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. Author manuscript; available in PMC: 2018 Oct 1.
Published in final edited form as: Am J Public Health. 2017 Aug 17;107(10):1554–1559. doi: 10.2105/AJPH.2017.303967

Rural vs. Urban Use of Traditional and Emerging Tobacco Products in the United States, 2013–2014

ME Roberts 1, NJ Doogan 1, CA Stanton 2,3, AJ Quisenberry 1, A C Villanti 4, DE Gaalema 4, DR Keith 4, AN Kurti 4, AA Lopez 4, R Redner 5, A Cepeda-Benito 4, ST Higgins 4
PMCID: PMC5607677  NIHMSID: NIHMS904246  PMID: 28817323

Abstract

Objectives

To examine urban/rural differences in U.S. prevalences of traditional and emerging tobacco product use, as well as dual/poly use of these products.

Methods

Using restricted-use data from Wave 1 (2013–2014) of the Population Assessment of Tobacco and Health (PATH) Study, analyses estimated weighted prevalences for adult tobacco use across urban/rural geography and also examined prevalences classified by gender, poverty level, and region of the country.

Results

Nationally, cigarette and smokeless tobacco use, as well as dual/poly use of traditional tobacco products were more prevalent in rural, compared to urban, areas. Conversely, cigarillo and hookah use, as well as dual/poly use of emerging tobacco products were higher in urban areas. There was no significant urban/rural difference for e-cigarettes. Gender, poverty, and region of the country did not seem to be driving most urban/rural differences, although differences for cigarillos and dual/poly use of emerging tobacco products became non-significant after controlling for covariates.

Conclusions

Findings highlight important urban/rural differences in tobacco use. Whether the changing landscape of tobacco products will contribute to a continuation of rural health disparities remains to be seen.

INTRODUCTION

Urban/Rural Disparities

The U.S. has been paying increased attention to the status of Rural America, from its economy, to the opioid epidemic, to its role in the 2016 presidential election.1–4 Yet the public health community has long considered rural communities to be vulnerable populations, due to the disparities that put them at risk for the relatively poor morbidity and mortality outcomes. Compared to non-rural individuals, rural individuals are more likely to have lower incomes and educational attainment, have more limited access to medical resources, and to be underserved by local health policies.5–9 Researchers have also discussed a “rural culture” in which many determinants of poor health behaviors are embedded and reinforced.10

Enmeshed in these disparities, rural areas of the U.S. have among the highest cigarette and smokeless tobacco use rates in the country.11 For example, in a recent study using national data, the prevalence of rural daily cigarette use was 16.3%, whereas the prevalence of urban use was 12.3%.12 Rural past-30-day use of cigarettes and smokeless tobacco were also higher, although there were no urban/rural differences at the national level for use of menthol cigarettes, cigars, or pipes.12 Other work examining national trends from 2007–2014 has shown that although there is a declining cigarette smoking rate in the U.S., the decline is more pronounced for urban than for rural populations.13

These urban/rural tobacco-use differences do not appear to be fully explained by differences in income,12,13 although prevalences are often highest among the rural poor.12 Urban/rural differences in tobacco use are also present for both males and females alone (prevalence is particularly high among rural males), and the largest urban/rural differences appear in the South region of the country.14 Such findings underscore that there is something unique about rurality as a risk factor, since other factors interact with—but do not seem to drive—the urban/rural differences in cigarette and smokeless tobacco use.

Emerging Tobacco Products

Cigarettes remain the main product of tobacco use among adults in the U.S.15 However, over the past decade, several emerging products have increased in popularity. These products, primarily e-cigarettes, hookah, and cigarillos, have produced a shift in the tobacco product landscape that previously comprised cigarettes, smokeless tobacco, pipes, and cigars. As all emerging tobacco products bear their own health risks and offer additional possibilities for dual/poly use, it is critical to monitor rural trends in the use of these emerging products. Yet most research on emerging tobacco products has either looked at overall, national trends,15–18 or focused on heavily populated areas,19–21 with very little focus on rural use of emerging tobacco products. Likewise, although there are extremely high rates of both cigarette and smokeless tobacco use among rural populations (e.g., one study on daily tobacco users in Appalachia found that one-third of the male participants used smokeless tobacco22), research has paid little attention to rural individuals engaged in the dual- or poly-use of tobacco products. In particular, we know of no work showing how emerging tobacco products have been incorporated into rural dual/poly tobacco use.

