AppalTRuST Project 1: Population based Cohort study of tobacco use prevalence in Appalachian KY

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ABSTRACT – PROJECT 1 Rural populations, who use tobacco at almost double national rates, have largely been omitted from studies of the potential impact of tobacco regulations. AppalTRuST’s overarching goal is to investigate the impact of Federal Drug Administration Center for Tobacco Products (FDA CTP) regulatory changes on tobacco product use in rural communities and examine variation based on relative rurality. The FDA regulatory policies have an outsized potential to reduce tobacco-related disparities in rural Appalachia and the rest of rural America, given the relatively limited disincentives for use in these areas (i.e., few smoke-free laws and low tobacco taxes). The goal of Project 1 (P1) is to close the rural tobacco disparities knowledge gap by documenting tobacco use behaviors and related factors over time among Appalachian KY adults (18+ years) to inform current and future FDA regulations. P1 addresses the Scientific Domain of Behavior and will be guided by the Health Belief Model (HBM). The HBM provides a framework to evaluate associations of knowledge, attitudes, perceptions, and external cues with tobacco use behaviors. P1 will use the AppalTRuST Cohort to enroll 2,000 participants using a longitudinal cohort design that will collect participant data every 6 months for four years. We will recruit adults 18+ years from two catchment areas comprising 8 Appalachian KY counties; these two areas represent a range of rurality and will allow us to make not only catchment comparisons between a rural area and peri- urban one (i.e., partly urbanized rural areas), but also to assess for associations between tobacco use indicators and relative rurality within each catchment area. In addition, 40 participants from the Cohort per year will complete key informant interviews to assess opinions about tobacco products and regulations and allow us to make annual updates to the survey. We will address the following aims: (1) evaluate baseline prevalence and longitudinal trends in the use of conventional (cigarettes, smokeless tobacco, hookah, cigars/cigarillos, and pipes) and novel (e-cigarettes, nicotine pouches, heated tobacco products, and very low nicotine [VLN] cigarettes) tobacco products, including initiation, continuation, switching, cessation, and dual/poly-use among Appalachian adults, testing for the effect of rurality and controlling for individual- and county-level demographics; (2) assess changes over time in knowledge, attitudes, and perceptions relative to tobacco product characteristics (including flavors/menthol and VLN), among Appalachian KY adults, while evaluating the effect of rurality and controlling for demographics; and (3) explore perceived benefits, risks, and intentions to use novel tobacco products among current tobacco product users and individuals susceptible to initiating novel product use, with annual key informant interviews to capture reaction to changes in the product and regulatory landscape. We will evaluate the effects of the introduction of novel products and potential restrictions on flavored and high-nicotine products in rural communities so that regulatory decisions will be made using a health equity lens and be guided by a definition of rurality that is diverse and heterogeneous.