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:

  • Medical history tablet with a no smoking sign and illustrating the age range of under 65

    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
  • Image illustrating the effects of second hand smoke on the human brain.

    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

The phrase 2 for 1 to illustrate why discounts and special sales are one of the main ways that tobacco companies keep their products cheap and visible.

Discounts are one of the main ways that tobacco companies keep their products cheap.

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 phrase 2 for 1 to illustrate why discounts and special sales are one of the main ways that tobacco companies keep their products cheap and visible.

Discounts are one of the main ways that tobacco companies keep their products cheap.

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
    • Photo of a woman riding her horse on a rodeo.

      Tobacco companies have sponsored rodeos in rural areas.

  • 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

Photo of a man sitting on a van with its door open.

People in rural areas can experience a heightened sense of stress and anxiety about environmental toxins.

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
*“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.
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