Associations between Appalachian youth tobacco consumption and communication channel use
Jack Pfeiffer 1
Jayesh Rai 3, 4
Clara G. Sears 1, 2
Kandi L. Walker 1, 2, 5
Joy L. Hart 1, 2, 5  
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Department of Communication, University of Louisville, Louisville, United States
American Heart Association Tobacco Regulation and Addiction Center, Dallas, United States
Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, United States
School of Medicine, Diabetes and Obesity Center, University of Louisville, Louisville, United States
School of Medicine, Envirome Institute, University of Louisville, Louisville, United States
Joy L. Hart   

Department of Communication, University of Louisville, Louisville, Kentucky, United States
Publication date: 2020-03-24
Submission date: 2019-11-04
Final revision date: 2020-02-02
Acceptance date: 2020-02-17
Tob. Prev. Cessation 2020;6(March):21
Youth tobacco use rates in Appalachia exceed the US national average, and e-cigarette use has increased. Thus, further research is needed to understand how these youth receive and share product information.

Middle and high school students in rural Appalachia were surveyed (N=1103). The primary outcome, tobacco use, was categorized as: never users, cigarette-only users, smokeless-only users, e-cigarette-only users, and polytobacco users. Associations between receiving or sharing conventional tobacco-related or e-cigarette-related information via specific communication channels and tobacco use were assessed.

Participants who received tobacco information from friends and family (FF) (OR=1.87; 95% CI: 1.35–2.57), public displays (PUB) (OR=1.49; 95% CI: 1.09–2.05), and digital media (DIG) (OR=1.95; 95% CI: 1.41–2.70) and e-cigarette information via the same communication channels, FF (OR=2.65; 95% CI: 1.93–3.65), PUB (OR=1.62; 95% CI: 1.17–2.26), and DIG (OR=2.24; 95% CI: 1.61–3.12), had greater odds of being polytobacco users, compared to never users. Participants who received e-cigarette-related information from FF (OR=2.42; 95% CI: 1.42–4.13) and PUB (OR=2.13; 95% CI: 1.25–3.65) had greater odds of being e-cigarette-only users compared to never users. Participants who shared e-cigarette-related information with FF had greater odds of being e-cigarette-only users (OR=3.16; 95% CI: 1.80–5.58) and polytobacco users (OR=4.48; 95% CI: 3.16–6.35) compared to never users.

Receiving and sharing tobacco-related and e-cigarette-related information via multiple communication channels is associated with e-cigarette and polytobacco use among Appalachian youth. Several channels may need to be utilized in health campaigns to influence youth.

We thank Shesh Rai for his assistance with data analysis; Alexander Lee, Allison Sia, and Courteney Smith for help with data collection; and the University of Louisville research computing group and the Cardinal Research Cluster, whose resources facilitated facets of this work.
The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. All authors report that they received grants from the National Institutes of Health and the Food and Drug Administration during the conduct of the study.
Research reported in this publication was supported, in part, by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) and the Food & Drug Administration’s Center for Tobacco Products (CTP) under Award Numbers P50HL120163 and U54HL120163. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, the Food & Drug Administration, or the American Heart Association.
Not commissioned; externally peer reviewed.
National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (US); 2014. PMID:24455788.
