Rural residents throughout the Global North experience inequities related to nicotine and tobacco use, including heavier and more frequent smoking, compared to people living in urban areas. These inequities are evident in rural northern California, where the prevalence of smoking among adults is double that of the state average. To understand the social and structural drivers underlying these tobacco-related inequities, we conducted a qualitative study with 87 rural emerging and early established adults in California’s north central and northeastern counties, who all had current or past experiences with nicotine and tobacco products. From a pattern- and constitutive-level analysis of the narrative data, we interpreted six themes related to the social and structural determinants of nicotine and tobacco use for younger rural adults in our sample: rural hardship, social acceptance of smoking, stigmatization of smoking, isolation, pleasure, and harm reduction amid competing crises. We contextualize these themes within the broader literature to illustrate the unique meanings and roles of nicotine and tobacco use within the lives of rural younger adults. By attending to these social and structural processes, public health can more effectively envision alternative approaches to tobacco prevention and treatment that simultaneously support overall health equity for rural adults.
The prevalence of smoking in the United States (US) has decreased during the past five decades (Vuong et al. 2019), but this decrease has not been experienced equitably. One neglected population in tobacco research is rural adults, who experience substantial inequities related to nicotine and tobacco (NT) use (American Lung Association 2012, Buettner-Schmidt et al. 2019, Cornelius 2023, Doescher et al. 2006, Doogan et al. 2017, Liu et al. 2016). Smoking is not only more prevalent among rural residents compared to urban residents (Cornelius 2023, Liu et al. 2016), but rural adults smoke more heavily, are more likely to use other NT products (e.g., smokeless tobacco), and are less likely to quit smoking than urban adults (American Lung Association 2012, Doescher et al. 2006).
In California – often considered a leader in tobacco control in the US – precipitous drops in smoking prevalence have been largely attributed to public health approaches that aim to denormalize tobacco use and the tobacco industry (CA Department of Public Health 2024). While these policies have been linked to broad reductions in tobacco use, they have also been associated with further concentrating the burdens of tobacco-related diseases and social stigmas within marginalized populations – including, for example, people who identify as LGBTQ2S+, people with lower socioeconomic status, and Native Americans (Bell et al. 2010, Marbin et al. 2021, Stuber et al. 2008, Wiley 2017). Similarly, for the relatively small proportion of the US population that lives in rural areas, studies suggest that reductions in smoking have lagged compared to urban areas (Cornelius 2023, Doogan et al. 2017). Consequently, rural communities experience inequities related to NT use (American Lung Association 2012, Buettner-Schmidt et al. 2019, Doescher et al. 2006, Doogan et al. 2017, Liu et al. 2016). This phenomenon is especially evident in California’s rural north central and northeastern counties, often referred to as the North State (NS), where smoking prevalence among adults ages 18 and older is double that of the state (~20%) as a whole (Vuong et al. 2019).
Most adults who use NT products begin during adolescence or in young adulthood (Bernat et al. 2012, Mayhew et al. 2000, US Department of Health and Human Services 2012). As a result, many public health interventions are designed to prevent initiation and, therefore, target youth. However, limited research suggests that inequities in NT use, particularly smoking, may be especially prominent for emerging (18-25) and early established (26-35) rural adults. For example, US-based research shows that rural emerging adults are 27% more likely to smoke compared to urban emerging adults (American Lung Association 2012). Likewise, pooled data between 2020-2022 from CA suggest that both rural emerging and rural early established adults in California’s NS are more than twice as likely to report current smoking compared to their counterparts in the CA general population (UCLA Center for Health Policy 2022). Despite evidence of rural inequities in smoking for these age groups, emerging and early established rural adults have received little attention in the literature. Consequently, little is known about the circumstances surrounding their everyday lives that may help to explain these inequities.
Studies have hypothesized several factors unique to rural settings in the Global North that may increase risk of NT use for all rural adults, including harsh socio-economic conditions (e.g., poverty, underemployment); favorable community, familial, and peer norms related to NT use; insufficient health and social services; a lack of reach of tobacco control and prevention efforts; and exposure to tobacco industry marketing (Agunwamba et al. 2017, American Lung Association 2012, Buettner-Schmidt et al. 2019). However, these factors remain underexplored (for exceptions, see Agunwamba et al. 2017, Bernat & Choi 2018), and they have not yet been considered within the context of emerging and early established adulthood. While research on NT use among rural emerging and early established adults is limited, a meta-ethnography of 30 studies examining smoking among young adults in general suggests that social identity construction during the transition to adulthood plays an important role in shaping the role of smoking. Smoking may function as a means of stress management, a performance of adulthood or rebelliousness, or as a way to cope with emerging responsibilities such as those related to family and finances (Poole et al. 2022).
