by Stacey Stevens, Brian Colwell, and Linnae Hutchison





  • Tobacco use is one of the 10 “leading health indicators” selected through a process led by an interagency workgroup within the U.S. Department of Health and Human Services.16
  • Rural adolescents (except in the Midwest) are more likely than their urban counterparts to smoke.4
  • Adult men and women in most rural counties, with some variation across regions, are more likely to smoke than those in urban counties.4
  • Tobacco has been ranked as the leading “actual cause of death” in the United States, i.e., contributing to the diagnosed condition associated with a death.17




The Healthy People 2010 goal is to reduce illness, disability, and death related to tobacco use and exposure to second hand smoke.1 Major objectives of Healthy People 2010 are reducing exposure to second hand smoke (SHS) and tobacco use by teens and pregnant women. Because there are rural and urban disparities in these major areas, this review focuses on the ill effects of smoking during adolescence as well as during pregnancy, and provides an overview of select prevention and cessation programs.


Tobacco use remains the leading cause of preventable death in the United States, with 430,000 deaths each year (one in five) attributable to tobacco use. The resulting cost is an estimated $50 to $73 billion dollars in health care costs¾nearly 12 percent of all medical costs7, 18, 19¾and another $50 billion dollars in indirect costs.20 Compounding the tobacco issue in rural versus urban areas is the “lack of critical mass of resources to deal with the consequence of substance abuse” in rural areas.8


This review addresses the following Healthy People 2010 objectives:


·         27-1. Adult tobacco use.

·         27-2. Adolescent tobacco use.

·         27-3. Initiation of tobacco use.

·         27-4. Age of first tobacco use.

·         27-6. Smoking cessation during pregnancy.

·         27-7. Smoking cessation by adolescents.

·         27-9. Exposure to tobacco smoke at home among children.

·         27-10. Exposure to second hand smoke.

·         27-14. Enforcement of illegal tobacco sales to minors.

·         27-16. Tobacco advertising and promotion targeting adolescents/young adults.




Tobacco use ranked sixth among the Healthy People 2010 focus areas in terms of rural health priority rating, selected by an average of 26 percent across the four groups of respondents within the states.2 Local public health agencies most frequently nominated tobacco use, and state agencies were least likely to nominate it as a priority in comparison to rural hospitals or rural health centers/clinics. The Northeast and Midwest produced higher percentages of nominations for tobacco use, the sixth most nominated priority area, than did the South or the West, where it ranked eighth and 13th, respectively. There was a statistically significant difference among the regions.




Cigarette use is more prevalent in rural areas than in large and small metropolitan areas. The overall rate of smoking is 33 percent in nonmetropolitan areas compared to 27 percent in large metropolitan areas and 28 percent in small metropolitan areas.3 Educational attainment has replaced gender as the most predictive sociodemographic predictor of smoking, with those not completing high school having the highest rates of smoking (37 percent) and college graduates having the lowest (17 percent).3, 19


Prevalence of Tobacco Use among Adults in Rural Settings


Adults living in the most rural areas are the most likely to smoke. In rural areas, 27 percent of women and 31 percent of men report themselves as regular smokers.4 Higher rates in rural counties likely reflect two factors, delayed access to medical and media resources and lower educational attainment, both of which are strongly associated with smoking.4 Of the 15 states with the highest prevalence of current cigarette smoking among adults, the majority were highly rural, southern, and tobacco producing.19 Among states with the highest number of adults currently smoking cigarettes were Kentucky (30.8 percent), West Virginia (27.9 percent), and South Dakota (27.3 percent), all of which are considered more rural states.21


Of particular concern across urban and rural settings alike is the prevalence of smoking among young adults and adolescents. The 1995 young adult smoking prevalence was 24.8 percent, up from 22.9 percent in 1991. A variety of investigations of smoking on college campuses have confirmed this trend in college students.23


Smokeless tobacco use is also particularly prevalent among adults in rural settings. After a review of six studies among adults, Bell et al. remarked, “among U.S. adults, smokeless tobacco use is associated with low socioeconomic status, male sex, Native American race, and southern or rural residence.”5 Usage of smokeless tobacco increased threefold from 1972 to 1991, and smokeless tobacco production increased in each of those nine years. Unfortunately, three million American users of smokeless tobacco are under 21 years of age.22 The prevalence of smokeless tobacco use remains highest among young males aged 18 to 24 years6 and is higher in rural versus urban areas.


