Cumulative Disadvantage as a Framework for Understanding Rural Tobacco Use Disparities

Abstract

Traditional tobacco product (cigarettes and smokeless tobacco) and polytobacco use rates are significantly higher among rural adolescents and adults compared to their nonrural counterparts. Such disparities are due to several factors that promote tobacco use initiation and continuation, including individual-level psychopharmacological factors and structural-level factors such as fewer tobacco control efforts (e.g., fewer smoke-free policies and lower tobacco excise taxes), targeted tobacco marketing, less access to health-relevant resources, and more positive cultural norms surrounding tobacco use in rural communities. In this review, we use cumulative disadvantage theory as a framework for understanding how psychopharmacological and structural-level factors serve as drivers of tobacco use in rural areas. We start by describing how structural-level differences between rural–nonrural communities impact psychopharmacological influences and, when available, how these factors influence tobacco use. We conclude by discussing the interplay between factors, providing suggestions for ways to assess our application of cumulative disadvantage theory empirically and making recommendations for research and policy implementation in rural areas.

Rural communities comprise ~97% of U.S. land, though they include only ~20% of the population (United States Census Bureau, 2017). Despite their shared designation of “rural,” these areas are often heterogeneous in physical (e.g., rural West Virginia [WV] vs. rural Iowa terrain) and demographic characteristics (e.g., residents in WV are predominantly White whereas residents in Arizona are predominantly Hispanic; Bolin et al., 2015). However, they tend to experience similar challenges with regard to tobacco use (Cunningham et al., 2019; Dilley et al., 2013; Owusu et al., 2019). Indeed, national declines in overall tobacco use have not been observed among rural communities (e.g., Noland et al., 2018; Pesko & Robarts, 2017; Roberts et al., 2017; Ziller et al., 2019), especially in Central Applachia where tobacco use rates have been disproportionately high for decades (Appalachia Regional Commission, 2019).

Geographic-related differences in tobacco use have been observed consistently for cigarettes and smokeless tobacco (SLT), as well as for polyuse patterns that include these products, in both rural adolescent (e.g., Bernat & Choi, 2018; Chaffee & Cheng, 2018; Noland et al., 2018; Pesko & Robarts, 2017) and adult populations (e.g., Chang et al., 2016; Roberts et al., 2016, 2017). Clearly, traditional tobacco product use disparities are evident across multiple life span periods. These differences also are observed independent of socioeconomic status (SES; Doogan et al., 2017; Roberts et al., 2016), despite rural areas having a higher percentage of residents living in poverty than nonrural areas (12% vs. 16%, respectively; Kyzyma, 2018). Traditional tobacco product use begins earlier in the life span of rural residents (Bernat & Choi, 2018; Brasky et al., 2018), and in turn, rural adults use such products for longer durations than do nonrural adults (Brasky et al., 2018). In addition, early-onset smoking initiation is associated with higher rates of continued smoking (Hu et al., 2020). Unfortunatey, in spite of ongoing public health efforts to reduce these disparities, the gap between rural and nonrural areas has only widened in recent years (Doogan et al., 2017; Ziller et al., 2019). In contrast, less is known about geographic differences in the use of less traditional tobacco products anad extant results are mixed, (a) there may be no differences in cigar/pipe use rates for adolescents (Pesko & Robarts, 2017); (b) rates of use for cigarillos and waterpipe/hookah may be higher among nonrural adults (Roberts et al., 2016; 2017); and (c) exclusive electronic cigarette (ECIG) use rates may not differ between rural and nonrural adolescents or adults (Pesko & Robarts, 2017; Roberts et al., 2016, 2017). However, among those who smoke cigarettes, nonrural adolescents may have higher rates of concurrent ECIG use (Noland et al., 2018), contributing to the higher rates of polytobacco use seen among youth in rural communities (Pesko & Robarts, 2017).

Recent evidence suggests that the growing geographic disparity in traditional tobacco use between rural and nonrural areas may be driven, at least in part, by gender. Independent of sociodemographic and psychosocial factors, the rates of cigarette smoking declined between 2007 and 2014 for rural males, nonrural males, and nonrural females, while the trend for rural females was flat (Cepeda-Benito et al., 2018). Perhaps related is that smoking prevalence and nicotine dependence are significantly greater among women of reproductive age in rural than in nonrural areas, and rural women are significantly less likely to quit smoking after becoming pregnant (Nighbor et al., 2018).

