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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: J Rural Health. 2021 Aug 2;38(2):360–363. doi: 10.1111/jrh.12610

Rural Disparities in Adolescent Smoking Prevalence

Sooyong Kim 1, Arielle Selya 1,2,a
PMCID: PMC8807753  NIHMSID: NIHMS1724450  PMID: 34339070

Abstract

Introduction:

Rural residence is a well-established risk factor for risk behaviors and subsequent morbidity and mortality in the United States. Smoking is the primary cause of preventable death and is more prevalent in rural America. As chronic smoking habits typically develop during adolescence, the discrepancy in smoking rates between rural and urban youth likely contributes to a significant geographic disparity in the long-term health of adults.

Methods:

Data were extracted from 12th-grader surveys of the U.S. Monitoring the Future study from 1998 to 2018. The historic trends of smoking initiation, ever-regular and current-regular smoking rates of rural and urban adolescents were estimated with intercept-only time-varying effect models. Differences in prevalence between rural and urban youth were calculated for each smoking behavior.

Results:

Though overall smoking prevalence continues to decline, this trend is significantly attenuated among rural adolescents compared to urban youth. The absolute difference in lifetime smoking prevalence between rural and urban youth has markedly increased from 6.9% in 1998 to 13.5% in 2018, which is among the highest in the past 20 years and is a potentially alarming upward trend. However, the absolute differences in ever-regular and current-regular smoking prevalence have shown an overall net decline, decreasing from 6.4% to 4.8%, and from 5.5% to 3.0%, respectively.

Conclusions:

This geographic disparity between rural and urban adolescents represents a potentially modifiable cause of increased morbidity and mortality in rural areas. Interventions and regulatory efforts should be tailored for rural adolescents to reduce the narrowing but persistent disparity in regular smoking.

Keywords: adolescents, rural health disparities, tobacco policy, youth tobacco use

Rural residence has been associated with greater disparities in various health-related risk behaviors,1 and resulting morbidity and mortality2 in the United States. Smoking in particular remains a prominent public health challenge, due to its continuing role as the leading preventable cause of death and disease. Although smoking prevalence has shown a drastic decline over the last several decades across all sociodemographic groups,3 geographic disparity persists in tobacco use. This disparity emerges as early as adolescence, as shown in higher rates of smoking among rural youth, compared to their urban peers.1,4 Furthermore, Ziller et al. reported that the rural-urban disparity in 2014–2016 has widened compared to 2008–2010, and there is a significant moderation effect of rural residence on youth smoking trends.5 However, continued monitoring of the long-term temporal trends is needed to reflect the rapidly changing nature of adolescent behaviors and to evaluate the effectiveness of youth tobacco control measures across geographic areas.

This study utilizes cross-sectional, population-level data over the past 20 years (from 1998 to 2018) from the Monitoring the Future (MTF) study, using time-varying effect modeling (TVEM), a novel methodology for empirically estimating trends and associations over time, without imposing strong parametric assumptions. This study retrospectively examines the 20-year trend of differences in smoking between rural and urban youth, and it demonstrates whether there is a need for anti-smoking interventions targeted to rural adolescents.

Methods

Sample

Data were extracted from the past 20 years (1998–2018) of the Monitoring the Future (MTF) study. MTF is a school-based, annual, cross-sectional survey of nationally representative samples of 8th, 10th, and 12th graders in the US on substance use behaviors and attitudes. MTF is administered in 48 contiguous US states by the University of Michigan and is conducted and funded by the National Institute on Drug Abuse. Approximately 15,000 12th-grade students participated in the survey each year with response rates ranging from 79% to 85%, resulting in an overall sample size of 299,435. Analyses focused on 12th-grade students in particular, to allow more time for ever-smoking to have occurred. This secondary analysis of publicly available data was exempt from IRB review at Sanford Research.