Prevalence of Tobacco Use among Adolescents in Rural Areas


A continuing concern is the age of initiation, that is, the age at which youth begin using tobacco products. Studies cited in the 1994 Surgeon General’s Report on Smoking found the mean age of onset for first use of cigarettes is 14.5 years, and 89 percent of daily smokers first try a cigarette by 18 years of age, with nearly 37 percent first trying a cigarette before age 14.19 Since most smokers try their first cigarette before the age of 18,19, 24, 25 children and adolescents should be considered the most important targets for education, prevention, and cessation efforts.23 Of all groups, tobacco use by adolescents has experienced the sharpest increase¾nearly 78 percent between 1988 and 1996.7 The rate of past month use has since decreased slightly from 14.9 percent in 1999 to 13.4 percent in 2000. The number of youth who begin to smoke each day decreased from 3,186 in 1997 to 2,145 in 2000; however, this decrease was primarily among male youth. The rate of smoking in 2000 was higher for female (14.1 percent) than male youth (12.8 percent).26


While these decreases are a positive sign, there is wide disparity in tobacco use between adolescents living in rural versus urban settings. The prevalence of past month smoking in adolescents aged 12 to 17 is higher in rural than urban counties (18 percent versus 11 percent, respectively).4 More alarming are data reported in the Center on Addiction and Substance Abuse (CASA) Whitepaper on substance abuse in rural America. They report both past month cigarette and smokeless tobacco use by eighth graders is higher in rural versus small and large metro areas. Specifically, rural eighth graders are twice as likely to smoke cigarettes (26.1 percent versus 12.7 percent in large metro areas), and they are nearly five times more likely to use smokeless tobacco (8.9 percent versus 1.8 percent) than those in metro areas.8 Finally, a study of smoking initiation utilizing data from the Cardiovascular Health in Children and Youth Studies (CHIC I and II) found that children in rural areas were significantly more likely to begin smoking than urban children at all time periods of the six year longitudinal study and were more likely than their urban counterparts to start smoking after 12 years of age.27


As demonstrated above, a problem exists not only with cigarette use among adolescents, particularly rural adolescents, but a significant problem also exists with the use of smokeless tobacco among these youth. The National Household Survey on Drug Abuse assesses smokeless tobacco use among youth and found that 25 percent of males and 3 percent of females between 12 and 17 years of age have tried some form of smokeless tobacco. Among 12th grade males, 12 percent used smokeless tobacco nearly every day.22 In general, research suggests an alarming bimodal distribution in which rural youth begin use of smokeless tobacco around age 12, while those urban youth who begin to use do so around age 18.9 According to one study, rural males who reported having tried smokeless tobacco outnumber urban males by a ratio of approximately 4:1. In that study, 36.4 percent of male rural first graders reported having tried smokeless tobacco, increasing to 72.5 percent by the seventh grade.9 The incidence of reported continued use of smokeless tobacco among rural youth was 9.1 percent, 12.8 percent, 12.9 percent, and 20 percent among first, third, fifth, and seventh graders, respectively. This study also supported findings that nicotine dependence may be common in rural boys as young as six years of age.


Prevalence of Tobacco Use during Pregnancy


In addition to tobacco use among adolescents, a second critical problem is tobacco use among pregnant women. Cigarette smoking is associated with increased rates of infant mortality and puts infants at risk for sudden infant death syndrome (SIDS), poor lung function, asthma, and respiratory infections. As such, nearly every prenatal care program addresses the use of tobacco in pregnancy.10

While the number of women smoking during pregnancy has decreased, smoking prevalence among pregnant women still exceeds the Healthy People 2000 objective to reduce smoking by pregnant women to 10 percent.12 U.S. birth certificate data in 1997 show that 13.2 percent of women giving birth reported that they smoked during pregnancy. Of particular concern is evidence suggesting that smoking rates among rural pregnant women remains higher than smoking rates among urban pregnant women. For example, reports from the Arizona Department of Health indicate that, in 1999, rural mothers were more likely to smoke than urban mothers.10 Disparities exist in progress against smoking as well. In Missouri, the greatest reductions in smoking during pregnancy and in heavy smoking during pregnancy occurred in women living in metropolitan statistical areas (MSAs) rather than in women living in rural settings. For pregnant women in urban areas, the rate of smoking was 20.5 percent in 1992 and dropped to 17.4 percent by 1997. During the same time period, the rate of smoking among pregnant women in non-MSAs was less significant, dropping from 25.7 percent in 1992 to 25 percent in 1997.28