Surveillance of all tobacco product use is critical for addressing and reducing rural health disparities. For example, it is important that any new tobacco policies do not disproportionately benefit urban communities—and thereby inadvertently exacerbate existing urban/rural disparities. Prevalence estimates not only provide a better scope of the problem, but will help policy-makers to understand the current reach of tobacco product popularity across all geographies.

Overview

The purpose of the present study was to examine urban/rural differences in U.S. use prevalences for both traditional and emerging tobacco products, as well as dual/poly use of these products. Given the potential for emerging tobacco products to impact overall rates and urban/rural differences in tobacco use, we sought to distinguish the use of traditional from emerging tobacco products. In addition, given that previous findings indicate important differences by gender, poverty-level, and region of the country,12,14 we also examined urban/rural prevalence further classified by these key demographic factors. Analyses were conducted with the adult Restricted Use Data from the first wave of the Population Assessment of Tobacco and Health (PATH) Study (2013–2014).23 PATH is a large, nationally-representative study, which allowed us to conduct a detailed examination of the prevalence of tobacco use in rural American populations.

METHODS

Participants

The PATH Study is an ongoing, household-based, nationally representative, longitudinal cohort study of U.S. youth and adults. Launched in 2011 and sponsored by the NIH and FDA, the purpose of the study is to inform the FDA’s regulatory activities under the Family Smoking Prevention and Tobacco Control Act. Data from the first wave (used for the present study) were collected from September 2013 to December 2014. The study sampled over 150,000 mailing addresses which, using a four-staged stratified sampling design, yielded a sample of 45,971 civilian, non-institutionalized youth and adult respondents. The present study uses data from the 32,320 adults who participated (aged 18–90). An overview by Hyland24 provides more detailed information on the PATH data, sampling method, and weighting procedures.

Measures

Urban and Rural

The PATH sampling procedure used geographical units called segments, which were based on U.S. Census blocks. A segment was classified as “urban” if the majority of its total population resided in areas classified as urban according to the 2010 Census (i.e., a minimum population density of at least 2,500 people); all others segments were classified as “not urban”, which we refer to as “rural” for this paper.

Tobacco Use

We used the PATH-derived variable for daily cigarette use, which was having smoked at least 100 cigarettes in one’s lifetime, and now smoking every day. We also used the PATH-derived variables for past-30-day use of cigarettes, e-cigarettes, cigars, cigarillos, pipes, hookah, and smokeless tobacco, which was having used the product at least once within the past 30 days (smokeless tobacco included loose snus, moist snuff, dip, spit, or chewing tobacco). We also defined past-30-day menthol cigarette use as using cigarettes within the past 30 days and answering “yes” to the item “Is your regular brand flavored to taste like menthol or mint?”

Dual- and Poly-Tobacco Use

There were over 300 unique dual/poly use combinations reported for this sample.18 As our main interest was to distinguish the use of traditional from emerging tobacco products, we grouped behaviors into three dual/poly tobacco use types. Traditional Only identified individuals who reported using only two or more traditional tobacco products (cigarettes, menthol cigarettes, smokeless tobacco, pipes, or cigars) within the past 30 days; Emerging Only identified individuals who reported using only two or more emerging tobacco products (e-cigarettes, cigarillos, or hookah) within the past 30 days; and Mixed identified individuals who used one or more traditional tobacco products and one or more emerging tobacco products within the past 30 days. These three dual/poly use categories were mutually exclusive; however, dual/poly users were included among the any-tobacco users described in the preceding paragraph.

Demographic Characteristics

We used PATH-imputed variables for gender, age, and race/ethnicity. Imputation was performed by first considering information provided in the PATH household screener and then by using statistical imputation methods (a full description of imputation methods is available in the PATH user guide). Poverty was a PATH-derived variable based on annual household income, and dichotomized (below the poverty level vs. at or above the poverty level) based on household size and the 2015 HHS poverty guidelines.25 Region of the country where the participant resided (Northeast, South, Midwest, and West) was defined based on the U.S. Census classifications.

Analyses

We accessed restricted-use PATH data remotely via a Virtual Data Enclave (VDE) managed by the Inter-university Consortium for Political and Social Research (ICPSR). The adult data file provided weights to adjust for non-responses and PATH’s complex sampling design. Therefore, the present analyses were weighted using the methods recommended in the PATH user guide (balanced repeated replication, or BRR, with Fay’s adjustment set to 0.3). After obtaining demographic information, our first analyses used design-based F tests (i.e., corrected weighted Pearson chi-square statistics) to compare rural vs. urban weighted national prevalence for all tobacco products and dual/poly use categories. Next, for each tobacco product and dual/poly use category, we tested for rural vs. urban differences within each level of our demographics of interest: gender, poverty, and region. Additional analyses used logistic regression where urban/rural status predicted tobacco product use while controlling for the effects of potential covariates (age, gender, poverty, and region). All analyses were conducted in Stata. Due to the multiple comparisons being made, we a priori set a conservative threshold for statistical significance at p < .01.