Niaura RS, Glynn TJ, Abrams DB. Youth experimentation with e-cigarettes: Another interpretation of the data. JAMA. 2014;312(6):641-642. doi:10.1001/jama.2014.6894
Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA. 2015;314(7):700-707. doi:10.1001/jama.2015.8950
Case KR, Mantey DS, Creamer MR, Harrell MB, Kelder SH, Perry CL. E-cigarette-specific symptoms of nicotine dependence among Texas adolescents. Addict Behav. 2018;84:57-61. doi:10.1016/j.addbeh.2018.03.032
Everett SA, Warren CW, Sharp D, Kann L, Husten CG, Crossett LS. Initiation of cigarette smoking and subsequent smoking behavior among U.S. high school students. Prev Med. 1999;29(5):327-333. doi:10.1006/pmed.1999.0560
Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Use of electronic cigarettes and any tobacco product among middle and high school students-United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 2018;67(45):1276–1277. doi:10.15585/mmwr.mm6745a5
Gentzke AS, Creamer M, Cullen KA, et al. Vital Signs: Tobacco product use among middle and high school students-United States, 2011-2018. MMWR Morb Mortal Wkly Rep. 2019;68(6):157-164. doi:10.15585/mmwr.mm6806e1
Hammond D, Reid JL, Rynard VL, et al. Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: Repeat national cross sectional surveys. BMJ. 2019;365:l2219. doi:10.1136/bmj.l2219
Mantey DS, Omega-Njemnobi O, Montgomery L. Flavored tobacco use is associated with dual and poly tobacco use among adolescents. Addict Behav. 2019;93:269-273. doi:10.1016/j.addbeh.2019.02.022
Dai H. Single, dual, and poly use of flavored tobacco products among youths. Prev Chronic Dis. 2018;15:170389. doi:10.5888/pcd15.170389
Dai H, Hao J. Flavored electronic cigarette use and smoking among youth. Pediatrics. 2016;138(6):e20162513. doi:10.1542/peds.2016-2513
National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (US); 2016.
Wakefield M, Terry-McElrath Y, Emery S, et al. Effect of televised, tobacco company-funded smoking prevention advertising on youth smoking-related beliefs, intentions, and behavior. Am J Public Health. 2006;96(12):2154-2160. doi:10.2105/AJPH.2005.083352
Sargent JD, Gibson J, Heatherton TF. Comparing the effects of entertainment media and tobacco marketing on youth smoking. Tob Control. 2009;18(1):47-53. doi:10.1136/tc.2008.026153
Mantey DS, Creamer MR, Pasch KE, Perry CL. Marketing exposure recall is associated with past 30-day single, dual, polytobacco use among US adolescents. Nic Tob Res. 2018;20(suppl_1):S55-S61. doi:10.1093/ntr/nty114
Pierce JP, Gilpin E, Burns DM, et al. Does tobacco advertising target young people to start smoking? Evidence from California. JAMA. 1991;266(22):3154-3158. doi:10.1001/jama.1991.03470220070029
Gostin LO, Arno PS, Brandt AM. FDA regulation of tobacco advertising and youth smoking. Historical, social, and constitutional perspectives. JAMA. 1997;277(5):410-418. doi:10.1001/jama.277.5.410
Pierce JP, Gilpin EA. A historical analysis of tobacco marketing and the uptake of smoking by youth in the United States: 1890-1977. Health Psychol. 1995;14(6):500-508. doi:10.1037//0278-6133.14.6.500
Padon AA, Maloney EK, Cappella JN. Youth-targeted e-cigarette marketing in the US. Tob Regul Sci. 2017;3(1):95-101. doi:10.18001/TRS.3.1.9
Freeman B. New media and tobacco control. Tob Control. 2012;21(2):139-44. doi:10.1136/tobaccocontrol-2011-050193
Marynak K, Gentzke A, Wang TW, Neff L, King BA. Exposure to electronic cigarette advertising among middle and high school students-United States, 2014-2016. MMWR Morb Mortal Wkly Rep. 2018;67(10):294-299. doi:10.15585/mmwr.mm6710a3
Vasiljevic M, St John Wallis A, Codling S, Couturier D-L, Sutton S, Marteau TM. E-cigarette adverts and children's perceptions of tobacco smoking harms: An experimental study and meta-analysis. BMJ Open. 2018;8(7):e020247. doi:10.1136/bmjopen-2017-020247
Pierce JP, Sargent JD, White MM, et al. Receptivity to tobacco advertising and susceptibility to tobacco products. Pediatrics. 2017;139(6):e20163353. doi:10.1542/peds.2016-3353