But what happens to the meanings and roles of smoking when the social and structural conditions of rural locations intersect with the life transitions that characterize emerging and early established adulthood? Given that earlier stages of adulthood may be a particularly vulnerable period for rural residents (Fenton et al. 2022), it is crucial to better understand how emerging and early established rural adults interpret the meanings and roles of NT use in their lives. Only then can ‘adjustments or new responses to prevention and cessation’ be imagined (Greaves 2015, p. 1452). Because no framework exists for understanding rural emerging and early established adults’ inequities in NT use, we conducted an interpretative, qualitative study in CA’s NS to uncover the social and structural drivers that may link rural settings to NT use for rural residents during these earlier stages of adulthood.
Drawing on cumulative disadvantage theory, we theorize that rural NT inequities are due to the systemic social and structural disadvantages unique to rural communities that accumulate over a person’s life (Dannefer 2003, Ozga et al. 2021). Rural communities throughout the Global North are not homogenous, but they often share similar systemic conditions that disenfranchise the people who live there (Antin & Hunt 2025). Understanding these cumulative disadvantages and their links with NT use for emerging and early established adults can yield a holistic framing that depicts the ways in which rurality intersects with earlier stages of adulthood to compound disadvantage and sustain inequities in health. By uncovering the cumulative disadvantages affecting the lives of emerging and early established rural adults, we attempt to produce a rich and complex understanding from a single case that is theoretically generalizable to other rural communities similarly disenfranchised (Carminati 2018). Revealing these hidden systemic processes is essential for developing tailored tobacco prevention and treatment strategies that are compassionately grounded in the lives of emerging and early established rural adults.
This analysis is based on the narratives of 87 participants, ages 18-35, living in the NS region of California who participated in in-depth qualitative interviews exploring the roles and meanings of NT use among emerging (18-25) and early established (26-35) adults in rural areas. Eligibility criteria included English fluency, reporting any lifetime use of NT, being between 18-35 years old, and either currently living in the study area or having previously lived there and only moved within the past year. Data were collected between July 2021 and March 2023. Demographic details for the sample are provided in Table 1. Participants were predominantly white, heterosexual, and cisgender. The mean age of participants was 25.8 (SD=4.5). A little over one-third of participants had not attended any college. Based on multiple survey indicators, most participants were struggling with economic insecurity, and many had experienced other forms of socioeconomic adversity, including housing insecurity and difficulty accessing medical care (Antin et al. 2024). On a five-point scale from ‘poor’ (1) to ‘excellent’ (5), on average participants rated their general physical health as 3.0 (SD=1.0) and mental health as 2.6 (SD=1.2). The majority of participants reported past-month use of at least one NT product. Of those, most reported cigarette smoking (58.2%), 20.7% reported smoking cigars/cigarillos/little cigars, 12.6% reported using smokeless tobacco, and 55.2% reported nicotine vaping. To maximize variation of NT perspectives and experiences within the sample, we included a small proportion of participants who did not currently use NT products but did report lifetime NT use (17.2%) (Maxwell 2013).
Participation involved a 30-minute online survey with a $20 honorarium, followed by an audio-recorded online Zoom or phone interview that ranged between 40 minutes to 2.5 hours, and included an additional $50 honorarium. We used a multi-tiered recruitment strategy involving posting flyers throughout the study area, paid social media and radio advertisements, outreach to local organizations, and paid referrals. To reduce sampling bias, each participant was limited to three referrals. Recruitment advertisements were visually attractive but simple in their design, stating that ‘we are recruiting people ages 18-35 living in the NS to participate in a paid research study about nicotine and tobacco use.’ Information about the honorarium was provided, along with a QR code to direct them to our study website. Volunteers were screened online or in-person, and if eligible were then contacted by the project manager to receive additional information and schedule the interview. Prior to the interview, participants received a unique link to complete the study consent form and confidential online survey. The survey included demographic, community, and NT use questions.
