Why is Maternal Smoking in Appalachia Pervasive?

We analyze the prevalence of maternal smoking in Appalachia relative to the rest of USA. Regression results from restricted-use Centers for Disease Control and Prevention natality data show that Appalachian maternal smoking rates substantially exceed the average national rate; the rate in West Virginia is substantially higher than in the rest of Appalachia. Controlling for observable maternal characteristics like age, education, and race, partially closes this gap, but not for the entire period of analysis. Controlling for state-level tobacco policies also does not fully explain observed regional differences. Peer effects like cultural factors unique to Appalachia may explain some of the observed differences.