Reproductive health care for incarcerated women in the prenatal and postpartum periods.

In 1976, the Supreme Court mandated that incarcerated individuals have a constitutional right to receive medical care; however, there are no mandatory standards so access to and quality of reproductive health care for incarcerated pregnant women varies widely across facilities. Without federal or state standards, there is variability in the type of prenatal care pregnant women receive, their birthing experience, how long they are able to stay with their infant after birth, and whether they are permitted to breastfeed or express milk. In this column, I review policies related to reproductive health care in carceral settings, the gaps in data collection and research, programs to support the needs of incarcerated pregnant women, and recommendations from professional organizations on reproductive health care for incarcerated women in the prenatal and postpartum periods.

Emerging Adult Mental Health During COVID: Exploring Relationships Between Discrete and Cumulative Individual and Contextual Stressors and Well-Being.

PURPOSE: Indicators of poor mental health increased during the COVID-19 pandemic among emerging adults aged 18-24 years, a group already at elevated risk. This study explores associations between contextual and personal stressors with symptoms of emerging adults' anxiety and depression, assessing both multidimensional and distinct measures of stress. METHODS: Using Census Household Pulse Surveys from emerging adults aged 18 to 24 years (N = 71,885) and administrative data from April 23, 2020 to March 29, 2021, we estimated logistic regression models adjusted for state and wave fixed effects. RESULTS: Rates of elevated anxiety and depressive symptoms rose dramatically among emerging adults during the first year of the COVID-19 pandemic. Results indicate that potential contextual stressors-state COVID-19 rates and state COVID-19 mitigation policies limiting social interactions (stay-at-home orders, restaurant closures, large gathering restrictions, and mask mandates)-were not significantly associated with symptoms. In contrast, personal economic stressors (nonemployment, household income loss, food insecurity, housing insecurity, lacking health insurance) and disruptions to education were associated significantly with elevated anxiety and depressive symptoms, with greater numbers of stressors associated with worse well-being. DISCUSSION: Emerging adults reported persistently high levels of elevated anxiety and depressive symptoms during the first year of the pandemic, outcomes associated not with COVID-19 rates or mitigation policies, but with economic inequities, and other personal stressors heightened by the pandemic. Providing targeted support for young adults, including ensuring access to mental health supports, health care, and economic relief, is critical.

Screening for Intimate Partner Violence.

More than a decade has passed since the Affordable Care Act (ACA) required screening for intimate partner violence (IPV) and related counseling with no co-payment and eliminated insurers' ability to deny coverage based on preexisting conditions, including IPV. While screening for IPV and coverage of services became more feasible after implementation of the ACA, in theory, gaps remain. Nearly half of women in the United States report that they have experienced IPV in their lifetime, but the true number is likely even higher. In this column, I review screening recommendations for IPV and related policies, gaps in research on groups at higher risk, systems-level approaches to increase screening, and recommendations from professional organizations on screening and supporting IPV survivors.

Affordable Care Act and Breastfeeding.

In 2010, the Patient Protection and Affordable Care Act was the first federal legislation to protect breastfeeding on a broad scale. Since its implementation, several provisions have been made, including the recent Providing Urgent Maternal Protections for Nursing Mothers (PUMP) Act, which went into effect in April 2023. In this column, I review current breastfeeding recommendations, the policy landscape related to state and federal laws that protect breastfeeding, research findings on breastfeeding policies, and recommendations from professional organizations that support women's breastfeeding decisions.

Current Evidence to Guide Practice, Policy, and Research: Extending Medicaid Coverage in the Postpartum Period.

The American Rescue Plan Act of 2021, signed into law on March 11, 2021, allowed states to extend Medicaid for a full 12 months in the postpartum period. As of October 2022, 15 states have yet to endorse this state option. In this column, I review Medicaid eligibility requirements, the proposed policy changes, and summarize research findings and recommendations from professional organizations supporting the permanent extension of Medicaid in the postpartum period.

