Given the paucity of evidence on smoking patterns over time focused on women, the present paper aimed to examine the emergence of socioeconomic gradients in smoking among women across multiple birth cohorts over the 20th century. Four central findings emerge. First, birth cohorts had specific smoking patterns that persisted across time, and more specifically, among the mothers, more recently-born cohorts of women had a high prevalence of smoking at every age across time than older cohorts of women. While more recently born cohorts of women could have higher prevalence of smoking due to developmental age differences (e.g., women in the youngest cohort were ages 15–23 years during pregnancy when smoking rates are typically high), we document that the smoking patterns remain cohort-specific throughout each group as they age, suggesting an underlying cohort effect rather than age effects alone. Cohort effects in smoking among women have been previous documented in the US and elsewhere (Davy, 2006
; Harris, 1983
; Kemm, 2001
; Laaksonen, Uutela, et al., 1999
;National Cancer Institute, 1997
). The present study documents this effect using longitudinal data on the same women observed over time, an advance over previous studies of women in this time period.
Second, we document high rates of smoking in pregnancy in 1961–1963, especially among young women, with little evidence for abatement in smoking prevalence across time. This indicates that women did not substantially reduce smoking as social awareness of adverse health effects increased in the United States following the publication of the Surgeon General’s report in 1964 (Brandt, 2007
).Young women showed the least reduction in smoking over this period. This stands in marked contrast to results among men, which show substantial decreases in smoking across a similar time period (Doll & Hill, 1954
; Doll, Peto, et al., 2004
;National Cancer Institute, 1997
). This underscores the differences in societal influences on smoking across gender, and supports evidence that the population-level smoking experience for women is markedly different than for men (Lopez, Collishaw, et al., 1994
Third, these data provide a novel perspective on the emergence of the SEP gradient in smoking across the 20th century in the US: SEP gradients in smoking emerged across birth cohorts rather than time periods alone. An influential body of work has interpreted the SEP gradient in cigarette smoking that emerged across the 20th century from a ‘fundamental cause’ (Link & Phelan, 1995
) perspective of health and wellness: as new information about the consequences of a health behavior (i.e., smoking) becomes available, those of higher SEP will have more resources to enact positive behavior change, creating health disparities by SEP. These data suggest that although uptake of health information may be one of the mechanisms through which smoking decreased in the US, it is not a sufficient explanation for the decrease, because time trends in smoking differed markedly by gender across time, whereas awareness of the adverse effects of smoking showed similar time trends by gender across time (Brandt, 1996
; Pacheco, 2011
Fourth, we document the emergence of a strong SEP gradient among the adolescent offspring of these women, across all birth cohorts. National surveillance data indicates that smoking among adolescent girls decreased markedly across the 1970s and 1980s (Department of Health and Human Services, 2001
; Gilpin, Lee, et al., 2005
; Johnston, O’Malley, et al., 2007
); our study results show that adolescents in the late 1970s and early 1980s were substantially less likely to smoke than their mothers, but that those with the least familial resources were twice as likely to smoke than those with the most familial resources.
While our main results used husband’s education as a marker of familial SEP, we also document cohort effects on the relation between SEP and smoking when using women’s own education. In fact, gradients emerged sooner and among older birth cohorts when examined by women’s education, and our evidence indicates that women with more than a high school education were especially protected from smoking onset and persistence. Women’s education in 1961–1963 likely also reflects factors such as SEP of the family of origin, cognition, literacy, and historical gender norms regarding educational attainment, as fewer women pursued higher education than men in this time period. Thus, these results suggest that highly educated women were especially protected from smoking onset and persistence.
Overall, these results are consistent with data from European countries, which have also documented that socioeconomic gradients in smoking are slower to develop among women compared to men (Evandrou & Falkingham, 2002
; Graham, 2009
;Huisman, Kunst, et al., 2005
). However, we note that these studies use women’s own education or employment grade as a marker for SEP; we find that the emergence of SEP gradients differs by women’s education and their husband’s education. Using women’s own education, gradients emerged more quickly in smoking status; using husband’s education, which is arguably a more robust indicator of familial resources, gradients emerge more slowly. Thus, these results may have implications for the study of tobacco use worldwide, and suggest that gender should be considered an important aspect of how smoking patterns are shaped at the population level.
Recent literature indicates a concerning growth in the incidence of lung cancer among young women in recent years (Levi, Bosetti, et al., 2007
). Furthermore, it is now widely reported that conditional on smoking patterns, women have higher rates of lung cancer than men, suggesting a greater susceptibility to the adverse effects of tobacco (Cohn, Wingard, et al., 1996
; Henschke, Yip, et al., 2006
; Zang & Wynder, 1996
). While men remain more likely than women to smoke in most low-income countries within which smoking overall is increasing, these collective results underscore that the cigarette smoking experience and the attendant consequences differ for women. A focus on women in research design and practice as well as public health prevention and intervention efforts is warranted.
The strengths of this study include its prospective design, population-based sample providing data comparable to data providing information on national averages of smoking, and comprehensive measures of maternal and offspring smoking across key time points in the sociological history of smoking in the US. Inference from the study is limited by the self-report of the respondents regarding smoking. However, validation analysis in this sample indicated strong associations between self report and serum cotinine (English, Eskenazi, et al., 1994
). Bias due to under-reporting of smoking is likely most apparent in the adolescent sample, when smoking was more socially non-normative. Moreover, the present report includes current smoking and quantity of smoking, but we did not have sufficient power to separate SEP gradients in cessation versus initiation, as not enough individuals in this sample quit. Finally, we note that this sub-sample of the CHDS comprises women who were more likely to be White, married, high school graduates, and multiparous than the total pregnancy sample. Generalizability of these results to populations with different demographic characteristics is limited, given that smoking patterns differ substantially for racial/ethnic minorities and by marital and educational status (Grant, Hasin, et al., 2004
In conclusion, the present study demonstrates the importance of birth cohort effects as well as gender as drivers of socioeconomic disparities in health. Cigarette smoking continues to be among the leading causes of preventable morbidity and mortality worldwide (World Health Organization, 2009
), and the gap in cigarette smoking and related health problems between those with high versus low SEP is widening (Meara, Richards, et al., 2008
). These results highlight the importance of considering social position when developing public health prevention efforts in order to prevent death and disability among the most vulnerable in the population, and the importance of considering birth cohort effects when examining trends over time in health disparities.