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      Disparities in Rural Tobacco Use, Smoke-Free Policies, and Tobacco Taxes

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          Abstract

          Tobacco use and exposure to secondhand smoke (SHS) remain leading causes of preventable disease, disability, and mortality in the United States. Rural populations are among those being left behind in the recent declining smoking rates and have become a focus of discussions on tobacco-related disparities. This article describes tobacco-related disparities in rural populations including tobacco use, exposure to SHS, smoke-free policies, and tobacco taxes. Nurses, as social justice and tobacco control policy advocates, are needed especially at the local level, where much of the policy work occurs and where nursing’s voice is respected and can be powerful.

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          Most cited references 45

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          Tobacco taxes as a tobacco control strategy.

          Increases in tobacco taxes are widely regarded as a highly effective strategy for reducing tobacco use and its consequences. The voluminous literature on tobacco taxes is assessed, drawing heavily from seminal and recent publications reviewing the evidence on the impact of tobacco taxes on tobacco use and related outcomes, as well as that on tobacco tax administration. Well over 100 studies, including a growing number from low-income and middle-income countries, clearly demonstrate that tobacco excise taxes are a powerful tool for reducing tobacco use while at the same time providing a reliable source of government revenues. Significant increases in tobacco taxes that increase tobacco product prices encourage current tobacco users to stop using, prevent potential users from taking up tobacco use, and reduce consumption among those that continue to use, with the greatest impact on the young and the poor. Global experiences with tobacco taxation and tax administration have been used by WHO to develop a set of 'best practices' for maximising the effectiveness of tobacco taxation. Significant increases in tobacco taxes are a highly effective tobacco control strategy and lead to significant improvements in public health. The positive health impact is even greater when some of the revenues generated by tobacco tax increases are used to support tobacco control, health promotion and/or other health-related activities and programmes. In general, oppositional arguments that higher taxes will have harmful economic effects are false or overstated.
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            Tobacco Use Among Middle and High School Students — United States, 2011–2014