Associations Between State-Level Changes in Reproductive Health Services and Indicators of Severe Maternal Morbidity.

This cross-sectional study examines the legislative, state, economic, and racial factors in increased severe maternal morbidity risk in pregnant individuals.

BRCA1/2 testing among young women with breast cancer in Massachusetts, 2010-2013: An observational study using state cancer registry and All-Payer claims data.

BACKGROUND: Testing for BRCA1/2 pathogenic variants is recommended for women aged ≤45 years with breast cancer. Some studies have found racial/ethnic and socioeconomic disparities in testing. We linked Massachusetts' All-Payer Claims Database with Massachusetts Cancer Registry data to assess factors associated with BRCA1/2 testing among young women with breast cancer in Massachusetts, a state with high levels of access to care and equitable insurance coverage of breast cancer gene (BRCA) testing. METHODS: We identified breast cancer diagnoses in the Massachusetts Cancer Registry from 2010 to 2013 and linked registry data with Massachusetts All-Payer Claims Data from 2010 to 2014 among women aged ≤45 years with private insurance or Medicaid. We used multivariable logistic regression to examine factors associated with BRCA1/2 testing within 6 months of diagnosis. RESULTS: The study population included 2424 women; 80.3% were identified as non-Hispanic White, 6.4% non-Hispanic Black, and 6.3% Hispanic. Overall, 54.9% received BRCA1/2 testing within 6 months of breast cancer diagnosis. In adjusted analyses, non-Hispanic Black women had less than half the odds of testing compared with non-Hispanic White women (adjusted odds ratio [OR] = 0.45, 95% CI = 0.31, 0.64). Medicaid-insured women had half the odds of testing compared with privately-insured women (OR = 0.51, 95% CI = 0.41, 0.63). Living in lower-income areas was also associated with lower odds of testing. Having an academically-affiliated oncology clinician was not associated with testing. CONCLUSION: Socioeconomic and racial/ethnic disparities exist in BRCA1/2 testing among women with breast cancer in Massachusetts, despite equitable insurance coverage of testing. Further research should examine whether disparities have persisted with growing testing awareness and availability over time.

Contested racial identity and the health of women and their infants.

Contested racial identity- self-identified race not matching socially-assigned race-may be an indication of experiences with racism. We aimed to understand the relationship between contested racial identity and women's health behaviors, health outcomes, and infant health outcomes. We used 2012-2015 Massachusetts Pregnancy Risk Assessment Monitoring System data on 5735 women linked with infants' birth certificates. We conducted regression analyses to examine associations between contested racial identity with pregnancy and infant health outcomes and further sub-analyses among women who had experienced a contested racial identity. A total of 901 (15.7%) women reported a contested racial identity. When compared to those who did not, women who had a contested racial identity had lower odds of initiating prenatal care in the first trimester (AOR: 0.76, 95% CI: 0.62, 0.95) and higher odds of smoking (AOR: 1.70, 95% CI: 1.32, 2.19). Among women who had experienced a contested racial identity, those who were socially-assigned as White had decreased odds of having a low birth weight baby (AOR: 0.52, 95% CI: 0.28, 0.99) when compared to those socially-assigned as non-White. Contested racial identity is common; it affects the behaviors that women engage in and the outcomes they experience postpartum. Further, we found that there is a potential benefit to a White social ascription. This work adds to growing evidence of the impact of racism on maternal and infant health in the United States.