Prevalence of Second Hand Smoke


A third and final critical area related to the ill effects of tobacco use in rural settings relates to second hand smoke, as it is often called. Tobacco-related illnesses as a result of exposure to SHS are clearly present in both rural and urban settings. However, some evidence suggests a greater tolerance for SHS and related illnesses in rural settings. The National Social Climate of Tobacco Control Survey (2001) measured the extent to which tobacco control and tobacco use are ingrained in the social institutions that influence decisions about tobacco. Rural responses to questions indicated more acceptance of tobacco in the household, in the car, around children, and less disagreement with children under 18 regarding smoking than those living in urban areas.11 Thus, we might expect to find a higher prevalence of SHS-related illnesses in rural settings, though sufficient research has yet to be completed.


Impact of the condition on Mortality


Tobacco use remains the leading cause of preventable death, resulting in 430,000 deaths among adults annually.1 The resulting cost is an estimated 50-73 billion dollars in medical bills.7


Tobacco use is also a significant contributor to many other health problems including coronary heart disease, lung disease, cancer, damage to the female reproductive system, and injury to an unborn fetus (including low birth rate, stillbirths, and a higher rate of infant mortality).12


As suggested in an earlier section, tobacco use among youth remains of great public health concern. More than five million youth under 18 years old living today will die prematurely as a result of their involvement with tobacco.13 Evidence suggests adverse changes in lipid proteins,29, 30 abnormal spirometry and lung function tests, and respiratory bronchiolitis among young adolescents who smoke.31 Since a larger percentage of rural versus urban youth use tobacco, in the future we might expect a corresponding higher percentage of adverse health consequences related to smoking in rural areas, which are not as equipped with the necessary resources to deal with these problems. Unfortunately, while it is obvious that age of initiation of tobacco use is lower and prevalence of use is higher in rural areas, the reasons for this are just beginning to be investigated by researchers.


Tobacco use during pregnancy is also a significant public health concern. Cigarette smoking during pregnancy is associated with increased rates of infant mortality. Smoking during pregnancy puts infants at risk for sudden infant death syndrome, poor lung function, asthma, and respiratory infections. Between 20 to 30 percent of low birth weight incidence is attributable to maternal cigarette smoking. In 1995, estimated smoking attributable medical costs for those with complicated births was $1.4 billion in 1995 dollars.12


SHS contributes to an estimated 3,000 lung cancer deaths and 62,000 coronary heart disease deaths in nonsmokers annually, as well as contributing to increased severity and frequency of asthma, SIDS, bronchitis, chronic middle ear infection, and pneumonia.14 One-third to one-half of current cigarette smokers have children living in the home, and 70 percent allow smoking in the home. Children exposed to SHS in the home have more annual days of restricted activity, bed confinement, school absences, increased risk of SIDS, and chronic middle ear infections. SHS also causes up to 300,000 lower respiratory tract infections like pneumonia and bronchitis and increases the risk of new cases of asthma as well as severity and number of attacks in children.32




Morbidity and mortality are treated under the mortality section because the death-dealing effects of tobacco work through its contribution to deadly illnesses.




Tobacco Use and Other Risk Behaviors


Cumulative risk behaviors often exist, and other risk behaviors are more common among those who smoke than those who do not smoke, particularly among adolescents. These include drinking alcohol,31, 33-36 using other illicit drugs,31, 33-35 engaging in sexual activity,31, 33, 34, 36 school misbehavior and low academic achievement,31, 33, 34, 37 violence or antisocial behavior,31, 33, 34, 36 and mental health problems.31, 34


A study of high school students in a rural, tobacco-growing county found a strong correlation between smoking and drinking. Approval of drinking had strong association with being a smoker, and having drinking friends increased the likelihood of being a smoker.38 In addition, tobacco and alcohol, as gateway drugs, may play a role in increased use of illicit drugs. Teens who drank or smoked in the past month are “30 times likelier to smoke marijuana than those who did not; those who used cigarettes, alcohol, and marijuana at least once in the past month are almost 17 times likelier to use another drug like cocaine, heroin, or LSD.”8 Rural students were found to have a higher prevalence for alcohol and cigarette use (particularly excessive use) than their urban counterparts.39


While limited in number, studies conducted in rural areas provide information about the various reasons for and correlates to tobacco use in general, and adolescent tobacco use specifically. Findings of the research indicate a lack of knowledge, issues related to susceptibility, and modeling of the social environment are among the most common reasons for tobacco use in rural areas.