Three local interviewers, who lived and worked within the study area and were within the age range of participants, were hired and trained to complete more than half of study interviews, contributing valuable community-based knowledge to the research process. The remaining interviews were conducted by experienced research staff with substantial qualitative interviewing expertise. The in-depth interview instrument began with questions about the participant’s daily life and background, followed by a section focused on perceptions of their local communities and meanings of rurality. Next, the instrument was designed to elicit participant narratives about their various identities, before shifting into questions about their NT use practices, histories, and access strategies, as well as their perceptions of NT-related policies, family and community attitudes, health considerations, and social meanings. The final questions centered on pressing issues in the community and how these issues may relate to wellbeing. Interview questions were designed to be open-ended, with interviewers trained to probe for additional details or ask follow up questions to encourage further elaboration. See Appendix I for the Interview Instrument. All interviews were professionally transcribed and transcripts reviewed by interviewers for accuracy. Study procedures were approved by the Institute for Scientific Analysis’ Institutional Review Board.
|
|
|
N |
% |
|
Age Groups
|
18-20 years old 21-25 years old |
10 39 |
11.5 44.8 |
|
26-30 years old 31-35 years old |
22 16 |
25.3 18.4 |
|
|
Gender
|
Man Woman |
44 43 |
50.6 49.4 |
|
Sexual Identity |
Straight or Heterosexual Gay or Lesbian Bisexual Unknown
|
61 4 21 1 |
70.1 4.6 24.1 1.2
|
|
Race/Ethnicity |
Asian American Indian/Alaska Native Black/African American Non-Hispanic/Latine White Latine More than one race/ethnicity Unknown or not reported |
1 3 1 61 13 7 1 |
1.2 3.5 1.2 70.1 14.9 8.1 1.2
|
|
Employment Status |
Full time Part-time |
24 29 |
27.6 33.3 |
|
Unemployed, but looking for a job Neither employed nor looking for a job |
22 5 |
25.3 5.8 |
|
|
On disability Unknown or not reported |
3 4 |
3.5 4.6 |
|
|
Post graduate degree |
2 |
2.3 |
|
|
Socioeconomic Status |
Reported perceived SES below average |
58 |
66.7 |
|
Housing Insecurity |
Insecure housing, lifetime Insecure housing, past month |
53 18 |
60.9 20.7
|
|
Insecure Income, Past Year |
Evicted from your home for not paying rent or mortgage |
2 |
2.3 |
|
Did not pay the full amount of the gas or electricity bill |
24 |
27.6 |
|
|
Had a phone disconnected because payments were not made |
25 |
28.7 |
|
|
Health Insurance |
Currently covered by Medi-Cal or have no health insurance |
61 |
70.1 |
|
General Perceived Physical Health |
Poor Fair |
5 21 |
5.8 24.1 |
|
Good Very good |
29 26 |
33.3 29.9 |
|
|
Excellent Unknown |
5 1 |
5.8 1.2
|
|
|
General Perceived Mental Health |
Poor Fair |
16 30 |
18.4 34.5 |
|
Good Very good |
21 12 |
24.1 13.8 |
|
|
Excellent Unknown |
7 1 |
8.1 1.2
|
|
|
Any Past Month NT Use |
|
72 |
82.8 |
Table 1: Sample Characteristics (N=87)
The research team coded all transcripts using qualitative analysis software ATLAS.ti to organize the data into analytically meaningful segments, which facilitates retrieval of relevant data for subsequent analysis targeting particular topics. The initial codebook included topical domains relevant to study aims (e.g., ‘NT Use Practices,’ ‘Personal Background,’ ‘Local Area’), and was revised throughout data collection to capture additional salient topics in participants’ narratives (e.g., ‘Structural Issues,’ ‘Accessibility,’ ‘Class/SES’). The research team collaborated throughout the course of data collection and coding to identify themes related to the social and structural drivers of NT use, especially smoking, across participants’ narratives. Our preliminary data analysis process included: a) regular, ongoing discussions about emerging themes; b) iterative readings of the data across multiple rounds of coding; and c) recording detailed analytical memos throughout data collection, coding, and analysis. Reflecting on our preliminary analysis, the lead author developed a list of initial themes related to the social and structural drivers of NT use among study participants, by interpreting relationships between the identified patterns. Next, the lead author and EP conducted a secondary analysis of narrative data germane to theorizing social and structural drivers of NT use in rural areas. They retrieved all narrative data indexed with the codes ‘Rurality,’ ‘Structural Issues,’ ‘Accessibility,’ ‘Other Drugs,’ ‘Isolation,’ and/or ‘Stigma’ which overlapped with ‘Context of NT use,’ ‘Exposure to NT Use’ and/or ‘NT Use Practices’ codes. Drawing on tenets of pattern- and constitutive-level analysis (LeCompte & Schensul 2013), they interpreted the following six themes related to the social and structural determinants of NT use: rural hardship, social acceptance of smoking, stigmatization of smoking, isolation, pleasure, and NT as harm reduction amidst competing crises. Themes are described below and summarized in Appendix II using direct quotes as evidence from participants’ interviews. All quoted narratives are attributed using pseudonyms selected by participants to ensure anonymity.