ACA and Medicaid Expansion Increased Breast Pump Claims and Breastfeeding for Women with Public and Private Insurance.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) required new private insurance plans to provide breast pumps with no cost sharing beginning August 2012, and in January 2014 expanded this requirement to Marketplace plans and expanded Medicaid coverage. We first examined the associations between the ACA reforms in 2012 and 2014 with rates of breast pump claims between Medicaid enrollees and those with private insurance. We next examined the associations between the monthly rate of breast pump claims with breastfeeding initiation and duration by insurance type. METHODS: Using 2011-2015 public and private health insurance claims in All-Payer Claims Databases from Massachusetts, Maine, and New Hampshire, we conducted a linear regression model to evaluate the associations between the 2012 and 2014 ACA health insurance reforms with rates of breast pump claims by health insurance status. We then linked the monthly rates of breast pump claims per 1,000 live births to the Pregnancy Risk Assessment Monitoring System with self-reported breastfeeding initiation and duration. We estimated probit regression models to examine the associations between monthly rates of breast pump claims per state, insurance type, age group, and breastfeeding outcomes. RESULTS: For the 2012 ACA reform, breast pump claims increased by 183.4 (143.7-223.1) per 1,000 live births for women with private insurance, but decreased for Medicaid enrollees (-99.3 [-139.0 to -59.6]). For the 2014 ACA reforms, the opening of health insurance Marketplaces had no effect on breast pump claims for women with private insurance (8.3 [-43.6 to 60.2]), whereas Medicaid expansion increased claims by 119.4 (67.5-171.3) per 1,000 live births for Medicaid enrollees. Every additional 10 breast pump claims per 1,000 live births was associated with a 1.08 percentage point increase in breastfeeding initiation among women with private insurance (0.108 [0.018-0.198]), but not Medicaid enrollees (0.076 [-0.078 to 0.230]). In contrast, every additional 10 breast pump claims per 1,000 live births was associated with a 1.79 percentage point increase in breastfeeding for 4 or more weeks for women with private insurance (0.179 [0.063-0.294]) and a 2.05 percentage point increase among women with public insurance (0.205 [0.033-0.376]). Interaction analysis revealed no significant differences in associations by insurance type across breastfeeding outcomes. CONCLUSIONS: The ACA breastfeeding coverage requirements fill a gap for women wanting to obtain a breast pump to support breastfeeding. The monthly rate of breast pump claims, as an indicator of access, translated into higher levels of breastfeeding for women with private and public insurance with the potential to reduce socioeconomic disparities.

Impact of Medicaid Eligibility Changes on Long-acting Reversible Contraception Use in Massachusetts and Maine.

BACKGROUND: Availability of long-acting reversible contraception (LARC) is an important indicator of high-quality women's health care. There are limited data on the impact of state-level Medicaid eligibility changes on LARC use. STUDY DESIGN: We used All-Payers Claims Databases to examine LARC insertions among women enrolled in Medicaid in Massachusetts, which expanded Medicaid in 2014, and Maine, which restricted Medicaid eligibility in 2013. We used interrupted time series (ITS) analyses to determine the impact of Medicaid eligibility changes on level and trends in LARC insertions in these states. RESULTS: In Massachusetts, graphical evidence demonstrates that after Medicaid expansion, there was an immediate increase in mean monthly LARC insertions and insertions per 1000 enrollees. In ITS regression adjusting for age, LARC insertions per enrollee increased immediately after Medicaid expansion by 32% (P<0.001). After expansion, as the number of enrollees continued to rise, mean monthly LARC insertions rose, but there was a slightly decreasing trend in insertions per enrollee by 1% per month (P<0.001). In Maine, graphical evidence shows that initial reductions in Medicaid eligibility were associated with an immediate drop in LARC insertion numbers and rates per 1000, with ITS regression demonstrating an immediate 17% drop in insertions per enrollee (P<0.001). As Maine's Medicaid enrollment declined from 2013 to 2015, the number of LARC insertions remained flat, leading to an increasing trend in insertions per enrollee, similar to pre-2013 trends (P=0.17). CONCLUSIONS: Medicaid eligibility changes were associated with immediate changes in LARC uptake. Medicaid expansion may help ensure access to this effective contraceptive method.

Associations between ACA-related policies and a clinical recommendation with HPV vaccine initiation.

