People in Some Geographic Regions Experience a Health Burden from Commercial Tobacco

Commercial tobacco* gets in the way of achieving health equity for people living in certain regions and communities across the nation. People living in these regions and communities experience the negative health effects related to the use of commercial tobacco products, like cigarettes, smokeless tobacco, and cigars.1 For example:

  • The percentage of adults who use commercial tobacco products is higher in the United States (U.S.) South and Midwest than in the Northeast or West.2
  • The percentage of adults who use more than one type of tobacco product is higher in the Midwest and South than in the Northeast. For example, they may use cigarettes at certain times and smokeless tobacco at other times.2
  • People living in rural areas have higher rates of poor health and health outcomes related to commercial tobacco compared to people in urban areas.3,4,5
  • People living in rural areas have 18–20% higher lung cancer death than people living in urban areas.6 Cigarette smoking causes about 80% to 90% of lung cancer deaths in the U.S.1
  • Four of the five leading causes of premature death for people in non-metropolitan areas (heart disease, cancer, chronic lower respiratory disease, and stroke)7 can be caused by cigarette smoking.1
*“Commercial tobacco” means harmful products that are made and sold by tobacco companies. It does not include “traditional tobacco” used by Indigenous groups for religious or ceremonial purposes.
Map of the United States showing the increase in South and Midwest and decline in the tobacco products in the Northeast and West
Tobacco products
Image of a head with stroke, ribbon, heart, and lungs to illustrate the four out of five  leading causes of premature death for people in non-metropolitan areas caused by cigarette smoking, which are heart disease, cancer, chronic lower respiratory disease, and stroke.
  1. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2022 Mar 22].
  2. Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco Product Use Among Adults — United States, 2020. MMWR Morb Mortal Wkly Rep. 2022; 71:397–405 [accessed 2022 Mar 22].
  3. American Lung Association. Cutting Tobacco’s Rural Roots: Tobacco Use in Rural Communities [PDF – 3 MB]. Chicago: American Lung Association; 2015 [accessed 2022 Mar 22].
  4. Croft JB, Wheaton AG, Liu Y, et al. Urban-Rural County and State Differences in Chronic Obstructive Pulmonary Disease – United States, 2015. MMWR Morb Mortal Wkly Rep. 2018;67(7):205-211 [[accessed 2022 Mar 22].
  5. Harrington RA, Califf RM, Balamurugan A, et al. Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association. Circulation. 2020;141(10):e615-e644 [accessed 2022 Mar 22].
  6. Singh GK, Williams SD, Siahpush M, Mulhollen A. Socioeconomic, Rural-Urban, and Racial Inequalities In US Cancer Mortality: Part I—All Cancers and Lung Cancer and Part II—Colorectal, Prostate, Breast, and Cervical Cancers. Journal of Cancer Epidemiology. 2011 [accessed 2022 Mar 22].
  7. Moy E, Garcia MC, Bastian B, et al. Leading Causes of Death in Nonmetropolitan and Metropolitan Areas — United States, 1999–2014. MMWR Surveill Summ 2017;66(No. SS-1):1–8 [accessed 2022 Mar 22].
  8. United States Census Bureau. Health Insurance in Rural America. 2019. accessed 2022 Mar 22].
  9. Institute of Medicine (US) Committee on Health Insurance Status and Its Consequences. America’s Uninsured Crisis: Consequences for Health and Health Care. Washington (DC): National Academies Press (US); 2009 [accessed 2022 Mar 22].
  10. Coughlin SS, Clary C, Johnson JA, et al. Continuing Challenges in Rural Health in the United States. J Environ Health Sci. 2019;5(2):90-92 [accessed 2022 Mar 22].
  11. Doney BC, Henneberger PK, Humann MJ, Liang X,  Kelly KM, Cox-Ganser JM. Occupational exposure to vapor-gas, dust, and fumes in a cohort of rural adults in Iowa compared with a cohort of urban adults. MMWR Surveillance Summary, 66 (SS-21) (2017), pp. 1-5 [accessed 2022 Mar 22].