Research examining the knowledge of the health effects of smoking indicates that most are aware of the relationship between smoking with cancer, but less than one-half of those surveyed recognized its association with heart disease.40 Those with less education were less informed about this association.40 There are also knowledge differences concerning the health effects of cigarettes versus smokeless tobacco. A majority of youth consider smokeless tobacco a safe alternative to cigarettes.9


Many factors are associated with the initiation of tobacco use. The 1994 Surgeon General’s report details a variety of sociodemographic, environmental, behavioral, and personal factors that are associated with the onset of smoking or use of smokeless tobacco.31 Among the factors listed were low socioeconomic status; male gender; accessibility to tobacco; tobacco advertising; parental, sibling, and peer use; normative expectations; and social support associated with use. Other variables that are commonly related include lack of academic achievement and other associated problem behaviors, intent to use, and previous experimentation with tobacco.


The personal factors that are commonly associated with increased risk of tobacco use include functional meanings of tobacco use to the individual as well as subjective expected utility, and self-esteem/self-image issues. Personality factors and a variety of measures of psychological well-being have been linked as well.31


Modeling the social environment has often been found to be associated with use of tobacco in rural areas. A North Carolina study of fourth and sixth grade children found modeling of use by best friends, and perceived prevalence of use among same-age peers were strongly related to the initiation and experimentation stages of tobacco use. Other key factors related to use were offers from friends and parents, adjustment to school, and behavioral self-regulation.41 Another study found that having friends or family members who smoke was significantly associated with increased susceptibility to smoking;42 another revealed peer pressure, identification with athletes, and association of tobacco use with maturity strongly influence initial trial of smokeless tobacco.9


In a study of tobacco cessation and determinants of relapse, most of those who had tried to quit and relapsed reported living with tobacco users; half reported that all or most of their close friends and co-workers used tobacco, and a small percent cited peer pressure as a reason for relapse.40




Overall, a lack of resources in rural areas is a major obstacle to tobacco use education, prevention, cessation, and treatment. Barriers to prevention and treatment in rural areas include transportation, lower median income to pay for treatment, lower prevalence of insurance coverage, limited media resources designed to change unhealthy habits, and minimal access to medical services for cessation assistance and treatment.8


Rural communities do not generally have the economies of scale needed to provide substance abuse treatment services. The responsibility falls to hospitals (40 percent) as opposed to 18 percent in the rest of the country.8 Moreover, individual tobacco users in rural areas often do not have sufficient resources to support treatment or cessation costs. A survey of Medicaid coverage in 2000 revealed only 33 of the 50 states and the District of Columbia offered some coverage for tobacco-dependence treatments, and only one state offered coverage for all treatments recommended by the Public Health Service. Some pharmacotherapy coverage was offered by 31 states¾an increase of 35 percent from 1998, and 23 offered coverage for over-the-counter drugs. Sixteen states offered coverage for all recommended pharmacotherapy treatments in 2000. A total of 13 states offered special tobacco-dependence treatment programs for pregnant women, and in two states, counseling services were covered for pregnant women only. Seventeen state Medicaid programs reported no coverage for tobacco-dependence treatment.43


Beyond limited financial resources to support treatment and cessation efforts, rural dwellers also face the challenge of limited access to care providers. As of 1997, more than three-fourths of the country’s Mental Health Professional Shortage Areas (MHPSAs) were in nonmetropolitan areas, which equates to 70 percent of the population residing in underserved areas.44 As tobacco dependence treatment often requires the use of a mental health professional, it would be more likely for rural areas to lack access to these services. Rural residents have difficulty accessing substance abuse treatment programs, as distance to treatment and transportation are primary obstacles.8, 45


The 1991–1995 National Ambulatory Medical Care Survey assessed trends in treatment of smokers by U.S. physicians to determine if physicians’ practices meet current standards. Smoking counseling increased from 16 percent in 1991 to 29 percent in 1993, but it then fell to 21 percent in 1995. Nicotine replacement therapy use increased from .4 percent in 1991 to 2.2 percent in 1993, and it fell to 1.3 percent in 1995. The study also found that identification of patient smoking status was done 67 percent of the time in 1991 but did not increase over time. Physicians’ practices fell far short on national health objectives and practice guidelines for treatment of smokers. Patient visits for diagnoses not related to smoking represent important missed intervention opportunities.46 Thus, tobacco users in rural settings face two critical barriers: first, limited access to primary care providers who may assist in their cessation efforts; and second, if the tobacco users have access to a primary care provider, the likelihood is that the physician will miss important intervention opportunities.