            Tobacco use and addiction most often begin during youth and young adulthood (1,2). Youth use of tobacco in any form is unsafe (1). To determine the prevalence and trends of current (past 30-day) use of nine tobacco products (cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, tobacco pipes, snus, dissolvable tobacco, and bidis) among U.S. middle (grades 6–8) and high school (grades 9–12) students, CDC and the Food and Drug Administration (FDA) analyzed data from the 2011–2014 National Youth Tobacco Surveys (NYTS). In 2014, e-cigarettes were the most commonly used tobacco product among middle (3.9%) and high (13.4%) school students. Between 2011 and 2014, statistically significant increases were observed among these students for current use of both e-cigarettes and hookahs (p<0.05), while decreases were observed for current use of more traditional products, such as cigarettes and cigars, resulting in no change in overall tobacco use. Consequently, 4.6 million middle and high school students continue to be exposed to harmful tobacco product constituents, including nicotine. Nicotine exposure during adolescence, a critical window for brain development, might have lasting adverse consequences for brain development (1), causes addiction (3), and might lead to sustained tobacco use. For this reason, comprehensive and sustained strategies are needed to prevent and reduce the use of all tobacco products among youths in the United States. NYTS is a cross-sectional, school-based, self-administered, pencil-and-paper questionnaire administered to U.S. middle and high school students. Information is collected on tobacco control outcome indicators to monitor the impact of comprehensive tobacco control policies and strategies (4) and inform FDA’s regulatory actions (5). A three-stage cluster sampling procedure was used to generate a nationally representative sample of U.S. students who attend public and private schools in grades 6–12. This report includes data from 4 years of NYTS (2011–2014), using an updated definition of current tobacco use that excludes kreteks (sometimes referred to as clove cigarettes).* Of 258 schools selected for the 2014 NYTS, 207 (80.2%) participated, with a sample of 22,007 (91.4%) among 24,084 eligible students; the overall response rate was 73.3%. Sample sizes and overall response rates for 2011, 2012, and 2013 were 18,866 (72.7%), 24,658 (73.6%), and 18,406 (67.8%), respectively. Participants were asked about current (past 30-day) use of cigarettes, cigars (defined as cigars, cigarillos, or little cigars), smokeless tobacco (defined as chewing tobacco, snuff, or dip), e-cigarettes,† hookahs,§ tobacco pipes (pipes),¶ snus, dissolvable tobacco (dissolvables), and bidis. Current use for each product was defined as using a product on ≥1 day during the past 30 days. Tobacco use was categorized as “any tobacco product use,” defined as use of one or more tobacco products and “≥2 tobacco product use,” defined as use of two or more tobacco products. Data were weighted to account for the complex survey design and adjusted for nonresponse; national prevalence estimates with 95% confidence intervals and population estimates rounded down to the nearest 10,000 were computed. Estimates for current use in 2014 are presented for any tobacco use, use of ≥2 tobacco products, and use of each tobacco product, by selected demographics for each school level (high and middle). Orthogonal polynomials were used with logistic regression analysis to examine trends from 2011 to 2014 in any tobacco use, use of ≥2 tobacco products, and use of each tobacco product by school level, controlling for grade, race/ethnicity, and sex and simultaneously assessing for linear and nonlinear trends.** A p-value <0.05 was considered statistically significant. SAS-Callable SUDAAN was used for analysis. In 2014, a total of 24.6% of high school students reported current use of a tobacco product, including 12.7% who reported current use of ≥2 tobacco products. Among all high school students, e-cigarettes (13.4%) were the most common tobacco products used, followed by hookahs (9.4%), cigarettes (9.2%), cigars (8.2%), smokeless tobacco (5.5%), snus (1.9%), pipes (1.5%), bidis (0.9%), and dissolvables (0.6%) (Table). Among high school non-Hispanic whites, Hispanics,†† and persons of non-Hispanic other races, e-cigarettes were the most used product, whereas among non-Hispanic blacks, cigars were used most commonly. Current use of any tobacco and ≥2 tobacco products among middle school students was 7.7% and 3.1%, respectively. E-cigarettes (3.9%) were the tobacco product used most commonly by middle school students, followed by hookahs (2.5%), cigarettes (2.5%), cigars (1.9%), smokeless tobacco (1.6%), pipes (0.6%), bidis (0.5%), snus (0.5%), and dissolvables (0.3%). From 2011 to 2014, statistically significant nonlinear increases were observed among high school students for current e-cigarette (1.5% to 13.4%) and hookah (4.1% to 9.4%) use (Figure 1). Statistically significant linear decreases were observed for current cigarette (15.8% to 9.2%) and snus (2.9% to 1.9%) use. Statistically significant nonlinear decreases were observed for current cigar (11.6% to 8.2%), pipe (4.0% to 1.5%), and bidi (2.0% to 0.9%) use. Current use of any tobacco product (24.2% to 24.6%) and use of ≥2 tobacco products (12.5% to 12.7%) did not change significantly from 2011 to 2014. Among middle school students, similar trends were observed during 2011–2014 (Figure 2). A statistically significant linear decrease was observed only in middle school students currently using ≥2 tobacco products (3.8% to 3.1%). In 2014, an estimated 4.6 million middle and high school students currently used any tobacco product, of which an estimated 2.2 million students currently used ≥2 tobacco products. Of current tobacco users, 2.4 million used e-cigarettes and 1.6 million used hookahs. The largest increase in current e-cigarette use occurred from 2013 to 2014. Current e-cigarette use tripled from 2013 (660,000 [4.5%]) to 2014 (2 million [13.4%]) among high school students (Figure 1); and among middle school students, prevalence increased by a similar magnitude, from 1.1% (120,000) to 3.9% (450,000) (Figure 2). From 2013 to 2014, substantial increases also were observed for current hookah use, with prevalence almost doubling for high school students from 5.2% (770,000) to 9.4% (1.3 million) and for middle school students from 1.1% (120,000) to 2.5% (280,000) over this period. Discussion From 2011 to 2014, substantial increases were observed in current e-cigarette and hookah use among middle and high school students, resulting in an overall estimated total of 2.4 million e-cigarette youth users and an estimated 1.6 million hookah youth users in 2014. Statistically significant decreases occurred in the use of cigarettes, cigars, tobacco pipes, bidis, and snus. The increases in current use of e-cigarettes and hookahs offset the decreases in current use of other tobacco products, resulting in no change in overall current tobacco use among middle and high school students. In 2014, one in four high school students and one in 13 middle school students used one or more tobacco products in the last 30 days. In 2014, for the first time in NYTS, current e-cigarette use surpassed current use of every other tobacco product, including cigarettes. These findings are subject to at least three limitations. First, data were collected only from youths who attended either public or private schools and might not be generalizable to all middle and high school-aged youth. Second, current tobacco use was estimated by including students who reported using at least one of the nine tobacco products asked in the survey but might have had missing responses to any of the other eight tobacco products; missing responses were considered as nonuse, which might have resulted in underestimated results. Finally, changes between 2013 and 2014 in the wording and placement of questions about the use of e-cigarettes, hookahs, and tobacco pipes might have had an impact on reported use of these products. Despite these limitations, overall prevalence estimates are similar to the findings of other nationally representative youth surveys (6,7). Tobacco prevention and control strategies, including increasing tobacco product prices, adopting comprehensive smoke-free laws, and implementation of national public education media campaigns, might have influenced the reduction of cigarette smoking in youths (2). However, the lack of decline in overall tobacco use from 2011 to 2014 is concerning and indicates that an estimated 4.6 million youths continue to be exposed to harmful constituents, including nicotine, present in tobacco products (Table). Youth use of tobacco in any form, whether it be combustible, noncombustible, or electronic, is unsafe (1); regardless of mode of delivery, nicotine exposure during adolescence, a critical time for brain development, might have lasting adverse consequences for brain development (1), causes addiction (3), and might lead to sustained use of tobacco products. Rapid changes in use of traditional and emerging tobacco products among youths underscore the importance of enhanced surveillance of all tobacco use. What is already known on this topic? Tobacco use and addiction most often begins during youth and young adulthood. Youth use of tobacco in any form is unsafe and might have lasting adverse consequences on their developing brains. What is added by this report? In 2014, an estimated 4.6 million youths, including 3.7 million high school and 900,000 middle school students, reported current use (use on one or more days in the past 30 days) of any tobacco product. From 2011 to 2014, statistically significant increases were observed in e-cigarette and hookah use among high school and middle school students, while statistically significant decreases were observed in the use of cigarettes, cigars, tobacco pipes, bidis, and snus. The increases in current use of e-cigarettes and hookahs offset the decreases in other tobacco products, resulting in no change in overall current tobacco use among youths. What are the implications for public health practice? In 2014, nearly one in four high school students and one in 13 middle school students reported current use of any tobacco product. Because the use of emerging tobacco products (e-cigarettes and hookahs) is on the rise among middle and high school students, it is critical that comprehensive tobacco control and prevention strategies for youths should address all tobacco products and not just cigarettes. Sustained efforts to implement proven tobacco control policies and strategies are necessary to prevent youth use of all tobacco products. In April 2014, FDA issued a proposed rule to deem all products made or derived from tobacco subject to FDA jurisdiction, and the agency is reviewing public comments on the proposed rule (8). Regulation of the manufacturing, distribution, and marketing of tobacco products coupled with full implementation of comprehensive tobacco control and prevention strategies at CDC-recommended funding levels could reduce youth tobacco use and initiation (1,2,9). Because use of emerging tobacco products (e-cigarettes and hookahs) is increasing among middle and high school students, it is critical that comprehensive tobacco control and prevention strategies for youths should address all tobacco products and not just cigarettes.
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              Health-Related Behaviors by Urban-Rural County Classification — United States, 2013