Given that cigarette smoking and SLT use rates are reliably higher among rural residents, including among rural pregnant women, it is not surprising that morbidity and mortality rates for the leading causes of death for which tobacco use is a risk factor—cardiovascular disease, various types of cancer, respiratory disease, and stroke—also are higher among rural than nonrural communities (e.g., Garcia et al., 2019; Moy et al., 2017). It also is not surprising that, because of these disparities, rural populations are classified by the Food and Drug Administration (FDA) as being vulnerable and thus a research priority for tobacco regulatory science (Food and Drug Administration, 2019). This vulnerability is particularly evident when considering their tobacco-risk environment (Garrett et al., 2015); rural residents experience relatively higher tobacco product accessibility, fewer tobacco control efforts, a greater level of targeted tobacco marking campaigns, more favorable cultural norms surrounding tobacco use, and less access to health care and related services (e.g., American Lung Association, 2012; Harrell et al., 2017; Lee et al., 2015; Roberts et al., 2015, 2016; Sutter et al., 2018; U.S. Department of Agriculture, 2017). Moreover, these structural-level influences likely have bidirectional relationships with those that are psychopharmacological in nature, such as brain perturbations due to early-life exposures to nicotine (e.g., in utero, during adolescence) and/or other stressors (e.g., poor nutrition or lack of proper medical attention). Because tobacco use risk factors are present early in life and persist over time, rural residents may experience a phenomenon known as “cumulative disadvantage,” which describes how social and material inequalities exert influence on life span trajectories, including health-relevant behaviors and associated outcomes (Nurius et al., 2015; Schafer et al., 2011; Seabrook & Avison, 2012).

The purpose of this review is to use cumulative disadvantage theory as a framework for understanding the disadvantages that cause increased tobacco use and related negative health outcomes in rural areas (Brondolo et al., 2009; Haas, 2008; Pais, 2014). According to Pais (2014), cumulative disadvantage is a selective process where health insults tend to accumulate with greater frequency and magnitude among socially and economically disadvtanged populations (p. 1730). To clarify further, Dannefer (2003) described cumulative advantage/disadvantage as “… the systematic tendency for interindividual divergence on a given characteristic (e.g., money, health, status) with the passage of time” (p. S327). This theory can be applied to rural tobacco-use health disparities in two ways: (a) systematic disadvantages experienced uniquely by those living in rural areas (e.g., less access to health care services; Brondolo et al., 2009) and (b) the cumulative and disproportionate disadvantages experienced by rural youth that lead to adult health disparities (e.g., having parents who smoke in the home; Haas, 2008). We postulate that the following factors promote tobacco use initiation and continuation among rural residents: tobacco control efforts, targeted tobacco marketing, access to health care and related services, cultural norms surrounding tobacco use, and psychopharmacological insults. Importantly, we use cumulative disadvantage theory to describe how these factors may compound with one another to exert a greater effect on tobacco use than any factor in isolation (e.g., Dannefer, 1987; Graham et al., 2006; Leventhal et al., 2019). We conclude by suggesting ways that our application of cumulative disadvantage theory can be examined empirically and by making research and policy recommendations that may reduce rural tobacco use disparities.

Drivers of Tobacco Use in Rural Areas

Structural-level factors influence individual behavior via family, community, state, and national levels, and relate directly to the social determinants of health. Structural-level factors that may help explain rural–nonrural tobacco use disparities include those that are (e.g., tobacco control efforts), versus are not, (e.g., access to health care) specific to tobacco. The following sections describe these factors in detail and when available, discuss their effects on incongruent tobacco use between rural and nonrural areas. Importantly, we also describe how such structural-level drivers are intertwined with psychopharmacological factors that promote tobacco use.