RESULTS

National Findings

Weighted prevalence values for this nationally-representative sample indicated an average age of 46.6 (SD = 0.4, range = 18–90). The sample was 52% female, 66% non-Hispanic White, and 25% were classified as living below the federal poverty level. A more complete description of the PATH sample is available elsewhere.18 Overall, 21% of the sample were classified as rural, which aligns closely with national figures reported by the Census Bureau.26 Table 1 provides national product-specific weighted prevalence estimates for each tobacco product and dual/poly use category.

Table 1.

National, rural and urban weighted prevalences (S.E.) of adult tobacco product use. All values are for past 30-day-use, unless otherwise specified.

Traditional Tobacco Product Use Emerging Tobacco Product Use Dual/Poly Use
Cigarettes (daily) Cigarettes Menthol Cigarettes Smokeless Tobacco Cigars Pipes E-Cigarettes Cigarillos Hookah Traditional Only Emerging Only Mixed
Overall 14.4% (.25) 22.5% (.31) 6.6% (.14) 3.0% (.10) 3.6% (.10) 0.9% (.05) 6.7% (.15) 4.4% (.10) 2.2% (.09) 1.4% (.05) 0.4% (.03) 8.5% (.17)
Rural 18.3% (.73) 24.6% (.91) 5.8% (.41) 6.3% (.31) 3.2% (.19) 0.9% (.11) 6.2% (.31) 3.8% (.19) 0.9% (.09) 2.2% (.14) 0.2% (.04) 7.8% (.35)
Urban 13.4% (.23) 22.0% (.30) 6.9% (.15) 2.1% (.11) 3.6% (.11) 0.9% (.05) 6.8% (.16) 4.6% (.12) 2.5% (.11) 1.2% (.05) 0.4% (.03) 8.7% (.19)
Difference test p-value <.001 .005 .03 <.001 .07 .74 .08 <.001 <.001 <.001 .005 .02
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Urban/Rural Differences

As shown in Table 1, any current use of cigarettes (both daily and past-30-day) and smokeless tobacco was more prevalent in rural areas than in urban areas. Among the more pronounced differences, the prevalence of any daily cigarette use was 18.3% in rural areas, compared to 13.5% in urban areas. The prevalence of smokeless tobacco use was three times as large in rural, compared to urban areas (6.3% vs. 2.1%). Traditional dual/poly use was also more prevalent in rural areas. Conversely, use of cigarillos and hookah, as well as emerging dual/poly use were higher in urban areas. There were no significant urban/rural differences for use of menthol cigarettes, e-cigarettes, cigars, pipes, or mixed dual/poly tobacco use. For all dual/poly tobacco use, it was most common for urban individuals to be using at least two products from the following combinations: cigarettes and e-cigarettes (5.3%) and cigarettes and cigarillos (3.3%); for rural individuals it was cigarettes and e-cigarettes (5.2%), cigarettes and cigarillos (2.9%), and cigarettes and smokeless tobacco (2.2%; data not shown in tables).

Gender, Poverty, and Region

When examining urban/rural differences separately for males and females, prevalences were generally higher among males. For example, the prevalence of smokeless tobacco use was 12.0% vs. 4.3% for rural and urban males, respectively, whereas it was 0.7% vs. 0.2% for rural and urban females, respectively. There was a higher prevalence of e-cigarette use, menthol cigarette use, and mixed dual/poly tobacco use among urban compared to rural males.

Many urban/rural differences remained when prevalences were categorized by poverty level (Table 2). For example, daily cigarette use, smokeless tobacco use, and traditional dual/poly tobacco use remained higher in rural areas regardless of poverty level. Strikingly, past-30-day use of cigarettes was at 43.3% for rural individuals living below the poverty level. For those living at or above the poverty level, there was also a slightly higher prevalence of e-cigarette use among urban (6.1%), compared to rural (5.1%) participants.

Table 2.

Rural and urban weighted prevalences (S.E.) of adult tobacco-product use, by gender, poverty, and region. All values are for past 30-day-use, unless otherwise specified.

