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Figure 1.  Smoking Quit Ratios for Individuals in Rural vs Urban Areas From 2010 to 2020
Smoking Quit Ratios for Individuals in Rural vs Urban Areas From 2010 to 2020
Figure 2.  Smoking Quit Ratios by Age for Individuals in Rural vs Urban Areas From 2010 to 2020
Smoking Quit Ratios by Age for Individuals in Rural vs Urban Areas From 2010 to 2020
1.
Doogan  NJ, Roberts  ME, Wewers  ME,  et al.  A growing geographic disparity: rural and urban cigarette smoking trends in the United States.   Prev Med. 2017;104:79-85. doi:10.1016/j.ypmed.2017.03.011 PubMedGoogle ScholarCrossref
2.
Mansfield  CJ, Wilson  JL, Kobrinski  EJ, Mitchell  J.  Premature mortality in the United States: the roles of geographic area, socioeconomic status, household type, and availability of medical care.   Am J Public Health. 1999;89(6):893-898. doi:10.2105/AJPH.89.6.893 PubMedGoogle ScholarCrossref
3.
Talbot  JA, Williamson  ME, Pearson  K,  et al.  Advancing Tobacco Prevention and Control in Rural America. National Network of Public Health Institute; 2019:75.
4.
American Lung Association. Rates by state. Accessed November 30, 2021. https://www.lung.org/research/trends-in-lung-disease/tobacco-trends-brief/rates-by-state
5.
Wewers  ME, Stillman  FA, Hartman  AM, Shopland  DR.  Distribution of daily smokers by stage of change: current population survey results.   Prev Med. 2003;36(6):710-720. doi:10.1016/S0091-7435(03)00044-6 PubMedGoogle ScholarCrossref
6.
Baker  TB, Piper  ME, McCarthy  DE,  et al; Transdisciplinary Tobacco Use Research Center (TTURC) Tobacco Dependence.  Time to first cigarette in the morning as an index of ability to quit smoking: implications for nicotine dependence.   Nicotine Tob Res. 2007;9(suppl 4):S555-S570. doi:10.1080/14622200701673480 PubMedGoogle ScholarCrossref
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    Research Letter
    Public Health
    August 3, 2022

    Trends in Rural and Urban Cigarette Smoking Quit Ratios in the US From 2010 to 2020

    Author Affiliations
    • 1Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, Indiana
    • 2Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York
    • 3Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, New York
    • 4Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
    • 5Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey
    • 6Department of Health Behavior, Society and Policy, Rutgers Center for Tobacco Studies, New Brunswick, New Jersey
    JAMA Netw Open. 2022;5(8):e2225326. doi:10.1001/jamanetworkopen.2022.25326
    Introduction

    Cigarette smoking prevalence is higher in rural than urban US communities. This disparity has increased over time.1 People in rural vs urban areas are more likely to die prematurely,2 which has been associated with reduced health care access and smoking cessation barriers.3 Lower smoking cessation rates4 could also be factors in increased morbidity and mortality burden in rural residents.2 Herein, we estimated trends in cigarette quit ratios for adults (≥18 years) in rural and urban areas from 2010 to 2020.

    Methods

    Publicly available, deidentified data were obtained from 2010-2020 National Survey on Drug Use and Health (NSDUH). Adults who had smoked 100 or more cigarettes were included in the analyses. This cross-sectional study followed the STROBE reporting guideline and was considered to be non–human participant research by Indiana University Institutional Review Board.

    Rurality was defined using US Office of Management and Budget Rural-Urban Continuum Codes. For 2010-2014 NSDUH, definitions were based on 2003 metropolitan or nonmetropolitan statistical area county-level groupings; for 2015-2020 NSDUH, updated 2013 groupings were used. Lifetime cigarette smoking was defined as having smoked at least 100 cigarettes in a lifetime, current smoking as 1 or more cigarettes in past month, and former smoking as no cigarettes in the past year. Overall and annual quit ratios were estimated as proportions of former smokers among lifetime smokers.

    Current smoking and quit ratios were estimated by rural or urban residence annually. Weighted, stratified logistic regression models tested linear time trends in quit ratios by rural or urban residence using year as a continuous variable. Models were unadjusted and then adjusted for sex, race and ethnicity, educational level, and income. Adjusted models, including year by rurality and year by age, were estimated separately to explore differential rural or urban and age time trends in quit ratios using the R survey package. α = .05 indicated significance.

    Results

    Of the 161 348 lifetime cigarette smokers analyzed, 54 080 (33.5%) were former smokers. Participants ranged in age (14.2% were 18-25 years; 15.9%, 26-34 years; 25.3%, 35-49 years; 44.6%, ≥50 years) and included 48.2% women and 51.8% men; 64.9% White individuals; and 35.8% individuals with more than $75 000 annual income.

