April 2019

PREPARED BY: 

East Tennessee State University and

NORC at the University of Chicago 

An initiative to identify and explore Appalachian communities with better-than-expected health outcomes

ISSUE BRIEF

Health Disparities Related to 

Smoking in Appalachia

Practical Strategies and

Recommendations for Communities

Photo: Ryan Parker on Unsplash
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities i

ACKNOWLEDGMENTS 

Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation (RWJF) is the nation’s largest philanthropy dedicated to health. 

For more than 40 years, RWJF has supported research and programs targeting some of the nation’s most 

pressing health issues. RWJF provided funding for this research project as part of its Culture of Health 

Initiative.

Appalachian Regional Commission

The Appalachian Regional Commission (ARC) provided funding, leadership, and project management for 

the project. ARC is an economic development agency of the federal government and 13 state 

governments focusing on 420 counties across the Appalachian Region. ARC’s mission is to innovate, 

partner, and invest to build community capacity and strengthen economic growth in Appalachia to help

the Region achieve socioeconomic parity with the nation. Julie Marshall, PhD, Senior Economist, 

Division of Research and Evaluation, served as the Project Director, with support from Kostas Skordas, 

Director, Division of Research and Evaluation. 

Foundation for a Healthy Kentucky

The Foundation for a Healthy Kentucky served as the grantee and fiscal agent for the project. Funded by 

an endowment, the nonpartisan Foundation’s mission is to address the unmet health needs of Kentuckians 

by developing and influencing policy, improving access to care, reducing health risks and disparities, and 

promoting health equity. Since the Foundation opened its doors in 2001, it has invested more than $27 

million in health policy research, advocacy, and demonstration project grants across the Commonwealth.

Research Team

Kate Beatty, PhD, and Nathan Hale, PhD, at the Center for Rural and Appalachian Health in the College 

of Public Health at East Tennessee State University (ETSU), along with researchers at NORC at the 

University of Chicago’s Walsh Center for Rural Health Analysis, led the development of this brief. The 

NORC team included Michael Meit, Megan Heffernan, Michelle Dougherty, Luciana Rocha, and Kelsey 

Ruane. Additional contributors from ETSU included Ginny Kidwell and Hadii Mamudu.
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities ii

TABLE OF CONTENTS

Why Address Smoking in Appalachia?...................................................................................1

Assessing Community Need for Smoking Prevention Programs..........................................3

Practical Strategies and Recommendations...........................................................................4

Recommendation #1: Prevent Smoking Initiation Among Youth ..........................................4

Recommendation #2: Increase Access to Tobacco Cessation Interventions ......................7

Recommendation #3: Launch Anti-Tobacco Communication Campaigns .........................10

Recommendation #4: Reduce Exposure to Secondhand Smoke........................................11

Strategies and Recommendations for Funders ....................................................................12
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 1

Creating a Culture of Health in Appalachia: Disparities and Bright Spots is a health research 

initiative sponsored by the Appalachian Regional Commission (ARC) and the Robert Wood Johnson 

Foundation (RWFJ), and administered by the Foundation for a Healthy Kentucky. This multipart research 

initiative has produced an interactive website, HealthinAppalachia.org, along with three reports: 1) Health 

Disparities in Appalachia,

1 2) Identifying Bright Spots in Appalachian Health: Statistical Analysis,2 and 

3) Exploring Bright Spots in Appalachian Health: Case Studies.

3

Throughout the Appalachian Region, smoking is a common health risk that contributes to significantly 

higher rates of tobacco-related disease and lower life expectancy compared to the rest of the United 

States. Drawing on the research presented in the health disparities and Bright Spot reports, this brief 

focuses on promising practices, intervention strategies, and policies aimed at reducing health disparities 

related to smoking. This brief:

■ summarizes statistics on smoking and related diseases in Appalachian communities,

■ discusses key strategies and resources for reducing tobacco use, and

■ provides recommendations for community leaders, funders, and policymakers. 