Finally, dentists are uniquely situated to identify tobacco use. According to one study, only two-thirds of dental schools offer tobacco cessation training for dentists, and only 8.7 percent of dentists surveyed reported having strong knowledge in tobacco cessation as compared to 25.4 percent of physicians surveyed reporting strong knowledge.47 Moreover, the limited number of dentists serving rural areas may be too busy to take advantage of opportunities to intervene and provide cessation support to their patients.




To identify potentially effective interventions or solutions to tobacco use, particularly among the high-risk populations identified previously such as adolescents and pregnant women, it is necessary to isolate factors contributing to tobacco use. Nicotine dependence, lack of educational resources, locality of tobacco growers, and failure to adequately enforce laws regarding tobacco sales to minors may contribute to an increased prevalence in rural areas. Tobacco is grown in approximately 500 counties in the southern states including Kentucky, North and South Carolina, Virginia, Tennessee, parts of Georgia, Florida, West Virginia, Maryland, southern Indiana, Pennsylvania, and Ohio,48 which correlates to the area with the highest prevalence of tobacco use for men.4


While the number of community tobacco prevention policies has increased in the past decade, rural communities do not necessarily comply with these policies. A Missouri study revealed that a majority of tobacco outlets in rural communities neither complied with the state law banning tobacco sales to minors, nor did the majority of businesses comply with the state clean indoor air act.49 Another study in rural Missouri revealed that half of police chiefs, city managers, and mayors were unaware of a state law restricting public smoking.49


Despite laws in all states to prevent underage tobacco use, many merchants sell directly to minors. Of minors who smoked, “38.7 percent reported they obtained cigarettes at a store, with only 15.8 percent needing to ask ‘someone to buy cigarettes for them’.”23 A study examining the effectiveness of a longitudinal community intervention on the reduction of tobacco sales to minors and subsequent effects on tobacco consumption by youth found that in intervention communities (community education, merchant education, and voluntary policy change), the proportion of stores selling to minors dropped significantly. While encouraging, youth reported still being able to obtain tobacco from other sources.50




Novotny, Romano, Davis and Mills15 noted that there are seven basic components to community tobacco control. These include surveillance, problem assessment, legislation, health department and community-based programs, public information campaigns, technical information collection and dissemination, and coalition building.


The Centers for Disease Control (CDC) document, Best Practices in Comprehensive Tobacco Control Programs – August 199918 recommends the inclusion of community programs to reduce tobacco use, chronic disease programs to reduce the burden of tobacco-related disease, school programs to prevent the onset of smoking in youth, enforcement of existing tobacco statutes (especially minors’ access and clean indoor air regulations), aggressive counter-marketing, cessation programs, and ongoing surveillance and evaluation of programming. All of these components seem to be necessary, but their incorporation into effective programming is made difficult by the diffused communication networks and the lack of economies of scale in rural areas.


The 1994 CDC Guidelines for School Health Programs to Prevent Tobacco Use and Addiction51 pointed out key principles for effective school-based interventions. These principles apply to all schools, regardless of geographic location, and incorporate broad concepts such as creating environmental supports for not using tobacco. This includes the prohibition of tobacco use in all areas of schools (including adults-only areas), at school sporting events, etc. Provision of cessation services to faculty and students is also recommended, as is appropriate classroom health education. The Guidelines also recommend a variety of environmental supports and barriers to tobacco use. One of the most important remains the necessity of providing regular messages regarding tobacco use from families, schools, and the community and reinforcement of community-based efforts to reduce tobacco use. The detailed recommendations include specific school tobacco-related policies such as the prohibition of tobacco use on school premises or at school functions and the prohibition of tobacco advertising (including clothing) at school events or in school-related publications.


