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Rural Populations with High Rates of Tobacco Use

While all populations are negatively impacted by tobacco, several population groups have particularly high rates of tobacco use and may benefit from tobacco prevention and control programs.

African American Populations

Research indicates that while African American populations take up smoking later in life, they still suffer from more smoking-related diseases when compared to White populations. Based on the 2021 National Survey on Drug Use and Health, 24.8% of Black or African American adults aged 18 years or older reported use of any tobacco product in the past month, compared to 23.1% of White adults. In addition, African American children and adults experience greater exposure to secondhand smoke than other groups.

Peer influences and parents are two social factors that appear to have a significant impact on rural African American children who take an interest in smoking. In addition, media advertisements may play a large role in the smoking activity of rural African Americans. Studies show that some media venues aggressively target the marketing of menthol cigarettes within African American communities. Factors such as social support, employment, and private health insurance may also be significant factors that affect smoking cessation within rural African American communities. Despite more quit attempts, African Americans have lower success rates of smoking cessation than Latino and White cigarette smokers. Lower rates of utilization of cessation treatments such as counseling and medication may contribute to the limited success of quit attempts among African Americans.

American Indian/Alaska Native Populations

Research indicates that smoking rates are highest among American Indian/Alaska Native populations. In 2021, 35.6% of American Indian or Alaska Native persons aged 18 years or older reported tobacco product use (cigarettes, smokeless tobacco, cigars, or pipe tobacco) in the past year. When discussing smoking rates among this community, it is important to note the distinction between commercial and traditional tobacco use due to possible tobacco use for ceremonial, religious, traditional, or medicinal purposes within the American Indian/Alaska Native population. See Module 4: Implementation Considerations for additional information about tobacco use among American Indian/Alaska Native populations.

Asian Americans, Pacific Islanders, and Native Hawaiians

Among racial and ethnic minority groups, Asian American, Pacific Islanders, and Native Hawaiians report the lowest use of cigarettes. However, there is wide variation in the prevalence of tobacco use among subgroups of Asian Americans/ Pacific Islanders/Native Hawaiians. Based on data from the 2019 National Survey on Drug Use and Health, 20.9% of Native Hawaiian/Pacific Islander adults aged 18 or older used tobacco in the past month, compared to 10.3% of Asian Americans. Among Asian Americans, cigarette use may vary significantly among specific populations. One Centers for Disease Control and Prevention (CDC) study found that between 2002 and 2005, past-month cigarette use among Asian Americans ranged from 8.8% among Chinese respondents to 26.6% among Korean respondents.

Tobacco use affects health outcomes among Asian Americans, Native Hawaiians, and Pacific Islanders. Among this population, cancer is the leading cause of death and lung cancer is the leading cause of cancer death.

Hispanic and Latino Populations

Similar to Asian American and Pacific Islander populations, there are variations in the prevalence of tobacco use among Hispanic and Latino subgroups. One CDC study found that between 2002 and 2005, past month cigarette use among Central or South American populations was 20.2%, compared to 31.5% among Puerto Rican populations.

Tobacco use is also known to contribute to the development of cancer and heart disease, the top two leading causes of death among Hispanic and Latino populations. The majority of cancer deaths among Hispanic men are due to lung cancer, which is also the second leading cause of cancer death among Hispanic women.

Lesbian, Gay, Bisexual, and Transgender Persons

According the 2014 National Health Interview Survey, lesbian, gay, and bisexual (LGB) individuals are more likely to use cigarettes daily than heterosexual individuals (23.9% versus 16.6%). LGB individuals may also have limited access to healthcare resources that could aid in tobacco cessation. For example, LGB and transgender individuals are less likely to be insured than heterosexual individuals and may feel uncomfortable about seeking healthcare in rural areas due to perceived stigmas. While the CDC reports that there is little available information about tobacco use among individuals who are transgender, researchers believe that individuals who are transgender may be at risk for high levels of cigarette smoking. This may be due to a high prevalence of conditions that are associated with smoking among individuals who are transgender, including substance use disorder and depression.