This brief discusses four recommendations in detail: 

1. Prevent smoking initiation among youth.

2. Increase access to tobacco cessation interventions.

3. Launch anti-tobacco communication campaigns.

4. Reduce exposure to secondhand smoke.

WHY ADDRESS SMOKING IN 

APPALACHIA? 

Tobacco farming contributes to the history and identity of many 

Appalachian communities. Cultural norms may contribute to 

more frequent use of tobacco within the Region. As shown in 

Figure 1, adult smoking prevalence rates are disproportionately 

high throughout the Region, particularly across the Central and 

North Central subregions. These higher rates of smoking are 

driving more frequent occurrences of tobacco-related diseases, 

cutting the lives of many Appalachians far too short.

The Creating a Culture of Health in Appalachia initiative has 

documented key health challenges and opportunities in 

Appalachia. The initiative’s reports offer a basis for 

understanding and addressing health issues in the Region and for 

identifying factors that support a culture of health in 

Appalachian communities.

A striking portrait of tobacco’s impact on the lives of those who 

call Appalachia home emerged in these reports. Findings suggest 

that residents of Appalachia die sooner than residents in the 

rest of the United States and are more likely to die from 

smoking-related diseases. 

Figure 1: Prevalence of Adult Smoking 

in Appalachia, 2014

Image source: Health Disparities in Appalachia. 

https://www.arc.gov/assets/research_reports/Health_Disp

arities_in_Appalachia_August_2017.pdf

Data source: County Health Rankings & Roadmaps, 

2016 edition. University of Wisconsin Population Health 

Institute supported by Robert Wood Johnson Foundation.

http://www.countyhealthrankings.org/rankings/data.
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 2

Smoking in Appalachia 

Smoking’s impact on health is well 

documented. Cigarette smoking causes more 

than 480,000 deaths each year in the United 

States, and remains a risk factor for a number of 

illnesses, including heart disease, respiratory 

disease, stroke, and cancer.

4

The impact of smoking on the health of 

Appalachians is noteworthy. Residents of 

Appalachia are more likely to die prematurely

than those who live in the non-Appalachian

United States. Among those living in Central 

Appalachia and in economically distressed 

counties, those differences are even greater.

1

While multiple factors contribute to these 

premature deaths, smoking remains a highimpact driver that underpins a greater loss of 

life in Appalachia than in the rest of the 

country.

Figure 2, which presents data from the Health 

Disparities in Appalachia report, shows that

approximately 20% of Appalachian adults report 

being smokers compared to 16% of adults in the 

non-Appalachian United States.

1 While rates of smoking are higher across all Appalachian subregions 

compared to the non-Appalachian United States, there are considerably higher proportions of smokers in 

the Central and North Central Appalachian subregions (see Figure 2).

Smoking-Related Diseases

The impact of smoking on the health and well-being of Appalachians is clear. Deaths from heart disease, 

cancer, and chronic lower respiratory disease—three of the four leading causes of death in the United 

States—occur more frequently in Appalachia than in the rest of the country.

1 Smoking is a key factor 

contributing to deaths from these causes and is the primary driver of premature death and disability 

from chronic lower respiratory disease and chronic obstructive pulmonary disease (COPD).

On average, Appalachians die from COPD at a rate that is 31% higher than the rate for residents in the 

rest of the country. The burden of COPD-related death in Central Appalachia is even more striking, with 

rates nearly twice that of the non-Appalachian United States. Economically distressed counties in 

Appalachia are also disproportionately burdened, with COPD mortality rates 43% higher than nondistressed counties across the Region.1

Notably, differences in COPD-related deaths within Appalachia are highest among those living in West 

Virginia and the Appalachian counties of Kentucky. While smoking is more common in these states, 

additional environmental stressors related to mine dust exposure may contribute to the markedly higher 

rates of COPD-related death.

1

Figure 2: Percentage of Adult Smokers by 

Appalachian Subregion, 2014

Image source: Health Disparities in Appalachia. 

https://www.arc.gov/assets/research_reports/Health_Disparities_in_Appa

lachia_August_2017.pdf

Data source: County Health Rankings & Roadmaps, 2016 edition. 

