Commercial Tobacco Availability and Promotion in Rural Communities

Commercial tobacco use is the leading cause of preventable disease, disability and death in the United States. Certain policies and practices have led to significant geographical differences in the prevalence of commercial tobacco use, as well as poor health outcomes associated with commercial tobacco, within the US. The commercial tobacco industry has a long history of targeting rural areas by offering discounts and special sales, tailored advertising, sponsoring cultural events such as rodeos, and placing commercial tobacco products in discount stores. These high-pressure marketing tactics, combined with the lack of state and local comprehensive smoke-free and retail policies, have led to longstanding disparities related to commercial tobacco product initiation, use, and cessation as well as secondhand smoke exposure and commercial tobacco-related health disparities in these areas.

 

In 2014, Family Dollar and Dollar General, the two largest dollar store chains, began selling commercial tobacco in their approximately 19,000 stores. These corporate decisions resulted in an increase of commercial tobacco retailers that was estimated to be 8 times greater in rural counties than urban areas.¹ Commercial tobacco retailer density has repeatedly been linked to greater initiation and use of commercial tobacco products among both youth and adults. ^2,3 The differences in the commercial tobacco retail environment between rural and urban communities don’t end with differences in density. There are disparities in the types of products available and how they are priced and promoted.

 

Big Tobacco has a long history of exploiting stereotypes and cultural hallmarks to market their products. In rural communities, this often comes in the form of commercial tobacco advertising depicting “rugged” and “manly” cowboys, hunters, and racecar drivers. These images and the accompanying pro-tobacco messages exploit such rural values as “self-reliance” and “resiliency”. Research shows this marketing works. For example, one study showed men and boys from rural Appalachian Ohio reported a strong belief that smokeless tobacco was “a rite of passage in the development of their masculine identity”.⁴ In addition to the heavy focus on masculinity, ruggedness, and resilience, smokeless tobacco advertisements in rural areas are often intertwined with images of nature and farmlands to tap into rural values and sentiments around agriculture and rural landscapes.

 

On top of this targeted advertising, rural populations face increased exposure to advertising for certain types of commercial tobacco products at the point of sale. In particular, advertising for smokeless tobacco products has been found to be significantly more concentrated in rural neighborhoods compared to urban ones.⁵ Similarly, research shows certain products to be more available and priced lower in rural stores. In a study of California commercial tobacco retailers, rural stores were 2.1 times more likely to sell chewing tobacco and 2.5 times more likely to sell roll-your-own tobacco, compared to nonrural stores. Meanwhile, rural stores sold larger packs of cigarillos for less than $1 while the cheapest pack of cigarettes averaged $0.21 less than the nonrural stores. Lastly, stores in rural areas were significantly more likely to advertise at least one discount for chewing tobacco.⁶

 

These characteristics of the retail environment help drive the higher rates of commercial tobacco use we see in rural communities. There are many policy options that can be designed to make commercial tobacco less available, attractive, and affordable in a way that promotes health equity, such as establishing pricing laws or implementing density restrictions in a way that takes into account the unique attributes of the rural retail environment. For example, caps on retailer proximity have been found to be less impactful in rural areas where retailers are more spread out.⁷ Instead, a modeling study conducted in Ohio suggests that capping the number of commercial tobacco retailer licenses issued in a geographic area (e.g. to 1 per 1,000 people) may be an effective way to reduce rural-urban disparities in commercial tobacco retailer density.⁸ Additionally, minimum floor price laws, a non-tax price policy that sets a price below which commercial tobacco products cannot be sold, is a strategy that can prevent significant disparities in commercial tobacco product pricing in certain communities. Unfortunately, rural communities often lack the commercial tobacco control policy coverage present in more urban areas. With about 46 million US residents living in rural communities across the country, we must do more to help level the playing field for rural residents.

 

^{[1] Hall J, Cho HD, Maldonado-Molina M, George TJ Jr, Shenkman EA, Salloum RG. Rural-urban disparities in tobacco retail access in the southeastern United States: CVS vs. the dollar stores. Prev Med Rep. 2019 Jul 2;15:100935. doi: 10.1016/j.pmedr.2019.100935. PMID: 31360628; PMCID: PMC6637220.}

^{[2] Cantrell J, Pearson JL, Anesetti-Rothermel A, Xiao H, Kirchner TR, Vallone D. Tobacco Retail Outlet Density and Young Adult Tobacco Initiation. Nicotine Tob Res. 2016 Feb;18(2):130-7. doi: 10.1093/ntr/ntv036. Epub 2015 Feb 8. PMID: 25666816; PMCID: PMC4830222.}

^{[3] Shelley D. Golden, Tzy-Mey Kuo, Amanda Y. Kong, Christopher D. Baggett, Lisa Henriksen, Kurt M. Ribisl, County-level associations between tobacco retailer density and smoking prevalence in the USA, 2012, Preventive Medicine Reports, Volume 17, 2020, 101005, ISSN 2211-3355, https://doi.org/10.1016/j.pmedr.2019.101005.}

^{[4] Nemeth JM, Liu ST, Klein EG, Ferketich AK, Kwan MP, Wewers ME. Factors influencing smokeless tobacco use in rural Ohio Appalachia. J Community Health. 2012 Dec;37(6):1208-17. doi: 10.1007/s10900-012-9556-x. PMID: 22427033; PMCID: PMC4298853.}

^{[5] Lee JG, Henriksen L, Rose SW, Moreland-Russell S, Ribisl KM. A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing. Am J Public Health. 2015 Sep;105(9):e8-18. doi: 10.2105/AJPH.2015.302777. Epub 2015 Jul 16. PMID: 26180986; PMCID: PMC4529779.}

^{[6] Henriksen L, Schleicher NC, Johnson TO, Roeseler A, Zhu SH. Retail Tobacco Marketing in Rural Versus Nonrural Counties: Product Availability, Discounts, and Prices. Health Promot Pract. 2020 Jan;21(1_suppl):27S-36S. doi: 10.1177/1524839919888652. PMID: 31908200; PMCID: PMC8722325.}

^{[7] Burgoon ML, Albani T, Keller-Hamilton B, Lu B, Roberts ME, Craigmile PF, Browning C, Xi W, Ferketich AK. Exposures to the tobacco retail environment among adolescent boys in urban and rural environments. Am J Drug Alcohol Abuse. 2019;45(2):217-226. doi: 10.1080/00952990.2018.1549562. Epub 2019 Jan 2. PMID: 30601033; PMCID: PMC6430681.}

^{[8] Craigmile PF, Onnen N, Schwartz E, et alEvaluating how licensing-law strategies will impact disparities in tobacco retailer density: a simulation in OhioTobacco Control 2021;30:e96-e103.}