PURPOSE: We examined associations between the 2010 Affordable Care Act (ACA) provisions, 2011 Advisory Committee on Immunization Practices (ACIP) recommendation, and 2014 ACA-related health insurance reforms with HPV vaccine initiation rates by sex and health insurance type. METHODS: Using 2009-2015 public and private health insurance claims for 551,764 males and females aged 9-26 years (referred to as youth) from Maine, New Hampshire, and Massachusetts, we conducted linear regression models to examine the associations between three policy changes and HPV vaccine initiation rates by sex and health insurance type. RESULTS: In 2009, HPV vaccine initiation rates for males and females were 0.003 and 0.604 per 100 enrollees, respectively. Among males, the 2010 ACA provisions and ACIP recommendation were associated with significant increases in HPV vaccine uptake among those with private plans (0.207 [0.137, 0.278] and 0.419 [0.353, 0.486], respectively) and Medicaid (0.157 [0.083, 0.230] and 0.322 [0.257, 0.386], respectively). Among females, the 2010 ACA provisions were associated with significant increases in HPV vaccine uptake among Medicaid enrollees only (0.123 [0.033, 0.214]). The ACA-related health insurance reforms were associated with significant increases in HPV vaccine uptake for male and female Medicaid enrollees (0.257 [0.137, 0.377] and 0.214 [0.102, 0.327], respectively), but no differences among privately insured youth. By 2015, there were no differences in HPV vaccine initiation rates between males (0.278) and females (0.305). CONCLUSIONS: Both ACA provisions and the ACIP recommendation were associated with significant increases in HPV vaccine initiation rates among privately and publicly insured males in three New England states, closing the gender gap. In contrast, females and youth with private insurance did not exhibit the same changes in HPV vaccine uptake over the study period.

Associations between insurance-related affordable care act policy changes with HPV vaccine completion.

BACKGROUND: Although all 11- or 12-year-olds in the US were recommended to receive a 3-dose series of the human papillomavirus (HPV) vaccine within a 12-month period prior to 2016, rates of completion of the HPV vaccine series remained suboptimal. The effects of the Affordable Care Act (ACA), including private insurance coverage with no cost-sharing and health insurance expansions, on HPV vaccine completion are largely unknown. The aim of this study was to examine the associations between the ACA's 2010 provisions and 2014 insurance expansions with HPV vaccine completion by sex and health insurance type. METHODS: Using 2009-2015 public and private health insurance claims from Maine, New Hampshire, and Massachusetts, we identified 9-to-26-year-olds who had at least one HPV vaccine dose. We conducted a logistic regression model to examine the associations between the ACA policy changes with HPV vaccine completion (defined as receiving a 3-dose series within 12 months from the date of initiation) as well as interactions by sex and health insurance type. RESULTS: Over the study period, among females and males who initiated the HPV vaccine, 27.6 and 28.0%, respectively, completed the series within 12 months. Among females, the 2010 ACA provision was associated with a 4.3 percentage point increases in HPV vaccine completion for the privately-insured (0.043; 95% CI: 0.036-0.061) and a 5.7 percentage point increase for Medicaid enrollees (0.057; 95% CI: 0.032-0.081). The 2014 health insurance expansions were associated with a 9.4 percentage point increase in vaccine completion for females with private insurance (0.094; 95% CI: 0.082-0.107) and a 8.5 percentage point increase for Medicaid enrollees (0.085; 95% CI: 0.068-0.102). Among males, the 2014 ACA reforms were associated with a 5.1 percentage point increase in HPV vaccine completion for the privately-insured (0.051; 95% CI: 0.039-0.063) and a 3.4 percentage point increase for Medicaid enrollees (0.034; 95% CI: 0.017-0.050). In a sensitivity analysis, findings were similar with HPV vaccine completion within 18 months. CONCLUSIONS: Despite low HPV vaccine completion overall, both sets of ACA provisions were associated with increases in completion among females and males. Our results suggest that expanding Medicaid across the remaining states could increase HPV vaccine completion among publicly-insured youth and prevent HPV-related cancers.