University of Wisconsin Population Health Institute supported by Robert 

Wood Johnson Foundation 

http://www.countyhealthrankings.org/rankings/data.
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 3

ASSESSING COMMUNITY NEED FOR SMOKING 

PREVENTION PROGRAMS 

Because smoking and smoking-related diseases are particularly prevalent throughout Appalachia, 

understanding how and to what extent smoking affects one’s community is an important first step for 

determining how to target limited resources. Assessing community needs can help community leaders, 

funders, and policymakers determine which of the recommendations presented in this brief have the 

greatest potential to reduce smoking rates.

Conducting a Needs Assessment

Needs assessments are formative research activities that can help communities understand important 

cultural norms and attitudes that may affect tobacco prevention and cessation efforts. They can help 

community leaders, funders, and policymakers understand the prevalence and nature of tobacco use in a 

particular community, including which populations have high rates of tobacco use and how individuals

are accessing it. Conducting a needs assessment will also help leaders take stock of which programs and 

policies are successfully addressing tobacco use or could be leveraged to do so.

5

The Community Anti-Drug Coalitions of America (CADCA) Initiative provides Tips on How to Conduct 

a Community Assessment on Tobacco Issues.

6 Communities may also consider the following local 

sources of data:

7

■ Civic and non-profit organizations, for lists of current projects, more information about who 

and how many individuals are served, and plans for the future

■ Community colleges/local universities, for academic research related to the community

■ Faith-based groups, for membership numbers and community needs

■ Health departments/healthcare providers, for local prevalence rates

■ Libraries, for local history/information unique to the county

Quantitative data in conjunction with qualitative data from community forums and focus groups can show 

how changes have occurred over time and the barriers to creating change. Additional resources for 

conducting community needs assessments are provided on the next page.

Using State- and County-Level Data to Prioritize Resources

To target limited resources appropriately, community leaders, funders, and policymakers may consider 

leveraging data from state and national surveys to understand how tobacco use varies across counties. For 

example, in 2016 the West Virginia Division of Tobacco Prevention created a strategic plan for 

preventing tobacco use and promoting cessation8 using data from the national Behavioral Risk Factor 

Surveillance System (BRFSS) Survey and the West Virginia Youth Tobacco Survey (YTS) to illustrate 

tobacco use trends. For additional data, policymakers may also consider using County Health Rankings9

to understand how smoking rates vary by county. HealthinAppalachia.org provides a comprehensive 

overview of health in the Appalachian Region using 41 county-level measures, including smoking 

prevalence. The Centers for Disease Control and Prevention’s State Tobacco Activities Tracking and 

Evaluation (STATE) System10 provides current and historical data on tobacco use prevention and control. 

It enables policymakers to view state highlights and interactive maps, and to build custom reports to 

explore a variety of historical and current data related to tobacco use policies and services. 
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 4

Additional Resources for Assessing Need in Your Community

Conduct a needs 

assessment

This Community Tool Box11 provides an overview of needs 

assessments.

Conducting a Community Health Assessment12 provides helpful tools 

and examples for identifying and analyzing data for a needs 

assessment.

Conducting Rural Health Research, Needs Assessment, and 

Program Evaluation13 is a collection of resources that communities 

can use to develop and refine their own research.

Use state- and countylevel data to prioritize 

resources

HealthData.gov14 is a searchable warehouse of health data.

The annual State of Tobacco Control15 report evaluates state and 

federal government policies on tobacco use and provides a scorecard 

for each state on key areas related to preventing and reducing 

tobacco use.

Based on the results of the community needs assessment, policymakers, funders, and community leaders 

should consider which recommendations and associated strategies described below are best suited for 

their communities. Many of the effective models for reducing tobacco use presented in this brief were 

part of multipronged efforts that combined community-based intervention with policy changes and health 

communications efforts. To successfully reduce tobacco use, community leaders, funders, and 

policymakers should work together to select a set of strategies that complement each other.