  12. McKnight RH, Spiller HA. Green tobacco sickness in children and adolescents. Public Health Reports. 2005;120(6): 602-5 [accessed 2022 Mar 22].
  13. U.S Department of Labor. Wages and the Fair Labor Standards Act [accessed 2022 Mar 22].
  14. Carson NJ, Rodriguez D, Audrain-McGovern J. Investigation of mechanisms linking media exposure to smoking in high school students. Preventive Medicine. 2005;41(2): 511-20 [accessed 2022 Mar 22].
  15. Charlesworth A, Glantz SA. Smoking in the movies increases adolescent smoking: A review. Pediatrics 2005;116(6): 1516-28 [accessed 2022 Mar 22].
  16. National Cancer Institute. The Role of the Media in Promoting and Reducing Tobacco Use. Tobacco Control Monograph No. 19. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. NIH Pub. No. 07-6242, June 2008 [accessed 2022 Mar 22].
  17. Lienemann BA, Rose SW, Unger JB, et al. Tobacco Advertisement Liking, Vulnerability Factors, and Tobacco Use Among Young Adults. Nicotine Tob Res. 2019;21(3):300-308 [accessed 2022 Mar 22].
  18. Pierce JP, Sargent JD, Portnoy DB, et al. Association Between Receptivity to Tobacco Advertising and Progression to Tobacco Use in Youth and Young Adults in the PATH Study. JAMA Pediatr. 2018;172(5):444–451 [accessed 2022 Mar 22].
  19. Henriksen L, Schleicher NC, Feighery EC, Fortmann SP. A longitudinal study of exposure to retail cigarette advertising and smoking initiation. Pediatrics. 2010;126(2):232-238 [accessed 2022 Mar 22].
  20. U.S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General [PDF – 9.8 MB]. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020 [accessed 2022 Mar 22].
  21. Henriksen L, Schleicher NC, Johnson TO, Roeseler A, Zhu SH. Retail Tobacco Marketing in Rural Versus Nonrural Counties: Product Availability, Discounts, and Prices. Health Promotion Practice. 2020; 21(1_suppl):27S-36S [accessed 2022 Mar 22].
  22. Pamela M. Ling, Lawrence A. Haber, and Stefani Wedl. Branding the Rodeo: A Case Study of Tobacco Sports Sponsorship. American Journal of Public Health. 2010; 100, 32_41 [accessed 2022 Apr 28].
  23. Ling PM, Haber LA, Wedl S. Branding the rodeo: a case study of tobacco sports sponsorship. American Journal of Public Health. 2010;100(1):32-41 [accessed 2022 Mar 22].
  24. Hall J, Cho HD, Maldonado-Molina M, George Jr TJ, Shenkman EA, Salloum RG. Rural-urban disparities in tobacco retail access in the southeastern United States: CVS vs. the dollar stores.  Preventive Medicine Reports. 2019;15, 100935 [accessed 2022 Mar 22].
  25. Robertson L, McGee R, Marsh L, Hoek J. A systematic review on the impact of point-of-sale tobacco promotion on smoking. Nicotine & Tobacco Research. 2015;17(1): 2-17 [accessed 2022 Mar 22].
  26. Hafez AY, Gonzalez M, Kulik MC, Vijayaraghavan M, Glantz SA. Uneven access to smoke-free laws and policies and its effect on health equity in the United States: 2000–2019. American Journal of Public Health. 2019;109(11): 1568-1575 [accessed 2022 Mar 22].
  27. Huang J, King BA, Babb SD, Xu X, Hallett C, Hopkins M. Sociodemographic Disparities in Local Smoke-Free Law Coverage in 10 States. American Journal of Public Health. 2015;105(9):1806-13 [accessed 2022 Mar 22].
  28. Centers for Disease Control and Prevention. State and Local Comprehensive Smoke-Free Laws for Worksites, Restaurants, and Bars—United States, 2015. Morbidity and Mortality Weekly Report. 2016;65(24):623-6 [accessed 2022 Mar 22].
