Prevalence and Predictors of Chronic Disease among Rural and Medically Underserved Populations Using Smokeless Tobacco

Elaine Sang^1,2Susan Silva³Sarah Grenon³Courtney Swinkels³Shamatree Shakya⁴Salsa Deshmukh³Laura Fish^5,6Mariana Da Costa⁷Leigh Ann Simmons⁸Herb Severson⁹Kathryn Pollak^10,6Devon Noonan^3,6*

• ¹New Courtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, United States
• ²Leonard Davis Institute of Health Economics, University of Pennsylvania, Philidelphia, United States
• ³School of Nursing, Duke University, Durham, United States
• ⁴School of Nursing, University of North Carolina Wilmington, Wilmington, United States
• ⁵Family Medicine and Community Health, School of Medicine, Duke University, Durham, United States
• ⁶Duke Cancer Institute, School of Medicine, Duke University, Durham, North Carolina, United States
• ⁷College of Health and Human Sciences, School of Nursing, Western Carolina University, Cullowhee, North Carolina, United States
• ⁸Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, California, United States
• ⁹Oregon Research Institute, Springfield, OR, United States
• ¹⁰Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, United States

Introduction: Smokeless tobacco (SLT) is significant public health problem in the U.S. and is associated with chronic diseases, which includes both physical and mental health conditions.Inequities in use exist as rural and other medically underserved populations use SLT more than that of the general population. Our study examined prevalence of chronic disease and identified associated risk factors among rural and medically underserved populations using smokeless tobacco.Methods: We conducted a cross-sectional analysis of baseline data (N=532) from a clinical trial promoting SLT cessation among adults living in rural and/or medically underserved areas and examined the rates of eight chronic diseases: cancer, lung disease, heart disease, stroke, mental health conditions, diabetes, arthritis/orthopedic conditions, and hypertension. Multivariable logistic regression was used to identify risk factors for four of the most common chronic diseases among study participants.Results: Over 60% of our sample of rural and medically underserved adults who use SLT also have at least one chronic disease. The most common chronic diseases were hypertension (38%), arthritis/orthopedic (23%), mental health (21%), and diabetes (12%). Increasing age and poor/fair health were associated with having hypertension, arthritis/orthopedic conditions, and/or diabetes. In addition, drinking alcohol less than five days per week was associated with having diabetes. Meanwhile, greater nicotine dependence, marital status, and having stained teeth were associated with having a mental health condition.Conclusions: Findings may inform the development of SLT cessation interventions as part of broader chronic disease management programs and as part of secondary prevention to minimize tobacco related morbidity.