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Tobacco Use in Rural Areas

Tobacco use is the leading cause of preventable mortality and morbidity in the United States and is responsible for over 400,000 deaths each year. Smoking causes about 90% of all lung cancer deaths in the United States. Those who smoke regularly are more likely than nonsmokers to develop heart disease, stroke, and lung cancer. About 50% of smokers develop chronic obstructive pulmonary disease. On average, there is a 6.5 year loss in life expectancy for smokers as compared to non-smokers.

As of 2015, tobacco has cost the nation approximately $289 billion in medical costs and productivity loss. Rural residency is associated with higher rates of smoking and smokeless tobacco use nationwide. Rural residency has also been linked to an earlier age of onset for smoking and a disproportionately high rate of smoking among pregnant women.

Cigarette Use

Overall, the prevalence of cigarette smoking is in decline among adults in the United States. However, adults in rural areas continue to smoke cigarettes more frequently than other individuals. Data from the National Survey on Drug Use and Health in 2021 indicate cigarette use was 20.3% among the general adult population and 28.9% among rural adults.

Smokeless Tobacco

While the rate of smoking among Americans has declined from 20.9% of adults in 2005 to 14% of adults in 2017, smokeless tobacco use among rural adults has increased and remains higher in rural populations than in non-rural populations. Smokeless tobacco is any type of tobacco that is not burned. Common terms for this form of tobacco are chewing tobacco, spitting tobacco, dip, chew, and snuff.

In 2021, the prevalence of smokeless tobacco use was 3.7% among American adults and 7.5% among rural adults (an increase from 7.1% in 2012). Rural youth in nonmetropolitan areas also use smokeless tobacco at higher rates (4.4%) than youth in metropolitan (1.2%) and small metropolitan (2.4%) areas.

Electronic Cigarettes

Also known as electronic nicotine delivery systems (ENDS), e-cigarettes are a relatively new method for nicotine delivery. Data from the HealthStyles Survey found that between 2010 and 2013, the percentage of adults who had used an e-cigarette at least once rose from 3.3% to 8.5% and the percentage of adults aware of e-cigarettes almost doubled from 40.9% to 79.7%.

E-cigarettes have been promoted as safer alternatives to traditional cigarettes or as smoking cessation aids. However, while these products do not produce smoke, they do expose others to secondhand emissions. ENDS also contain nicotine, a highly addictive drug that can lead to negative birth outcomes and is shown to increase adolescents' risk of developing mental and behavioral disorders later in life. There has also been recent evidence of increased poisonings in both users and non-users resulting from the ingestion of the liquid nicotine, absorption through the skin, and inhalation.

Secondhand Smoke

The Centers for Disease Control and Prevention (CDC) defines secondhand smoke as “smoke from burning tobacco products.” Common sources of secondhand smoke are cigarettes and cigars. Tobacco smoke contains several toxic chemicals that are linked to cancer. Among children, exposure to secondhand smoke may lead to sudden infant death syndrome (SIDS), ear infections, asthma attacks, and other respiratory symptoms and infections. Secondhand smoke exposure also has profound impacts on adults. For nonsmokers, breathing secondhand smoke can increase the likelihood of developing heart disease and lung cancer, as well as having a heart attack or stroke.

Children who live in rural communities are more likely to live in a house with a smoker, and may consequently have a higher risk of secondhand smoke exposure than children who live in other areas. The National Survey of Children's Health reports that while 24.4% of children in urban areas lives with a smoker, 33.1% of children in large rural areas and 35% of children in small rural areas live with a smoker. The survey also found that rural residents are more likely to allow smoking in the presence of their children in comparison to urban areas.

Resources to Learn More

The 2014 Update of the Rural-Urban Chartbook
This chartbook includes demographics and statistics on various health-related topics, including rates of cigarette use in rural and urban areas and risk factors.
Author(s): Meit, M., Knudson, A., Gilbert, T., Tzy-Chi Yu, A., Tanenbaum, E., Ormson, E., TenBroeck, S., Bayne, A., & Popat, S.
Organization(s): Rural Health Reform Policy Research Center
Date: 10/2014

Combustible and Smokeless Tobacco Use Among High School Athletes – United States, 2001-2013
Reports recent YRBSS findings related to increased smokeless tobacco use among high school athletes and discusses possible reasons for the increased rates.
Author(s): Agaku, I.K., Singh, T., Everett Jones, S., King, B.A., Jamal, A., Neff, L., & Caraballo, R.S.
Citation: Morbidity and Mortality Weekly Report (MMWR), 64(34), 935-939
Date: 9/2015

