Rural adults are more likely to smoke cigarettes (24.1% vs 21%, respectively) and use smokeless tobacco (5.6% vs2.3%, respectively) than urban adults.[3] Adults living in rural areas are also more likely to have lower levels of education, to have lower income, to be white, and to work in outdoor occupations.[3] The differences in tobacco use trends between rural and urban populations were not always so pronounced – it became more discernible between 2007 and 2014 when clean indoor air policies were becoming more prominent in the United States.[3] A 2017 study examining data from the National Survey on Drug Use and Health regarding cigarette smoking trends yielded models to demonstrate the difference in smoking prevalence and whether the differences remained between rural and urban populations after demographic adjustment. Data between the years 2007 and 2014 were used to ensure consistency and incorporate recent trends of tobacco use. Data showed a slower and non-statistically significant decline in prevalence of smoking for rural populations while the prevalence decreased substantially for urban populations, creating a substantial gap between smoking rates for rural and urban populations.[3] This research also helps portray the lack of improvement of tobacco cessation in rural populations. Unadjusted cigarette smoking prevalence dropped significantly from 24% to 20% for urban populations, while rural populations saw an insignificant decrease between the same years of 2007 and 2014. The study also suggests that rural residents should be treated as a vulnerable population and rural residency as a greater risk factor for tobacco initiation and usage.[3] The decrease in societal acceptance of smoking stigmatizes those still smoking, even in conditions where it’s difficult to stop smoking, and this stigmatization can exacerbate health and social disparities.[3] Current best practices in tobacco control policy may not affect all populations with the same intensity or efficacy, and may need modifications to account for the impacts of rural residency on smoking prevalence. Differentiating between the tobacco usage trends in rural and urban populations will help provide a framework for understanding policy efficaciousness and why certain patterns exist. This report will explore those differences as well as what point-of-sale tobacco control policies may help best address rural tobacco use.

Rural vs. Urban Use of Tobacco

Cigarettes are still the primary tobacco product being used by adults in the United States.[17] The tobacco landscape has been changing in recent years with the introduction of products such as e-cigarettes and cigarillos. The distinction between rural and urban areas is that rural residents use cigarettes and smokeless tobacco at higher rates; cigarettes are still the most popular tobacco product, but urban residents have higher cigarillo and hookah usage than rural residents. Surveys found that there is no significant difference in the use of e-cigarettes, cigars, pipes, or menthol cigarettes.[17] The rural-urban difference was more noticeable in men, with 12% rural men using smokeless tobacco versus 4.3% of urban men. It is critical to monitor what types of tobacco products are being used in rural areas because they carry different health risks.[17] Most research has been focused on national trends or populated areas, neglecting rural product usage. There has also been little to no research on rural resident dual use of emerging tobacco products. Understanding tobacco product usage and prevalence is crucial to addressing rural health disparities. It’s important that new tobacco policies not disproportionately benefit urban populations or exacerbate the rural-urban disparities.

Adolescent Tobacco Use in Urban Versus Rural Areas

Cigarette usage has declined for both urban and rural residents over time but more so for urban adolescents.[18],[19] Despite the decrease, rural adolescents are 1.4 times more likely to use cigarettes and three times more likely to use smokeless tobacco products than urban adolescents, 6.3% versus 2.1% respectively.[16],[19] In contrast, urban adolescents are 0.8 times more likely to use hookah.[19],[20]

Surveys conducted on rural and urban adolescents between 2008-2010 and 2014-2016 depict significant differences in smoking prevalence. Between 2008 and 2010, 10.9% of rural adolescents smoked while 8.3% of urban adolescents smoked. From 2014 to 2016, the prevalence was 7.3% and 3.7%, for rural and urban adolescents respectively.[20] The gap between rural and urban youth smoking rates widened and this gap persisted even after the adjustment of socioeconomic factors that contribute to smoking. This widening gap has serious implications for rural morbidity and mortality. Multivariable analysis also found a statistically significant interaction between urban or rural residence and smoking behavior. The odds of cigarette smoking decreased for both rural and urban youth, but the magnitude of change was smaller for rural youth.[20]