Targeted Marketing

Longitudinal studies show that nonsmoking adolescents who are receptive to advertising (e.g., having a favorite tobacco advertisement) are more likely to experiment with cigarettes and/or become an established smoker than adolescents who are not (Lovato et al., 2011; Roberts et al., 2019). Moreover, greater advertising exposure is associated with an increased likelihood of later smoking among adolescents (Hanewinkel et al., 2011), indicating that advertising is a powerful tool used by the tobacco industry to increase uptake among youth that extends into adulthood. Rural areas have been the target of industry-sponsored marketing campaigns for decades in terms of both quantity and type of advertisements. For quantity, rural residents report seeing pro-tobacco messages in more locations than their nonrural counterparts, including via the internet, direct mail, convenience stores, and other sources (Bernat & Choi, 2018; Branstetter et al., 2015; Roberts et al., 2019). Still, lower-income neighborhoods are exposed to more tobacco advertising whether rural or nonrural in nature. In contrast, advertisement types differ as a function of rural–nonrural location independent of SES (Lee et al., 2015; Roberts et al., 2015). Marketing for cigarillos is significantly greater in low-income nonrural communities, whereas marketing for cigarettes and SLT is significantly greater in low-income rural communities (Lee et al., 2015; Roberts et al., 2015). Campaigns for cigarettes and SLT often appeal to rural residents by taking advantage of rural stereotypes, such as “rugged,” “outdoor,” and “masculine” (Hendlin et al., 2017; Lee et al., 2015). Although rural residents report that tobacco marketing does not influence their tobacco use or choice to quit (Branstetter et al., 2015), empirical studies indicate that targeted marketing is related directly to increased levels of use among rural residents (Owotomo et al., 2017; Pesko & Robarts, 2017).

Tobacco Control Efforts

Smoke-Free Policies

The primary purpose of smoke-free policies is to reduce non-smokers’ exposure to secondhand smoke (SHS; Centers for Disease Control and Prevention [CDC], 2014b; U.S. Department of Health and Human Services, 2006), though they also promote cessation and reduce tobacco use initiation and social acceptability (CDC, 2014b; Kaufman et al., 2018; Persoskie et al., 2015; Titus et al., 2019). Because SHS exposure can stimulate nicotinic acetylcholine receptors in a manner similar to cigarette smoking (Brody et al., 2011), it may lead to unintended nicotine dependence (Small et al., 2010) and deficits in neural functioning during critical periods of development (see review by Gould et al., 2020). Furthermore, SHS contains at least 70 carcinogens (IARC, 2012) known to promote cancer, respiratory illness, coronary heart disease, premature death, and poor development (CDC, 2006). Unfortuantely, there are fewer smoke-free policies in rural than nonrural areas (Buettner-Schmidt et al., 2019; CDC, 2019; Hafez et al., 2019; Hood et al., 2014; Tynan et al., 2016). This is an example of how psychopharmacological and social-environmental factors can interact over time, illustrating the concept of cumulative disadvantage.

Rural disparities in SHS exposure hold for indoor areas like personal residences, worksites, restaurants, and bars (Buettner-Schmidt et al., 2019; Tynan et al., 2016; Vander Weg et al., 2011), as well as outdoor areas like public parks (e.g., Hood et al., 2014). For example, smoke-free policies exist for ~50% of worksites in rural areas versus ~77% of those in nonrural areas (Ablah et al., 2017; Tynan et al., 2016; Vander Weg et al., 2011). Complicating matter is that rural residents demonstrate high compliance with policies for public indoor areas (e.g., restaurants), but not with those for outdoor (Buettner-Schmidt et al., 2018, 2019) or residential areas (Hafez et al., 2019; Jiang et al., 2018; Kaufman et al., 2018; Kopp et al., 2018). When considering signs stating “No Smoking Within 20 feet of Entrance,” for instance, noncompliance rates were ~26% versus ~41% in nonrural and rural communities, respectively (Buettner-Schmidt et al., 2018). Failure to follow such policies may be the result of opposition to tobacco control among rural respondents (Hahn et al., 2013; Klein et al., 2014; Stillman et al., 2018). Importantly, compliance with smoke-free laws can lead to immediate, sustained, and substantial reductions in SHS exposure and possibly eliminate the related disparities observed for rural communities (Buettner-Schmidt et al., 2018).