It is not simply that there are multiple forms of disadvantage, but when those multiple forms clump together they create a deep and enduring form of hardship (Desmond & Western 2018, p. 309).
Hardship has long been implicated in NT-related inequities (Ozga et al. 2021), and yet little attention in public health has been paid to understanding the complexity of rural hardship (Conrad & Ronnenberg 2022), let alone its relationship to NT use. While participants in our study expressed gratitude for their communities and appreciation for the natural beauty surrounding them, they also described the lived experience of rural hardship as a backdrop to NT use, particularly smoking. For example, Loki, a 33-year-old father and veteran who does manual labor and smokes half a pack a day, discussed being laid off after a traumatizing wildfire destroyed his workplace and much of the town, leaving him trying to scrape together odd jobs to support his family. He described how conditions in some rural areas, including lack of industry and infrastructure, contextualize the hardships and sense of hopelessness that he perceives as contributing to rural smoking:
There’s a lot of hopelessness that goes along with the socioeconomic impact of living in a rural area that doesn’t have any industry...The lifestyle up here is very rough...there’s no internal infrastructure to get like, natural gas and stuff like that…Anyplace that’s…socioeconomically poorly…you’re gonna find a lot of smokers there…I’ve gone through the couch a few times to find change for a [cigarillo]…And I’ve known everybody else to do it too...Rich people don’t smoke. They have more to live for...the top is a lot prettier than the bottom.
Managing stress and feeling stuck about one’s ability to improve their current situation were often described as fundamental causes underlying the health and health behaviors of rural residents (see Appendix II, quotations A1, A2, A3). Data from the 2020 US Census suggests that NS residents are more likely to experience poverty compared to the CA general population (California Census Bureau 2020). A dearth of livable wage jobs combined with high housing costs in the North State further compounds disadvantage for the least privileged NS residents, making it extremely difficult to overcome rural hardship (Albrecht & Albrecht 2000, Antin et al. 2024). In geographically isolated rural regions where resources are scarce and challenges to daily living widespread, NT use, especially smoking, can offer a momentary sense of relief, essentially serving as a palliative in the face of ongoing hardship (see Appendix II, quotation A2). While not all study participants experienced the same level of rural hardship, even participants who experienced relatively more privileges (due often to generational family wealth) drew attention to the challenges facing those with fewer advantages, in some cases directly positioning NT use as a buffer against rural hardship.
[S]moking facilitates social connections with others who smoke, and can be normative group behaviour in certain circumstances (Dono et al. 2020, p. 241).
Participants emphasized widespread social acceptance of NT use, especially smoking, within their communities. John, a 28-year-old father who started smoking at age 11 and currently smokes heavily, said that ‘pretty much everybody that I’ve had in my life has smoked…I grew up thinking everybody smoked…it just seems like a regular thing.’ Given the role of community norms in perpetuating smoking, California has long spearheaded environmental-level approaches designed to shift such norms. Nevertheless, our participants described smoking as a ‘regular thing,’ suggesting that broad environmental approaches may be less successful in rural communities.
