Rural–Urban Disparities in Perinatal Smoking in the United States: Trends and Determinants

Objective: To examine trends in perinatal smoking across rural and urban areas and investigate whether structural and intermediary health factors explain rural-urban disparities. Methods: This cross-sectional study used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) collected between 2009 and 2021 in the United States. Perinatal smoking patterns were based on self-reported smoking before, during, and after pregnancy. Weighted prevalence estimates with 95% confidence intervals (CIs) were calculated for persistent smoking and cessation, stratified by rural–urban residence. Temporal trends were analyzed using logistic regression. Multivariable weighted logistic regression was performed on Phase 8 data (2016–2021) to examine associations between rural–urban status and perinatal smoking patterns, adjusting for maternal age, year of delivery, region, and structural (e.g., education, Tobacco 21 policy) and intermediary (e.g., perinatal stressors) health determinants. All analyses accounted for the complex survey design. Results: Although perinatal smoking declined over time, prevalence remained consistently higher among rural mothers. From 2009 to 2021, persistent smoking decreased significantly in both rural and urban areas ( p < 0.001). Smoking cessation rates remained stable ( p = 0.087), with no significant difference by rural–urban status ( p = 0.475). After adjustment, rural women were 45% more likely to smoke persistently than urban women (OR = 1.45, 95% CI: 1.35–1.56) and 26% less likely to quit smoking. Conclusions: While perinatal smoking declined overall, rural mothers remained more likely to smoke throughout pregnancy. Structural and intermediary determinants partially explained this persistent rural–urban disparity.