              Problem/Condition Persons living in rural areas are recognized as a health disparity population because the prevalence of disease and rate of premature death are higher than for the overall population of the United States. Surveillance data about health-related behaviors are rarely reported by urban-rural status, which makes comparisons difficult among persons living in metropolitan and nonmetropolitan counties. Reporting Period 2013. Description of System The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services related to the leading causes of death and disability. BRFSS data were analyzed for 398,208 adults aged ≥18 years to estimate the prevalence of five self-reported health-related behaviors (sufficient sleep, current nonsmoking, nondrinking or moderate drinking, maintaining normal body weight, and meeting aerobic leisure time physical activity recommendations) by urban-rural status. For this report, rural is defined as the noncore counties described in the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties. Results Approximately one third of U.S. adults practice at least four of these five behaviors. Compared with adults living in the four types of metropolitan counties (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan), adults living in the two types of nonmetropolitan counties (micropolitan and noncore) did not differ in the prevalence of sufficient sleep; had higher prevalence of nondrinking or moderate drinking; and had lower prevalence of current nonsmoking, maintaining normal body weight, and meeting aerobic leisure time physical activity recommendations. The overall age-adjusted prevalence of reporting at least four of the five health-related behaviors was 30.4%. The prevalence among the estimated 13.3 million adults living in noncore counties was lower (27.0%) than among those in micropolitan counties (28.8%), small metropolitan counties (29.5%), medium metropolitan counties (30.5%), large fringe metropolitan counties (30.2%), and large metropolitan centers (31.7%). Interpretation This is the first report of the prevalence of these five health-related behaviors for the six urban-rural categories. Nonmetropolitan counties have lower prevalence of three and clustering of at least four health-related behaviors that are associated with the leading chronic disease causes of death. Prevalence of sufficient sleep was consistently low and did not differ by urban-rural status. Public Health Action Chronic disease prevention efforts focus on improving the communities, schools, worksites, and health systems in which persons live, learn, work, and play. Evidence-based strategies to improve health-related behaviors in the population of the United States can be used to reach the Healthy People 2020 objectives for these five self-reported health-related behaviors (sufficient sleep, current nonsmoking, nondrinking or moderate drinking, maintaining normal body weight, and meeting aerobic leisure time physical activity recommendations). These findings suggest an ongoing need to increase public awareness and public education, particularly in rural counties where prevalence of these health-related behaviors is lowest.
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                Author and article information

                Journal
                West J Nurs Res
                West J Nurs Res
                WJN
                spwjn
                Western Journal of Nursing Research
                SAGE Publications (Sage CA: Los Angeles, CA )
                0193-9459
                1552-8456
                17 February 2019
                August 2019
                : 41
                : 8 , Special Issue: Tobacco and Social Justice
                : 1184-1202
                Affiliations
                [1 ]North Dakota State University, Fargo, ND, USA
                Author notes
                Kelly Buettner-Schmidt, School of Nursing, College of Health Professions, North Dakota State University, Fargo, ND 58102, USA Email: Kelly.buettner-schmidt@ 123456ndsu.edu
                Article
                10.1177_0193945919828061
                10.1177/0193945919828061
                6613179
                30774036
                © The Author(s) 2019

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

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