Rural–Urban Disparities in Perinatal Smoking in the United States: Trends and Determinants
Abstract
1. Introduction
2. Methods
2.1. Study Design and Setting
2.2. Sample
2.3. Measures
2.3.1. Cigarette Smoking and Cessation
2.3.2. Rural vs. Urban
2.3.3. Social Determinants of Health (SDOH) Factors
2.4. Statistical Analysis
3. Results
3.1. Participant Characteristics
3.2. Trends in the Prevalence of Perinatal Smoking Behavior by Rural–Urban Residence
3.3. Explaining the Association Between Perinatal Smoking Behaviors and Rural–Urban Residence
4. Discussion
4.1. Limitations
4.2. Implications and Future Directions
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Variable | Category | Unweighted N | Overall % a (95% CI) | Urban % a (95% CI) | Rural % a (95% CI) |
---|---|---|---|---|---|
Smoking status | |||||
Before pregnancy | Yes | 39,441 | 15.5 (15.2–15.7) | 13.7 (13.5–14.0) | 24.9 (24.2–25.6) |
During pregnancy | Yes | 19,280 | 7.1 (6.9–7.3) | 5.9 (5.7–6.0) | 13.8 (13.2–14.4) |
After pregnancy | Yes | 26,358 | 10.0 (9.8–10.2) | 8.6 (8.4–8.8) | 17.6 (17.0–18.3) |
Persistent | Yes | 17,367 | 6.4 (6.2–6.5) | 5.2 (5.1–5.4) | 12.6 (12.1–13.1) |
Cessation | Yes | 20,326 | 54.6 (53.7–55.4) | 57.8 (56.8–58.7) | 44.9 (43.2–46.5) |
Maternal age (yrs.) | <20 | 10,330 | 4.2 (4.1–4.3) | 3.8 (3.7–4.0) | 6.3 (6.0–6.7) |
20–24 | 41,169 | 18.0 (17.8–18.3) | 16.6 (16.4–16.9) | 25.7 (25.0–26.4) | |
25–29 | 66,363 | 28.7 (28.4–29.0) | 28.0 (27.7–28.4) | 32.6 (31.9–33.4) | |
30–34 | 69,641 | 30.0 (29.8–30.3) | 31.3 (30.9–31.6) | 23.3 (22.7–24.0) | |
≥35 | 44,896 | 19.0 (18.7–19.2) | 20.3 (20.0–20.5) | 12.1 (11.6–12.5) | |
Missing | 9 | 0.0 (0.0–0.0) | 0.0 (0.0–0.0) | 0.0 (0.0–0.0) | |
Race/Ethnicity | White | 104,681 | 56.7 (56.4–57.0) | 53.6 (53.3–53.9) | 73.9 (73.2–74.5) |
Black | 41,396 | 15.0 (14.8–15.2) | 16.2 (16.0–16.5) | 8.1 (7.6–8.5) | |
Hispanic | 40,954 | 18.0 (17.8–18.2) | 19.4 (19.1–19.7) | 10.3 (9.9–10.8) | |
Other b | 39,179 | 9.4 (9.3–9.6) | 10.0 (9.8–10.2) | 6.5 (6.1–6.7) | |
Missing | 6198 | 0.9 (0.8–0.9) | 0.8 (0.7–0.8) | 1.3 (1.3–1.4) | |
Marital status | Married | 139,066 | 61.7 (61.4–62.0) | 62.5 (62.2–62.8) | 57.2 (56.4–58.0) |
other | 93,156 | 38.3 (38.0–38.6) | 37.4 (37.1–37.8) | 42.7 (41.9–43.5) | |
Missing | 186 | 0.1 (0.0–0.1) | 0.0 (0.0–0.1) | 0.1 (0.1–0.2) | |