    In 2020, current smoking prevalence was higher in rural (19.2%; 95% CI, 16.9%-21.7%) than urban areas (14.4%; 95% CI, 13.3%-15.5%; P < .001), whereas quit ratios were similar in rural (52.9%; 95% CI, 48.3%-57.4%) and urban areas (53.9%; 95% CI, 51.4%-56.5%; P = .70). From 2010 to 2020, odds of quitting were lower in rural vs urban areas (odds ratio [OR], 0.85 [95% CI, 0.81-0.88; P < .001]; adjusted OR [AOR], 0.93 [95% CI, 0.89-0.98; P = .008]). Quit ratios increased over time (OR, 1.03 [95% CI, 1.03-1.04; P < .001]; AOR, 1.01 [95% CI, 1.01-1.02; P < .001]) (Figure 1), and no significant interaction was observed between rural or urban residence and time (χ2 = 0.027; P = .89). However, the interaction between age and time was significant (χ2 = 75.90; P < .001) (Figure 2); odds of quitting were still lower in rural vs urban areas (AOR, 0.93; P = .006).

    Discussion

    Findings from 2010-2020 NSDUH data support a persistent rural-urban disparity. Higher smoking prevalence and lower quit ratios were observed in rural vs urban areas after adjusting for sociodemographic characteristics. These results may reflect an earlier stage of motivation to quit5 and reporting of higher nicotine dependence and heaviness of smoking among rural vs urban residents.6 Rural residents may also face structural barriers to cessation services, including lower rates of insurance coverage and fewer available health care practitioners,3 which warrant future research.

    A study strength is its high external validity. Limitations include its cross-sectional design, although we used multiple years of data, and potential measurement error from self-reported data.

    Intervention at the clinical setting, health system, or population level might improve reach and sustainability of cessation services for rural, especially older, residents. Leveraging existing quit lines and telehealth solutions may minimize barriers to accessing cessation services.3

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    Article Information

    Accepted for Publication: June 19, 2022.

    Published: August 3, 2022. doi:10.1001/jamanetworkopen.2022.25326

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Parker MA et al. JAMA Network Open.

    Corresponding Author: Maria A. Parker, PhD, MPH, Indiana University School of Public Health, 809 E Ninth St, Bloomington, IN 47405 (map2@iu.edu).

    Author Contributions: Dr Parker had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: M. A. Parker.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: M. A. Parker, Eggers, E. S. Parker.

    Critical revision of the manuscript for important intellectual content: M. A. Parker, Weinberger, E. S. Parker, Villanti.

    Statistical analysis: E. S. Parker.

    Supervision: M. A. Parker.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Dr Villanti was supported in part by grant UD9RH33633 from Health Resources and Services Administration, US Department of Health and Human Services.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Doogan  NJ, Roberts  ME, Wewers  ME,  et al.  A growing geographic disparity: rural and urban cigarette smoking trends in the United States.   Prev Med. 2017;104:79-85. doi:10.1016/j.ypmed.2017.03.011 PubMedGoogle ScholarCrossref
    2.
    Mansfield  CJ, Wilson  JL, Kobrinski  EJ, Mitchell  J.  Premature mortality in the United States: the roles of geographic area, socioeconomic status, household type, and availability of medical care.   Am J Public Health. 1999;89(6):893-898. doi:10.2105/AJPH.89.6.893 PubMedGoogle ScholarCrossref
    3.
    Talbot  JA, Williamson  ME, Pearson  K,  et al.  Advancing Tobacco Prevention and Control in Rural America. National Network of Public Health Institute; 2019:75.
    4.
    American Lung Association. Rates by state. Accessed November 30, 2021. https://www.lung.org/research/trends-in-lung-disease/tobacco-trends-brief/rates-by-state
    5.
    Wewers  ME, Stillman  FA, Hartman  AM, Shopland  DR.  Distribution of daily smokers by stage of change: current population survey results.   Prev Med. 2003;36(6):710-720. doi:10.1016/S0091-7435(03)00044-6 PubMedGoogle ScholarCrossref
    6.
    Baker  TB, Piper  ME, McCarthy  DE,  et al; Transdisciplinary Tobacco Use Research Center (TTURC) Tobacco Dependence.  Time to first cigarette in the morning as an index of ability to quit smoking: implications for nicotine dependence.   Nicotine Tob Res. 2007;9(suppl 4):S555-S570. doi:10.1080/14622200701673480 PubMedGoogle ScholarCrossref
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