Cumulative Psychosocial and Health Disparities in US Adolescent Cigarette Smoking, 2002 to 2019

Background Understanding disparities in adolescent cigarette smoking is important for effective prevention. Methods We investigated disparities in adolescent smoking based on cumulative reported psychosocial/health risk among respondents ages 12-17 years in the US National Survey of Drug Use and Health from 2002 to 2019. Multivariable regression estimated associations of cumulative risk, survey years, and their interaction predicting past-month and daily smoking. Eleven psychosocial/health variables associated with youth smoking formed composite measures of cumulative risk, categorizing risk as Low (0-2), Moderate (3-4), or High (5+). The main outcomes were weighted past-month and daily smoking by cumulative risk and time, examining prevalence and proportional change across years. Results Among 244,519 adolescents, greater cumulative risk predicted higher smoking prevalence across all outcomes. Compared to the Low-risk category, past-month smoking odds (adjusted odds ratio, 95%CI) were 9.14 (8.58-9.72) and 46.15 (43.38-49.10) times greater in the Moderate- and High-risk categories. For daily smoking, odds were 14.11 (11.92-16.70) and 97.32 (83.06-114.03) times greater among the Moderate- and High-risk categories. Regarding proportional change, the Low-risk category exhibited the steepest decline in past-month smoking from 2002-2003 to 2018-2019 (-85.1%), followed by the Moderate- (-79.2%) and High-risk (-65.7%) categories. Daily smoking declined more steeply among the Low- (-96.5%) and Moderate- (-90.5%) than High-risk category (-86.4%). Conclusions Cumulative risk is a robust predictor of adolescent smoking. While record-setting reductions in adolescent smoking extend across risk categories, disparities favoring youth with fewer risks are evident throughout. Recognizing cumulative risk can inform the development of more targeted and effective prevention efforts.