In addition to community-level acceptance, participants emphasized social group acceptance of smoking, especially within worksites characteristic of many rural NS communities. For example, John J., a 23-year-old man who lives with his parents due to high housing costs and mostly smokes pipe tobacco, explained:
Being a firefighter makes [smoking] kind of normal for me…we'd get off of a call, and everyone would be there smoking…it didn't seem like it was a bad thing because you know, these are my role models…the people I look up to, and they smoke. And they're successful. So, why can't I? And then…the smoke exposure - it seems like it's no big deal because, ‘Oh, well, I'm already breathing smoke. Why not breathe more?’…When I worked in the fire department, everyone smoked. When I worked a tree-harvest job, just about everyone smoked…
Social group norms related to smoking serve to reinforce group belonging. Yet such group norms do not emerge solely on their own, they are also shaped by external forces. For example, some participants observed that tobacco industry marketing likely influenced the products adopted within their social groups, a phenomenon far from overlooked in research on NT-related inequities in rural communities (Cruz et al. 2019). For example, Zach, a 23 year-old outdoor guide who used to smoke and now uses nicotine pouches, expressed his suspicion that the tobacco industry effectively promoted the adoption of specific nicotine products in his social group (see Appendix II, quotation B2).
Given the acceptability of smoking within both their communities and social groups, participants also stressed how not smoking could make you an ‘outcast’ (see Appendix II, quotation B1). Participants often attributed the widespread social acceptance of smoking to the acceptability of smoking across generations, particularly within one’s family, leading to the intergenerational transmission of smoking, a phenomenon documented in the literature (Bierut et al. 1998, Kandel et al. 2015, Ozga et al. 2021, Vandewater et al. 2014). In rural communities, where generations of families are likely to live in close proximity, elder family members may have more influence on younger generations. For instance, Sara, a 20-year-old woman whose parents smoke and who herself recently switched from smoking to vaping, maintained that ‘if everybody's grandparents and parents are smoking and it's not frowned upon…one day when you're of age and start smoking…nobody really says anything. It's just like, Okay. Well, now they smoke.’
Though the transmission of smoking across generations is well known, few scholars have sufficiently considered precisely why it is so difficult to disrupt this legacy. One contribution is Thirlway’s (2016) ethnographic research in a rural coal mining town in the North of England where she found smoking to be symbolically important for young women to emotionally connect with their mothers. Due to this affective meaning of smoking, Thirlway suggests that cessation may risk fracturing social relationships that are nurtured by smoking, a phenomenon that we observed in interviews particularly with young women (Thirlway 2016). For example, take V, a 24 year-old woman living with her mother after recently being released from prison and recovering from a decade-long heroin addiction. Although V doesn’t ‘associate’ with most of her large family, which she described as ‘full of felons’ and ‘addicts,’ V regularly smokes with her mom and explained how smoking together provides a meaningful time to connect (see Appendix II, quotation B3).
The goal of the California Tobacco Control Program is to change the social norms surrounding tobacco use…by creating a social milieu and legal climate in which tobacco becomes less desirable, less acceptable, and less accessible (CA Department of Public Health 2024).
Despite the social acceptance of smoking within their communities, social groups, and families, participants suggested that people who use NT products are simultaneously vulnerable to tobacco-related stigma. Some participants, especially those with more privileges and who were less likely to smoke cigarettes, reluctantly admitted pejorative stereotypes about people who smoke. For example, Maria, a 22-year-old woman from a relatively privileged background, had never smoked cigarettes but qualified for the study because of her lifetime blunt [an emptied cigar or other tobacco-based wrap filled with cannabis] use and reported nicotine vaping. She described associating cigarette smoking with ‘white trash’ from ‘a small, really hick town’ who are ‘not really caring about other people.’ Her comments illustrate how tobacco-related stigma often reinforces class-based stigmatization, potentially resulting in troubling consequences for people who smoke. For instance, already hard-to-access socioeconomic opportunities may be further diminished in a small community where there is an increased likelihood of being ‘caught’ smoking by people in positions of power who control access to opportunities (see Appendix II, quotation C1).
The stigmatization of tobacco can also result in other social consequences, especially for women who internalized the belief that tobacco use was not ‘ladylike’ or ‘classy’ for them. For example, V (introduced above) explained that one of her few social connections wants her to stop smoking so she can conform to ‘proper’ femininity: ‘a woman is supposed to be clean and gentle and smell good and ... cigarettes have a more masculine air to them.’ Similarly, Anna, a 24-year-old woman who began using chew at age 9 with her father, switched to cigarettes at age 14 to avoid being viewed as overly masculine by peers. She only vapes now when she is stressed and described how her gender and previous experiences with homelessness encouraged her to shed her smoking habit so that she could be perceived as ‘a classy person’ (see Appendix II, quotation C2).
