The forgotten smoker lives in rural America

OPINION:

For years, the United States’ relationship with smoking has been framed as a story of decline. Fewer people smoke than they once did. Rates have fallen significantly over the past two decades. According to the National Health Interview Survey, in 2024, the U.S. adult smoking rate was 9.9%, the first time the adult smoking rate in the United States was ever below 10%. Public attitudes have shifted. In many places, cigarettes now feel like a fading part of American life.

But that is not the whole story. In rural America, smoking remains a daily reality and a disproportionate health burden. The forgotten smoker is not hard to find. In many communities, that person is a neighbor, a family member, a patient or a coworker. What has faded is not the problem itself, but the attention paid to the people still living with it.

The numbers tell part of the story. According to data from the U.S. Centers for Disease Control and Prevention (CDC), in 2024, adults in nonmetropolitan counties smoked cigarettes at nearly double the rate of adults in large metropolitan counties. People living in rural areas also face lung cancer death rates that are 18 to 20% higher than those in urban areas. These are not small differences to be ignored. They are signs of a burden that remains concentrated in rural communities too often treated as an afterthought.

There are many reasons that burden persists. Rural communities often face greater barriers to healthcare, fewer local resources and longer distances to care. Reports suggest that in some places smoking remains tied to economic hardship, higher disability rates, social stress and a healthcare system that feels far removed. Access to less harmful, smoke-free alternatives is also more limited in many rural areas, removing one of the practical off-ramps that can help adults who smoke move away from cigarettes. None of that lessens the damage that smoking can cause, but it should shape how we talk about the people still affected and whether we are willing to meet them where they are.

Too often, today’s public discourse about smoking swings between celebration and judgment. We celebrate how far the country has come in reducing smoking rates to historic lows, and judge those who continue to smoke. But neither response is enough for the rural communities still carrying an outsized share of the burdens that can be caused by smoking. If anything, they call for more humility, more empathy and more attention.

The forgotten smoker lives in rural America not because rural communities matter less, but because the national conversation has too often deprioritized them. That must change. This is a population that smokes more, receives less support and often pays a heavier price in health outcomes, including with generally higher rates of heart disease, cancer, stroke, and chronic lower respiratory disease. If we want a fuller and more honest conversation about ending smoking in America, we should start by looking again at the places and people we have been too quick to leave behind.

• Matt Holman, Ph.D., is Vice President, U.S. Scientific Engagement & Regulatory Strategy, PMI U.S. and former Chief Scientist at the Center for Tobacco Products at the FDA.