Tobacco Retailer Laws and Densities

As of 2019, only 38 states in the U.S. required a retailer license to sell tobacco (Countertobacco.org, 2020). Among those states without retailer licensing laws are Kentucky and Tennessee, which are at least 50% rural by area. Overall, there are more permissive retailer licensing policies in rural areas (CDC, 2019), leading to tobacco retailer densities that are 2.6–8 times higher in rural than in nonrural areas (Adibe et al., 2019; Hall et al., 2019). Critically, a lack of tobacco licensing laws is associated with a greater density of tobacco retailers, and greater retail availability of tobacco is related directly to heightened social acceptability of tobacco use, enhanced point-of-sale tobacco advertising, and higher rates of smoking (Countertobacco.org, 2020). In turn, rural residents often have fewer choices for places to shop without being exposed to tobacco marketing (Public Health and Tobacco Policy Center, 2020).

Excise Taxes and Minimum Price Laws

In general, when tobacco is more expensive, fewer people initiate use and more engage in cessation (U.S. Department of Health and Human Resources, 1994). Lower tobacco prices facilitate the purchase of tobacco among low-SES individuals, including those who live in rural communities (Buettner-Schmidt et al., 2019). There are two ways in which the cost of tobacco can be increased through policy change: (a) tobacco excise taxes and (b) minimum allowable sale price(s).

Predominantly rural states tend to be more conservative politically (Ulrish-Schad & Duncan, 2018), and because state tax rates on tobacco are linked to political views, these states tend to require lower tobacco taxes as compared to states with smaller rural areas (Fox et al., 2017; Golden et al., 2014). For example, WV has a $1.20 per pack cigarette excise tax whereas California has a $2.87 per pack tax (Campaign for Tobacco Free Kids, 2020a). Importantly, increasing excise taxes can effectively increase cessation rates for cigarettes and SLT (CDC, 2014a; Center for Public Health Systems Science, 2014; Dave & Saffer, 2013), reduce tobacco use disparities (CDC, 2014a; Center for Public Health Systems Science, 2014), and increase life expectancies (Baum et al., 2020). In fact, some work indicates that for every $1.00 increase in taxes per cigarette pack, life expectancy increases by approximately 1 year, and has a larger effect on life expectancy in rural as compared to nonrural communities (i.e., 1.05 years vs. 0.92 years; Baum et al., 2020). Still, the tobacco industry offers coupons or other promotions to circumvent the increased cost imposed by excise taxes (ChangeLab Solutions, 2020; Federal Trade Commission, 2006).

Minimum price laws for tobacco products, which set prices below which products cannot be sold, were enacted by more than half of U.S. states by the 1950s. Initially, such laws were created to protect small businesses from predatory practices imposed by larger retailers, such as selling tobacco products below cost to attract more business (CDC, 2010). However, minimum price laws have the ability, if implemented properly, to offset tobacco industry tactics that circumvent increased excise taxes (ChangeLab Solutions, 2020). Still, few places have taken advantage of the public health benefits offered by increasing the minimum price of tobacco. In 2014, New York City became the first to set a minimum price of $5.00 per cigarette pack, but its effectiveness for reducing tobacco use relative to excise taxes has been difficult to assess. Notably, one simulation study suggests that increasing minimum prices on tobacco by $2.00 or more will reduce consumption by ~16% (Golden et al., 2016). Still, the minimum price that reduces consumption most effectively may vary by geographic location, with areas comprised of higher-income residents requiring higher minimum prices than areas with lower-income residents. Given the lack of research in this area, studies are needed to elucidate the most effective parameters of minimum price laws, particularly for those in rural versus nonrural areas.