Tobacco-related stigma can operate as a structural determinant of smoking for pockets of Californians experiencing cumulative disadvantages and who may be unwilling or who lack the resources they need to quit. This may be due, in part, to the way in which stigmatization processes intentionally relegate people who smoke to the margins of society, which has the unintended consequence of creating ‘smoking islands’ where smoking is reinforced rather than discouraged (Barnett et al. 2017, Thompson et al. 2007). For example, Jenna, a 27 year-old woman who works multiple jobs and is trying to establish a career in recovery services, explained how her vaping and occasional smoking impacts how she is viewed professionally and also who she feels comfortable being around:
[Smoking’s] just frowned upon, like professionally. There’s just a lot of stigma to it…It’s just hard for me because I do…have…a professional career and try to be a part of the community…But then it’s hard because there’s other people that are…constantly judging me. So then I feel kind of safe with the other people who do smoke, because they’re more openminded and nonjudgmental.
The health and societal impacts of social isolation and loneliness are a critical public health concern in light of mounting evidence that millions of Americans lack adequate social connection in one or more ways (US Office of the Surgeon General 2023, p. 9).
Participants’ narratives frequently touched on experiences with social isolation, often as a result of living in geographically isolated communities, as a reason for smoking. For example, Bob, a 31-year-old father who quit smoking and vaping upon becoming a self-identified orthodox Christian, unequivocally attributed inequities in rural smoking to ‘isolation’:
Isolation...most of the time when I see people smoking…it's more on the outskirts…because there's not a large amount of people who are close to each other all the time and then interacting with each other, having real human interaction…that was a large part of the reason that I turned to it. I was like, ‘Well, [I'm] on a break’, and I didn't really connect to the people at work or - I was living out in [tiny town]…sort of a disaffected, young adult. Isolation just sort of kept me [smoking].
While strong, close-knit communities are often described as a part of the ‘rural idyll,’ Sherman (2023) has argued that ‘“rural” and “tightly knit” are not synonymous’ due in part to the social inequalities that that exist within rural communities (Sherman 2023, p. 130). In her ethnographic work in the US’s rural Pacific Northwest, she found that poorer residents faced several structural barriers that undermined ‘their abilities to create and maintain social support,’ which is a profoundly important resource for surviving in under-resourced rural communities (p. 112). Interviews with our participants further emphasized the health-compromising legacy of social isolation, which included anxiety and depression as well as smoking as a tool for coping (see Appendix II, quotation D1). For instance, V, introduced above, described living in an area that’s ‘very secluded’ and gives her ‘anxiety,’ causing her to smoke ‘way more cigarettes’ especially at times when she doesn’t have access to cannabis.
In 2023, the US Surgeon General issued an advisory drawing attention to social isolation as a pressing public health problem, arguing that the lack of social connection ‘can increase the risk for premature death as much as smoking up to 15 cigarettes a day’ (US Office of the Surgeon General 2023, p. 8). The advisory also suggests that rural residents may be especially affected, though acknowledges that more research is needed. Our study supports the salience of social isolation for emerging and early established rural adults and illustrates how smoking may be perpetuated within this context, further compounding the health effects of rural social isolation.
…expecting people to voluntarily give up what might be seen as small pleasures, or the only ones they perceive that they have, is asking a lot (Thompson & Coveney 2018, p. 123).
Our participants, especially those in geographically isolated communities with limited opportunities, often brought up boredom as a feature of rural life that contributes to smoking (see Appendix II, quotation E1). Relief from boredom, as well as from feelings of hopelessness or ‘being stuck,’ may be important pleasurable aspects of NT use alongside the more obvious perceived physiological effects like enhancing mood and temporarily reducing stress. For example, Scarlett, a 20-year-old woman who works a foodservice job and vapes infrequently, explained how NT use was a pleasurable way to escape boredom in rural places where leisure and recreational opportunities are lacking:
I think, in a rural area, why so many people smoke is because there's really…not much to do besides like, just sit there…and hang out with your friends…So, they say, ‘Oh, you don't need substances to have fun.’ Yeah, you don't, but they do make it more fun. You know? Plus, it's just like something to do.