PRACTICAL STRATEGIES AND RECOMMENDATIONS 

Reducing the smoking rate in Appalachia could help decrease the number of tobacco-related deaths and 

diseases in the Region. In this section, we present policies, programs, and initiatives that show promise or 

have successfully reduced smoking rates. We also provide examples of intervention strategies that have 

been deployed in Appalachia. 

Recommendations for reducing smoking and smoking-related health disparities include the following:

1. Prevent smoking initiation among youth.

2. Increase access to tobacco cessation interventions.

3. Launch anti-tobacco communication campaigns.

4. Reduce exposure to secondhand smoke.

RECOMMENDATION #1: PREVENT SMOKING 

INITIATION AMONG YOUTH

The majority of smokers begin using tobacco in adolescence.16 Because smoking is more common in 

Appalachia, adolescents are more likely to be surrounded by role models who use tobacco. Furthermore, 

tobacco industry messaging that targets rural communities coupled with a gap in antismoking campaigns 

in these areas contributes to a higher chance of early tobacco use.17 Both community- and policy-based 

strategies can help prevent tobacco use among adolescents in Appalachia. 
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 5

Community-Based Strategies 

Implement Tobacco Prevention in Schools

Decades of research have shown that school-based tobacco prevention and cessation programs can be 

effective in preventing and decreasing tobacco use among youth, particularly when combined with 

broader community initiatives.

18 While the Centers for Disease Control and Prevention (CDC) provide 

key recommendations for preventing tobacco use19 that all schools can consider, schools in Appalachia 

can look toward the keepin’ it REAL adaptation in Pennsylvania and Ohio for an example of how to tailor 

prevention programs. The keepin’ it REAL (“REAL” is an acronym for Refuse, Explain, Avoid, and 

Leave) is an interactive curriculum used by the Drug Abuse Resistance Education (D.A.R.E.) program. In 

Pennsylvania and Ohio, keepin’ it REAL was adapted by interviewing 118 adolescents from rural school 

districts and was successful in reducing alcohol and drug use.20 Engaging youth in the program’s design 

ensured it reflected their perspectives and experiences. The success of the Students Against Destructive 

Decisions (SADD) program in Grant County, West Virginia, profiled in the report Exploring Bright Spots 

in Appalachian Health: Case Studies3 (referred to hereafter as “Bright Spot case studies report”), 

indicates that student-led efforts are particularly successful in Appalachian communities. To replicate 

keepin’ it REAL, schools may consider connecting with local D.A.R.E. programs21 and involving students 

in tailoring the curriculum, similar to the rural adaptation of keepin’ it REAL.

22

Mobilize Communities to 

Restrict Minors’ Access 

to Tobacco Products

Community mobilization can 

be effective for reducing youth 

tobacco use when combined 

with other interventions.28

Mobilizing communities often 

begins with coalition building, 

which provides a platform for 

educating community 

members, supporting policy 

changes, and launching and 

amplifying mass-media 

campaigns. The Southern 

Coalfields Tobacco Prevention 

Network,

29 a six-county 

coalition in rural West Virginia

that promotes tobacco-free 

policies and conducts outreach 

to coal miners and pregnant 

women, exemplifies such a 

coalition. Forming a coalition is 

a key part of the Communities 

That Care30 model, which has shown success in reducing cigarette and smokeless tobacco among youth. 

The success of Tioga County, New York, profiled in the Bright Spot case studies report, highlights how a 

strong sense of volunteerism can be instrumental in solving community challenges. Tioga County citizens 

have started a range of organizations that rely on volunteers to serve the community, including Reality 

Reducing Electronic Cigarette Use Among Youth

High school and middle school students use electronic cigarettes 

(e-cigarettes) more commonly than any other tobacco product.23 A 

recent school-based survey in northeast Tennessee showed that 

this trend also exists in Appalachia.24 Key strategies for addressing 

e-cigarette use include the following:

Educate parents, teachers, health professionals, and youth 

about the risks. Many adults are not aware of the risks 

associated with e-cigarette use and may view e-cigarettes as a 

safe alternative, a belief that is supported by e-cigarette 

marketing tactics.25 Schools, in particular, should increase 

education around the risks associated with e-cigarettes.26 The 

U.S. Surgeon General,27 in partnership with the CDC, provides 

fact sheets, tips for parents, and sample ads to communicate 

the risks of e-cigarettes.