Image sourced from Stanford University’s Research into the Impact of Tobacco Advertising

Utilizing a social-ecological framework to examine tobacco usage provides a context to view how smoking-specific factors vary at individual, peer, family, and community levels between rural and urban youth. A study examining adolescents in Florida in 2012 found that rural adolescents have a younger tobacco initiation age and also report smoking more, such as daily smoking and consistently in the past 30 days.[1] Rural adolescents were also more likely to report that someone besides them smoked at home, with smoking being permitted at home and having a parent that has offered them a cigarette.[1] Fewer rural adolescents reported that parents talked to them about the dangers of tobacco compared to metro youth. The rural youth were also more likely to be allowed to smoke in the home with a reported rate of 15.7% versus 9.2% of the urban youth.[1]

Studies examining the culture of tobacco supporting youth utilization provide insights into the factors maintaining the rural-urban gap. Between the Fall of 2014 and Spring of 2015, focus groups of middle and high schoolers in Appalachian counties of Kentucky were given open-ended questions in group sessions to explore youth perceptions of tobacco.[7] Focus groups in historically tobacco growing regions described tobacco culture as being reinforced by family and community practices. Specifically, they found the following factors that may affect smoking initiation in rural areas:

  • Tobacco is accepted in the community and at home, creating an environment for youth experimentation
  • Adults ignore youth tobacco use
  • Adults do not enforce tobacco-free policies at school
  • Adults use tobacco with students
  • Smoking with an adult is considered a rite of passage [7]

The research suggests that youth susceptibility to tobacco initiation is shaped by social and community influences, like family tobacco usage and tobacco accessibility. Examining youth views on tobacco is critical because 80% of lifetime tobacco users will start using before the age of 18. Understanding the opinions of adolescents in areas with high tobacco usage might aid in creating culturally relevant messages to apply to intervention programs. This study also showed the need to communicate to adults to modify their behavior, to reduce the facilitation of youth tobacco access.[7]  

Image sourced from Stanford University’s Research into the Impact of Tobacco Advertising

The use of electronic cigarettes is on the rise for American youth. E-cigarette use is now more common nationally among high school students than cigarettes and smokeless tobacco, and the same trends have been found in rural areas.[11] The increase in e-cigarettes use is counterintuitive after the public health successes in reducing the use of tobacco products in the last 50 years. The major public health concern stems from the threat of a new generation of nicotine users, and a re-normalization of smoking. Learn more about e-cigarettes here.

A study conducted in 2017 found that sociodemographics, cigarette taxes, and tobacco advertisement exposure are all significant predictors of adolescent tobacco use but these factors do not explain entirely the urban-rural disparities.[13] Tobacco advertisement exposure was significantly positively associated with all current tobacco outcomes for adolescents except for e-cigarettes.[13] County median household income was negatively associated with all forms of current tobacco use except for e-cigarettes.[19] These trends warrant further investigation as to why e-cigarettes seem to be exempt from tobacco advertisement and household income patterns.

The limitation of many of these surveys and focus groups previously mentioned is that they were conducted in regions of Ohio, Tennessee, and Florida so not all results are generalizable to every adolescent in America. Urban populations also vary by demographics and cultural practices throughout the United States, so the survey responses may not be representative of all adolescent tobacco practices.

Context for Differential Tobacco Usage

There are many factors that influence higher rural tobacco use rates at the community and structural level. Tobacco growing states might be more inclined to use tobacco because tobacco is culturally embedded.[19] Rural, tobacco-growing areas are disproportionately affected by tobacco use and weak tobacco control policies.[5] Tobacco producing states lag behind others in implementing progressive tobacco control policies. The differential tobacco usage by urban or rural residence could be due in part to smoke-free policy and enforcement stringency.[19] School tobacco policies might also influence what types of tobacco products are used. School policies are variable and could reflect the community culture in regard to tobacco use. With the rural-urban difference in youth cigarette smoking increasing over time, it’s crucial to implement best practices like comprehensive tobacco-free school policies and higher tobacco taxes in rural areas.[20] However, to reduce adolescent tobacco use initiation and reduce the disparities, prevention methods need to be targeted towards rural residents.