Education (yrs) | <12 | 27,944 | 11.6 (11.4–11.8) | 11.1 (10.9–11.3) | 14.1 (13.6–14.7) |
12 | 55,825 | 24.6 (24.3–24.9) | 23.4 (23.0–23.7) | 31.6 (30.9–32.4) | |
>12 | 146,638 | 63.0 (62.7–63.3) | 64.7 (64.3–65.0) | 53.8 (53.0–54.6) | |
Missing | 2001 | 0.8 (0.8–0.9) | 0.9 (0.8–0.9) | 0.5 (0.4–0.6) | |
Household income (US$) | ≤$24,000 | 70,727 | 28.4 (28.1–28.7) | 27.0 (26.7–27.4) | 35.7 (35.0–36.5) |
$24,001–60,000 | 60,649 | 25.6 (25.3–25.9) | 24.6 (24.3–24.9) | 31.0 (30.3–31.7) | |
>$60,001 | 79,183 | 37.0 (36.6–37.2) | 39.0 (38.7–39.4) | 25.4 (24.7–26.0) | |
Missing | 21,849 | 9.1 (8.9–9.3) | 9.3 (9.1–9.5) | 7.9 (7.5–8.4) | |
Received WIC | Yes | 83,337 | 33.6 (33.3–33.9) | 31.9 (31.5–32.2) | 43.4 (42.6–44.1) |
No | 145,727 | 65.0 (64.7–65.3) | 66.7 (66.4–67.1) | 55.7 (54.9–56.5) | |
Missing | 3344 | 1.3 (1.3–1.3) | 1.4 (1.3–1.5) | 0.9 (0.8–1.1) | |
Parity | 0 | 90,641 | 38.8 (38.5–39.2) | 39.4 (39.0–39.7) | 35.9 (35.2–36.7) |
1 | 72,802 | 32.8 (32.5–33.1) | 33.0 (32.7–33.3) | 31.5 (30.8–32.2) | |
2 | 38,356 | 16.5 (16.2–16.7) | 16.1 (15.9–16.4) | 18.1 (17.5–18.7) | |
≥3 | 30,173 | 11.8 (11.5–12.0) | 11.3 (11.1–11.5) | 14.3 (13.8–14.9) | |
Missing | 436 | 0.2 (0.2–0.2) | 0.2 (0.2–0.2) | 0.1 (0.1–0.2) | |
Pregnancy intention | Planned | 99,561 | 44.9 (44.4–44.4) | 44.4 (44.1–44.8) | 42.1 (41.4–42.9) |
Mistimed | 76,229 | 33.0 (32.7–33.4) | 33.2 (32.9–33.6) | 32.1 (31.3–32.8) | |
Unsure | 52,934 | 21.3 (21.0–21.6) | 20.8 (20.5–21.0) | 24.4 (23.7–25.1) | |
Missing | 3684 | 1.6 (1.5–1.7) | 1.6 (1.5–1.7) | 1.4 (1.3–1.6) | |
Prenatal depression | Yes | 160,357 | 85.2 (85.0–85.4) | 86.0 (85.7–86.2) | 80.8 (80.2–81.5) |
No | 22,997 | 13.8 (13.6–14.0) | 13.0 (12.8–13.2) | 18.3 (17.7–19.0) | |
Missing | 2437 | 1.0 (0.9–1.1) | 1.0 (1.0–1.1) | 0.8 (0.7–1.0) | |
Perinatal stressors c | No | 222,777 | 96.4 (96.3–96.5) | 96.7 (96.5–96.8) | 95.0 (94.6–95.3) |
Yes | 9631 | 3.6 (3.5–3.7) | 3.3 (3.2–3.5) | 5.0 (4.7–5.4) | |
Region | Midwest | 59,428 | 25.1 (25.0–25.2) | 23.3 (23.2–23.4) | 35.1 (34.5–35.8) |
Northeast | 58,871 | 26.2 (26.2–26.3) | 28.9 (28.7–29.0) | 11.8 (11.3–12.4) | |
South | 55,747 | 32.8 (32.7–32.9) | 31.6 (31.4–31.7) | 36.3 (35.6–37.0) | |
West | 58,362 | 16.3 (16.3–16.4) | 16.3 (16.2–16.3) | 16.8 (16.4–17.1) | |
Tobacco 21 Grade | A | 39,168 | 18.9 (18.8–19.0) | 20.8 (20.7–20.9) | 8.5 (8.1–8.9) |