Farrelly MC, Duke JC, Crankshaw EC, et al. A randomized trial of the effect of e-cigarette TV advertisements on intentions to use e-cigarettes. Am J Prev Med. 2015;49(5):686-693. doi:10.1016/j.amepre.2015.05.010
Singh T, Agaku IT, Arrazola RA, et al. Exposure to advertisements and electronic cigarette use among US middle and high school students. Pediatrics. 2016;137(5):e20154155. doi:10.1542/peds.2015-4155
Bunnell RE, Agaku IT, Arrazola RA, et al. Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users: National Youth Tobacco Survey, 2011-2013. Nicotine Tob Res. 2015;17(2):228-235. doi:10.1093/ntr/ntu166
Mantey DS, Cooper MR, Clendennen SL, Pasch KE, Perry CL. E-cigarette marketing exposure is associated with e-cigarette use among US youth. J Adolesc Health. 2016;58(6):686-690. doi:10.1016/j.jadohealth.2016.03.003
Loukas A, Paddock EM, Li X, Harrell MB, Pasch KE, Perry CL. Electronic nicotine delivery systems marketing and initiation among youth and young adults. Pediatrics. 2019;144(3):e20183601. doi:10.1542/peds.2018-3601
Roditis ML, Halpern-Felsher B. Adolescents' perceptions of risks and benefits of conventional cigarettes, e-cigarettes, and marijuana: A qualitative analysis. J Adolesc Health. 2015;57(2):179-185. doi:10.1016/j.jadohealth.2015.04.002
Park E, Kwon M, Gaughan MR, Livingston JA, Chang YP. Listening to adolescents: Their perceptions and information sources about e-cigarettes. J Pediatr Nurs. 2019;48:82-91. doi:10.1016/j.pedn.2019.07.010
Hébert ET, Case KR, Kelder SH, Delk J, Perry CL, Harrell MB. Exposure and engagement with tobacco- and e-cigarette–related social media. J Adolesc Health. 2017;61(3):371-377. doi:10.1016/j.jadohealth.2017.04.003
Tsai J, Walton K, Coleman BN, et al. Reasons for electronic cigarette use among middle and high school students-National Youth Tobacco Survey, United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(6):196-200. doi:10.15585/mmwr.mm6706a5
Jamal A, Homa DM, O’Connor E, Babb SD, Caraballo RS, Singh T, Hu SS, King BA. Current cigarette smoking among adults-United States, 2005-2014. MMWR Morb Mortal Wkly Rep. 2015;64(44):1233-1240. doi:10.15585/mmwr.mm6444a2
Appalachian Regional Commission. The Appalachian Region: A data overview from the 2013-2017 American Community Survey. Available at: Αccessed December 20, 2019.
Centers for Disease Control and Prevention. State Tobacco Activities Tracking & Evaluation (STATE) System: Map of Current Cigarette Use Among Adults. Atlanta, GA: U.S. Department of Health & Human Services; 2017. Accessed December 20, 2019.
Appalachian Regional Commission. Lifestyle. Accessed December 13, 2019.
Ziller EC, Lenardson JD, Paluso NC, Talbot JA, Daley A. Rural–urban differences in the decline of adolescent cigarette smoking. Am J Public Health. 2019;109(5):771-773. doi:10.2105/AJPH.2019.304995
Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation System: Map of Current Cigarette Use Among Youth. Accessed November 13, 2019.
Kruger TM, Howell BM, Haney A, Davis RE, Fields N, Schoenberg NE. Perceptions of smoking cessation programs in rural Appalachia. Am J Health Behav. 2012;36(3):373-384. doi:10.5993/AJHB.36.3.8
Meyer MG, Toborg MA, Denham SA, Mande MJ. Cultural perspectives concerning adolescent use of tobacco and alcohol in the Appalachian mountain region. J Rural Health. 2008;24(1):67-74. doi:10.1111/j.1748-0361.2008.00139.x
Moreland JJ, Raup-Krieger JL, Hecht ML, Miller-Day MM. The conceptualization and communication of risk among rural appalachian adolescents. J Health Commun. 2013;18(6):668-685. doi:10.1080/10810730.2012.743620
Hart JL, Walker KL, Sears CG, et al. The ‘state’ of tobacco: Perceptions of tobacco among Appalachian youth in Kentucky. Tob Prev Cessat. 2018;4(January):1-5. doi:10.18332/tpc/81857
Curtis, AC, Waters CM, Brindis C. Rural adolescent health: The importance of prevention services in the rural community. J Rural Health 2010;27(1):60-71. doi:10.1111/j.1748-0361.2010.00319.x
Lutfiyya MN, Shah KK, Johnson M, Bales RW, Cha I, McGrath C, Serpa L, Lipsky MS. Adolescent daily cigarette smoking: Is rural residency a risk factor? Rural Remote Health. 2008;8:875. PMID:18366278.