Measures

Outcomes included ever-smoking, ever-regular smoking, and current-regular smoking. All outcomes were derived from the question, “Have you ever smoked cigarettes?” The following five options were given: “Never,” “Once or twice,” “Occasionally but not regularly,” “Regularly in the past,” and “Regularly now.” Ever-smoking was dichotomized into never-smokers vs. all other responses. Ever-regular smoking was defined as having ever been a regular smoker (“Regularly in the past” or “Regularly now”). Current-regular smoking was defined as having reported smoking “Regularly now.”

Geographical residential area was determined by the location of the school of the respondent and dichotomized into urban (metropolitan statistical area, MSA) and rural (non-MSA), as defined by the United States Office of Management and Budget at the time of the survey.

Analysis

Time-varying effect modeling (TVEM) is a statistical method which empirically models dynamic changes over time without strong parametric assumptions. To estimate the prevalence of smoking among rural and urban adolescents, this study utilizes intercept-only TVEMs with prevalence as a function of the survey year. The use of intercept-only TVEMs provides an examination of continuous moderation over time of rural-urban residence, allowing a facilitated interpretation of historic trends in the differences between rural and urban areas.6–8 No covariates were included, as the goal of this study was simply to characterize population-level trends. The model was run using a publicly available SAS (SAS Institute Inc., Cary, NC) macro, the WeightedTVEM Macro, version 2.6, using MTF’s survey weights.9 Those with missing information on smoking outcomes and/or rural/urban residence were excluded from the modeling (N=9086; 3.0%). Point estimates and confidence intervals of smoking prevalence trends were computed from coefficients and standard deviations, which were used to calculate absolute differences in prevalence between rural and urban adolescents. Graphs were created using the “ggplot2”10 package in R software.11

Results

From 1998 to 2018, a total of 299,435 12th grade students in the US participated in the MTF survey. Among all participants, 78.1% (95% CI: 78.0%–78.3%) reported attending schools in urban areas, while 21.9% (95% CI: 21.7%–22.0%) were located in rural areas.

Figure 1 demonstrates the changes in the smoking disparity between rural and urban adolescents over the past 20 years. The absolute difference in the prevalence of ever-smoking was the lowest at the beginning of the time period under examination (~2000). But this difference consistently widened, leading to an all-time high of 13.5% in 2018 (rural: 34.4%; urban: 20.9%), the latest available data point in this study. In contrast, the absolute difference in ever-regular smoking prevalence has fluctuated but showed a net decline across time. However, significant differences persisted in ever-regular smoking, which was approximately 4.8% higher in rural areas in 2018 (rural: 8.6%; urban: 3.8%) while averaging a 5.1% difference across the past 20 years. The absolute difference in current-regular smoking prevalence showed a steadier decline, although again persisted. Rural adolescents’ rate of current-regular smoking was 3.0% higher than their urban peers in 2018 (rural: 4.7%; urban: 1.7%), a decrease from the 5.5% difference in 1998.

FIGURE 1 :

FIGURE 1 :

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Rural-urban difference in prevalence of ever smoking, ever regular smoking, and current regular smoking based on modelled intercept-only time-varying effect models

Discussion

This study aims to quantify rural-urban differences in smoking prevalence among adolescents in the United States using nationally representative survey data. Over the past two decades, rural adolescents showed a significantly higher prevalence of smoking initiation and ever-/current-regular smoking compared to their urban counterparts, with the disparity in smoking initiation continuously widening over time, while the disparity in ever-regular and current-regular smoking slightly narrowed (though not enough to close the disparity).

