A Health Inequity: Associations Between Cigarette Smoking Status and Mammogram Screening Among Women of Color

Abstract

Introduction

We evaluated differences in yearly mammogram screening by smoking status in a sample of US women. We also examined differences in mammogram screening by race/ethnicity, age, and health care coverage.

Methods

Data were from 1884 women participants in the 2018 Health of Houston Survey study. Binary logistic regression was used to assess the association between smoking status (current/former/non-smokers) and mammograms within 12 months. Moderators included race/ethnicity (Hispanic, Black, Asian, Other, White), age, and health care coverage

Results

In comparison to women who were non-smokers, current and former smokers showed lower odds to get a yearly mammogram (OR = 0.720; 95% CI = 0.709, .730 and OR = 0.702; 95% CI = 0.693, 0.710, respectively). Current smokers who identified as Hispanic or Black women and former smokers who identified as Hispanic, Asian, and other women showed lower odds of getting a mammogram (OR = 0.635, 95% CI = 0.611, 0.659; OR = 0.951, 95% CI = 0.919, 0.985) and (OR = 0.663, 95% CI = 0.642, 0.684; OR = 0.282, 95% CI = 0.263, 0.302; OR = 0.548, 95% CI = 0.496, 0.606) compared to White women. There were significant interactions by age and health care coverage.

Conclusions

Women of color who are current and former smokers showed lower odds to engage in mammogram screening, thus increasing their risk of undiagnosed breast cancer when compared to non-smokers. Ethnically diverse women already experience increased health disparities and smoking puts them at exacerbated risk of health complications and death.

Implications

Our findings suggest that smoking status is a modifiable behavioral risk factor that requires further attention in the prevention of breast cancer in ethnic minority women. Health care institutions and policymakers need to increase their awareness of and outreach efforts to women of color who smoke. These outreach efforts should focus on increasing access to smoking interventions and cancer screenings.

Introduction

Breast cancer is the most common cancer in women worldwide^1,2 and the second leading cause of cancer death for women in the United States besides lung cancer.^1,2 The frequencies of breast cancer diagnosis and death predicted for 2021 in the United States are 281,550 women and 43,600 women, respectively.^1,2 The rate of breast cancer death has been steadily decreasing in the general population; however, the baseline rates of mortality have historically not been similar. Breast cancer is the leading cause of death for Black women and Hispanic/Latinx women and the second leading cause of death for Asian American, American Indian, and Alaska Native women.³ Black women historically had higher rates of mortality, largely due to later diagnoses of more fatal cancer. This health disparity contributes to the health inequity Black women face in cancer care.^4–6 Behavioral risk factors associated with breast cancer are important to consider for ethnic minority groups as it relates to the continued health inequity strain women of color face in health care.^7,8 For instance, higher stress levels and resultant higher rates of smoking⁹ are contributing factors for the higher levels of cancer risk, diagnosis, and death¹⁰ in ethnic minority groups.

Smoking cigarettes is a behavioral risk factor that requires further attention in relation to breast cancer risk. Of note, smoking rates for women have not decreased as rapidly as those for men,^11,12 and smoking rates among women differ by ethnicity/race,¹¹ which may be related to other cancer risk behaviors. Smoking is associated with an increased incidence of breast cancer, as active smokers have a 9% increased risk of developing breast cancer.^13–15 A recent study replicated findings suggesting that smoking is associated with a higher risk of developing breast cancer and also found that smokers who quit for less than 10 years had a 28% increased risk of developing breast cancer in their lifetime compared to women who had never smoked.¹⁶ Because of these associations, some researchers suggest that tobacco use should be examined as a predictor of women who are less likely to engage in preventative and screening services.^17,18

