census Bureau. https://www.census.gov/data/tables/time-series/demo/educational-attainment/cps-historical-time-series.html. Updated February 24, 2022. Accessed November 16, 2022.Google Scholar Thus, the 1950 birth cohort of people with a college education has a substantially different demographic profile from that of the 1990 birth cohort with college degrees. Because college education is often completed earlier in life, this characteristic is then carried forward, affecting the educational mix in future years. Other broader demographic developments over time, such as patterns of immigration,30U.S. Immigration trends. Migration Policy Institute. https://www.migrationpolicy.org/programs/data-hub/us-immigration-trends. Updated December 23, 2022. Accessed January 6, 2023.Google Scholar combined with differences in birth rates31Health, United States, 2020–2021: birthsCenters for Disease Control and Prevention. 2022; (Updated August 12, 2022. Accessed October 3.)https://www.cdc.gov/nchs/hus/topics/births.htmGoogle Scholar mean that among U.S. births, larger shares have come from Hispanic women, reflecting the rising proportion of Hispanics in the overall population. This translates into recent birth cohorts being more comprised Hispanics than older birth cohorts.32Krogstad JM, Passel JS, Noe-Bustamante L. Key facts about U.S. Latinos for national Hispanic heritage month. Washington, DC: Pew Research Center.https://www.pewresearch.org/fact-tank/2022/09/23/key-facts-about-u-s-latinos-for-national-hispanic-heritage-month/. Published September 23, 2022. Accessed October 3, 2022.Google Scholar Therefore, the cohort perspective facilitates trend analysis of smoking by sociodemographic groups that may be changing in size and composition. Most reports analyze data and trends in smoking prevalence—the main metric used to evaluate smoking progress in the population and the primary point of comparison between advantaged and disadvantaged groups. However, overall smoking prevalence is a function of multiple underlying drivers at the individual level. To reconstruct individual-level smoking histories across the population, information is needed regarding who started smoking (ever use) and when (initiation), who is smoking now (current use), how long people who smoke continue to do so (duration), the intensity with which they smoke (cigarettes per day), and who quit (former use) and when (cessation). These behavioral components represent different points for intervention and metrics of progress and collectively shape disparities in smoking prevalence across populations and across time and age. For example, similar overall smoking prevalence estimates for White and Black Americans may mask key differences: Black Americans start smoking at older ages than Whites but have less success with quitting.33Holford TR Levy DT Meza R. Comparison of smoking history patterns among African American and White cohorts in the United States born 1890 to 1990.Nicotine Tob Res. 2016; 18: S16-S29https://doi.org/10.1093/ntr/ntv274Crossref PubMed Scopus (65) Google Scholar Therefore, Black Americans tend to have longer smoking duration and thus a higher risk of lung cancer.33Holford TR Levy DT Meza R. 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The Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Working Group has previously constructed age, period, and birth cohort (APC) models for the whole U.S. population's smoking history using data from the 1965–2018 National Health Interview Surveys.27Jeon J Holford TR Levy DT et al.Smoking and lung cancer mortality in the United States from 2015 to 2065: a comparative modeling approach.Ann Intern Med. 2018; 169: 684-693https://doi.org/10.7326/M18-1250Crossref PubMed Scopus (82) Google Scholar,28Holford TR Levy DT McKay LA et al.Patterns of birth cohort-specific smoking histories, 1965–2009.Am J Prev Med. 2014; 46: e31-e37https://doi.org/10.1016/j.amepre.2013.10.022Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar These analyses generated estimates of the distribution of individual-level parameters for smoking initiation; cigarettes smoked per day; and smoking cessation by age, gender, and birth cohort, starting with the generation born in 1890. Collectively, these parameters are validated by reproducing observed trends in smoking prevalence in the U.S. population. These estimates are internally consistent, forming a comprehensive picture of the smoking experience for specific groups. For example, Figure 1 presents smoking prevalence by birth cohort for the entire U.S. population generated by the CISNET Lung Working Group. The APC approach can be applied across different sociodemographic groups, thereby facilitating comparisons of smoking patterns across groups accounting for age, period, and cohort differences. This process allows historical comparisons of the specific smoking metrics by race/ethnicity, SES, and geographic location, thereby providing a more complete picture of the components affecting past and present smoking disparities. Research in this arena could help to further develop strategies that aim to achieve tobacco and health equity but have yet to achieve their full potential. The CISNET smoking history parameters are age and cohort specific and the statistical distribution of individual-level inputs that have been leveraged to make projections about future smoking trends for the population as a whole (Figure 2). 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