These results are consistent with previous studies on rural adolescents’ heightened risk for smoking1,4,5 and demonstrate a continuing disproportionate burden of smoking among rural youth, although some of the differences may be explained by sociodemographic differences.12 These differences may be due to rural adolescents perceiving easier cigarette access compared to urban youth,13 higher likelihood of being exposed to tobacco advertisement,14 being less likely to recall anti-tobacco media messages, and less likely to perceive a significant harm on themselves and others.4,15 These differences may contribute to the lower degree of perceived harm16 and a higher level of cigarette susceptibility17 in rural areas. Lastly, the enforcement of anti-tobacco regulation is weaker in the rural areas,18,19 such as lower rates of compliance to age verification.20 These individual-level and community-level factors collectively predispose rural adolescents to a higher likelihood of cigarette initiation and regular smoking. In fact, some have suggested that the observed rural-urban disparity is largely attributable to the migration of those with a higher propensity to smoke to rural areas, rather than the effects of differential tobacco policies.21

The absolute difference in ever-smoking showed an increasing trend from 2013 onward after staying relatively stable between 2008 and 2012. The disparate effects of policies and interventions in rural and urban areas may explain this increase in disparity. For example, the “Real Cost” youth tobacco prevention campaign, which was initiated in 2014, may have had a greater impact on urban adolescents than it had on rural youth, potentially contributing to the widening disparity. While the net decrease in differences in ever- and current-regular smoking is reassuring, the attenuated decline in ever-smoking among rural adolescents is a potential cause for concern, should this ever-smoking lead to longer-term, regular use. Although the increased initiation disparity has not led to widening disparities in problematic smoking over the same time frame (as suggested by the declining rural-urban difference in “regular” smoking), a persistent disparity nevertheless exists in regular smoking among rural youth. It is possible that increased initiation (as measured by ever-smoking) may lead to higher rates of regular smoking beyond the age range captured in these data, which would contribute to eventual health disparities among rural populations.

It is important to note that e-cigarettes have become extremely popular among youth starting around 2013. Previous studies on the prevalence of e-cigarette use in urban and rural settings have been inconsistent. Rural adults have a higher prevalence of e-cigarette use than urban adults.22 Among adolescents, some studies report no significant differences between areas,23–25 and others show a higher rate of e-cigarette use among urban adolescents.14 The potential role of e-cigarette trends in explaining the current findings is unclear. It remains a matter of active debate whether e-cigarette use causes later cigarette smoking,26 whether both behaviors originate from a common liability for tobacco use,27 or whether e-cigarette use diverts youth away from cigarette smoking.28 Even less is certain about this question in the context of rurality, and this a critical topic for ongoing research.

This study has several limitations. The MTF study is a cross-sectional survey with inherent limitations of self-report. The current study focuses on the prevalence of ever-, ever-regular, and current-regular smoking, and it is not intended to perform policy analyses or draw conclusions about specific policies. The growing disparity in ever-smoking, while alarming, may not directly translate into long-term health impacts. Notwithstanding these limitations, this study demonstrates persistent geographic smoking disparity for rural adolescents by monitoring the continuous trend in the past 20 years and emphasizes the urgent need for geographically tailored youth smoking prevention efforts.

Conclusion

Smoking continues to be one of the biggest challenges in public health in the United States. While smoking prevalence has shown a consistent decline in all sociodemographic subgroups, the trend is significantly attenuated among rural adolescents. The increasing gap in rural adolescents’ smoking initiation may represent a possibly modifiable cause of the longstanding disparity in morbidity and mortality between urban and rural areas. This study calls for future research on mechanisms underlying the persistent disparity in regular smoking between rural and urban adolescents, as well as geographically tailored anti-smoking efforts.

Acknowledgments

Funding: This work was supported by the National Institute of General Medical Sciences grant number P20GM121341 to PI Weimer, Sanford Research, which supported both authors’ contribution. The content is solely the work of the authors, and does not necessarily reflect the views of the NIH or NIGMS.

Footnotes

Disclosures: After conceptualizing and starting this study, AS and SK became employed by PinneyAssociates, Inc. PinneyAssociates provides consulting services on tobacco harm reduction on an exclusive basis to JUUL Labs, Inc. Neither PinneyAssociates nor JUUL had any role in conceptualization, design, analysis, interpretation, or presentation of data.

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