Rural-Urban Patterns in Household Rules Limiting Combustible Tobacco, Noncombustible Tobacco, and E-Cigarette Use.

Rationale: Rural Americans experience higher rates of smoking and smoking-associated disease compared to urban Americans. Household rules limiting smoking inside the home decrease secondhand smoke exposure and may facilitate quitting among those who smoke. Limited research suggests that rural Americans are less likely to report household smoking restrictions. We studied the relationship between rurality and household rules limiting combustible tobacco, non-combustible tobacco, and electronic cigarette (e-cigarette) use.

Methods: Cross-sectional data for 10,126 United States respondents aged ≥ 40 years from the Population Assessment of Tobacco and Health Study Wave 5 (2018-2019) was used to assess the relationship between residence rurality (rural, small-town, suburban, urban) and household rules limiting combustible tobacco, non-combustible tobacco, or e-cigarette use. Multivariable Poisson regression analyses were adjusted for respondent age, sex, race, education, family income, and product use.

Results: Rural (vs urban) respondents more commonly allowed combustible tobacco (17.6% vs 13.6%), non-combustible tobacco (26.4% vs 16.4%), and e-cigarette use (20.8% vs 15.1%) in the home. The fully adjusted risk ratio (ARR) for rural (vs urban) homes was 1.27; 95% CI [1.12, 1.44] for combustible tobacco, 1.36; 95% CI [1.20, 1.54] for noncombustible tobacco, and 1.34; 95% CI [1.17, 1.55] for e-cigarettes. Small-town respondents had similarly increased ARRs, while suburban respondents' ARRs were not different compared to the urban reference group.

Conclusions: Rural and small-town Americans were more likely to allow household use of all tobacco product types compared to urban respondents. This pattern persisted when adjusted for socioeconomic factors and respondent product use. These findings may help address tobacco-related diseases that disproportionately affect rural Americans.