Tobacco-21 Laws

Federal tobacco-21 law went into effect in December 2019, raising the minimum age requirement for purchasing tobacco products to 21 years (Tobacco21.org, 2020). This law was developed based on statistics showing that 54% of cigarette smokers initiate use before the age of 18 while 85% intiate by the age of 21 (Institute of Medicine, 2015). Limited research suggests that tobacco-21 law does have a positive impact (Ali et al., 2020; Oregon Health Authority, 2019); a national survey found that the odds of recent and current established cigarette smoking was reduced by as much as 39% among 18–20 year olds (Friedman et al., 2019). However, it is unclear whether residents of rural areas specifically are benefiting from tobacco-21 law. Importantly, many more rural tobacco users report initiating use before their 18th birthday compared to their nonrural counterparts (Bernat & Choi, 2018; Brasky et al., 2018), suggesting that access restrictions are largely unenforced in rural areas. Indeed, many underage tobacco users report relying on “social sources” (friends and family) to get tobacco products (Liu et al., 2019), making tobacco accessible despite the minimum age requirement. The impact of adolescent nicotine exposure on brain development includes long-term alterations in neuronal and cognitive function (see review by Yuan et al., 2015) and these neurological changes are implicated in subsequent use of other drugs as well as mood disorders (Yuan et al., 2015). Although many rural youth get tobacco from social sources, increasing the minimum age requirement may change cultural norms and acceptability of tobacco use over time, leading to reductions in tobacco use initation and continuation (Institute of Medicine, 2015).

Antitobacco Campaigns

To help counteract pro-tobacco marketing, antitobacco campaigns deliver messages aimed at reducing tobacco use. Messages may include statements about the health consequences of tobacco use, and have been successful for opposing the culture of tobacco normalization (e.g., Zollinger et al., 2006). To illustrate, the Campaign for Tobacco Free Kids’ website is dedicated to antitobacco messages that include annual health care expenditure and mortality statistics due to tobacco use (Campaign for Tobacco Free Kids, 2020b). The Truth campaign promotes similar messages to youth, and encourages them to become an active participant in community efforts to reduce tobacco use (Truth Initiative, 2019a, 2019b). However, rural areas are historically exposed to fewer antitobacco messages than are nonrural areas (Couch et al., 2017; Zollinger et al., 2006), which adds to the favorable environment for tobacco use in rural communites. At least one study suggests that increasing Truth campaign exposure through purchasing airtime on local media networks results in greater awareness and receptiveness of these antitobacco messages among rural youth (Duke et al., 2009). Still, fewer rural residents have access to cable television (Duke et al., 2009) and/or broadband internet (McKinley, 2020) than their nonrural counterparts.

Among rural residents without access to television or internet, exposure to antitobacco messages may be increased by repurposing former tobacco barns to promote cessation (Beam, 2017). Indeed, “tobacco barns” are now considered landmarks in many rural communities, previously serving as the symbol of a cash crop for the community as well as a popular avenue for product advertising by the industry (Hart et al., 2018). To our knowledge, there is no work assessing the effectiveness of such messages delivered via tobacco barns. Also needed is more work identifying the types of messages that resonate best with rural communities (see review by Cruz et al., 2019). Given the relatively high levels of religiosity in rural areas (Dillon & Henly, 2008), messages from religious leaders or that have religion-based framing may be effective (Kostygina et al., 2014; Lewis-Thames et al., 2020). On the other hand, several studies suggest that health-related messages are effective without cultural adaptation (e.g., Patten et al., 2018; Walker et al., 2018). Because cultural tailoring of antitobacco media is a practice widely used (Talbot et al., 2019b), more work is needed to determine whether incorporating rural themes is essential for increasing effectiveness.

Access to Health Care and Related Services

Rural disparities in access to health-related services refer to service proximity as well as the skills required to obtain those services. Lower population densities in rural areas result in fewer health care services in those areas, and dampened communication of health information to residents (Matthews et al., 2017). In fact, access to health care is cited consistently as the top rural health priority, with relatively fewer emergency services, primary care services, and medially insured individuals as compared to nonrural areas (Bolin et al., 2015; National Center for Health Statistics, 2017). In turn, rural residents have less access to evidence-based tobacco cessation treatments (American Lung Association, 2012). Rural residents also have lower health and health-insurance literacies than nonrural residents (Halverson et al., 2013; Zahnd et al., 2009), making them less equipped to shop for plans that provide adequate protection and reduce financial burden (Braun et al., 2017).

