SimSmoke simulation models by educational status: past and future US trends and the potential role of policy

Simulation models are helpful in anticipating future trends and developing effective tobacco control policies to reduce smoking-related inequities. However, few models have systematically analysed smoking trends by education group.

We developed four separate SimSmoke models by educational group: less than high school, high school, some college and college and above. Education status is based on the US Census estimates, and smoking prevalence is based on the Current Population Survey-Tobacco Use Supplement (CPS-TUS). Following a first-order Markov process, smoking prevalence evolves through yearly initiation, cessation and relapse, subject to tobacco control policies. The models begin in 2006 and incorporate the impact of tobacco control policies implemented through 2023. They are used to project trends in smoking prevalence and smoking-attributable deaths (SADs) and the impact of policies. The smoking prevalence estimates from the model have also been compared with the CPS-TUS in recent years.

Adults with higher educational attainment had the lowest smoking prevalence with the greatest relative decline from 2006 to 2023. Per capita SADs were highest among adults with less education. Price increases, Tobacco 21 laws and smoke-free air laws were most effective in reducing long-term smoking prevalence. The models underestimate the reduction in smoking prevalence relative to CPS-TUS estimates in recent years, especially among youth.

We found major differences in the initial levels and rates of decline in smoking prevalence by education, leading to widening health inequities. Further study is warranted on education-related policy impacts and the relationship of electronic nicotine delivery systems and other non-cigarette product use to cigarette use.