Increased use and effectiveness of preventative services^1,2,19 such as mammogram screening, is one of the many reasons why early-stage breast cancer incidence has increased annually. Breast cancer mortality rates have been reduced, in part, due to the increase in mammographic screening for early-stage cancer detection and proactive treatment.² Mammogram screening is the use of images of the breast to detect the abnormal growth of tumors and is helpful for cancer early detection and death risk reduction.^20,21 Since the 1980s, mammogram screenings have been regularly suggested to women aged 40 or older, leading to a 40% decrease in breast cancer death.¹⁹ Tabár and colleagues²² found in their longitudinal study that regular mammograms reduce breast cancer death by one-third for women 40 and over. Current guidelines suggest that mammogram screening begin at age 40 and strongly recommend mammogram screening be continued regularly from ages 50 to 75.⁴ However, data vary with regard to the age in which women utilize mammograms.^4,20,23 Furthermore, many scholars have indicated that lack of health insurance coverage decreases cancer screening and efficient cancer care when compared with those who have health insurance coverage.²⁴

Clinical observations and empirical evidence have demonstrated that multiple health risk behaviors contribute more to disease risk than single behaviors.²⁵ Thus, the co-occurrence of smoking and limited engagement in breast cancer screening among women is crucial for disease management. For instance, perception of low susceptibility and high barriers to care among smokers may be related to a decreased involvement in cancer prevention services.²⁶ Also, women who smoke may feel less inclined to get additional health screenings when they are managing their tobacco addiction,²⁷ thus their smoking status may influence their low engagement in prevention services.

While previous research have investigated barriers in the use of breast cancer screening services^14,28–30 only a few^31,32 have explored the link between smoking status and mammogram use, and none, to our knowledge, have explored differences by race/ethnicity. Research has documented that smoking increases breast cancer risk;^13–15 relatedly, multiple health risk behaviors are associated with worse health outcomes. Therefore, with the emerging recommendations that tobacco use should be considered a predictor of less screening engagement,^17,18 we sought to explore cigarette use as a risk factor for low engagement in breast cancer screening among women of color.^31,32 For this study, we evaluated if smoking status was related to women’s odds to receive a mammogram within the past 12 months. We also investigated whether the relationship between smoking status and mammogram use was moderated by racial/ethnic groups, health care coverage, and age. To identify factors that are associated with engagement (or lack thereof) in this cancer prevention service is imperative to address health inequities among particular subgroups of women.

Methods

Sample

This retrospective, cross-sectional population study used data from the 2018 Health of Houston Survey (HHS), which investigated population health variables. The sample is representative of the non-institutionalized adult population living in households in Harris County and the City of Houston, Texas. Data were collected from June 2017 to February 2018 through a complex, stratified random sample survey that was designed to capture reliable data for subpopulations in the sub-county areas, main racial, and ethnic groups, and main age and income groups. This is a publicly accessible and de-identified dataset; details of the survey’s methodology and questionnaires can be found at www.hhs2010.net.

The current study included woman participants (n = 1884) ages 40–75 years who reported their smoking status (current smokers, former smokers, non-smokers) and their mammogram use from the time of the survey. The original sample included 1931 women ages 40–75 years; however, 47 participants had missing data for the mammogram screening question and were not included in our analyses.

Study Variables

Sociodemographic Variables

The HHS collected data on age group (40–49, 50–59, 60–69, and 70–75), race/ethnicity (Hispanic, Black, Asian, other/multiracial, White), partner status (not partnered [divorced, widowed, separated, never married], and partnered [married living with partner]), education level (high school/GED or less, some college, college graduate, post-bachelor, and beyond), and health care coverage (not insured and insured [private insurance, Medicare, other public insurance, unknown insurance]). Each categorical variable were dummy coded using ages 50–59, White, partnered, high school/GED, or less, and insured as the reference groups, respectively.

Mammogram Screening

The survey administrators asked only women in the 40–75 age range if they used preventative and screening services for cancer. The survey questions on mammogram screening included “How long has it been since you had your last mammogram?” with the following response options: “I’ve never had a mammogram”, “Within the past 12 months”, “Within the past 2 years”, “Within the past 3 years”, “Within the past 5 years”, “5 or more years ago”, or “Don’t know/refuse”. Mammogram screening was recoded to “yes” for respondents who selected “Within the past 12 months”. Other respondents (except the ones who reported “Don’t know/refuse to answer”) were coded as “no”. This coding reflected the recommendation that women in this age group undergo mammography yearly. The reference group was comprised of the women who answered “no” to yearly mammography. There were 28 participants who responded “Don’t know/refuse” and were excluded from the data analysis.