Traditional Tobacco Product Use Emerging Tobacco Product Use Dual/Poly Use
Cigarettes
(daily)		 Cigarettes Menthol
Cigarettes		 Smokeless
Tobacco		 Cigars Pipes E-Cigarettes Cigarillos Hookah Traditional
Only		 Emerging
Only		 Mixed
Gender
 Male Rural 19.4% (.84)* 26.6% (1.1) 5.8% (.53)* 12.0% (.71)* 5.6% (.33) 1.5% (.18) 6.1% (.35)* 5.7% (.29) 1.1% (.14)* 3.9% (.30)* 0.3% (.08) 9.0% (.44)*
 Male Urban 15.6% (.29)* 25.8% (.40) 7.5% (.21)* 4.3% (.22)* 6.5% (.21) 1.6% (.10) 7.9% (.23)* 6.6% (.22) 3.1% (.16)* 2.2% (.11)* 0.5% (.05) 11.3% (.30)*
 Female Rural 17.3% (.86)* 22.7% (1.0)* 5.9% (.40) 0.7% (.16)* 0.9% (.12) 0.3% (.07) 6.2% (.40) 1.9% (.21)* 0.7% (.09)* 0.5% (.10) 0.1% (.03)* 6.6% (.39)
 Female Urban 11.4% (.29)* 18.5% (.36)* 6.3% (.19) 0.2% (.04)* 1.0% (.06) 0.2% (.03) 5.8% (.19( 2.8% (.10)* 2.0% (.10)* 0.3% (.04) 0.3% (.04)* 6.4% (.18%)
Poverty Level
 Belo w Rural 32.0% (1.79)* 43.3% (1.92)* 11.6% (.84) 7.1% (.80)* 4.6% (.43) 1.5% (.20) 11.4% (.73) 7.9% (.61) 1.9% (.25)* 3.7% (.33)* 0.3% (.36) * 15.2% (.80)
 Below Urban 20.4% (.56)* 34.7% (.70)* 11.8% (.41) 2.2% (.18)* 4.5% (.21) 1.5% (.11) 9.4% (.39) 9.3% (.35) 4.4% (.25)* 1.6% (.12)* 0.7% (.21) * 14.3% (.50)
 At or Above Rural 15.1% (.64)* 20.2% (.84) 4.6% (.40) 6.3% (.32)* 3.1% (.19) 0.7% (.11) 5.1% (.32)* 2.8% (.21) 0.6% (.09)* 1.9% (.19)* 0.2% (.13) 6.1% (.38)
 At or Above Urban 11.4% (.26)* 18.4% (.31) 5.6% (.15) 2.3% (.12)* 3.5% (.13) 0.7% (.05) 6.1% (.17)* 3.2% (.12) 2.0% (.10)* 1.1% (.06)* 0.3% (.08) 7.2% (.19)
Region
 NE Rural 16.6% (1.16)* 21.9% (1.45) 5.1% (.56)* 4.4% (.67)* 3.5% (.40) 1.1% (.24) 4.5% (.38) 3.2% (.45) 0.8% (.11)* 1.8% (.15) * 0.3% (.09) 6.1% (.42)*
 NE Urban 12.9% (.63)* 21.3% (.77) 7.5% (.36)* 1.3% (.19)* 4.4% (.26) 0.6% (.10) 5.0% (.35) 4.2% (.29) 2.9% (.28)* 1.2% (.14) * 0.4% (.07) 7.6% (.34)*
 MW Rural 19.1% (1.8) 25.8% (1.77) 5.2% (.92)* 6.9% (.58)* 3.9% (.41) 1.0% (.30) 8.0% (.78) 3.8% (.36)* 0.9% (.13)* 2.9% (.43)* 0.3% (.12) 8.7% (.74)
 MW Urban 16.5% (.54) 24.6% (.66) 8.2% (.40)* 2.4% (.16)* 3.7% (.23) 1.0% (.11) 7.4% (.37) 4.9% (.24)* 2.1% (.16)* 1.5% (.11)* 0.4% (.09) 9.5% (.40)
 S Rural 20.0% (1.18)* 26.8% (1.50) 7.2% (.65) 7.3% (.52)* 2.9% (.32) 0.8% (.11) 6.2% (.41) 4.3% (.30)* 0.9% (.18)* 2.2% (.19) * 0.2% (.05)* 8.4% (.56)
 S Urban 14.0% (.50)* 23.3% (.64) 7.9% (.30) 2.6% (.24)* 3.7% (.18) 0.9% (.08) 7.4% (.28) 5.5% (.27)* 2.4% (.18)* 1.2% (.07) * 0.4% (.05)* 9.7% (.35)
 W Rural 12.3% (1.4) 17.6% (2.4) 2.8% (.32) 4.0% (.96)* 2.7% (.29) 1.0% (.27) 5.2% (.94) 2.3% (.27)* 1.1% (.24)* ** ** **
 W Urban 10.4% (.57) 18.7% (.81) 4.0% (.27) 1.8% (.20)* 2.9% (.19) 0.8% (.12) 6.7% (.39) 3.5% (.23)* 2.8% (.26)* ** ** **
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*

