Changes in Smoking Inequalities among U.S. Young Adults, 2017-2023

• In Event: How Policy Shapes the Development of LGBTQ Youth and Young Adults

Abstract

BACKGROUND: Tobacco is responsible for approximately 30% of cancer deaths with significant racial, ethnic, and socioeconomic inequalities. In December 2019, federal Tobacco 21 (T21) legislation was enacted to raise the minimum legal sales age of tobacco from age 18 to 21. 

AIMS: This study aimed to (1) Estimate changes in smoking rates among US young adults between 2017-2023; (2) Test whether changes in smoking rates among US young adults between 2017-2023 between varied by sociodemographic groups; (3) Quantify the proportion of the total decline in smoking rates between 2017-2023 that occurred after T21 implementation by sociodemographic groups.

METHODS: We restricted the analytic sample to respondents aged 18-20 years from Behavioral Risk Factor Surveillance System (BRFSS) 2017-2023. To describe smoking patterns surrounding implementation of the federal T21 policy, we used survey weighted linear regression techniques to estimate the smoking prevalence across three time periods: pre-implementation of T21 (2017-2019), T21 implementation transition (2020-2021), and post-implementation of T21 (2022-2023) in the total population, and then stratified by sex, high school degree completion (HSD), federal poverty level (FPL), and sexual minority status (SM). To meet research objective 1, we estimated the absolute percentage-point decline in smoking in the total population from pre-implementation of T21 to post-implementation of T21. To meet research objective 2, we generated stratified estimates by sociodemographic subgroups and tested subgroup differences in declines from pre-implementation of T21 to post-implementation of T21. To meet research objective 3, we estimated the absolute percentage-point decline and the proportion of the total decline in smoking which occurred after T21 implementation stratified by sociodemographic subgroups. 

RESULTS: In the overall sample of 62,626 U.S. young adults aged 18-20, 8.67% [95% CI 8.08 to 9.25%] of respondents were current smokers in the pre-T21 implementation period which declined to 5.01% [95% CI 4.48 to 5.54%] at T21 implementation transition, and declined to 4.17% [95% CI 3.62 to 4.72%] in the post-T21 implementation period, an absolute reduction of -4.50 percentage points (pp) [95% CI -5.30 to -3.69pp, p<.001]. The absolute reduction in current smoking was significant for all sociodemographic subgroups, however the relative inequality between subgroups was only significant by education attainment (HSD vs. no HSD, p<.001) and income level (>200% FPL vs. <200%FPL, p=. 038), but not by sex (female vs. male, p=.156) or sexual orientation (heterosexual vs. SM, p=.115). Between 8.69% (SM subgroup) to 34.19% (heterosexual subgroup) of the total decline in smoking occurred in the T21 implementation period to post-T21 implementation period. In total, only 18.67% of the total decline in smoking observed between 2017-2023 occurred in the T21 post-implementation period. 

CONCLUSIONS: We find that current smoking significantly declined in the overall study sample, as well as across all subgroups studied. While smoking declined throughout the study period for all subgroups, federal T21 implementation was not associated with reductions in smoking inequalities by binary sex, household income, or sexual minority (SM) identity. Prevention and cessation policies that are accessible to SM respondents and respondents from lower socioeconomic backgrounds are needed to mitigate tobacco-related harms.

Author

• Nathaniel M Tran, University of Illinois, Chicago
  Presenting Author