Associations between local cigarette and e-cigarette prices and smoke-free legislation with prenatal smoking and...

While state cigarette taxes have been shown to reduce disparities in prenatal smoking and birth outcomes, less is known about the effects of local tobacco control policies. We examined the associations between county-level cigarette and e-cigarette prices and smoke-free legislation with racial/ethnic and educational disparities in prenatal smoking and birth outcomes.

Using 2013-2018 county-level natality data on 18,663,683 singletons linked to cigarette and e-cigarette price data and smoke-free legislation, we conducted conditional mixed-process models to examine the associations between tobacco control policies and prenatal smoking, then on the associated changes in birth outcomes. We included interactions between race/ethnicity, education, and prices.

Cigarette price increases were associated with larger declines in prenatal smoking than e-cigarette prices, with effect sizes decreasing across the educational gradient. Among women with 0-11 years of education, a 10 % increase in cigarette prices was associated with a decrease in smoking by 8.61 percentage points for White women and 2.92 percentage points for Black women and subsequently an increase in their infants' birth weights by 8.01 and 2.72 g, respectively. Increases in cigarette and e-cigarette smoke-free legislation coverage were associated with small declines in prenatal smoking, but no subsequent changes in birth outcomes.

Local cigarette price increases contribute to the flattening of educational gradients in prenatal smoking and birth outcomes, particularly among White and Black women. Local cigarette prices may be more indicative of how fiscal policies influence smoking behavior than state cigarette taxes, particularly for low-educated pregnant women who are more likely to be price sensitive.