by Stacey Stevens, Brian Colwell, and Linnae Hutchison
GOALS AND OBJECTIVES
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
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.
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
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
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.
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.
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
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.
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.
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
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
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
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
National Ambulatory Medical Care Survey assessed trends in treatment of smokers
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.
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
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
PROPOSED Solutions or Interventions THAT ARE FEASIBLE IN RURAL COMMUNITIES
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 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.
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.
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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.