Tobacco Use Among the Amish in Holmes County, Ohio

There are approximately 160,000 Amish in North America who live mostly in rural areas in Pennsylvania, Ohio, and other Midwestern states.1,2 Individuals living outside the Amish community are familiar with some characteristics of the Amish lifestyle, including their avoidance of telephones and electricity and their use of a horse and buggy for transportation. Typical jobs performed by the Amish include farming and woodworking; however, Amish men also work in manufacturing jobs. The lifestyle of the Amish is largely influenced by the Ordnung, which is a set of rules dictating what is permitted and what is forbidden in their culture.1,2 These rules vary among Amish church districts and are periodically reviewed and revised. The Holmes County Amish settlement, with approximately 24,000 members, is the largest in the world.1 This settlement is centered in Holmes County, Ohio, but Amish can also be found in the surrounding counties. Holmes County is 1 of the 29 Appalachian counties in Ohio and, according to the 2000 US Census, 89% of the households in the county are in rural areas.3 Lower cancer incidence rates have been reported among Holmes County Amish adults compared to non-Amish adults in Ohio.4 In this cancer incidence study, men and women from 92 households randomly selected from the Holmes County Amish Directory were interviewed and reported on cancer occurrences in their extended families. The estimated age-adjusted cancer incidence rate for all cancers was 55% of the age-adjusted adult rate in Ohio. A reduction was also observed for tobacco-related cancer incidence, which was 37% of the age-adjusted rate for Ohio adults. This latter finding suggested a low prevalence of tobacco use in this group.4 Tobacco use is widely discouraged by leaders in many Amish church districts.2 However, there is a period of time in the life of an Amish person where some behaviors are more tolerated. Over 80% of youth are baptized into the church as adults and many of them make this decision following a period of rumspringa (“running around”), which occurs between the completion of school (after the 8th grade) and baptism, usually occurring during the early 20s in the life of an Amish person.1 During this time, Amish interact to a greater extent with the non-Amish world and their social norms are unlike those followed to that point.5 According to Reiling,5 alcohol use is somewhat common during this period. Depression is also more prevalent during this period and it is likely attributed to the fact that youth are engaging in behaviors that are not part of the Amish culture. In the general population, alcohol use and depression among youth are related to tobacco use.6 Thus, if the Amish develop an addiction to nicotine during rumspringa, it is not clear if the strong adult Amish cultural influence will change the behavior. There have been few studies that have examined tobacco use among the Amish. In 2003, a face-to-face version of the Behavioral Risk Factor Surveillance System (BRFSS) survey was conducted among Holmes County Amish adults and the estimated prevalence of tobacco use was low: 13% (95% confidence interval 7%-19%) among males and 0% among females.7 Biochemical verification of the self-reported behavior with a marker of nicotine exposure, such as cotinine, was not included in the BRFSS. In most non-diseased populations little is gained with biochemical verification, as there is generally good agreement between the self-report and a biological marker.8 However, in populations where tobacco use is stigmatized there may be a more marked difference between self-reported tobacco use and a true marker of tobacco exposure.8,9 No current estimates of biochemically verified tobacco use are available for the Amish, which is important from a public health perspective because it is not known if they could benefit from prevention and cessation programs. The objectives of this study were to estimate the self-reported and cotinine-verified prevalence of tobacco use among Amish males and females and to estimate the extent of tobacco use misclassification. It was hypothesized that Amish men and women would use tobacco at a significantly lower rate than the general population.