Drivers of rural inequities in nicotine and tobacco use: A qualitative study of emerging and early established adults in California’s North State in the USA

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.