  29. American Nonsmokers’ Rights Foundation. Bridging the Gap: Status of Smokefree Air in the United States, 2019 [accessed 2022 Mar 22].
  30. Slopen N, Dutra LM, Williams DR, et al. Psychosocial stressors and cigarette smoking among African American adults in midlife. Nicotine Tobacco Res. 2012;14(10):1161-1169 [accessed 2022 Mar 22].
  31. Williams , D. R. , & Mohammed , S. A. ( 2009 ). Discrimination and racial disparities in health: Evidence and needed research. Journal of Behavioral Medicine. 2009 Feb; 32(1): 20 – 47 [accessed 2022 Mar 22].
  32. Slopen N, Kontos EZ, Ryff CD, Ayanian JZ, Albert MA, Williams DR. Psychosocial stress and cigarette smoking persistence, cessation, and relapse over 9-10 years: a prospective study of middle-aged adults in the United States. Cancer Causes Control. 2013;24(10):1849-1863 [accessed 2022 Apr 28].
  33. Purnell JQ, Peppone LJ, Alcaraz K, et al. Perceived discrimination, psychological distress, and current smoking status: results from the Behavioral Risk Factor Surveillance System Reactions to Race module, 2004-2008. Am J Public Health. 2012;102(5):844-851 [accessed 2022 Apr 28].
  34. U.S. Department of Agriculture. Economic Research Service, Rural income, poverty and welfare: summary of conditions and trends [accessed 2022 Mar 22].
  35. Richman L, Pearson J, Beasley C, & Stanifer J. Addressing health inequalities in diverse, rural communities: An unmet need. SSM-Population Health. 2019;7: 100398 [accessed 2022 Mar 22].
  36. Arora K, Cheyney M, Gerr F, Bhagianadh D, Gibbs J, Anthony TR. Assessing health and safety concerns and psychological stressors among agricultural workers in the US Midwest. Journal of Agricultural Safety and Health. 2020;26(1) 45-58 [accessed 2022 Mar 22].
  37. James CV, Moonesinghe R, Wilson-Frederick SM, Hall JE, Penman-Aguilar A, Bouye K. Racial/Ethnic Health Disparities Among Rural Adults — United States, 2012–2015. MMWR Surveill Summ 2017;66(No. SS-23):1–9 [accessed 2022 Mar 22].
  38. Centers for Disease Control and Prevention. CDC Health disparities and inequalities report—United States, 2013 [PDF – 4 MB]. MMWR 2013;62(Suppl 3) [accessed 2022 Mar 22].
  39. Agency for Healthcare Research and Quality. 2014 national healthcare quality and disparities report. Rockville, MD: Agency for Healthcare Research and Quality; 2015 [accessed 2022 Mar 22].
  40. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015 [accessed 2022 Mar 22].
  41. Ramsey AT, Baker TB, Pham G, et al. Low Burden Strategies Are Needed to Reduce Smoking in Rural Healthcare Settings: A Lesson from Cancer Clinics. International Journal of Environmental Research and Public Health. 2020;17(5), 1728 [accessed 2022 Mar 22].
  42. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking Among Adults — United States, 2000–2015. MMWR Morb Mortal Wkly Rep 2017;65:1457–1464 [accessed 2022 Mar 22].
  43. DiGiulio A, Jump Z, Babb S, et al. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments — United States, 2008–2018. MMWR Morb Mortal Wkly Rep 2020;69:155–160 [accessed 2022 Mar 22].
  44. Lebrun-Harris LA, Fiore MC, Tomoyasu N, and Ngo-Metzger Q. Cigarette Smoking, Desire to Quit, and Tobacco-Related Counseling Among Patients at Adult Health Centers. American Journal of Public Health. 2015; 105 (1): 180-188 [accessed 2022 Mar 22].
  45. Flocke SA, Hoffman R, Eberth JM, Park H, Birkby G, Trapl E, et al. The Prevalence of Tobacco Use at Federally Qualified Health Centers in the United States, 2013. Preventing Chronic Disease. 2017; 14:160510 188 [accessed 2022 Mar 22].