indicates p < .01 for the urban/rural comparison.

**

One or more cell sizes for this urban/rural comparison did not meet minimum threshold for disclosure.

Finally, when examining urban/rural differences across each region of the country, many national urban/rural differences remained (Table 2). In particular, rural smokeless tobacco use was higher across all regions, and urban hookah use was higher across all regions. Urban/rural differences in daily cigarette use remained significant for the Northeast and the South regions; however, there were no significant urban/rural differences for past-30-day use of cigarettes for any region of the country. There were also no significant urban/rural differences for e-cigarettes, cigars, or pipes for any region of the country. Yet some differences emerged where they had not at the national level: There was a higher prevalence of menthol cigarette use for the Northeast and Midwest regions in urban areas, and a higher prevalence of mixed dual/poly tobacco use for the Northeast region in urban areas. Exploratory analyses examining use among young adults (aged 18–28) indicated that although prevalences were higher than the national average, the pattern of significant urban/rural differences was very similar to what was found nationally; the exception to this was cigarillos use, which had no urban/rural difference.

In the logistic regression analyses, which examined the effects of urban/rural status while controlling for age, gender, poverty, and region, we found a very similar pattern (see Table 3). Specifically, we found that any current use of cigarettes (both daily and past-30-day), smokeless tobacco use, and traditional dual/poly use were significantly higher among individuals living in rural, compared to urban areas. Hookah use remained higher among those in urban areas. The only major divergences from the effects presented in Table 1 were that urban/rural differences for cigarillos and emerging dual/poly use were no longer significant.

Table 3.

Odds ratios (95% CIs) for the effect of urban/rural status in logistic regressions predicting tobacco product use. Analyses control for age, gender, poverty, and region.

Traditional Tobacco Product Use Emerging Tobacco Product Use Dual/Poly Use
Cigarettes
(daily)		 Cigarettes Menthol
Cigarettes		 Smokeless
Tobacco		 Cigars Pipes E-Cigarettes Cigarillos Hookah Traditional
Only		 Emerging
Only		 Mixed
Urban/Rural (ref: urban) 1.50
(1.36, 1.66) 		1.25
(1.13, 1.38) 		0.86
(0.74, 1.01)		 3.35
(2.81, 3.99) 		0.93
(0.82, 1.05)		 1.07
(0.83, 1.38)		 1.07
(0.96, 1.20)		 0.93
(0.83, 1.04)		 0.48
(0.37, 0.62) 		1.93
(1.63, 2.29) 		0.81
(0.54, 1.22)		 1.02
(0.92, 1.12)
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Note: Bold indicates odds ratios that are significant at p < .01.

DISCUSSION

Consistent with previous research,11–14 this study found that current cigarette and smokeless tobacco use were more prevalent in rural, compared to urban, areas. This study was among the first to report that dual/poly use of traditional-only tobacco products is also more prevalent in rural areas. Novel findings are that current use of cigarillos and hookah, as well as dual/poly use of emerging-only products, appear to be higher in urban areas.

We found few urban/rural differences for the current use of e-cigarettes (with the exception of slightly higher prevalence among males and individuals above the poverty level). Yet the prevalence of e-cigarettes was not negligible—it was as high as 11.4% among rural individuals living below the poverty level. Moreover, the most common dual/poly tobacco use combination in both urban and rural areas was the use of at least both cigarettes and e-cigarettes. Such findings suggest that the use of e-cigarettes extends well beyond urban centers. There are likely a multitude of factors contributing to why e-cigarettes have been equally adopted in rural and urban areas, including a desire to quit smoking and product marketing. Future research will need to investigate the factors contributing to uptake of emerging tobacco products among rural populations.