B | 26,218 | 10.1 (10.1–10.2) | 10.2 (10.1–10.3) | 9.5 (9.0–9.9) | |
C | 75,271 | 39.0 (38.9–39.1) | 39.9 (39.8–40.1) | 34.0 (33.3–34.7) | |
F | 65,510 | 21.5 (21.4–21.5) | 19.7 (19.6–19.8) | 31.3 (30.7–31.9) | |
No policy | 26,241 | 10.5 (10.4–10.5) | 9.3 (9.3–9.4) | 16.7 (16.3–17.2) |
Variable | Category | Smoking Persistence (N = 221,236) | Smoking Cessation (N = 37,547) | ||
---|---|---|---|---|---|
Unadjusted OR (95% CI) | aOR (95% CI) | Unadjusted OR (95% CI) | aOR (95% CI) | ||
Residency | Rural | 2.61 (2.46–2.77) | 1.45 (1.35–1.56) | 0.59 (0.55–0.64) | 0.74 (0.67–0.80) |
Urban | ref | ref | ref | ref | |
Maternal age | <20 | 1.56 (1.35–1.81) | 0.30 (0.25–0.36) | 1.34 (1.13–1.60) | 0.32 (0.27–0.39) |
20–24 | 1.95 (1.78–2.13) | 0.59 (0.53–0.67) | 1.08 (0.97–1.21) | 0.64 (0.58–0.72) | |
25–29 | 1.70 (1.57–1.85) | 0.91 (0.83–1.01) | 0.92 (0.83–1.02) | 0.99 (0.90–1.08) | |
30–34 | 1.15 (1.05–1.25) | 1.02 (0.92–1.13) | 1.02 (0.91–1.14) | 1.08 (0.98–1.19) | |
≥35 | ref | ref | ref | ref | |
Race/ Ethnicity | White | 1.94 (1.77–2.11) | 2.45 (2.21–2.71) | 0.84 (0.75–0.93) | 2.38 (2.16–2.63) |
Black | 1.26 (1.13–1.40) | 0.58 (0.52–0.66) | 0.96 (0.84–1.10) | 0.57 (0.50–0.64) | |
Hispanic | 0.41 (0.35–0.47) | 0.22 (0.18–0.25) | 1.89 (1.61–2.20) | 0.24 (0.21–0.28) | |
Missing | 1.35 (1.08–1.67) | 1.25 (0.97–1.61) | 0.96 (0.71–1.30) | 1.11 (0.88–1.42) | |
Other | ref | ref | ref | ref | |
Marital status | Married | ref | ref | ref | ref |
Other | 4.71 (4.44–4.99) | 2.73 (2.53–2.95) | 2.74 (2.55–2.95) | 2.74 (2.55–2.95) | |
Education (yrs) | <12 | 4.23 (3.93–4.54) | 2.97 (2.69–3.27) | 0.35 (0.31–0.38) | 2.92 (2.66–3.20) |
12 | 3.42 (3.22–3.64) | 1.81 (1.68–1.96) | 0.55 (0.51–0.60) | 1.84 (1.71–1.97) | |
>12 | ref | ref | ref | ref | |
Household income (US$) | ≤$24,000 | 12.87 (11.63–14.24) | 5.38 (4.70–6.16) | 0.21 (0.19–0.24) | 0.32 (0.27–0.39) |
$24,001–$60,000 | 4.90 (4.39–5.46) | 2.94 (2.60–3.33) | 0.39 (0.35–0.44) | 0.49 (0.43–0.57) | |
Missing | 4.35 (3.79–4.98) | 2.90 (2.46–3.41) | 0.30 (0.26–0.35) | 0.40 (0.33–0.49) | |
>$60,001 | ref | ref | ref | ref | |
Received WIC | Yes | 3.08 (2.92–3.26) | 1.30 (1.21–1.39) | 0.55 (0.51–0.58) | 0.82 (0.76–0.89) |
No | ref | ref | ref | ref | |
Zero | ref | ref | ref | ||
Parity | 1 | 1.39 (1.30–1.49) | 1.43 (1.32–1.55) | 0.61 (0.56–0.66) | 0.65 (0.59–0.71) |