West Virginia Department of Health and Human Resources, Bureau for Public Health, Office of Epidemiology and Health Promotion. Health risks: The Appalachian lifestyle. Published December, 1995. Accessed December 13, 2019.
Ahijevych K, Kuun P, Christman S, Wood T, Browning K, Wewers ME. Beliefs about tobacco among Appalachian current and former users. Appl Nurs Res 2003;16(2):93-102. doi:10.1016/S0897-1897(03)00009-0
Rodriguez EM, Twarozek AM, Erwin DO, Widman C, Saad-Harfouche FG, Fox CH, Underwood W, Mahoney MC. Perspectives on smoking cessation in Northern Appalachia. J Community Health. 2016;41(2):211-219. doi:10.1007/s10900-015-0084-3
Soneji S, Pierce JP, Choi K, et al. Engagement with online tobacco marketing and associations with tobacco product use among U.S. youth. J Adolesc Health. 2017;61(1):61-69. doi:10.1016/j.jadohealth.2017.01.023
Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O'Malley PM. The impact of retail cigarette marketing practices on youth smoking uptake. Arch Pediatr Adolesc Med. 2007;161(5):440-445. doi:10.1001/archpedi.161.5.440
Dai H, Hao J. Exposure to advertisements and susceptibility to electronic cigarette use among youth. J Adolesc Health. 2016;59(6):620-626. doi:10.1016/j.jadohealth.2016.06.013
Pierce JP, Sargent JD, Portnoy DB, et al. Association between receptivity to tobacco advertising and progression to tobacco use in youth and young adults in the PATH Study. JAMA Pediatr. 2018;172(5):444-451. doi:10.1001/jamapediatrics.2017.5756
The rural Boradband Association, Foundation for Rural Service. 2017 Rural Youth Telecom Survey. Accessed December 13, 2019.
Lee JG, Henriksen L, Rose SW, Moreland-Russell S, Ribisl KM. A systematic review of neighborhood disparities in point-of-sale tobacco marketing. Am J Public Health. 2015;105(9):e8–e18. doi:10.2105/AJPH.2015.302777
Bernat DH, Choi K. Differences in cigarette use and the tobacco environment among youth living in metropolitan and nonmetropolitan areas. J Rural Health. 2018;34(1):80–87. doi:10.1111/jrh.12194
Kurtz ME, Kurtz JC, Johnson SM, Cooper W. Sources of information on the health effects of environmental tobacco smoke among African-American children and adolescents. J Adolesc Health. 2001;28(6):458-464. doi:10.1016/s1054-139x(01)00197-5
Centers for Disease Control and Prevention. Smoking & Tobacco Use. Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products, 2019. Accessed November 17, 2019.
Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance-United States, 2017. MMWR Surveill Summ. 2018;67(8):1-114. doi:10.15585/mmwr.ss6708a1
Odani S, Armour BS, Agaku IT. Racial/ethnic disparities in tobacco product use among middle and high school students-United States, 2014-2017. MMWR Morb Mortal Wkly Rep. 2018;67(34):952-957. doi:10.15585/mmwr.mm6650a2
Noland M, Rayens MK, Wiggins AT, et al. Current use of e-cigarettes and conventional cigarettes among US high school students in urban and rural locations: 2014 National Youth Tobacco Survey. Am J Health Promot. 2018;32(5):1239-1247. doi:10.1177/0890117117719621
Dai H. Tobacco product use among lesbian, gay, and bisexual adolescents. Pediatrics. 2017;139(4):e20163276. doi:10.1542/peds.2016-3276