The pleasures participants associated with NT use – from escaping ‘boredom’, to experiencing a ‘rush’, to enjoying relaxation – were also described as being more accessible and affordable forms of pleasure for lower income rural residents, a phenomenon observed in other studies of people living in poverty where smoking is ‘the only pleasure they can afford’ and ‘the one thing that offers them “a little moment of happiness”’(Peretti-Watel & Constance 2009, p. 618). See also Appendix II, quotation E2. Jane, a 27-year-old mother who quit smoking upon having kids but recently picked up vaping, explained that in her community:
The cost of living is the biggest problem…not having…the opportunity to spend money in the ways that they want…they spend the money in the ways that they think they need…It’s like, ‘Oh. I can’t afford to take a trip. I’m going to instead just go buy a six pack and a pack of smokes.’…Because they look at it as ‘Well, this is what I can afford to be able to have a better…day or a better week.’
If we ignore the pleasures experienced from NT use, our public health efforts risk becoming disconnected from people’s actual needs and experiences, compromising their reach and their ability to eliminate NT-related inequities.
Long-term drug users often encounter health and social problems…Left largely on their own, drug users must devise their own ways of solving problems in a practice of self-care (Duff 2015, p. 94).
Participants, many of whom discussed personally struggling with addictions to illicit drugs, saw drug abuse as a major issue in many of their communities, often associated with overdose-related deaths, debilitating addiction, dysfunctional intoxication, psychosis, and/or crime such as DUIs, assaults, and theft. Within this context, NT use was not perceived as equally concerning (see Appendix II, quotation F1). For example, Tom, a 28-year-old father who was proud that he had switched to vaping from smoking at age 24, compared his own drug use practices to those of other young adults in his community:
I feel like I’m doing good that I don’t smoke cigarettes anymore. Most people my age are on f*ckin’ meth…are on the streets, don’t have their own car, don’t have their own house. Most people my age are doing that right now...So, I’m proud of myself, man. I could be out killing people. I could be out robbing people. I could be out doing all that crazy stuff. But I work every day and come home…I feel like I’m doing good...
Not only did participants describe smoking as relatively trivial given widespread problems with drug abuse, but in some cases, participants described smoking as a direct and intentional substitute for their other drug use which they were trying to cut down on or quit entirely. For example, Christine is a 33-year-old mother who used to use meth and currently smokes a pack a day, occasionally also vaping at work. She explained that she regularly encounters meth-related triggers in her life and community that are challenging to overcome, so she smokes cigarettes and practices psychological techniques she learned in treatment to support her recovery from meth (see Appendix II, quotation F2). For participants like Christine, smoking filled the space and time left over after stopping their use of other drugs or helped them cope with cravings. Perhaps the mildly intoxicating benefits of nicotine that enable ‘individuals to maintain normality rather than escape it,’ (Keane 2020, p. 54) positions cigarette smoking as suitable substitute for other drug addiction.
Although smoking certainly carries its own stigma (Bell et al. 2010, Stuber et al. 2008), participants’ narratives suggest that NT may still be perceived as a comparatively manageable risk in the context of other competing crises, namely illicit drug abuse. When other forms of intoxication are viewed as more harmful, disruptive, and incompatible with daily responsibilities, NT use can become a more desirable option. The possibility that NT use poses more predictable or longer-term risks compared to the use of other drugs warrants further consideration, particularly given tobacco’s legal availability and the widespread concern surrounding drug use in many rural communities (Peterkin 2022).
Participants in this study positioned their own NT use within a context of cumulative disadvantages marked by rural hardship, where inadequate industry and infrastructure further compounded the effects of geographic isolation. Furthermore, geographic isolation can heighten the negative impact of social isolation for rural residents who have little social capital and are living in poverty (Sherman 2021). Participants in our study described how social isolation within their communities served as a catalyst for psychological distress and ill health. In this context, smoking served as an accessible source of pleasure and stress relief, as well as a practice of self-care for some participants, though such beliefs may conflict with mainstream public health perspectives. Alternative public health approaches in response might incorporate components designed to address features of rural cumulative disadvantage and social isolation. For example, approaches that increase access to affordable housing (Antin et al. 2024), assist in the development of local job opportunities, provide social opportunities and support, seek to reduce stigma through compassionate approaches, and acknowledge the importance of pleasure can benefit rural communities and overtime filter down to ameliorate tobacco-related inequities.