2 | 2.00 (1.85–2.16) | 1.66 (1.51–1.83) | 0.45 (0.41–0.50) | 0.56 (0.50–0.62) | |
3+ | 2.86 (2.65–3.10) | 1.91 (1.72–2.12) | 0.28 (0.26–0.32) | 0.40 (0.35–0.45) | |
Pregnancy intention | Planned | ref | ref | ref | ref |
Mistimed | 1.49 (1.39–1.60) | 1.21 (1.11–1.30) | 0.88 (0.81–0.96) | 0.90 (0.82–0.99) | |
Unsure | 3.58 (3.36–3.83) | 1.75 (1.62–1.89) | 0.55 (0.51–0.60) | 0.75 (0.68–0.83) | |
Prenatal Depression | Yes | 5.13 (4.70–5.60) | 2.08 (1.94–2.23) | 0.56 (0.52–0.60) | 0.71 (0.66–0.78) |
No | ref | ref | ref | ref | |
Perinatal stressors | Yes | 2.02 (1.81–2.26) | 2.02 (1.81–2.26) | 0.52 (0.46–0.58) | 0.69 (0.61–0.79) |
No | ref | ref | ref | ref | |
Region | Midwest | 1.58 (1.47–1.69) | 1.25 (1.15–1.36) | 0.76 (0.69–0.82) | 0.83 (0.75–0.92) |
Northeast | 0.98 (0.90–1.07) | 1.19 (1.07–1.33) | 0.97 (0.88–1.07) | 0.86 (0.76–0.98) | |
South | 1.23 (1.15–1.33) | 1.07 (0.98–1.17) | 0.89 (0.81–0.97) | 0.99 (0.89–1.11) | |
West | ref | ref | ref | ref | |
Tobacco 21 Grade | A | ref | ref | ref | ref |
B | 1.65 (1.48–1.85) | 1.25 (1.11–1.39) | 0.82 (0.71–0.94) | 0.93 (0.79–1.10) | |
C | 1.51 (1.38–1.65) | 1.24 (1.09–1.41) | 0.77 (0.69–0.86) | 0.87 (0.76–0.99) | |
F | 1.79 (1.63–1.97) | 1.41 (1.23–1.62) | 0.74 (0.66–0.83) | 0.92 (0.79–1.06) | |
No policy | 2.21 (1.99–2.44) | 1.25 (1.11–1.39) | 0.61 (0.54–0.69) | 0.79 (0.67–0.92) |
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Da Rosa, P.; Richter, M. Rural–Urban Disparities in Perinatal Smoking in the United States: Trends and Determinants. Int. J. Environ. Res. Public Health 2025, 22, 895. https://doi.org/10.3390/ijerph22060895
Da Rosa P, Richter M. Rural–Urban Disparities in Perinatal Smoking in the United States: Trends and Determinants. International Journal of Environmental Research and Public Health. 2025; 22(6):895. https://doi.org/10.3390/ijerph22060895
Chicago/Turabian StyleDa Rosa, Patricia, and Matthias Richter. 2025. "Rural–Urban Disparities in Perinatal Smoking in the United States: Trends and Determinants" International Journal of Environmental Research and Public Health 22, no. 6: 895. https://doi.org/10.3390/ijerph22060895
APA StyleDa Rosa, P., & Richter, M. (2025). Rural–Urban Disparities in Perinatal Smoking in the United States: Trends and Determinants. International Journal of Environmental Research and Public Health, 22(6), 895. https://doi.org/10.3390/ijerph22060895