Restrict access. Policy strategies that have shown success in 

preventing tobacco use among youth show promise for 

reducing e-cigarette use. These include raising the minimum 

age of legal access (MLA) and increasing the price of ecigarettes.27

Expand smoke-free policies. Many smoke-free policies were 

put in place before the rise of e-cigarettes and therefore do not 

prohibit their use. Smoke-free policies can be updated or 

developed to include bans on e-cigarette use.27, 25
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 6

Check,

31 a youth tobacco-control project. Sequatchie County, Tennessee, another community profiled in 

the Bright Spot case studies report, also mobilized volunteers to organize events that help people quit 

smoking through the program, Step Up Sequatchie: Improve Your Health One Step at a Time. Fostering 

and leveraging the pride that citizens demonstrate for their communities through volunteerism may be an 

important strategy for replicating these successes in other Appalachian communities. 

Policy-Based Strategies 

Raise the Minimum Age of Legal Access to Tobacco Products

Minors frequently obtain cigarettes from their social networks. Raising the minimum age of legal access 

(MLA) to tobacco products to 21 has strong potential to reduce smoking among youth, because minors 

are less likely to share social networks with 21-year-olds compared to 18-year-olds.32 The Institute of 

Medicine states that increasing the MLA to tobacco products from 18 to 21 years of age will likely reduce 

the number of adolescents who begin using tobacco, lower smoking prevalence, and improve overall 

health.32 Current research supports focusing policy and law enforcement efforts on limiting the sale of 

tobacco to youth as opposed to penalizing youth for possession.33,34 Appalachian counties in New York 

have successfully increased the MLA of tobacco. For example, in April 2016 the Chautauqua County 

Legislature in New York increased the minimum age for tobacco sales to 21. Cattaraugus, Cortland, and 

Tompkins counties in Appalachian New York have also raised the MLA to 21.35 Some states have 

preemption laws limiting the ability of local governments to raise the MLA. Policymakers can use CDC’s 

STATE system10 to understand how preemption laws may impact their efforts to raise the MLA.

Increase the Price of Tobacco Products

Increasing the price of tobacco is an effective strategy for decreasing overall tobacco use, increasing 

cessation rates, and preventing initiation among youth.36 States and municipalities can designate tax 

revenue on tobacco products for public health programs, including cessation services.36 The Healthy

Maryland Initiative was successful in working with the state legislature to raise taxes on cigarette packs 

and later on smokeless tobacco and little cigars.37 For counties considering how to implement this 

strategy, the Public Health Law Center38 provides resources on taxation and product pricing, preemption, 

and sales restrictions. Policymakers pursuing this option should consider strategies for increasing access 

to cessation support services, potentially by using revenue gained from increased taxes.39
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 7

Additional Resources for Preventing Smoking Initiation Among Youth

Implement tobacco 

prevention in schools

The REAL prevention website40 includes a wealth of resources on the 

keepin’ it REAL program.

CrimeSolutions.gov41 has a searchable database of school-based 

programs.

Youth Tobacco Cessation: A Guide for Making Informed Decisions42

provides helpful guidance on selecting a program.

Mobilize communities to 

restrict minors’ access 

to tobacco products

Best Practices for Comprehensive Tobacco Control Programs User 

Guide43 describes key aspects of effective coalitions.

Raise the MLA access 

to tobacco products

The Tobacco Legal Consortium (TLC) provides a technical assistance 

guide44 with policy considerations for raising the MLA.

TLC also offers a sample ordinance45 and a sample resolution46 for 

developing an MLA policy.

The Tobacco21 “Healthy Towns, Healthy Kids” toolkit47 offers talking 

points on raising the MLA.

Increase the price of 

tobacco products

Counties can also look at excise tax rates and rankings by state48 to 

see how their rates compare to others.

The Campaign for Tobacco-Free Kids49 has numerous fact sheets that 

provide more information on state and federal tobacco taxes.