People of Low Socioeconomic Status

Poverty and low educational attainment are associated with higher rates of cigarette use. For example, among adults with only a GED certificate, smoking prevalence was approximately 43% in 2014, compared to 16.8% among all adults. Data also indicates that individuals living in poverty smoke cigarettes for a longer duration than those who are three times above the poverty level.

According to 2018-2022 data from the American Community Survey (ACS), the poverty rate was 12.5% nationwide but 15.2% in micropolitan areas and 15.7% in nonmetropolitan areas. Also according to ACS 2018-2022 data, educational attainment of people living in nonmetro and micropolitan areas lagged, with 34.3% of people 25 and older having a bachelor's degree or higher nationwide, compared to 23.1% in micropolitan and 19.3% in nonmetro areas.

The greater use of tobacco among those of lower socioeconomic status has profound impacts on tobacco-related disease incidence. Findings suggest that, among cigarette smokers, individuals with lower incomes are more likely to be affected by diseases caused by smoking and less likely to have successful quit attempts than individuals of higher socioeconomic status.

Adults with Mental Illness and Substance Use Disorders

Mental illness and substance use disorders are often comorbid with tobacco use. Nearly one in five rural adults 18 and older report experiencing any mental illness, compared to 17.8% of urban adults. For example, research indicates that as many as 70-85% of patients with schizophrenia smoke cigarettes. The 2013 National Survey on Drug Use and Health found that those with mental illness and substance use disorders were responsible for 40% of all the cigarettes smoked by the sample of adults.

Children and Youth

Data indicate that 37.4% of rural adolescents smoke on a daily basis. Research has shown that a larger percentage of adolescents in rural areas smoke cigarettes than youth in urban areas (9% versus 5.6% in 2012) and that rural youth typically start using tobacco at an earlier age than urban youth. Children in rural areas who experimented with tobacco at an early age are more likely to become regular smokers. Therefore, preventing children from smoking is critical.

Pregnant Women

Women in rural areas are more likely to smoke during their pregnancies than those living in urban communities. According to the American Lung Association, 27.4% of pregnant women in rural communities smoke throughout the duration of their pregnancy. In comparison, only 11.2% of pregnant women in urban communities report smoking during this time frame. This disparity may affect health outcomes for children in rural areas, as pregnant women who smoke are more likely to have children born with a low birthweight, impaired physical and mental development, and other birth defects and behavioral disorders. Sudden Infant Death Syndrome (SIDS) is also associated with maternal prenatal smoking.


Veterans in rural areas are disproportionately high users of tobacco products. One study by the Department of Veteran's Affairs (VA) found that rural veterans were more likely to report a lifetime history of cigarette use, current cigarette use, and a lifetime history of smokeless tobacco use than veterans living in urban or suburban areas. Another study by the VA also found that rural veterans were regularly exposed to harmful environmental tobacco smoke. Veterans in rural areas were more likely to report that someone at home and at work smoked in their presence in the past week than veterans in suburban areas.

Working Adults

The National Institute for Occupational Safety and Health recommends that employers take actions to eliminate tobacco use in the workplace and ensure that tobacco cessation programs are available to workers. Tobacco use among working adults is a problem that varies by industry. According to the CDC, the age-adjusted cigarette smoking prevalence among working adults ranged from 9.7% in education services to 30.0% in mining. As of July 2017, 24 states have enacted smoke-free laws restricting tobacco smoking in non-hospitality workplaces, restaurants, and bars. The American Lung Association has created a comprehensive toolkit to assist employers in developing and implementing work place policies to promote a tobacco-free environment.

Resources to Learn More

African Americans and Tobacco Use
Access to important statistics, references, and resources regarding tobacco use and prevalence among African Americans.
Organization(s): Centers for Disease Control and Prevention

American Indian and Alaska Native People and Commercial Tobacco: Health Disparities and Ways to Advance Health Equity
Access to important statistics, references, and resources regarding tobacco use and prevalence among the American Indian/Alaska Native populations.
Organization(s): Centers for Disease Control and Prevention

Veterans' Environmental Tobacco Smoke (ETS) Exposure
Provides insight regarding veterans' exposure to secondhand smoke.
Author(s): Vander Weg, M., & Cunningham, C.
Organization(s): Veterans Rural Health Resource Center - Central Region, U.S. Department of Veterans Affairs
Date: 2011