Maternal Health Behaviors and Infant Health Outcomes Among Arab American and Non-Hispanic White Mothers in Massachusetts, 2012-2016.

OBJECTIVES: The health profile of Arab American mothers and infants may differ from that of non-Arab American mothers and infants in the United States as a result of social stigma experienced in the historical and current sociopolitical climate. The objective of our study was to compare maternal health behaviors, maternal health outcomes, and infant health outcomes of Arab American mothers and non-Hispanic white mothers in Massachusetts and to assess the role of nativity as an effect modifier. METHODS: Using data from Massachusetts birth certificates (2012-2016), we conducted adjusted logistic and linear regression models for maternal health behaviors, maternal health outcomes, and infant health outcomes. We used Arab ethnicity as the exposure of interest and nativity as an effect modifier. RESULTS: Arab American mothers had higher odds than non-Hispanic white mothers of initiating breastfeeding (adjusted odds ratio [aOR] = 2.61; 95% CI, 2.39-2.86), giving birth to small-for-gestational-age infants (aOR = 1.28; 95% CI, 1.18-1.39), and having gestational diabetes (aOR = 1.31; 95% CI, 1.20-1.44). Among Arab American mothers, non-US-born mothers had higher odds than US-born mothers of having gestational diabetes (aOR = 1.80; 95% CI, 1.33-2.44) and lower odds of initiating prenatal care in the first trimester (aOR = 0.41; 95% CI, 0.33-0.50). In linear regression models, infants born to non-US-born Arab American mothers weighed 42.1 g (95% CI, -75.8 to -8.4 g) less than infants born to US-born Arab American mothers. CONCLUSION: Although Arab American mothers engage in positive health behaviors, non-US-born mothers had poorer maternal health outcomes and access to prenatal care than US-born mothers, suggesting the need for targeted interventions for non-US-born Arab American mothers.

Impact of State-Level Changes on Maternal Mortality: A Population-Based, Quasi-Experimental Study.

INTRODUCTION: Recent increases in maternal mortality and persistent disparities have led to speculation about why the U.S. has higher rates than most high-income countries. The aim was to examine the impact of changes in state-level factors plausibly linked to maternal mortality on overall rates and by race/ethnicity. METHODS: This quasi-experimental, population-based, difference-in-differences study used 2007-2015 National Vital Statistics System microdata mortality files from 38 states and DC. The primary exposures were 5 state-level sexual and reproductive health indicators and 6 health and economic conditions. Maternal mortality rate was defined as number of deaths of women while pregnant or within 42 days of termination of pregnancy per 100,000 live births. A difference-in-differences zero-inflated negative binomial regression model was estimated using the race/ethnicity-age-state-year population as the denominator and adjusting for race/ethnicity, age, state, and year. Data were analyzed in 2017-2018. RESULTS: There were 4,767 deaths among women up to age 44 years, resulting in a maternal mortality rate of 17.9. Reducing the proportion of Planned Parenthood clinics by 20% from the state-year mean increased the maternal mortality rate by 8% (incidence rate ratio, 1.08; 95% CI=1.04, 1.12). States that enacted legislation to restrict abortions based on gestational age increased the maternal mortality rate by 38% (incidence rate ratio, 1.38; 95% CI=1.03, 1.84). Planned Parenthood clinic closures negatively impacted all women, increasing mortality by 6%-15% across racial/ethnic groups, whereas gestational limits primarily increased mortality among white women. CONCLUSIONS: Recent fiscal and legislative changes reducing women's access to family planning and reproductive health services have contributed to rising maternal mortality rates.

Rural-urban disparities in colonoscopies after the elimination of patient cost-sharing by the Affordable Care Act.