RECOMMENDATION #2: INCREASE ACCESS TO 

TOBACCO CESSATION INTERVENTIONS 

Although evidence shows that cessation counseling effectively reduces cigarette use, individuals often 

struggle to access these services due to challenges with transportation, insurance coverage, and provider 

shortages. These challenges are particularly notable in many Appalachian communities with limited 

resources. Several strategies have emerged to increase access to cessation services and reduce barriers to 

participation. 

Community-Based Strategies 

Work with Faith-Based Organizations

For many of the communities profiled in the Bright Spot case studies report, active faith communities 

play an instrumental role in promoting community health by shaping attitudes, sharing information, and 

providing services. The Faith Moves Mountains50 smoking cessation program, which reached 590 

smokers across 26 rural churches in Appalachian Kentucky, found that churches can facilitate smoking 

cessation by leveraging social connections among participants, providing a convenient location to access 

services, and helping individuals who might not otherwise be able to obtain cessation support gain access 

to these services. Faith-based organizations may take part in tobacco prevention and cessation efforts to 

varying extents. The Southern Coalfields Tobacco Prevention Network51 works with faith-based 

organizations to deliver tobacco cessation education, and sends cessation counselors to deliver food 

through their faith-based partner’s food delivery program, allowing these counselors to deliver brief 

interventions and refer individuals to services as they are delivering food. African American churches in 
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 8

western Georgia successfully used the CDC’s Community Health Assessment and Group Evaluation 

(CHANGE)52 action guide to develop a range of initiatives to address tobacco use, among other health 

issues.53

Quitlines and Other Telehealth Interventions

Quitlines are telephone- and web-based resources through which individuals can access tobacco cessation 

counseling. Quitlines are an effective way of increasing access to cessation programs, especially in areas 

with few local treatment options or for individuals with limited time or ability to travel to receive 

cessation services.54 Although they are typically implemented at the state level, community-based 

quitlines can be effective in referring callers to local resources, where available, and offering counseling 

tailored to address community-specific cultural factors.55 Important aspects of implementing successful 

quitlines include promoting programs through mass-reach health communication campaigns, linking 

callers to tobacco cessation medications, and ensuring a pathway to referral for health care providers.56

Resources for developing or enhancing telephone-based tobacco cessation services are available along 

with technical assistance from the North American Quitline Consortium.

57

Quitlines are an example of telehealth, which involves the use of telecommunications technology to

provide long-distance health care, education, and other wellness activities.58 Other forms of telehealth 

typically used for smoking cessation include mobile and web-based applications that can help users 

monitor their progress, identify triggers, and learn management techniques. For example, the National 

Institutes of Health offer a text-messaging program, SmokefreeTXT,

59 and two smartphone applications, 

QuitGuide and quitSTART,

60 which can provide tailored quit plans for users. One smoking cessation 

program in Appalachian Kentucky and Ohio61 used a web-based application called Motiv862 that 

collected carbon monoxide breath samples and provided incentives for reduced smoking. 

Policy-Based Strategies 

Reduce Out-Of-Pocket Costs for Cessation Treatments

Reducing out-of-pocket costs for evidence-based cessation counseling and medications is an effective

way of increasing the number of individuals who receive treatment for tobacco dependence and ultimately 

quit.

63 Although almost all insurers are required to cover some level of tobacco cessation services without 

cost-sharing, this coverage may not be comprehensive.64 Only a limited number of state Medicaid 

programs provide coverage for all FDA-recommended medications and counseling.65 Making additional 

benefits available and clearly communicating them to providers and tobacco users can increase use of 

these services.66 To understand how this issue affects their communities, policymakers can consult the 

American Lung Association’s database67 and the CDC’s STATE System10 on smoking cessation 

coverage. Policymakers can also look to Kentucky as an example for expanding treatment coverage; the 

Kentucky state legislature recently passed Senate Bill 89,

68 expanding coverage to include all tobacco 

cessation services recommended by the U.S. Preventive Services Task Force.
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 9

Additional Resources for Increasing Access to Tobacco Cessation Interventions 

Work with faith-based 

organizations

Engaging and Partnering with Faith-Based Organizations in Initiatives for 

Children, Youth, and Families69 is intended for community organizations 

seeking to partner with faith-based organizations.