POS Tobacco Marketing in Rural and Urban Areas, Differential Cigarette Advertisements

Image sourced from Stanford University’s Research into the Impact of Tobacco Advertising

Due to the many restrictions placed on cigarette advertising, the tobacco industry focuses their marketing dollars on point-of-sale tobacco (POS) marketing and promotion. Tobacco use rates are higher among rural communities, people in lower socioeconomic statuses, and racial/ethnic minority groups, and yet these vulnerable populations are targeted by the tobacco industry. For example, external POS advertisements disproportionately target economically disadvantaged African American communities.[15],[18] A study conducted in 2014 sampled retailers from rural and urban communities of Ohio to determine differential POS marketing tactics in association with community-level demographics.[15] Results from the study also show that urban areas experience greater POS marketing for alternative products while rural areas receive marketing for cigarettes and smokeless tobacco.[15] Smokeless tobacco products were also targeted towards neighborhoods with more white residents,[8] while lower-income neighborhoods and neighborhoods with more African American residents had more inducements to start smoking and keep smoking.[8] A 2008 Boston study also found that increased tobacco marketing was generally associated with communities with more low-income residents and African Americans. These studies reinforce the importance of understanding how environmental cues affect disparities in tobacco use. Differential marketing dependent on a community’s demographics may perpetuate already existing tobacco-related health disparities. This presents a need to research how low-income, rural communities are affected specifically, not just in comparison to urban communities. Future research should also examine whether these neighborhood trends of targeted marketing dependent on community demographics are mutually exclusive or concurrent.

Differences in the tobacco retailer landscape in urban and rural areas also affect how adolescents are exposed to tobacco. A 2018 survey of rural and urban adolescent males in Ohio was conducted to ascertain the relationship between self-reported tobacco exposures and actual geographically estimated exposure. The survey found that rural adolescents had higher self-reported exposure while urban adolescents had more potential to be exposed to tobacco retailers between home and school. This suggests that differential tobacco policy will be beneficial for rural and urban communities; rural communities will benefit from POS marketing limitations while urban areas would benefit more from tobacco retailer density limitations.

Policy

Knowing what types of tobacco products are popular and why they continue to be popular specifically in urban or rural areas can help construct comprehensive intervention programs. As e-cigarettes are increasing in usage regardless of urban or rural residence, age restriction policies (e.g. raising the minimum legal sales age for all tobacco products, including e-cigarettes, to 21) may help address the rising prevalence rates. The FDA should also regulate the promotion and sale of tobacco products more stringently.[4] However, these policies can also be implemented at the state and local level as well. As suggested by Best Practices for Comprehensive Tobacco Control Programs, interventions to prevent tobacco use among youth should focus on:

  • Increasing the unit price of tobacco products
  • Conducting mass-media education campaigns
  • Mobilizing the community to restrict minors’ access to tobacco

In addition, regulating the retail environment could help reduce disparities, in part by reducing some of the tobacco industry’s geodemographic targeting.[8] To explore how promising and evidence-based point-of-sale policies may impact rural areas:

Pricing policies: In addition to raising excise taxes, prohibiting price promotions would limit the available price reduction strategies smokers use to buy tobacco. This could in turn reduce someone’s supply of tobacco and likelihood of using. Distance and price promotions play a role in tobacco product purchase quantity. A study conducted in Ohio in 2018 found that people bought more cigarette packs if they lived farther from a tobacco retailer and if they could use a price promotion. Travel distances are generally larger in rural areas compared to urban areas so rural residents tend to buy more in one purchase.[4] The presence of price promotions and large distances between participants’ homes and the nearest tobacco outlet was associated with substantially larger purchases. This indicates that policies restricting the use of price promotions could impact the purchasing behavior of tobacco users in rural areas that live farther away from tobacco outlets in addition to the expected impact from raising prices. It could also impact disparities currently seen with higher rates of cigarette and smokeless tobacco use in rural areas. This infographic illustrates community strategies to potentially decrease tobacco use and curb the exposure to tobacco marketing. Instituting a minimum floor price and prohibiting price promotions can increase prices and cessation rates. Learn more about pricing policies here.