Culture in Evaluation #2: Rural - Tobacco Control Evaluation with Rural Populations
This brief provides an overview of cultural competency when working with issues of tobacco control among rural populations.
Author(s): Treiber, J. & Satterlund, T.
Organization(s): Tobacco Control Evaluation Center
Date: 2010

Current Cigarette Smoking Among Adults – United States, 2005-2014
Summarizes findings from the 2014 National Health Interview Survey (NHIS) related to prevalence of cigarette smoking among adults in the United States as well as prevalence by age, race, education, poverty status, health insurance coverage, disability, and sexual orientation.
Author(s): Jamal, A., Homa, D., O'Connor, E., Babb, S.D., Caraballo, R.S., Singh, T., Hu, S.S., & King, B.A.
Citation: Morbidity and Mortality Weekly Report (MMWR), 64 (44), 1233-1240
Date: 11/2015

DrugFacts: Electronic Cigarettes (E-Cigarettes)
This fact sheet answers questions about how e-cigarettes work, their safety, and their effectiveness as a smoking cessation aid.
Organization(s): National Institute on Drug Abuse
Date: 5/2016

E-Cigarettes: A Review of the Literature
This summary of peer-reviewed literature about e-cigarettes provides and overall introduction to cigarettes and discusses secondhand aerosol, marketing, dual use with tobacco, tobacco cessation, harm reduction, and policy recommendations.
Author(s): Bushore, C. & Pizacani, B.
Organization(s): Alaska Department of Health and Human Services
Date: 1/2015

The Health Consequences of Smoking – 50 Years of Progress. A Report of the Surgeon General
This comprehensive report provides a history of tobacco use in the United States for the past 50 years.
Organization(s): U.S. Department of Health and Human Services
Date: 2014

Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes – United States, September 2010 – February 2014
Analyzes the number of calls involving e-cigarettes to poison centers with regard to age and exposure.
Author(s): Chatham-Stephens, K., Law, R., Taylor, E., Melstrom, P., Bunnell, R., Wang, B., Apelberg, B., & Schier, J.G.
Citation: Morbidity and Mortality Weekly Report (MMWR), 63 (13), 292-293
Date: 4/2014

State-Specific Prevalence of Current Cigarette Smoking and Smokeless Tobacco Use Among Adults Aged ≥18 Years – United States, 2011–2013
Summarizes findings from the Behavioral Risk Factor Surveillance System (BRFSS) related to adults tobacco use by state.
Author(s): Nguyen, K., Marshall, L., Hu, S., & Neff, L.
Citation: Morbidity and Mortality Weekly Report (MMWR), 64 (19), 532-536
Date: 5/2015

Statement on E-Cigarettes
This position statement from the American Lung Association provides a brief overview of early research related to the components of e-cigarettes and the effects of nicotine.
Organization(s): American Lung Association
Date: 3/2015

Supporting Regulation of Electronic Cigarettes
This policy statement from the American Public Health Association discusses e-cigarettes in terms of secondhand exposure, children and youth, cessation research, and advertising and marketing. The statement also lists action steps for organizations to take in addressing the issue.
Organization(s): American Public Health Association
Date: 11/2014

Tobacco Use in Rural America
This chapter of Rural Healthy People 2020, Volume 1 discusses the scope of tobacco use in rural areas as it relates to the Health People 2020 objectives. The chapter discusses tobacco use differences by ethnicity, barriers, and proposed interventions. Author(s): Geletko, K. & Bellamy, G.
Organization(s): Texas A&M University Health Science Center, School of Public Health, Southwest Rural Health Research Center
Date: 2015

Trends in Awareness and Use of Electronic Cigarettes among U.S. Adults, 2010-2013
This article reviews data from the 2010-2013 HealthStyles Survey, describing emerging trends in the use of electronic cigarettes among adults in the U.S.
Author(s): King, B.A., Patel, R., Nguyen, K.H., & Dube, S.R.
Citation: Nicotine and Tobacco Research, 17 (2), 219-227
Date: 2/2015

Urban and Rural Disparities in Tobacco Use
Presentation Slides
This presentation from the 2012 National Conference on Health Statistics explores significant predictors of tobacco use among rural and urban areas and determines areas where programs and advocacy could be useful.
Author(s): Shan, M., Jump, Z., & Lancet, E.
Organization(s): American Lung Association
Date: 8/2012