PILOT: Social Vulnerability and Rurality: Understanding Disparities in Tobacco Product Use Among Adult Cancer Survivors in the United States

ABSTRACT: Tobacco remains the leading cause of preventable morbidity and mortality in the United States (US), contributing to cancer, cardiovascular disease, and respiratory illnesses. Different tobacco products, including combustible and smokeless forms, vary in toxicity, use patterns, and health consequences. Adult cancer survivors represent a vulnerable population requiring focused attention, especially regarding adverse health behaviors, such as tobacco use, after diagnosis. Despite tobacco’s well-established role as a major contributor to multiple cancers, many survivors continue tobacco use post-diagnosis, jeopardizing their quality of life, increasing risks of cancer recurrence and secondary malignancies, and reducing long-term survival. Cancer survivors may persist in tobacco use due to nicotine addiction or switch to alternative nicotine delivery devices like vaping, despite ongoing health risks. Use of tobacco products also exacerbates health disparities, with social vulnerability and place-based disadvantages influencing use behaviors and access to cessation resources, particularly among marginalized communities. The Social Vulnerability Index (SVI), an area-level social determinant of health, measures community resilience using 16 social factors grouped into four themes: socioeconomic status, household composition, racial and ethnic minority status, and housing and transportation. The SVI correlates with tobacco use disparities, explaining much of the difference in cigarette use between rural and urban populations. However, it does not account for rural-urban variation, which is critical for understanding disparities in tobacco use and cancer outcomes. Our central hypothesis is that social vulnerability is linked to tobacco use among adult cancer survivors, with stronger associations among rural residents. Using data on adult cancer survivors (n=~66,000) from the All of Us Research Program, we will (1) examine whether social vulnerability and rurality are independently associated with tobacco product use outcomes, including current use and dual/poly use, among a sample of US adult cancer survivors, and (2) investigate how rurality modifies the relationship between social vulnerability and tobacco use outcomes by examining effect modification through statistical interactions. Exploration of the impact of social vulnerability and rurality on tobacco product use outcomes will inform efforts to address tobacco-related health disparities among cancer survivors. This project aligns with the American Cancer Society’s commitment to prevent, address, and mitigate cancer disparities. Completing these aims will generate evidence on how social vulnerability influences tobacco use and how rurality shapes these relationships, providing actionable insights to guide targeted prevention and cessation strategies. Findings will directly inform future research focused on identifying structural determinants of health contributing to cancer disparities and developing culturally and geographically relevant interventions for cancer survivors.