The CDC reports that there are effective school-based curricula in its Programs that Work database. These curricula are common in that they utilize some type of social influences approach to teaching youth about tobacco. Such an approach incorporates traditional forms of education about the health effects of tobacco, but with it there is a focus on analyzing and understanding environmental influences on smoking initiation, media messages, etc. Effective curricula also incorporate methods of countering social pressure to use. Such curricula are designed to enhance general skill sets that are useful for youth in a variety of situations: refusal skills, assertiveness, stress management, etc.


There is also evidence that some approaches to youth prevention do not work, are to be avoided, and may actually be iatrogenic. Many adults find scare tactics such as showing pictures of diseased organs, etc. attractive, but youth appear to be less affected over the long term. Kelder, Edmundson, and Lytle52  warn against using this type of approach, as it may weaken adults’ arguments by overstatement. Approaches that use affective education also demonstrate little success and, in some cases, iatrogenesis. One of the best suggestions, then, is for schools (within the context of comprehensive community tobacco control) to perform quality, comprehensive health education, with an appropriate amount of time dedicated to the effort. The importance of family and community support, teaching, and modeling cannot be overstated.


Environmental support for avoiding tobacco includes actions such as limiting access to tobacco through enforcing sales bans to minors at the retail level (through banning direct sales as well as minors’ access to vending machines). Police, prosecutor, and judge support, then, is also important. There is also evidence that high sales taxes significantly affect youth use. Data indicate that a 10 percent increase in the price of cigarettes yields an overall reduction in cigarette consumption by approximately 3-5 percent and reduces the number of youth who use tobacco by as much as 7 percent.53, 54 Price increases through taxation are even more effective in reducing consumption among minorities and those with a lower income.55


While interventions have been conducted in rural communities, applicability and feasibility of implementation in other rural communities is not known. School-based education programs (beginning in the elementary grades) and enforcement of existing tobacco sales laws and ordinances may decrease rates of tobacco use in adolescents. Worksite health promotion programs may do likewise for adults. Finally, promotion of tobacco cessation training to physicians and dental care providers may decrease tobacco use in adolescents and adults. However, their direct applicability and level of effectiveness specifically in rural settings is only speculative at this point.


Community models known to work


Community interventions or model programs “known” to work are difficult to identify in rural settings. Almost no information or evaluation exists on the effectiveness of classroom or community prevention programs or treatment programs in rural communities nationwide.


See the Models for Practice section in Volume 1 for a catalog of models.


SUMMARY AND Conclusions


There is a clear difference in tobacco use prevalence among those living in rural versus urban areas, whether the individual is an adolescent, adult, or pregnant woman. Higher use in rural areas will eventually lead to higher numbers of people with health problems that rural areas are ill equipped to handle. While past research has shown that education, enforcement of existing laws, product labeling, and anti-tobacco advertising campaigns may reduce tobacco use, more research is needed to understand the factors that contribute to higher prevalence of both smoke and smokeless tobacco use in rural areas.




1. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.


2. Gamm, L.; Hutchison, L.; Bellamy, G.; et al. Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health 18:9-14, 2002.


3. Office of Applied Studies. National Household Survey on Drug Abuse Advance Report. 1995. <http://www.>August 10, 2001.


4. Eberhardt, M.S; Ingram, D.D.; Makuk, D.M; et al. Urban and Rural Health Chartbook. Health, United States, 2001. Hyattsville, MD: National Center for Health Statistics, 2001, 32-35.


5. Bell, R.A.; Spangler, J.G.; and Quandt, S.A. Smokeless tobacco use among adults in the Southeast. Southern Medical Journal 93(5):456-462, 2000.


6. Boyle, R.G.; Stilwell, J.; Vidlak, L.M.; et al. “Ready to quit chew?” Smokeless tobacco cessation in rural Nebraska. Addictive Behaviors 24(2):293-297, 1999.


7. Kendell, N. Medicaid and indigent care issue brief: Youth access to tobacco. Issue Brief Health Policy Tracking Service, 2000, 1-32.


8. National Center on Addiction and Substance Abuse (CASA). CASA whitepaper: No place to hide: Substance abuse in mid-size cities and rural America. Commissioned by the United States Conference of Mayors. Funded by the Drug Enforcement Administration with support from the National Institute on Drug Abuse, 2000.


9. Lisnerski, D.D.; McClary, C.L.; Brown, T.L.; et al. Demographic and predictive correlates of smokeless tobacco use in elementary school children. American Journal of Health Promotion 5(6):426-431, 1991.