Partnerships with Faith-Based & Community-Based Organizations: 

Engaging America's Grassroots Organizations in Promoting Public 

Health70 describes successful strategies that the CDC has used with faithbased organizations on public health issues.

Implement quitlines 

and other telehealth 

interventions

Telephone Quitlines: A Resource for Development, Implementation, and 

Evaluation71 provides more information on setting up a telephone-based 

quitline.

Telehealth as a Vehicle to Support Tobacco Cessation72 gives an 

overview of considerations for counties seeking to employ cessation 

services via telehealth.

Reduce out-of-pocket 

costs for cessation 

treatments

Reimbursement for Smoking Cessation Therapy: A Healthcare 

Practitioner’s Guide, 3rd Edition73 includes information on tobacco 

cessation treatments and reimbursement.

This Case Study on the Effect of Cessation Coverage—The 

Massachusetts Medicaid Cessation Benefit74 may serve as a useful 

example.
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 10

RECOMMENDATION #3: LAUNCH ANTI-TOBACCO 

COMMUNICATION CAMPAIGNS 

Mass-reach anti-tobacco communication efforts have been effective in reducing tobacco use initiation and 

increasing tobacco cessation,75 particularly among youth who are more likely to be impacted by protobacco marketing,

76 and can include a broad range of themes.76 Key considerations for launching antitobacco communication interventions include identifying messages that will resonate with the target 

audience and communication channels that will best reach community members.

77

Anti-tobacco media campaigns can be used to 

complement other strategies recommended in this 

brief. For example, the Spit It Out West Virginia78

program implemented mass-reach communication 

efforts, offered educational interventions, campaigned 

for smoke-free policies, and engaged with faith-based 

organizations. Communication efforts included 

billboards and hundreds of radio ads that aired during 

hunting season on local stations, and anti-smoking 

handouts given with bank statements from local banks. 

Wirt County, West Virginia, profiled in the Bright 

Spot case studies report, also executed a successful 

anti-tobacco health messaging campaign in the form of 

the “Tobacco Prevention Barn,” pictured here. 

Stakeholders seeking to kick-start similar mass-reach 

communication campaigns can use the W.K. Kellogg 

Foundation’s Strategic Communications Plan 

Template79 and CDC’s Tips from Former Smokers 

Campaign Materials,

80 in addition to the other 

materials described below.

Additional Resources for Launching Anti-Tobacco Media Campaigns 

This Communication Toolkit81 details strategies that rural healthcare facilities can use to 

communicate with the media.

The Implementing a Social Marketing Effort82 toolbox has resources for launching marketing 

initiatives centered on healthy living.

Framing 10183 includes considerations on public health messaging.

Media Advocacy 10184 is a primer on using mass media to address public health issues.

Health officials in Wirt County, West Virginia 

implemented a “Tobacco Prevention Barn” healthmessaging campaign to promote smoking cessation

to residents.

© Jon Rodgers
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 11

RECOMMENDATION #4: REDUCE EXPOSURE TO 

SECONDHAND SMOKE 

Smoke-free policies have been strongly linked to reductions in secondhand smoke exposure, heart attacks, 

asthma attacks, sudden infant death syndrome, and low birth weight infants.85 Appalachian communities 

in tobacco-producing regions may be opposed to smoke-free policies because of their potential effect on 

the local economy. A presentation86 by the University of Kentucky discusses strategies for addressing 

concerns in rural, tobacco-growing regions of Kentucky. Although smoke-free policies are commonly 

enacted by state and local governments, local businesses and stakeholders can be instrumental in

enforcing government policies and voluntarily adopting their smoke-free policies. For example,

community leaders in McCreary County, Kentucky, profiled in the Bright Spot case studies report,

engaged with work sites and restaurants to voluntarily establish smoke-free policies. Bright Spot case 

study community, Tioga County, New York, also pushed for an increase in smoke-free spaces by 

leveraging community-wide interest in improving the well-being of youth. 