Smoking Status

Smoking status was determined through two questions. The first question was “Altogether, have you smoked at least 100 or more cigarettes in your entire lifetime?” If the participants responded yes, they were asked the follow-up question: “Do you now smoke cigarettes every day, some days, or not at all?” and had the following choices: “Every day”, “Some days”, and “Not at all”. Smoking status was coded to “current smoker”, “former smoker”, and “never smoker”, with the non-smokers as the reference group. Current smokers consisted of the “Every day” and “Some days” respondents, and former smokers consisted of the “not at all” respondents to the second question.

Data Analysis

Descriptive analysis was used to describe the demographic characteristics of the sample. Sampling weights were applied to all regression analyses to ensure that the sample represented the population. Binary logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between smoking status and mammogram screening within 12 months. All adjusted analyses controlled for partner status and education level. Adjusted analyses also controlled for age, race/ethnicity, and health care coverage except when one of those variables was the moderator variable of relevance. Weighted analyses in this study are based on 855,215 individuals. The survey weights generated from the sampling to estimate mammography rates. p < .05 were considered statistically significant. All analyses were conducted using SPSS 26.0 software package for Macintosh.

Results

A majority of the women were non-smokers (n = 1330, 70.6%), and 29.4% (n = 554) identified as ever smokers (current smokers: n = 183, 9.7%, and former smokers: n = 371, 19.7%). Tables 1 and 2 include descriptive statistics for the demographic variables. For all binary logistic models, the reference categories were non-smokers for the smoking status variable, White women for race/ethnicity, 50–59 age bracket for the age variable, and insured for the healthcare coverage variable. In the unadjusted model, women who were current smokers or former smokers had lower odds of a mammogram within the past 12 months (current: OR = 0.628, 95% CI = 0.619, 0.636 and former: OR = 0.749, 95% CI = 0.741, 0.758) compared with women who were non-smokers. Similarly, after controlling for partner status, education level, race/ethnicity, age, and health care coverage, women who were current smokers or former smokers had lower odds of a mammogram within 12 months (current: OR = 0.720; 95% CI = 0.709, 0.730 and former: OR = 0.702; 95% CI = 0.693, 0.710) compared with women who were non-smokers (Table 3).

Table 1.

Sample demographics by smoking status (n = 1884)

Demographic variable	Total n (%)	Non-smoker n (%)	Current smoker n (%)	Former smoker n (%)
Age
40–49 y	510 (27.1)	417 (22.1)	42 (2.2)	51 (2.7)
50–59 y	564 (29.9)	384 (20.4)	75 (4.0)	105 (5.6)
60–69 y	543 (28.8)	359 (19.1)	47 (2.5)	137 (7.3)
70–75 y	267 (14.2)	170 (9.0)	19 (1.0)	78 (4.1)
Race/ethnicity
Hispanic	453 (24.0)	367 (19.5)	33 (1.8)	53 (2.8)
Black	458 (24.3)	329 (17.5)	60 (3.2)	69 (3.7)
Asian	69 (3.4)	64 (3.4)	1 (0.1)	4 (0.2)
Other/multiracial	44 (2.3)	29 (1.5)	6 (0.3)	9 (0.5)
White	860 (45.6)	541 (28.7)	83 (4.4)	236 (12.5)
Partner status
Not partnered	831 (44.1)	532 (28.2)	116 (6.2)	183 (9.7)
Partnered	1053 (55.9)	798 (42.4)	67 (3.6)	188 (17.9)
Education level
Grade 12 or less	540 (28.7)	390 (20.7)	74 (3.9)	76 (4.0)
Some college	524 (27.8)	323 (17.1)	75 (4.0)	126 (6.7)
College graduate	445 (23.6)	339 (18.0)	20 (1.1)	86 (4.6)
Post-bachelor	375 (19.9)	278 (14.8)	14 (0.7)	83 (4.4)
Health care coverage
Not insured	294 (15.6)	224 (11.9)	40 (2.1)	30 (1.6)
Insured	1590 (84.4)	1106 (58.7)	143 (7.6)	341 (18.1)

Table 2.