INTRODUCTION: Improving the prevention and early detection of colorectal cancer is a priority for reducing rural-urban disparities in colorectal cancer mortality. By eliminating out-of-pocket (OOP) costs for preventive colonoscopies, the Affordable Care Act (ACA) could have reduced rural-urban disparities in screening. METHODS: We used the Maine Health Data Organization All-Payer Claims Database including all commercially-insured and Medicare beneficiaries aged 50-75 between 2009 and 2012. Rural-urban commuting areas were used to classify rural/urban residence. ICD-9 and CPT codes identified colonoscopies. We summed all OOP payments per patient-day. An interrupted time series model estimated the impact of the ACA on trends in rural-urban disparities in colonoscopy rates and OOP costs. RESULTS: Before the ACA, colonoscopy rates were 16% lower in rural than urban areas (5.1% vs. 6.1% of enrollees annually) and median OOP costs were nearly double ($195 vs. $98). The ACA reduced median OOP payments by $94 (p = .001) initially and $4 monthly (p = .038) in rural areas, and $63 (p < .001) in urban areas. The rural-urban gap in OOP payments dropped by $4 monthly (p = .007). The ACA also reduced rural-urban disparities in colonoscopy rates (disparity decrease of 0.005 (6%) monthly, p < .001). The rural-urban gap in colonoscopy rates declined 40% relative to the pre-ACA period by December 2012. CONCLUSIONS: The ACA was associated with significant reductions in rural-urban disparities in colonoscopies in Maine, suggesting that OOP costs are an important barrier for rural residents. Further research is needed to determine whether increased uptake, particularly in rural areas, translated into better patient outcomes for colorectal cancer.

The downstream effects of state tobacco control policies on maternal smoking during pregnancy and birth outcomes.

BACKGROUND: Research has demonstrated that the implementation of tobacco control policies is associated with improved birth outcomes. Ascertainment of prenatal smoking on the US birth certificate has changed over the past decade to record smoking across each trimester. METHODS: Using 2005-2015 birth certificate data on 26,436,541 singletons from 47 states and DC linked to state-level cigarette taxes and smoke-free legislation, we conducted conditional mixed-process models to examine the impact of tobacco control policies on prenatal smoking and quitting, then on the associated changes in birth outcomes. We included interactions between race/ethnicity, education, and taxes and present average marginal effects. RESULTS: Among white and black mothers with less than a high school degree, 36.0% and 14.1%, respectively, smoked during the first trimester and their babies had the poorest birth outcomes. However, they were the most responsive to cigarette taxes. Every $1.00 increase in taxes was associated with a 3.45 percentage point decrease in prenatal smoking among white mothers and a 1.20 percentage point decrease among black mothers. These reductions translated to increases in birth weight by 4.19 g for babies born to white mothers and 0.89 g for babies born to black mothers. Among smokers, there was some evidence that taxes increased quitting and improved birth outcomes, although most associations were not statistically significant. We found limited effects of smoke-free legislation on smoking, quitting or birth outcomes. CONCLUSIONS: Cigarette taxes continue to have important downstream effects on reducing prenatal smoking and improving birth outcomes among the most vulnerable mothers and infants.

Impact of state tobacco control policies on birth defects.

While research has demonstrated the effects of tobacco control policies on birth outcomes, there is little known about their impact on birth defects. Using 2005-2015 natality data on 26,334,854 singletons from 47 US states and District of Columbia linked to state-level cigarette taxes and smoke-free restaurant legislation, we examined the impact of tobacco control policies on birth defects by maternal race/ethnicity and education. We found that among white women with less than a high school degree, every $1.00 increase in cigarette taxes reduced prenatal smoking by 3.48 percentage points and reduced the risk of their infant having any birth defect by 0.0023 percentage points. Tax increases also reduced the risk of cyanotic heart defects, cleft palate, gastroschisis, and limb reduction. We found no evidence for associations between the enactment of smoke-free legislation, prenatal smoking and birth defects. Our findings suggest that state cigarette taxes are a population-level intervention that can help reduce prenatal smoking and the risk of birth defects.