The themes interpreted from our participants’ narratives also draw attention to the conflicting discourses in which NT use emerged as meaningful within people’s everyday lives. Specifically, across interviews, smoking was described as both stigmatized and normalized, as a behavior that could both jeopardize and solidify social connection, as a coping strategy for social isolation even as it simultaneously created opportunities for belonging, and as both a practice of pleasure and a means for managing addiction. These tensions illustrate how smoking is wrapped up in negotiations of risk, identities, and self-care. As previous research has shown, ambiguities can reveal different lenses through which people make sense of their experiences and behaviors, shedding light on the complexity of the human experience (Antin et al. 2015, Watson 2006).
Within public health, we often attempt to isolate a single predictor (e.g., social isolation) of a particular outcome (e.g., smoking), yet the present analysis reminds us that such relationships are dynamic and shifting. Social isolation, for instance, is not a static concept that either exists or not, but its relevance and importance shift depending upon the context. One might be fortunate to have the social support of their family yet still experience profound isolation due to geographic distance, constrained resources, stigma, or societal marginalization. Likewise, the stigmatization of smoking may be deeply felt within workplaces or through tobacco control policies, while smoking simultaneously operates as a valued social practice. Together these themes remind us that NT use cannot be understood apart from the intersecting social and structural conditions that shape rural life, particularly for those who experience cumulative disadvantage at a time in their lives when they transition into adulthood.
Finally, it is important to acknowledge the ways in which some groups of people—particularly those who are historically marginalized such as people who use drugs, rural populations, women, people living in poverty—create ‘counterdiscourses’ that may conflict with mainstream public health values but that are nevertheless grounded within people’s ‘identities, interests, and needs’ (Warner 2002, p. 85; see also Balshem 1991, Race 2009). For example, some participants used NT to help them maintain abstinence from other, more immediately life-threatening substances. In rural communities impacted by disastrous consequences of opioids and other drugs – especially deaths from overdose – achieving abstinence from NT may be understood as relatively trivial, and even harmful for people who struggle to abstain from other substances simultaneously. By working to understand the various meanings of NT use that may conflict with dominant public health messages, it becomes clear that public health efforts which stress abstinence from nicotine along with the protracted risks associated with NT use may have little effect on people who perceive far more immediate and severe risks to their everyday lives. It is only through an empathic understanding of the perspectives of people who continue to use NT products that we can envision alternative and more equitable approaches to supporting the health and wellbeing of populations experiencing NT-related inequities.
This manuscript has a history shaped by the contemporary political context in which public health research is produced and disseminated in the USA. We withdrew an earlier accepted version of this manuscript from a federally-affiliated US public health journal in 2025 due to editorial direction during the proofing stage to remove or modify language deemed out of compliance with presidential executive orders. We acknowledge this history to underscore the importance of journals, scholars, and communities committed to adhering to principles of scientific integrity and preserving critical, independent, and equity-oriented public health research.
Sincere appreciation is due to the participants who volunteered their time and stories to us. Without them, this research would not have been possible. We would also like to thank co-author, Shelly Brantley’s many colleagues at RISE, the Rural Initiatives Strengthening Equity project of the California Health Collaborative. We are so grateful for their support and guidance throughout the study. Additional appreciation is due to Ida Wilson, the study’s initial Project Manager, who contributed greatly to the project, including troubleshooting recruitment issues, managing data collection, and providing ongoing support and training to local interviewers.
Generative AI was used sparingly in the preparation of this manuscript to improve the clarity of some sentence phrasing.
This research is supported by funds from the Tobacco-Related Disease Research Program (TRDRP), grant number T31IR1513 (Tamar Antin, PI). The content provided here is solely the responsibility of the authors and does not necessarily reflect the opinions of TRDRP.
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Tamar MJ Antin https://orcid.org/0000-0002-2490-419X
Emile Sanders https://orcid.org/0000-0002-1392-6983
Sharon Lipperman-Kreda https://orcid.org/0000-0002-7463-938X
Geoffrey Hunt https://orcid.org/0000-0001-8806-0099
Rachelle Annechino https://orcid.org/0000-0002-2436-3178
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