Smoking status and sample demographics by mammogram screening within past 12 months

Smoking status	Mammogram within past 12 months, n (row %)		n (column %) (n = 1884)
	Yes	No
Current smokers	92 (50.3)	91 (49.7)	183 (9.7)
Former smokers	222 (59.8)	149 (40.2)	371 (19.7)
Non-smokers	483 (36.3)	847 (63.7)	1330 (70.6)
Age
40–49 y	273 (53.5)	237 (12.6)	510 (27.1)
50–59 y	348 (61.7)	216 (38.3)	564 (29.9)
60–69 y	366 (67.4)	177 (32.6)	543 (28.8)
70–75 y	174 (65.2)	93 (34.8)	267 (14.2)
Race/ethnicity
Hispanic	269 (59.4)	184 (40.6)	453 (24.0)
Black	312 (68.1)	146 (31.9)	458 (24.3)
Asian	43 (62.3)	26 (37.7)	69 (3.6)
Other/multiracial	21 (47.4)	23 (52.3)	44 (2.3)
White	516 (60.0)	344 (40.0)	860 (45.6)
Partner status
Not partnered	487 (58.6)	344 (41.4)	831 (44.1)
Partnered	674 (64.0)	379 (37.5)	1053 (55.9)
Education level
Grade 12 or less	317 (58.7)	223 (41.3)	540 (28.7)
Some college	312 (59.5)	212 (40.5)	524 (27.8)
College graduate	274 (61.6)	171 (38.4)	445 (23.6)
Post-bachelor	258 (68.8)	117 (31.2)	375 (19.9)
Health care coverage
Not insured	122 (6.5)	172 (9.1)	294 (15.6)
Insured	1039 (55.1)	551 (29.2)	1590 (84.4)

Table 3.

Unadjusted and adjusted models of mammogram screening within past 12 months by smoking status

	Exp(B)	95% CI for Exp(B)
		Lower	Upper
Unadjusted model
Current smokers	0.628*	0.619	0.636
Former smokers	0.749*	0.741	0.758
Non-smokers	Ref	Ref	Ref
Adjusted modela
Current smokers	0.720*	0.709	0.730
Former smokers	0.702*	0.693	0.710
Non-smokers	Ref	Ref	Ref

p < .001.

Binary logistic regression-adjusted: partner status, education, age, race/ethnicity, health care coverage.

Significant two-way interactions were found for race/ethnicity, age, and health care coverage by smoking status in the prediction of mammogram use (Table 4). Compared to White women, Hispanic women (OR = 0.635, 95% CI = 0.611, 0.659) and Black women (OR = 0.951, 95% CI = 0.919, 0.985) had even smaller odds to get a mammogram as a current smoker compared to non-smokers. Similarly, compared to White women, Hispanic women (OR = 0.663, 95% CI = 0.642, 0.684), Asian women (OR = 0.282, 95% CI = 0.263, 0.302), and other/multiracial women (OR = 0.548, 95% CI = 0.496, 0.606) showed even lower odds to get a mammogram as a former smoker compared to non-smokers. However, the results regarding Asian and other/multiracial groups should be interpreted with caution. The sample size was small for the Asian women (total n = 69; 1 Asian woman who was a current smoker and 4 Asian women who were former smokers) and other/multiracial women (n = 44; 6 other/multiracial women who were current smokers and 10 other/multiracial women who were former smokers) groups; therefore, the interaction coefficients were not reliable for current smokers who were Asian or other/multiracial (large standard errors; 1985.74 and 1042.81, respectively). There were no significant interactions found for Black former smokers.

Table 4.

