Unfair and Unjust Practices and Conditions Harm People in Some Geographic Regions and Drive Health Disparities
Some policies and practices have led to health risks and challenges, and related long-term health outcomes, for people living in certain geographic areas. For example:
People in rural areas are less likely to be covered by policies that protect and promote health:
People living in rural counties lack health insurance at higher rates than those living in urban areas.8 Uninsured people have worse health and die sooner than people with health insurance.9
- People living in rural areas may face barriers when accessing health care services such as long travel times to reach care and decreased availability of public health and health care services.10
People in rural areas may face greater occupational exposure to dust, fumes, and other forms of unhealthy air on the job, both in agricultural and non-agricultural jobs, than people who work in urban areas.11
- People who grow and harvest tobacco can be exposed to workplace injuries and nicotine poisoning (also known as green tobacco sickness.)12 The Fair Labor Standards Act prohibits children under age 16 from doing agriculture work deemed hazardous, but the US Department of Labor has not included exposure to tobacco leaves or plants in its rules about hazardous jobs.13
There are also other reasons—like the ones explored below—that help explain why commercial tobacco* affects the health of people in some geographic areas.
The tobacco industry targets some areas of the country with marketing and advertising
Marketing plays a big role in whether people try or use commercial tobacco products. Commercial tobacco ads make smoking appear more appealing and increase the chance that someone will try smoking for the first time or start using commercial tobacco products regularly.14,15,16,17,18,19,20
The tobacco industry has used these strategies to market products to people in rural areas:
- Discounts. Discounts and special sales are one of the main ways that tobacco companies keep their products cheap and visible. For example, one California study of stores that sold tobacco products found lower prices for the cheapest packs of cigarettes in rural areas of California compared to non-rural areas.21 Stores located in rural areas, in the same study, were also more likely to advertise discounts for smokeless tobacco than stores in non-rural areas.21
- Tailored advertising. The tobacco industry tailors marketing to young men in rural areas by advertising chewing or dipping tobacco using images depicting cowboys, hunters, and race-car drivers. These images placed on product packaging and in advertisements are placed in retail settings most likely to reach young men in rural areas.3
- Cultural events. Tobacco companies have sponsored rodeos in rural areas where rodeos are popular.22 Tobacco companies themselves have estimated that 25–30% of the audience is made up of children and youth.23
- Placing commercial tobacco products in discount stores. Dollar stores have opened new stores at record pace since the 2008, specifically targeting small towns in rural areas with large numbers of people with lower incomes. When dollar stores began selling commercial tobacco products in 2012 and 2013, this added significantly to the number of places where people living in rural areas in the Southeastern states could purchase tobacco products.24
To help protect people from tobacco marketing and discourage tobacco product use, states and communities could consider increasing prices and prohibiting price discounts, prohibiting the sale of flavored tobacco products, and either allowing fewer stores in a neighborhood to sell commercial tobacco products or prohibiting tobacco product sales altogether.25
Stress can increase commercial tobacco use, and can make health problems worse
When people have multiple forms of stress—like financial problems, discrimination, or unsafe neighborhoods—they can be more likely to smoke.30,31,32,33
People in rural areas experience many types of pressure:
- Unemployment rates in rural areas are generally high, and rural residents are more likely than urban residents to have incomes below the poverty level.34
- People in rural areas can experience a heightened sense of stress and anxiety about environmental toxins – such as being exposed to dangerous levels of agricultural chemicals through contaminated water or through handling them in their workplace.35,36
- Within rural communities, Black, American Indian/Alaska Native, and Hispanic/Latino people often have higher levels of stress, greater barriers to health care, and more health problems than white residents of rural communities.37,38,39
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- United States Census Bureau. Health Insurance in Rural America. 2019. accessed 2022 Mar 22].
- 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].
- 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].
- 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].
- McKnight RH, Spiller HA. Green tobacco sickness in children and adolescents. Public Health Reports. 2005;120(6): 602-5 [accessed 2022 Mar 22].
- U.S Department of Labor. Wages and the Fair Labor Standards Act [accessed 2022 Mar 22].
- 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].
- Charlesworth A, Glantz SA. Smoking in the movies increases adolescent smoking: A review. Pediatrics 2005;116(6): 1516-28 [accessed 2022 Mar 22].
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- American Nonsmokers’ Rights Foundation. Bridging the Gap: Status of Smokefree Air in the United States, 2019 [accessed 2022 Mar 22].
- 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].
- 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].
- 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].
- 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].
- U.S. Department of Agriculture. Economic Research Service, Rural income, poverty and welfare: summary of conditions and trends [accessed 2022 Mar 22].
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- 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].
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- 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].
- 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].
- 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].
- 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].
- 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].
- 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].
- 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].