10. Office of Epidemiology and Statistics, Bureau of Public Health Statistics, Arizona Department of Health Services. Arizona Health Status and Vital Statistics 1999 Annual Report. Natality: Maternal Characteristics and Newborn’s Health. 1999. < /1999ahs/pdf/017_19_21_23_25_27_29_30.pdf>July 29, 2002.


11. McMillen, R.; Frese, W.; and Cosby, A. The national social climate of tobacco control, 2000-2001. Social Science Research Center, Mississippi State University, 2001.


12. Centers for Disease Control and Prevention (CDC). Smoking and Pregnancy Fact Sheet. 1997. <>September 10, 2001.


13. CDC. Tobacco Information and Prevention Resources. 2002. <>March 15, 2002.


14. CDC. State-specific prevalence of current cigarette smoking among adults and the proportion of adults who work in a smoke-free environment-United States 1999. Morbidity and Mortality Weekly Report 49:978-982, 2000.


15. Novotny, T.E.; Romano, R.A.; Davis, R.M.; et al. The public health practice of tobacco control: Lessons learned and directions for the states in the 1990s. Annual Review of Public Health 13:287-318, 1992.


16. U.S. Department of Health and Human Services. Leading Health Indicators.



17. McGinnis, J.M., and Foege, W.H. Actual causes of death in the United States. Journal of the American Medical Association 270:2207-2212, 1993.


18. CDC. Best practices for comprehensive tobacco control programs-August 1999. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and Health Promotion, Office on Smoking and Health, 1999.


19. Smith, S.S., and Fiore, M.C. The epidemiology of tobacco use, dependence, and cessation in the United States. Journal of Primary Care 26:433-461, 1999.


20. CDC. Targeting Tobacco Use: The nation’s leading cause of death at-a-glance. 2000. <>June 29, 2002.


21. CDC. State-specific Prevalence of Current Cigarette and Cigar Smoking among Adults-United States Fact Sheet, 1998. Tobacco Information and Prevention Source (TIPS). 1999. <>August 10, 2001.


22. Brownson, R.C.; DiLorenzo, T.M.; Van Tuinen, M.; et al. Patterns of cigarette and smokeless tobacco use among children and adolescents. Preventive Medicine 19(2):170-180, 1990.


23. Kumra, V., and Markoff, B.A. Who’s smoking now? The epidemiology of tobacco use in the United States and abroad. Clinics in Chest Medicine 21(1):1-9, vii, 2000.


24. Houston, T.; Kolbe, L.J.; and Eriksen, M.P. Tobacco-use cessation in the '90s¾not “adults only” anymore. Preventive Medicine 27(5 Pt 3):A1-2, 1998.


25. D’Onofrio, C. N. Making the case for cancer prevention in the schools. Journal of School Health 59(5):225-231, 1989.


26. Substance Abuse and Mental Health Service Administration. Summary of Findings from the 2000 National Household Survey on Drug Abuse. Rockville, MD: Office of Applied Studies, NHSDA Series H-13, DHHS Publication No. (SMA) 01-3549, 2001.


27. Harrell, J.S.; Bangdiwala, S.I.; Deng, S.; et al. Smoking initiation in youth: The roles of gender, race, socioeconomics, and developmental status. Journal of Adolescent Health 23(5):271-279, 1998.


28. Monthly Vital Statistics. Focus...Maternal Smoking Trends in Missouri: 1978-1997. 1998. < Aug98Vol32No6.html >July 26, 2002.


29. Rice, P. Health Psychology. Pacific Grove, CA: Brooks/Cole Publishing, 1998.


30. Stone, S.L., and Kristeller, J.L. Attitudes of adolescents toward smoking cessation. American Journal of Preventive Medicine 8(4):221-225, 1992.


31. U.S. Department of Health and Human Services. Preventing Tobacco Use among Young People: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.


32. CDC. Smoking prevalence and exposure to tobacco smoke among children. 1997. <>July 31, 2002.


33. Ellickson, P.L.; Tucker, J.S.; and Klein, D.J. High-risk behaviors associated with early smoking: Results from a 5-year follow-up. Journal of Adolescent Health 28(6):465-473, 2001.


34. Coogan, P.F.; Adams, M.; Geller, A.C.; et al. Factors associated with smoking among children and adolescents in Connecticut. American Journal of Preventive Medicine 15(1):17-24, 1998.


