Unveiling socioeconomic disparities in maternal smoking during pregnancy: a comprehensive analysis of rural and Appalachian areas in Virginia utilizing the multi-dimensional YOST index.

Background: Maternal smoking during pregnancy carries significant health risks for both mothers and infants, especially in vulnerable regions like rural and Appalachian areas with high smoking rates. Understanding the causes of high smoking rates in vulnerable areas is crucial for designing effective interventions to promote smoking cessation and reduce preventable health disparities.

Methods: Data from the Virginia Pregnancy Risk Assessment Monitoring System (PRAMS; years 2009-2020) comprised of 7,861 women aged over 18 were used in this cross-sectional observational study. Pregnant individuals were categorized as smoking if they reported smoking during the last trimester. A multi-level logistic regression was employed to examine the association of individual sociodemographic factors, rurality, Appalachian status, and county socioeconomic status (SES) proxied by Yost Index quintiles with smoking behaviors during pregnancy. The county of residence was considered as a random factor in the analysis. Trend analysis were also conducted.

Results: Out of the overall sample, 92.8% (n = 7,292) were non-smokers, while 7.2% (n = 569) were smokers. The multi-level logistic regression analysis showed pregnant individuals aged 18-24 had 1.06 times higher odds of smoking compared to those over 35 (95% CI [1.02-1.10]). Those with a college education or higher had significantly reduced odds (OR: 0.10, 95% CI [0.10, 0.10]), as did racially minoritized individuals (OR: 0.59, 95% CI [0.51-0.68]) and Hispanic individuals (OR: 0.14, 95% CI [0.09-0.21]). Living in rural areas was associated with a 26% higher likelihood of smoking during pregnancy compared to urban areas (OR: 1.26, 95% CI [1.21-1.31]), while residing in Appalachian regions led to a 25% higher probability of smoking. Additionally, lower SES quintiles were linked to higher odds of smoking, with the lowest quintile at OR: 2.10 (95% CI [1.67-2.65]) and the second quintile at OR: 1.64 (95% CI [1.53-1.76]) as compared with the most affluent quintile. Trend analsysis shows smoking has declined across all quintiles, but a substantial gap persists between lowest and highest SES regions.

Conclusions: Smoking rates during pregnancy have dropped overall but remain alarmingly high in specific rural and Appalachian areas. As smoking during pregnancy poses significant health risks, targeted interventions and resources for tobacco cessation programs are needed in these highly vulnerable regions.

Trial registration: Not Applicable.