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J Rural Health. 2019 Mar 13. doi: 10.1111/jrh.12356. [Epub ahead of print]

Tobacco Use Among Rural and Urban US Middle and High School Students: National Youth Tobacco Survey, 2011-2016.

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College of Nursing, University of Kentucky, Lexington, Kentucky.
School of Nursing, University of Louisville, Louisville, Kentucky.
Center for Vaccines and Immunology, University of Georgia, Athens, Georgia.
College of Public Health, University of Kentucky, Lexington, Kentucky.
College of Education, University of Kentucky, Lexington, Kentucky.



Rural adolescents engage in higher smoking and smokeless tobacco use rates than those from urban communities; urban adolescents are more likely to use e-cigarettes. The study investigated whether place of residence (rural vs urban) is associated with tobacco use prevalence and change in prevalence among middle and high school students over time.


We analyzed data from the National Youth Tobacco Survey (2011-2016). Multiple logistic regression methods for weighted survey data assessed the relationship of place of residence with current tobacco product use over time, adjusting for demographics.


There was no difference in rate of change in use of any tobacco product between rural and urban middle or high school students. Adjusting for age, sex, race/ethnicity, and survey year, both middle and high school rural students were more likely to use cigarettes and smokeless tobacco, whereas urban high school students were more likely to use hookah. Significant polynomial trends were observed for e-cigarette and hookah use patterns, whereas linear changes in use patterns were detected for cigarette and smokeless tobacco use over time.


Rural high school students are more likely to smoke cigarettes and use smokeless tobacco than their urban counterparts, although prevalence rates have decreased over time. However, use of hookah and e-cigarettes among middle and high school students has increased over time regardless of place of residence. To stem the rapid increase in use of hookah and e-cigarettes, comprehensive tobacco control policies are needed regardless of rural or urban location.


adolescents; e-cigarettes; nicotine; smoking; students


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