35. Lamkin, L.; Davis, B.; and Kamen, A. Rationale for tobacco cessation interventions for youth. Preventive Medicine 27(5 Pt 3):A3-8, 1998.


36. Coker, A.L.; Richter, D.L.; Valois, R.F.; et al. Correlates and consequences of early initiation of sexual intercourse. Journal of School Health 64(9):372-377, 1994.


37. Bryant, A.L.; Schulenberg, J.; Bachman, J.G.; et al. Understanding the links among school misbehavior, academic achievement, and cigarette use: A national panel study of adolescents. Prevention Science 1(2):71-87, 2000.


38. Ritchey, P.N.; Reid, G.S.; and Hasse, L.A. The relative influence of smoking on drinking and drinking on smoking among high school students in a rural tobacco-growing county. Journal of Adolescent Health 29(6):386-394, 2001.


39. Cronk, C.E., and Sarvela, P.D. Alcohol, tobacco, and other drug use among rural/small town and urban youth: A secondary analysis of monitoring the future data set. American Journal of Public Health 87(5):760-764, 1997.


40. Wewers, M.E.; Ahijevych, K.; et al. Tobacco Use Characteristics among Rural Ohio Appalachians. Journal of Community Health 25(5):377-388, 2000.


41. Jackson, C. Initial and experimental stages of tobacco and alcohol use during late childhood: Relation to peer, parent, and personal risk factors. Addictive Behaviors 22(5):685-698, 1997.


42. Dalton, M.A.; Sargent, J.D.; Beach, M.L.; et al. Positive and negative outcome expectations of smoking: Implications for prevention. Preventive Medicine 29:460-465, 1999.


43. CDC. State Medicaid coverage for tobacco-dependence treatments-United States, 1998 and 2000. Morbidity and Mortality Weekly Report 50(44):979-982, 2001.


44. Hartley, D.; Bird, D.; and Dempsey, P. Rural Mental Health and Substance Abuse. In Ricketts, T.C., ed. Rural Health in the United States. New York, NY: Oxford University Press, 1999, 159-176.


45. Indiana Prevention Resource Center at Indiana University. Rural Indiana Profile: Alcohol, Tobacco, and Other Drugs. Washington, DC: Drug Strategies, 1998.


46. Thorndike, A.N.; Rigotti, N.A.; Stafford, R.S.; et al. National patterns in the treatment of smokers by physicians. Journal of the American Medical Association, 279(8):604-608, 1998.


47. Block, D.E.; Block, L.E.; Hutton, S.J.; et al. Tobacco counseling practices of dentists compared to other health care providers in a midwestern region. Journal of Dental Education 63(11):821-827, 999.


48. Gale, F. Tobacco Communities Facing Change. Rural Development Perspectives 14(1):36-43, 1999.


49. Davis, J.R. Community Advocacy for Tobacco Policy Compliance. National Rural Health Research in Progress Database. <>April 11, 2002.


50. Altman, D.G.; Wheelis, A.Y.; McFarlane, M.; et al. The relationship between tobacco access and use among adolescents: A four community study. Social Science and Medicine 48(6):759-775, 1999.


51. CDC. Guidelines for school health programs to prevent tobacco use and addiction. Journal of School Health 64(9):353-360, 1994.


52. Kelder, S.H.; Edmundson, E.W.; and Lytle, L.A. Health behavior research and school and youth health promotion. Handbook of Health Behavior Research IV: Relevance for Professionals and Issues for the Future. New York, NY: Plenum Press, 1997.


53. Chaloupka, F.J. Macro-social influences: The effects of prices and tobacco-control policies on the demand for tobacco products. Nicotine and Tobacco Research Suppl 1:S105-109, 1999.


54. Emery, S.; White, M.M.; and Pierce, J.P. Does cigarette price influence adolescent experimentation? Journal of Health Economics 20(2):261-270, 2001.


55. CDC. Responses to cigarette prices by race/ethnicity, income, and age groups - United States 1976-1993. Morbidity and Mortality Weekly Report 47(29):605-609, 1998.


Chapter Suggested Citation


Stevens, S.; Colwell, B.; and Hutchison, L. (2003). Tobacco Use in Rural Areas: A Literature Review. Rural Healthy People 2010: A companion document to Healthy People 2010. Volume 2. College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.