Remote-access health programs have been implemented on state and national levels to help circumvent access obstacles faced by rural residents, including telephone quitlines, telemedicine, and mobile phone-based smoking cessation (Talbot et al., 2019b). Some suggest that these programs have had the intended effect, with rural Medicaid beneficiaries being more likely to use telemedicine than their nonrural counterparts (Talbot et al., 2019a). Still, remote-access programs require a mobile phone and/or the internet, which may not be feasible for those of lower SES (Sheffer et al., 2015) or those living in areas with poor broadband internet (Drake et al., 2019). As a result, some rural residents may be unable to engage with remote health programs (Vanderpool, 2008). In addition, remote programs for tobacco cessation may not be as effective for rural users as those that are completed in-person, though it is unclear why that may be (Zanis et al., 2011). Overall, more work is needed on improving remote-access health resources for tobacco cessation.

Culture Surrounding Tobacco

There is no extant work regarding the rural culture around less traditional tobacco products (e.g., ECIGs or hookah), though a normalized culture of traditional tobacco use has been engrained in rural communities for decades. Normalization is shown through enduring symbols of tobacco in these areas, such as historic tobacco barns and festivals (FestivalNet, 2020) celebrating tobacco heritage (e.g., Hart et al., 2018). For many rural residents, smoking and SLT use are described as part of a common, normative way of life in rural “country” culture (Couch et al., 2017; Hart et al., 2018). This culture may contribute to noncompliance with smoke-free (Buettner-Schmidt et al., 2018) and tobacco-21 (Liu et al., 2019) laws, leading to reduced impact of these laws on tobacco use. Another possible contributor is the significant source of income that tobacco crops have provided to rural areas over the years (American Lung Association, 2012). Indeed, the residents of areas that grow tobacco have historically resisted tobacco control efforts because they believe that such efforts economically disadvantage their families and communities (Denham et al., 2004; Ferketich et al., 2010; Hahn et al., 2013; Wilson et al., 2004). The tobacco industry has reinforced this idea by promoting imagery that portrays tobacco as a source of employment rather than as a product to be regulated (American Lung Association, 2012; Kostygina et al., 2014). However, the number of tobacco farms has decreased dramatically; in North Carolina, which produces most of the nation’s tobacco crop, tobacco farming now makes up less than 2% of manufacturing employment (Campaign for Tobacco Free Kids, 2019). With the reduction in tobacco-related manufacturing jobs over time, attitudes about tobacco control have the potential to shift (Sanders-Jackson et al., 2020).

The occupations of rural residents can influence the normalization of tobacco use in rural culture. Rural males in particular often work in occupations that require physical labor, such as mining and farming (Laughlin, 2016; Pratt, 1990). Mining has the highest percentage of cigarette smokers (30%) and SLT users (18.8%) compared to all other U.S. occupations (National Institute for Occupational Safety and Health, 2016). Many miners also are polytobacco users given that they cannot smoke cigarettes on the job site, using products like SLT during work hours (Graber et al., 2016). Individuals in this and similar professions (e.g., extraction workers) are already at risk for respiratory diseases such as chronic obstructive pulmonary disease (COPD) due to their inhalation of mineral dust; this risk increases greatly when individuals also smoke cigarettes (Cohen et al., 2008). These same physical laborers also have been targeted by tobacco advertisements that equate tobacco use with masculinity (Zwick, 2018). Together, research indicates that professions with the highest rates of tobacco use are engrained in rural culture.

Another potential cause for a normalized culture of tobacco use in rural areas may be community and family connectedness. Though it is unclear whether connectedness differs as a function of rural/nonrural community type, among rural women, the odds of being a smoker increases by 12%–14% as neighborhood cohesion increases, which may be due to stronger perceptions of tobacco’s social acceptability among cohesive neighborhoods (Nemeth et al., 2018). Family members also sometimes enable youth tobacco use in rural communities (Bernat & Choi, 2018; Hart et al., 2018), subsequently reducing their perceptions of tobacco as harmful (Chaffee & Cheng, 2018; Couch et al., 2017). Smoking may, in fact, be transmitted intergenerationally (Bierut et al., 1998), with certain aspects of parenting being predictive of youth smoking (e.g., low parental involvement and monitoring; Harakeh et al., 2004). Indeed, rural male adolescent SLT users support the idea that family SLT use plays a prominent role in their own use, … your dad chewed, your grandpa chewed, great-uncles, and so on … So it’s like in your blood (Couch et al., 2017) and Once you get to a certain age, everyone just assumes that you use tobacco. (Hart et al., 2018). Rural residents are also more likely than nonrural residents to report that someone smokes in their presence at home or at work (Bernat & Choi, 2018; Ebrahimi Kalan et al., 2020), and living with a tobacco user significantly increases SHS toxicant exposure (Park, 2020) and leads to tobacco use among adolescents (Helme et al., 2019; Owusu et al., 2019).

