Health care access and seven-year change in cigarette smoking: The CARDIA study

Objectives: To determine associations among health care access, cigarette smoking, and change in cigarette smoking status over 7 years. Methods: A cohort of 4,086 healthy young adults was followed from 1985–1986 through 1992–1993. Participants were recruited from four urban sites balanced on gender, race (African Americans and whites), education (high school or less, and more than high school), and age (18–23 and 24–30). Outcome measures were smoking status at Year 7, as well as 7-year rates of smoking cessation and initiation. Results: For each of three access barriers reported at Year 7 (lack of health insurance, lack of regular source of medical care, and expense), participants experiencing the barrier had a higher prevalence of smoking, quit smoking less frequently, and started smoking more frequently; e.g., only 15% of participants with health insurance lapses quit smoking over the 7-year period, compared with 26% of those with insurance (P < 0.001). Results were similar for each race/gender stratum, and persisted after adjustment for usual markers of socioeconomic status: education, income, employment, and marital status. Conclusions: Health care access was associated with lower prevalence of smoking and beneficial 7-year changes in smoking, independent of socioeconomic status. The possibility that this is a causal relationship has implications in the prevention of cardiovascular disease, cancer and multiple other smoking-related diseases, and deserves further exploration.