Main effects and interaction terms of mammogram screening within past 12 months by smoking status and moderators

Variable name	Exp(B)	95% CI for Exp(B)		Variable name	Exp(B)	95% CI for Exp(B)
		Lower	Upper			Lower	Upper
Smoking status and race/ethnicitya				Smoking status and race/ethnicity interactionsa
Current Smokers	0.862**	0.844	0.880	Hispanic × current smoker	0.635**	0.611	0.659
Former smokers	0.811**	0.798	0.824	Hispanic × former smoker	0.663**	0.642	0.684
Non-smokers	Ref	Ref	Ref	Black × current smoker	0.951*	0.919	0.985
Hispanic	2.194**	2.160	2.228	Black × former smoker	0.972	0.939	1.005
Black	1.961**	1.931	1.991	Asian × current smoker	0.000	0.000	-†
Asian	1.356**	1.325	1.388	Asian × former smoker	0.282**	0.263	0.302
Other/multiracial	1.723**	1.642	1.807	Other × current smoker	0.000	0.000	–†
White	Ref	Ref	Ref	Other × former smoker	0.548**	0.496	0.606
Smoking status and ageb				Smoking status and age interactionsb
Current smokers	0.942**	0.921	0.964	Ages 40–49 × current smoker	0.657**	0.634	0.680
Former smokers	0.848**	0.831	0.866	Ages 40–49 × former smoker	0.757**	0.734	0.781
Non-smokers	Ref	Ref	Ref	Ages 60–69 × current smoker	0.598**	0.577	0.621
Ages 40–49	0.788**	0.778	0.798	Ages 60–69 × former smoker	0.701**	0.680	0.724
Ages 50–59	Ref	Ref	Ref	Ages 70–75 × current smoker	0.698**	0.653	0.746
Ages 60–69	1.504**	1.480	1.529	Ages 70–75 × former smoker	0.871**	0.838	0.906
Smoking status and health care coveragec				Smoking status and health care coverage interactionsc
Current smokers	0.691**	0.680	0.703	Not insured × current smoker	1.187**	1.147	1.229
Former smokers	0.733**	0.723	0.742	Not insured × former smoker	0.611**	0.586	0.637
Non-smokers	Ref	Ref	Ref
Not insured	0.397**	0.391	0.403
Insured	Ref	Ref	Ref

p < .01, **p < .001

Estimates are not provided due to small sample size.

Binary logistic regression-adjusted: partner status, education, age, health care coverage.

Binary logistic regression-adjusted: partner status, education, race/ethnicity, health care coverage.

Binary logistic regression-adjusted: partner status, education, race/ethnicity, age.

Regarding age groups, the women in the 40–49 age range compared with those in the 50–59 age range showed even lower odds of getting a mammogram as a current or former smokers compared to the non-smokers (current smokers: OR = 0.657, 95% CI = 0.634, 0.680; former smokers: OR = 0.757, 95% CI = 0.734, 0.781). Also, women in the age ranges of 60–69 (current smokers: OR = 0.598, 95% CI = 0.577, 0.621; former smokers: OR = 0.701, 95% CI = 0.680, 0.724,) and 70–75 (current smokers: OR = 0.698, 95% CI = 0.653, 0.746; former smokers: OR = 0.871, 95% CI = 0.838, 0.906, respectively) compared with women in the 50–59 age range showed even lower odds to get a mammogram as a current or former smoker compared to a non-smoker.

While in general, current smokers showed lower odds to get a mammogram scan in the past year compared to non-smokers, the women who did not have health care coverage showed slightly higher odds than those who had health care coverage (⁠$\mathrm{O}{\mathrm{R}}_{\mathrm{i}\mathrm{n}\mathrm{t}\mathrm{e}\mathrm{r}\mathrm{a}\mathrm{c}\mathrm{t}\mathrm{i}\mathrm{o}\mathrm{n}}$= 1.187, 95% CI = 1.147, 1.229). A simple slope was calculated for uninsured women. This calculation resulted in OR = exp(‐0.197) = 0.821, which indicated that although uninsured women showed higher odds than the insured (OR = 0.691, 95% CI = 0.680, 0.701), the odds for current smokers to get a mammogram was lower compared to non-smokers. Similarly, in general, the former smokers showed a lower odd to get a mammogram in the past year compared to non-smokers. The odds were even lower among women who did not have health care coverage (⁠$\mathrm{O}{\mathrm{R}}_{\mathrm{i}\mathrm{n}\mathrm{t}\mathrm{e}\mathrm{r}\mathrm{a}\mathrm{c}\mathrm{t}\mathrm{i}\mathrm{o}\mathrm{n}}$= 0.611, 95% CI = 0.586, 0.637).