Current use of some tobacco products, such as smokeless tobacco, tended to be both more prevalent and to show greater urban/rural percentage point differences among males. Depending on the product, urban/rural differences were also often more pronounced for a particular poverty level or region of the country. Yet the fact that most urban/rural differences remained when further classified by the demographic variables suggests that these additional variables were not driving the urban/rural effects. For example, although past-30-day cigarette use was higher among individuals living below the poverty level, use remained significantly higher among the rural (43.3%) vs. the urban (34.7%) poor subgroups. This interpretation for the demographic variables was also supported by logistic regression analyses that indicated greater rural use of cigarettes, smokeless tobacco, and traditional dual/poly use after controlling for covariates. Findings for hookah, cigars, and pipes were consistent: across all demographic levels tested, there was always significantly higher hookah use in urban areas, whereas cigars and pipes never showed any significant urban/rural difference. Urban/rural differences for cigarillos and dual/poly use of emerging tobacco products became non-significant after controlling for covariates. Overall, findings support previous arguments that there may be something unique about rurality as a risk factor12, 13 and suggest that tailored interventions accounting for “rural culture”10 may have promise.

Public Health Implications

These findings have important implications for tobacco-related health disparities. Specifically, results suggest that the higher prevalence of rural, compared to urban, cigarette and smokeless tobacco use that has been reported in previous papers11–14 still persists. Likewise, as dual/poly use of traditional-only tobacco products—such as using both cigarettes and smokeless tobacco—is higher in rural areas, this may increase health risks27 and may interfere with cessation.28,29 Although findings suggest that the use of some products (menthol cigarettes, cigarillos, and hookah) is more common among urban populations, use of e-cigarettes appears to have similar prevalence among both urban and rural populations. Longitudinal data is needed to examine whether the use of e-cigarettes will create a shift away from the predominance of cigarettes and smokeless tobacco that has been the mainstay of rural tobacco users for decades. The question of whether e-cigarette use aids cessation is complex and continues to be debated;30–31 how use of e-cigarettes and other emerging tobacco products will contribute to the rise or decline of rural tobacco use remains to be seen. More broadly, how the changing landscape of tobacco products will contribute to the currently higher rural rates of tobacco-related morbidity and mortality14,32,33 is likewise a question for future research.

Results also underscore the importance of regulatory policies that will benefit both urban and rural communities. Signed into law in 2009, the Family Smoking Prevention and Tobacco Control Act gives the Food and Drug Administration (FDA) authority to regulate the manufacturing, distribution, and marketing of cigarettes and traditional smokeless tobacco products. Yet a subsequent “deeming rule” has only recently extended the FDA authority to regulate emerging tobacco products, as well as pipes and cigars (FDA, 2016). Given the prevalences we have found for the use of these products, it is critical that the FDA fully implement the deeming rule and build upon it by imposing restrictions that are in accordance with the emerging evidence on the health effects of these products. Further, it is vital that any new tobacco policies do not inadvertently exacerbate existing urban/rural disparities by disproportionately benefitting urban communities. Empirically-driven research including the findings of this study are critically important in guiding the FDA’s ability to implement regulations.

Limitations

This study relied on the PATH-defined urban/rural dichotomy, which belies a more continuous distinction in urbanicity vs. rurality. For example, as the greatest health differences are often seen between rural and suburban areas,14,34 future work using more nuanced taxonomies may find sharper disparities. Likewise, although data confidentiality restrictions prevented us from parsing our groupings into smaller units (e.g., division of the country rather than region, the intersection of high-poverty men, etc.), it is worth focusing on such groups in targeted studies. The present work used broad categories to examine dual/poly use in terms of traditional only vs. emerging only tobacco products. Although a more nuanced examination of specific dual/poly use combinations was beyond the scope of this study, it has been examined well at the national level elsewhere.18,35

Conclusions

Rural Americans remain an at-risk segment of the U.S. population in need of more attention from tobacco control. Overall, the present study supports previous reports of greater cigarette and smokeless tobacco use in rural areas, and extends this work by indicating greater dual/poly use of traditional tobacco products in rural areas as well. Findings further indicate that e-cigarette use is similar in both urban and rural U.S. communities. Understanding the urban/rural use of tobacco products presented in this paper provides a fuller comprehension of an important contributor to health disparities in the U.S.

Acknowledgments

This work was supported by the National Cancer Institute under grant P50CA180908, the National Institute on Drug Abuse under grant P50DA036114, and the Center for Evaluation and Coordination of Training and Research (CECTR) in Tobacco Regulatory Science (1U54CA189222-01; NIDA/FDA).

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