Smoking Rate Reduction: Progress, Rural and Appalachian Disparities, and the Road Ahead

Asal Pilehvari, PhD; Bengucan Gunen, MSPH; Jennifer Mandelbaum, PhD - Population Health Sciences SIG

The prevalence of cigarette smoking among U.S. adults has decreased significantly over the past several decades, reaching an all-time low of 14%.¹ This progress, however, has not been evenly distributed, with rural areas, such as those in Appalachia, continuing to experience disproportionately high smoking rates.² In some counties, smoking rates remain as high as 33%, comparable to national averages seen decades ago.³ Consequently, mortality rates for chronic obstructive pulmonary disease, a chronic lung condition associated with long-term exposure to irritants such as tobacco smoke, is nearly twice as high among Central Appalachians.⁴ This raises a critical question: why do certain geographic areas persistently struggle with elevated smoking rates?

An interplay of multilevel factors contributes to these disparities. Socioeconomic determinants—such as education and poverty—are well-documented contributors,¹ but unique regional characteristics also play a significant role. Economic reliance on tobacco agriculture, availability of healthcare providers, and industries like coal mining are strongly associated with elevated smoking rates in rural areas.⁵ However, even after accounting for these factors, disparities in rural Appalachia persist, suggesting unexplained factors may be driving these trends.⁵

Rural areas experience significant disparities in access to and engagement with smoking cessation programs,^6,7 such as state Quitlines.^6–8 Analysis of the Virginia Quitline reveals that Appalachian counties demonstrate lower Quitline utilization compared to non-Appalachian regions.⁸ Factors such as limited availability of healthcare providers, the prevalence of tobacco farming, and a higher percentage of the population living below the poverty line are all associated with reduced Quitline usage.⁸ A South Carolina study found that 94% of rural health clinics ask about tobacco use, but only 71% refer users to cessation services.⁹ These patterns highlight the influence of individual, regional, and socioeconomic factors on disparities in smoking rates and cessation program utilization. Addressing these inequities requires targeted interventions to ensure equitable access to smoking cessation resources.

Smoking cessation programs must be enhanced with culturally and regionally tailored interventions, ensuring that cessation aids, behavioral counseling, and support groups are accessible to rural populations. Increasing the availability of healthcare providers in these areas and expanding telehealth services is critical to addressing the shortage of resources. Tackling socioeconomic vulnerabilities, such as poverty and limited education, through policies that promote education, job training, and economic diversification can help reduce the reliance on industries like tobacco agriculture and coal mining. Regulating tobacco retailers, particularly in socially vulnerable counties, is another key strategy, as is enforcing stricter zoning laws to limit retailers’ proximity to schools and residential areas. Additional tobacco taxes and increased exposure to mass media campaigns focused on the health risks of smoking could significantly support smoking cessation efforts, while also generating revenue to fund cessation services.¹⁰ Research into underexplored factors driving smoking disparities should be prioritized, with a focus on understanding cultural, psychological, and historical influences unique to specific regions. Public health campaigns must resonate with local values, reduce the stigma surrounding smoking cessation, and highlight the health and economic benefits of quitting. These strategies, implemented collectively, can help reduce tobacco-related health disparities across all communities.

References:

1. U.S. Department Of Health And Human Services PHS. Smoking Cessation: A Report of the Surgeon General.; 2020. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf
2. Cardarelli K, Westneat S, Dunfee M, May B, Schoenberg N, Browning S. Persistent disparities in smoking among rural Appalachians: evidence from the Mountain Air Project. BMC Public Health. 2021;21(1):1-12.
3. Pilehvari A, You W, Krukowski RA, Little MA. Examining Smoking Prevalence Disparities in Virginia Counties by Rurality, Appalachian Status, and Social Vulnerability, 2011–2019. American Journal of Public Health. 2023;(0):e1-e4.
4. Health Disparities in Appalachia. Appalachian Regional Commission. Accessed February 10, 2025. https://www.arc.gov/report/health-disparities-in-appalachia/
5. Pilehvari A, Krukowski RA, You W, et al. Unveiling rural and Appalachian disparities in cigarette smoking through the social vulnerability index and other county-level characteristics. The Journal of Rural Health. 2025;41(1):e12860. doi:10.1111/jrh.12860
6. Goodin A, Talbert J, Freeman PR, Hahn EJ, Fallin-Bennett A. Appalachian disparities in tobacco cessation treatment utilization in Medicaid. Subst Abuse Treat Prev Policy. 2020;15(1):5. doi:10.1186/s13011-020-0251-0
7. Northridge ME, Vallone D, Xiao H, et al. The importance of location for tobacco cessation: Rural–urban disparities in quit success in underserved West Virginia counties. The Journal of Rural Health. 2008;24(2):106-115.
8. Pilehvari A, Krukowski RA, Wiseman KP, Little MA. Tobacco Quitline utilization compared with cigarette smoking prevalence in Virginia across rurality and Appalachian Status, 2011–2019. Preventive Medicine Reports. 2024;42:102716. doi:10.1016/j.pmedr.2024.102716
9. Mandelbaum J, Kilpatrick D, Brightharp C, Myers K, Biggers S, Hicks S. Tobacco documentation and referral to cessation programs in medically underserved South Carolina counties. Annals of Epidemiology. 2021;65. doi:10.1016/j.annepidem.2021.10.007
10. Onwuzo CN, Olukorode J, Sange W, et al. A Review of smoking cessation interventions: efficacy, strategies for implementation, and future directions. Cureus. 2024;16(1).