Discussion

Mammogram screening is an important screening tool to reduce later-stage cancer diagnosis and death from cancer. Our study demonstrates that some ethnic minority women who are current or former smokers show lower odds to have had a mammogram screening within the past 12 months. Our findings underscore the need to consider race/ethnicity with respect to mammogram use among women who are current and former smokers. Smoking history and multiple cancer prevention behaviors are imperative to consider for women smokers of color. Communities of color show some of the highest rates of tobacco use and are at increased risk of death from a later-stage cancer diagnosis.⁴ Rates of tobacco use and cancer screening utilization are cancer health disparities that require further attention.

There is growing evidence demonstrating the association between smoking and breast cancer risk.^28,33 Previous investigations link tobacco use to many other cancer deaths. Tobacco use is reported as the most important factor for predicting cancer incidence according to the World Health Organization, and smoking is associated with 22% of all cancer deaths.¹⁰ This is significant as the association of tobacco use and breast cancer is linked to health disparities, as marginalized individuals are more likely to smoke and not have access to robust health services. Our study demonstrated that current and former smokers, compared to non-smokers, showed lower odds to get a mammogram screening within the past year. Previous studies have similarly indicated that mammography use is related to smoking status.^17,18,34 Hispanic women and Black women compared to White women showed an even stronger negative relationship between smoking status and mammogram use. Two recent studies did not find mammogram use differences by race/ethnicity;^35,36 however, other studies found that increasing the number of provider^37,38 and community^39,40 educational programs increased cancer screening adherence for ethnic minority groups including Black Americans, Hispanic Americans, and Asian Americans. Although speculative from this study, it is possible that multiple psychosocial factors influence women of color who smoke to engage in low mammogram use. For instance, previous research has identified cultural beliefs and low acculturation as predictors of delay of breast cancer screening among Latinas⁴¹ while fear of the healthcare systems were salient for African American women.⁴² Studies like these suggest that the barriers for mammogram screening among women of color may be applicable to smokers as well but may vary across race/ethnic groups. Thus, to achieve healthy equity in mammography and smoking cessation, professional practices, and structural changes must be tailored for women of color who smoke.

Our results indicated that insurance is a significant factor in relation to mammogram use. Similar to our findings, previous studies indicate that women of color are less likely to have access to preventative services and are less likely to engage in screening treatments for early breast cancer detection.^3,43–45 Mammogram screening is significantly associated with health coverage; in 2015, 76.7% of women 50 years and older with received a mammogram within 2 years; yet, only 35.3% of uninsured women were screened.²¹ Therefore, health care coverage may be a barrier to accessing prevention services for women smokers. For example, women in the U.S. who are current smokers (12%) and former smokers (18.7%) are less likely to have private health insurance coverage compared to non-smokers.⁴⁶ In the U.S., current smokers (including both men and women) are more likely to have Medicaid (24.9%) and to be uninsured (22.5%) compared to non-smokers.^46,47 Further research and policy modifications are needed to increase screening engagement opportunities at the community level as breast cancer screening has been linked to reducing breast cancer mortality; and women of color may benefit from services outside of the formal level of care.²²

Lastly, age was found to be a significant moderator in determining mammogram use for current smokers and former smokers. This interaction between smoking status and age may be due to health care coverage access or the conflicting mammography recommendations of many healthcare providers and institutions in the US.⁴⁸ Our findings indicated an overall decreased odds of yearly mammography for women 49 years and younger as well as 60 years and older. The literature recommends mammogram screening at a frequency between 12 months and 2 years for women 50–55 years and older, with the most conservative method for mammogram screening being once per year^1,2 for women 40 years or older. This discrepancy in provider knowledge and recommendation may be contributing to smokers and former smokers not utilizing mammography at different age points. Additional research is warranted to disentangle these relationships.