Restricting POS Advertising: Reducing storefront tobacco advertisements may also help stem the tobacco use disparities, limiting advertisements for products and price promotions that target rural and low-income customers. Part of the marketing disparities may be due to the tobacco industry’s geodemographic targeting, but they can be reinforced by economic conditions and consumer demand. The intersection of demand, marketing, and community demographics influence the type of retail environment created for residents and further studying this interplay may present valuable information to help further tobacco cessation efforts.

While First Amendment commercial free speech concerns do not allow the regulation of the content of advertising,jurisdiction can regulate the total amount of advertising allowed on the exterior or tobacco retailers through content-neutral sign ordinances that limit the space all ads (regardless of content) can cover to a certain percentage (e.g. 25%) of the window space or exterior. Learn more about what this looks like in Orangeburg, SC. To work within the First Amendment restrictions, localities and states can also still restrict advertising by time, place, and manner. The Public Health Law Center’s guide for restricting tobacco advertising suggests Time, Place and Manner restrictions could potentially be effective for both rural and urban youth. As urban youth report a denser concentration of tobacco retailers on their path between home and school, timing the visibility of advertisements may limit students’ exposures to tobacco marketing. For rural youth who see fewer tobacco retailers on a daily basis, limiting the proximity of advertisements to the point-of-sale may prove beneficial. Learn more here.

Restricting the number, type, and location of tobacco retailers  

This infographic illustrates community strategies to potentially decrease tobacco use and curb the exposure to tobacco marketing by limiting tobacco retailer density. These strategies may remove some retailers from rural areas, but research also suggests that they may be more effective in urban areas. However, some rural areas such as Rock County, MN have found success in prohibiting the sale of tobacco in pharmacies and prohibiting tobacco retailers from locating near schools or other youth-oriented facilities.

Restricting the Sale of Flavored Tobacco Products

The 2009 Family Smoking and Tobacco Prevention Act banned the sale of cigarettes with “characterizing” flavors other than menthol or tobacco. However, other flavored tobacco products (smokeless tobacco, little cigars and cigarillos, e-cigarettes, hookah, etc.) have remained on the market and become much more prevalent in the years since and are sold in an array of flavors that range from fruit flavors to candy or confectionery flavors.National data show that 80% of youth who have ever used a tobacco product started with a flavored product. While studies have not examined rural tobacco use of flavored products in particular, implementing policies that limit the availability of flavored tobacco products would likely help reduce rural tobacco use as well, especially given the rise in e-cigarette use among rural youth as well. This is another policy area where the early adopters of most flavored tobacco sales restrictions have been primarily urban to date (as on July 2019). To ensure rural areas are covered by these policies as well, special attention may need to raise awareness for the need for these policies in all places. Implementing flavored tobacco sales restrictions at the state and/or federal level with adequate enforcement mechanisms and funding would also help ensure that rural areas do not face another policy disparity. 

Restricting Product Placement

POS product displays can increase the perception of availability of tobacco products, increase brand recognition, and encourage impulse purchases. These results of tobacco product displays increase the likelihood of smoking and undermine quit attempts. Restricting the tobacco product placement would help limit the consequences of massive product marketing. Making sure products, including e-cigarettes and cigarillos, are not available in self-service displays could help restrict youth access to these products in both urban and rural stores alike.

While other strategies to limit product placement, such as display bans, have run into legal issues in the United States, they have been successful internationally and if implemented in the U.S., they could have an impact on rural tobacco use by reducing youth exposure to tobacco product displays in stores. Eliminating product displays could also help improve cessation success rates across rural and urban environments by reducing impulse purchases triggered by exposure to products in stores. Though overall product placement restrictions may not address the present disparities between urban and rural communities, the restrictions are commonsense measures that can help reduce visibility and youth exposure. To learn more about restricting product placement, click here.