Associations Between State Tobacco Control Policies and Adolescent ENDS Use.

BACKGROUND: Despite an increase in adolescent use of electronic nicotine delivery systems (ENDS), little is known about the role of tobacco control policies on ENDS use. OBJECTIVE: For aim 1, we examined how trends in adolescent use of cigarettes were affected by the introduction of ENDS; for aim 2, we examined the associations between ENDS age restrictions, cigarette taxes, and smoke-free legislation and adolescent use of ENDS and cigarettes. DESIGN AND SETTING: Repeated cross-sections of the 1999-2015 Youth Risk Behavior Surveys linked to state-level tobacco control policies. PARTICIPANTS: 938 486 adolescents aged 14 to 18 years from 45 states. MAIN OUTCOME MEASURES: For aim 1, we examined adolescent use of cigarettes. For aim 2, we examined adolescent use of ENDS, only ENDS, and cigarettes. RESULTS: We found there was an overall decreasing trend in adolescent use of cigarettes, but the actual decline was greater than the predicted decline for 17- and 18-year-olds. While we found no associations between ENDS use and ENDS age restrictions or cigarette taxes, ENDS use was 3.8 percentage points higher in those states with smoke-free legislation for combustible tobacco products. CONCLUSIONS: Our findings highlight that ENDS age restrictions may not be adequate to curb ENDS use and additional local- and state-level policies governing ENDS are needed.

US state cigarette tax increases and smoke-free legislation in relation to cigarette expenditure across household socio-economic circumstances: a quasi-experimental study.

BACKGROUND AND AIMS: While research has focused on outcomes of tobacco control policies, less is known about the mechanisms by which policies may affect tobacco use. We estimated the associations of changes in cigarette taxes and smoke-free legislation with (1) any household cigarette expenditure and (2) the level of household expenditure on cigarettes, as well as (3) tested interactions with socio-economic circumstances. DESIGN: Difference-in-differences regression models to estimate the associations between changes in US state cigarette taxes and smoke-free legislation with changes in household expenditure on cigarettes. SETTING: Forty US states and District of Columbia. PARTICIPANTS: From annual, cross-sectional surveys (with a longitudinal component) between 2000 and 2014, 128 138 households interviewed quarterly in the Consumer Expenditure Survey. MEASUREMENTS: Dependent measures included any household cigarette expenditure, expenditure in real dollars and budget share of cigarette expenditure. Policy measures included state cigarette taxes and 100% smoke-free legislation. Covariates included respondent age, race/ethnicity, sex; household education; poverty level; family structure; and number of children and adults. FINDINGS: Every $1.00 cigarette tax increase was associated with a 1.5 percentage point (-0.028, -0.002) reduction in any cigarette expenditure and an increase of 0.1% (0.1%, 0.1%) budget share and $10.11 ($8.38, $11.84) absolute expenditure. The association with absolute expenditure was stronger among smoking households above poverty level ($10.73; $8.94, $12.51) than below ($4.72; $2.37, $7.07). The enactment of smoke-free legislation was associated with $2.33 (-$4.56, -$0.10) less expenditure, but not with any expenditure (0.1%; -1.6%, 1.8%) or budget share (-0.1%; -0.1%, 0.1%). The association with absolute expenditure was stronger among households above poverty level (-$2.62; -$4.95, -$0.29) than below (-$0.34; -$4.27, $3.58) CONCLUSION: Cigarette tax increases in the United States between 2000 and 2014 may have reduced smoking prevalence due to an absolute and relative increase in household tobacco expenditure while smoke-free policies appear to have led to a reduction in expenditure. Although tax increases had a stronger impact on absolute expenditure among households above the poverty level, impact on relative expenditure was similar, and consequences for socio-economic inequalities in smoking will vary based on the broader financial situation of households.