Understanding the Sources of Subnational Disparities in Cigarette Smoking Prevalence: Findings From a Multi-State Rapid-Response Survey in the U.S., 2023–2024

INTRODUCTION: Cigarette smoking prevalence among U.S. adults varies widely across states. This study examines major sociodemographic and economic factors underlying subnational smoking disparities. METHODS: Data were from a rapid-response online survey of a probability sample of 12,300 adults (aged ≥18 years) in 13 high-tobacco-burden states (Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, South Carolina, Tennessee, and West Virginia) and 4 low-tobacco-burden comparison states (California, Illinois, Maryland, and Virginia), conducted in 2023 and 2024 and analyzed in 2024. Threefold Oaxaca-Blinder linear decomposition analysis was used to identify sources of disparities in cigarette smoking prevalence between high- and low-tobacco-burden states. RESULTS: Differences in smoking propensities by population characteristics (population composition held constant) accounted for 56.7% of the subnational disparity in smoking prevalence. This was largely driven by higher smoking prevalence in high-tobacco-burden states among older adults (aged 40-65 years) and individuals with less than a high-school education. Convergence of smoking prevalence of college graduates and those aged 18-20 years partially offset the difference. Variation in population composition (smoking propensities held constant) contributed 22.9% of the difference, driven by larger proportions of individuals in the group with less than college education in high-tobacco-burden states with significantly higher smoking rates. The residual 20.4% was attributable to unmeasured macrolevel differences simultaneously affecting individual smoking propensities and population composition by educational status. CONCLUSIONS: The mitigation of subnational smoking disparities requires concerted tobacco control efforts tailored to smoking cessation among older adults and persons with less than college education and population-level advancement in educational attainment.