Smoking Disparities by Level of Educational Attainment and Birth Cohort in the U.S.

INTRODUCTION: Little is known about how U.S. smoking patterns of initiation, cessation, and intensity vary by birth cohort across education levels or how these patterns may be driven by other demographic characteristics. METHODS: Smoking data for adults aged ≥25 years was obtained from the National Health Interview Surveys 1966–2018. Age-period-cohort models were developed to estimate the probabilities of smoking initiation, cessation, intensity, and prevalence by age, cohort, calendar year, and gender for education levels: ≤8th grade, 9th–11th grade, high school graduate or GED, some college, and college degree or above. Further analyses were conducted to identify the demographic factors (race/ethnicity and birthplace) that may explain the smoking patterns by education. Analyses were conducted in 2020–2021. RESULTS: Smoking disparities by education have increased by birth cohort. In recent cohorts, initiation probabilities were highest among individuals with 9th–11th-grade education and lowest among individuals with at least a college degree. Cessation probabilities were higher among those with higher education. Current smoking prevalence decreased over time across all education groups, with important differences by gender. However, it decreased more rapidly among individuals with ≤8th grade education, resulting in this group having the second lowest prevalence in recent cohorts. This may be driven by the increasing proportion of non-U.S. born Hispanics in this group. CONCLUSIONS: Although smoking is decreasing by cohort across all education groups, disparities in smoking behaviors by education have widened in recent cohorts. Demographic changes for the ≤8th-grade education group need special consideration in analyses of tobacco use by education.