Are Higher Rates of Tobacco Use in Rural Communities At Least Partly Responsible for the Rural-Urban Gap in Mortality?

Tobacco, but primarily cigarettes, remains the leading cause of preventable disease in the US, claiming 480,000 lives per year and affecting an additional 16 million smokers who suffer from smoking-related chronic diseases (“Smoking and Tobacco Use,” 2020). Tobacco use varies by geographic region within the United States (US) but prevalence of cigarette smoking is highest among those living in rural areas (28.5%) compared to urban areas (25.1%) and small metropolitan areas (22.0%) (“Tobacco Use by Geographic Region,” 2019). Additionally, dual or poly-tobacco use of traditional products is more prevalent in rural areas (Roberts et al., 2017). Traditional products referred to two or more of these products: cigarettes, menthol cigarettes, smokeless tobacco, pipes, or cigars (Roberts et al., 2017). Smokeless tobacco, such as chewing tobacco or moist snuff, is three times more prevalent in rural than urban areas (6.3% vs 2.1%) (Roberts et al., 2017). Rural communities are vulnerable due to disparities that place them at risk for relatively poor health outcomes (Byun, Meece, & Irvin, 2012). Rural communities experience disproportionately lower incomes and educational attainment, less access to medical resources and are underserved by local health policies (Byun et al., 2012; Caldwell, Ford, Wallace, Wang, & Takahashi, 2016; McMillen, Breen, & Cosby, 2004; Northridge et al., 2008). These disparities can lead to adverse outcomes, for example…