Chronic Stress

Differences in tobacco use between rural and nonrural communities may be explained partly by differences in the stressors they experience. Some of those stressors have been described in earlier sections of this review: low SES, few local health care resources, poor internet service, etc. Given that more rural residents live in poverty (Kyzyma, 2018), individuals of low SES may have reduced access to pleasurable activities (e.g., shopping and concerts), possibly leading to heightened substance use experimentation and continuation (see review by Acuff et al., 2019) and creating additional stress. Stress experienced chronically causes an inflammatory response that leads to various disease states (Slavich & Irwin, 2014) like depression, anxiety, cardiovascular disease, and cancer (see review by Slavich, 2016). Adding insult to injury, the same disadvantaged individuals who develop these diseases may be less able to receive the health care they need for treatment.

Cumulative Disadvantage Promoting Tobacco Use in Rural Areas

Structural-level and psychopharmacological drivers of tobacco use may influence one another over time, resulting in a cumulative disadvantage. This disadvantage can promote tobacco use initiation and continuation among rural residents at higher rates than would individual factors alone. Consider rural adolescents who live in households with multiple family members who use tobacco and who are exposed to nicotine/tobacco pre and/or postnatally. When they step outside of their home, these young people enter a community environment with a disproportionate amount of pro- (e.g., advertisements, tobacco retailers, tobacco barns and festivals) versus antitobacco messages (e.g., smoking restrictions and antitobacco campaigns) coupled with additional exposure to SHS. This may result in rural adolescents being more likely to initate tobacco use at an early age and to continue using tobacco throughout adulthood. They may then be unable to escape this pro-tobacco environment while experiencing other stressors: health problems from tobacco use, poor medical care due to a lack of health-relevant resources, low income, and/or few alternative reinforcers. When rural tobacco users have children of their own, the children are exposed to the same factors promoting their own tobacco use and the aforementioned cycle continues.

Despite the many factors promoting disadvantage, no studies have assessed empirically the way such factors work together to promote tobacco use in rural areas. A popular method for studying cumulative disadvantage is to create a quantitative index that represents the amount of disadvantage experienced by individuals; the index is a summation of dichotomized factors (1 = experience with factor, 0 = no experience with factor), with higher scores representing greater disadvantage. Such a method has been used extensively in studies on youth development (e.g., Lin & Seo, 2017; Nurius et al., 2015). Though some have evaluated the interactions between tobacco risk factors (Gaalema et al., 2018; Higgins et al., 2016), only one study has used a cumulative disadvantage index to quantify risk. In this recent study (Leventhal et al., 2019), national-level disadvantage was quantified using six binary factors: unemployment, poverty, low education, disability, psychological distress, and heavy drinking. Results indicated that disadvantages combine with one another in a summative fashion to promote cigarette smoking, with current smokers being more likely to score 3 or higher on the cumulative disadvantage index. Given that rural areas experience disadvantages that are specific to rural communities, it is important to consider how the psychopharmacological and structural-level factors promoting disadvantage in rural areas may differ quantitatively from those promoting disadvantage on a national level.

In addition to research quantifying cumulative disadvantage, work is needed that assesses how state- or federal-level policies impact rural communities, specifically. Policy recommendations for reducing tobacco use can be found in Talbot et al. (2019b), though addressing disparities for rural residents likely will require policy changes that target multiple structural-level causes of cumulative disadvantage. A starting point might be the Truth Initiative’s (2017) report titled “Tobacco Nation: An Ongoing Crisis,” which highlights that U.S. states with the highest rates of tobacco use are highly rural in nature (e.g., Kentucky, Mississippi, Missouri, WV) and have relatively weak tobacco control policies (Truth Initiative, 2017). Using WV as an example, this predominantly rural state has relatively low taxes per cigarette pack ($1.20 vs. the national average of $1.82), low quit line investments ($0.97 per smoker vs. the national average of $2.14), and a tobacco prevention budget that is only 1.8% of that recommended by the CDC (Truth Initiative, 2020). WV also currently ranks highest in cigarette smoking (25.2% vs. 13.7% national) and second highest in SLT use (8.5% vs. 4.0% national) among U.S. adults, and has rates of youth ECIG, SLT, and cigar use that are higher than national averages (Truth Initiative, 2020). Based on current evidence, it is likely that increasing tobacco excise taxes, increasing the minimum price of tobacco, and ramping up smoke-free and retailer licensing laws simultaneously will lead to an immediate and sustained reduction in tobacco use and SHS exposure among residents in rural states, including WV.

