Tobacco retailer density and rurality across four US states: California, Connecticut, North Carolina, and Ohio

Research has demonstrated many types of disparities in tobacco retailer density (TRD), but these analyses often fail to explore rural disparities. Given the substantial burden of rural tobacco use in the USA, this is a critical gap. The purpose of the present study was to estimate rural disparities in TRD across four US states. For the states of California, Connecticut, North Carolina, and Ohio, we used spatial statistical methods to model per capita TRD at the census tract level. Rurality was defined by the US Department of Agriculture Rural-Uran Commuting Area (RUCA) codes and categorized into Metropolitan, Micropolitan, Small Town, and Rural. Tobacco retailer count was highest in California (22,533), but TRD was highest in Connecticut (1.23 retailers per 1000 residents). In models for California, North Carolina, and Ohio (but not Connecticut), there was an association between rurality and TRD, such that rural census tracts had greater TRD than metropolitan census tracts. Micropolitan and small town (vs. metropolitan) census tracts also had greater TRD, although the association was not as strong. Models further showed associations between TRD and census tract poverty, racial and ethnic composition, and Appalachian designation. Although there are notable state-level differences, TRD is clearly associated with rurality. Given the literature on the impacts of living in tobacco-retailer-dense areas, rural disparities in TRD likely contribute to rural disparities in tobacco use. There is a need for further policies in rural areas of the USA that address the tobacco retailer environment.