Strengths and Limitations

The strengths of this study include the moderate-to-large sample size and ethnic diversity of the participant cohort. Few studies have examined a large, ethnically diverse cohort of women to understand their mammogram use in relation to smoking status.

A limitation of this study include its cross-sectional nature as we cannot establish causality from our results. Also, the measure of age limited the scope of our analyses. The survey administrators asked only women in the 40–75 age range whether they used preventative and screening services for cancer. Therefore, our analysis did not include women 39 years and younger. There may be critical information to uncover about women who are 39 years or younger regarding their cancer risk. In particular, recent models suggests that Black women should be screened at a younger age compared to White women in order to reduce some aspects of the cancer health disparities Black women endure.⁴⁹ Future studies should seek to include younger ages.

The American Cancer Society^23,50 recommendations for breast cancer screening depends on age: every year for ages 45–54 years and at least every other year for ages 55 and above. In this study, we were unable to retrieve the exact age information (age were in age brackets) due to the sensitive nature of the data; therefore, we could not match the participant’s age with the recommended period for undertaking a mammogram examination. Future studies should examine the relationship between smoking status and mammogram use within the recommended period by age.

Data for this study were drawn from a parent study taking place in the same geographical area, potentially limiting generalizability of findings. Additionally, future research should further explore the relationship of mammography by health insurance type. Finally, replication of this study with national datasets or cohort studies in other states is critical to examine if the relationship between smoking status and yearly mammogram use exists in other populations.

Conclusion and Future Directions

In summary, smoking history decreases the odds of a breast cancer screening. Additionally, the relationship between smoking status and mammogram use depends on women’s race/ethnicity, age, and health care coverage. This investigation suggests the need to increase access to smoking cessation interventions and to breast cancer screening to increase the well-being and quality of life for women at risk of breast cancer.

Providers and public health officials must continue to increase the awareness of smoking cessation practices alongside resources to increase cancer screening services. Multiple health behavior change interventions have shown promise for cancer prevention; these interventions have the potential to have a greater impact on public health compared with interventions focused on a single behavior.⁵¹ There may be increased reach and cost-effectiveness of integrating interventions instead of relying on referrals to separate/individualized health care services and is an important consideration to address the health needs of women of color who smoke.

In order to address the health inequity women of color face in cancer prevention, structural changes to cancer health care seem warranted. Changes can include the availability of educational materials in various languages that include smoking and breast cancer information; increasing primary care providers knowledge of the associations of smoking and decrease breast cancer screening among women of color; and increase in supportive services that aid in jointly decreasing smoking and increasing cancer screening services, such as routinely addressing both components in single medical visits. For instance, it would be of great benefit for all women—and woman of color in particular- that professionals conducting breast cancer screenings are trained to provide brief smoking cessation interventions during the mammogram visit. Similarly, it may be beneficial that quit lines have additional questions regarding cancer prevention as well as resources or referral information available to provide to callers. Lastly, health insurance coverage must be updated and monitored to more broadly support smoking cessation services. It is crucial to construct and enforce the implementation of comprehensive and reasonably priced health coverage and health practices that focus on preventative services that encourage all women to actively engage in their health journey. Medications, both prescribed and over the counter, can be expensive and their use may be low partially due to people’s financial concerns. These programmatic and structural changes may increase early cancer detection, thus increasing the longevity of woman smokers. Therefore, genetics is not the only factor to address to prevent breast cancer; instead, researchers, and clinicians must examine people’s entire development with a biological, psychological, and social lens to prevent further deaths due to cancer among women in the United States. It is crucial to construct and enforce the implementation of comprehensive and reasonably priced health coverage and health practices that focus on preventative services that encourage all women to actively engage in their health journey.

Acknowledgments and Funding Disclosure

We thank the research personnel of the Health of Houston Survey team. We thank Sarah Bronson for her editing contributions to the manuscript. DHL’s research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health to the University of Houston under Award Number P20CA221697 and to MD Anderson Cancer Center under Award Number P20CA221696. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Declaration of Interests

The authors have no disclosures or conflicts of interest.

Financial Disclosure

No financial disclosures are reported by the authors of this paper.

Data Availability

Data is publicly accessible at www.hhs2010.net.