Restricting Product Packaging

Restricting tobacco packaging that entices new, current, and recently quit smokers may help reduce the influence of the tobacco industry in the retail environment. While under federal law, cigarettes must be sold in packs of 20, nofederal standard exists for cigars. This allows companies to sell the products at extremely low prices, making them extremely appealing to price sensitive shoppers like youth. However, localities can establish a minimum pack size for cigars and cigarillos, which are most effective when paired with minimum price. While requiring cigarettes to be sold in plain packaging has seen success internationally, commercial free speech protections would likely prevent such regulations in the United States. Based off the 2018 survey of adolescent males in rural and urban Ohio, limiting product packaging in the retail environment may pose a promising barrier to stopping tobacco exposure and thus initiation among rural adolescents. Because rural male adolescents more frequently visit tobacco retailers, reducing their overall exposure to tobacco products may limit their likelihood of tobacco initiation. To learn more about restricting product packaging, click here.

Community Readiness

The current smoke-free policy landscape seems to be benefitting urban residents, so rural areas should develop policies that expand policy coverage to their communities and address the current disparities that account for the cultural and historical differences. A 2016 quasiexperimental study conducted in New Hampshire and Vermont among rural, blue-collar employees utilized a pilot study to create culturally relevant material for anti-tobacco interventions. The material deemed culturally appropriate by the pilot subjects was then displayed and disseminated to one employer while a control employer was not given the anti-tobacco materials. Creating tobacco cessation material with the inclusion of rural residents’ opinions helps make the information culturally relevant. This method of creating relevant cessation material may serve as a complement to tobacco policies and could also prepare a platform for future tobacco policy implementation. For example, collecting and analyzing community-specific data can help develop and implement culturally appropriate interventions. The CDC’s Best Practices for Comprehensive Tobacco Control Programs recommends funding community-based organizations to strengthen their capacity, which will help build relationships and empower locals. Community-based trials in rural communities to promote smoke-free policies produced hopeful results. Communities were provided policy development strategies tailored to their stage of readiness to help build capacity and disseminate science.[6] The community’s readiness is the degree to which a community is prepared to participate and succeed in enacting a smoke-free law. It was also important for communities to determine their limitations and values and beliefs to develop policies that were meaningful and effective. Communities that received the stage-specific intervention had higher community readiness scores and better policy outcomes. Nearly 1/3 of the intervention counties ended up implementing smoke-free laws for restaurants and bars and all workplaces. Creating and providing stage-specific, tailored policy-focused interventions to communities as a value-added resource helps promote readiness for future policies. Though the actual policy change was modest in the study, it is a step towards accelerating smoke-free policy changes. This type of readiness assessment and stage-specific tailored interventions may be useful for other types of policy work in rural areas as well, including policies affecting the tobacco retail environment. Identifying tobacco as a community-level health problem engages the community and helps lay the foundation for future policy change. More resources on the policy change process can be found here:

Conclusion

Research has established the tobacco use disparities between rural and urban communities. Differences in types of tobacco product use and point-of-sale marketing is apparent across the urban-rural divide. Despite the conclusive differences between smoking patterns of urban and rural residents, whether they be adults or adolescents, there is still a large gap in the literature. Future studies should be geared towards understanding the interplay of rural residence and health disparities and how policies can be adapted or developed to address these disparities. Though studies conducted within specific states may not be entirely representative of all urban and rural communities in the United States, the trends provide an insight into how tobacco policies and attitudes impact tobacco use patterns.

Image sourced from the CDC’s Best Practices for Comprehensive Tobacco Control Programs

Next Steps:

Certain strategies may help build an infrastructure to eliminate the apparent tobacco-related disparities. These strategies can include:

  • Conduct up-to-date surveillance to identify the populations disproportionately affected by tobacco use
  • Ensuring health equity is a constant and integral part of strategic planning for state and community organizations
  • Provide culturally competent technical assistance and training to local partners

Additional Resources: 

CounterTobacco.org is a project of Counter Tools. Counter Tools (logo)