Along with policy changes, cultural norms surrounding tobacco use must be addressed within rural communities. Such norms are the result of decades of tobacco crop-derived income, targeted marketing, and intergenerational tobacco use among rural residents. Notably, tobacco-related norms may vary across rural regions as well as between rural-residing racial/ethnic groups. For instance, religion is engrained in daily life for many people living in rural Appalachia (White, 2019), though such strong religious ties may not be true of non-Appalachian rural communities. Given such potential cultural differences, community-engagement approaches that include consultation with health care providers, public health agencies, and community members are warranted in the development of programs for reducing positive attitudes surrounding tobacco. Changing the culture surrounding tobacco use is not something that will happen quickly nor by addressing just one or two of the structural factors mentioned previously. It will be important to increase tobacco control efforts among rural communities, reduce tobacco marketing, increase the cost of tobacco, and increase the prevalence of smoke-free policies. Taking this approach will presumably lead to reduced rates of tobacco use among rural residents. With fewer residents using tobacco, there will be less parental and peer use, which will also reduce the social acceptability of tobacco use among subsequent generations.

Adding to the complexity of addressing the factors that promote cumulative disadvantage are issues surrounding the different definitions of “rural.” For instance, some definitions determine area boundaries using counties (e.g., Office of Management and Budget [OMB]), whereas others use zip codes (e.g., Frontier and Remote Area) or census tracts (e.g., Census Bureau); some dichotomize the U.S. to “rural” versus “urban” areas (e.g., Census Bureau, OMB) in contrast to others that categorize areas into more than two categories (e.g., Frontier and Remote Area) or a continuous system (Isolation Scale; Doogan et al., 2018). Importantly, the use of varying rural definitions can lead to bias in scientific measurement and research findings (Bennett et al., 2019). Work in this area will benefit greatly from measurement consistency across research fields that is sensitive to the various aspects of rural areas that contribute to their rurality (e.g., access to health-relevant resources, including internet and grocery stores; population density); see Bennett et al. (2019) for recommendations on definitions of rurality that may better serve those living in rural communities.

Conclusion

Traditional tobacco product (cigarettes and SLT) and polytobacco use rates are consistently higher in rural than in nonrural areas. Illustrating the concept of cumulative disadvantage, such disparities are evident for adolescents and grow over time, leading to even wider disparities among rural adults. Many factors promote cumulative disadvantage and tobacco use among rural residents, including psychopharmacological insults, fewer tobacco control efforts, targeted marketing, reduced access to health-relevant resources, and a positive culture surrounding tobacco. These factors likely accumulate with one another and exert a greater effect on tobacco use and health via cumulative disadvantage than when each is considered in isolation. Although research among rural communities is highlighted as a priority by the FDA, there is relatively little research with this vulnerable population compared to others (Higgins et al., 2019). To effectively reduce tobacco use among rural communities, work needs to be done that addresses multiple factors contributing to the ever-widening disparities experienced by rural populations, including policy implementation that reduces tobacco use and ultimately, over time, changes the favorable culture surrounding tobacco use.

Public Significance Statement.

Despite public health efforts, rural–nonrural disparities for traditional tobacco products (cigarettes and smokeless tobacco) have only widened in recent years. We use cumulative disadvantage theory as a framework for describing the interplay between psychopharmacological and structural-level drivers of tobacco use in rural areas. Based on this framework, we suggest ways to assess our proposed model empirically and make research and policy recommendations for reducing tobacco use in rural areas.