Stakeholders seeking to implement or expand smoke-free policies should consider the extent to which 

state laws preempt local laws, and how these policies may be enforced and promoted. Similar to other 

strategies presented in this brief, implementing or expanding smoke-free policies should be considered 

alongside other strategies, such as media campaigns that promote awareness of these policies and 

increased access to cessation services in order to promote compliance with these policies.87 Resources are 

available for stakeholders considering working with schools, businesses, healthcare facilities, and 

multifamily housing units to introduce smoke-free policies. Americans for Nonsmokers’ Rights88 also 

provides an array of resources for implementing smoke-free policies in communities. 

Additional Resources for Eliminating Exposure to Secondhand Smoke

Businesses 

settings

Smoke-Free Laws Do Not Harm Business at Restaurants and Bars89 provides 

evidence and examples showing that smoke-free laws improve public health 

without harming businesses.

Residential 

settings

Smoke-Free Multifamily Housing Toolkits90 provide information and resources that 

can help managers and residents of public and assisted multifamily housing

improve the safety of their homes.

Smoke-Free Housing Resources91 includes information on creating and 

implementing regulations on smoke-free housing.

Workplace 

settings

Smoke-Free Policies: Establishing a Smoke-Free Ordinance to Reduce Exposure 

to Secondhand Smoke in Indoor Worksites and Public Places—An Action Guide92

describes how to develop smoke-free ordinances for indoor worksites and public 

spaces.

Tobacco in the Workplace: A Model Policy93 offers steps for developing and 

implementing smoke-free policies in the workplace. 

Healthcare 

settings

Treating Tobacco Dependence as a Standard of Care: A Health Systems 

Approach94 provides steps for implementing smoke-free policies in healthcare 

settings.
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 12

STRATEGIES AND RECOMMENDATIONS FOR 

FUNDERS

Funders throughout the Region have the opportunity to invest in initiatives and activities that help prevent 

and reduce smoking and tobacco use across Appalachia. Below, we describe strategies for funders 

seeking to reduce smoking-related health disparities in the Appalachian Region. 

 Leverage existing assets

Appalachian communities have many assets that should be recognized and promoted. These 

include strong communities with members who are connected through volunteering and coalition 

building, and who build strong social ties through faith- and community-based organizations, 

schools, local business, and shared culture and history. Funders can leverage existing programs, 

practices, and policies by highlighting the work of Appalachian grantees. Additionally, existing 

Appalachian work can be disseminated and shared to stimulate replication and adoption of programs 

and strategies elsewhere. 

 Strengthen community implementation capacity

Funders can strengthen community implementation capacity in Appalachian communities. 

Opportunities to increase capacity include 1) enhancing individual-level knowledge and skills that 

facilitate community action, and 2) fostering organizational- and systems-level capacity. Examples of 

organizational- and systems-level capacity include engaging in community visioning and strategic 

planning, building networks and engaging community stakeholders, writing grants, and engaging in 

local and regional policy advocacy, among others. 

 Focus on cross-sector collaboration through philanthropic strategies

Funders can help facilitate collaboration between community members, the public, and privatesector individuals, which is critical to addressing tobacco use and smoking within the Region. 

Through a coordinated use of resources, leadership, and action, communities can work together 

toward a common goal, using multiple perspectives and different areas of expertise. Government, 

the health care system, schools, private businesses, and community organizations all have critical 

roles in this effort.

 Build the Appalachian evidence base

The Bright Spot case studies report identified examples of promising practices to address smoking in 

Appalachian communities. However, these programs and their outcomes are often not well 

documented. For long-term changes to occur, successful programs need to be evaluated rigorously 

and shared widely. Funders should encourage evaluation among their grantees, to ensure program 

effectiveness is measured and documented. Evaluation, along with increased efforts to document 

local successes, will provide a more robust evidence-base for specific Appalachian programs and 

policies to address smoking and tobacco control.
Health Disparities Related to Smoking in Appalachia | Practical Strategies and Recommendations for Communities 13

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