Understanding smokeless tobacco use in rural United States: A narrative synthesis of contributing factors and prevention efforts.

Objectives: Smokeless tobacco (SLT) use remains disproportionately high in rural regions of the United States, particularly among youth, due to perceptions of lower risk compared with smoking. Despite clear evidence of its addictive potential and serious health consequences, limited attention has been given to the social, cultural, and structural drivers of SLT use in these underserved communities. This review aims to synthesize existing evidence on the prevalence, risk factors, and prevention strategies related to SLT use in rural America. Study design: Narrative review. Methods: A narrative synthesis of peer-reviewed studies was conducted to integrate findings across heterogeneous study designs and contexts. Results: The literature highlights multiple contributors to SLT use, including ease of access, lower taxation, reduced risk perception, and demographic influences such as age, gender, race/ethnicity, and educational attainment. Cultural acceptance and intergenerational norms further reinforce its use. While interventions such as public health campaigns and behavioral therapies have been attempted, their effectiveness has often been limited by insufficient cultural tailoring and persistent misinformation. Conclusions: SLT use in rural America reflects deeply rooted sociocultural dynamics and structural inequities that are not adequately addressed by existing tobacco control approaches. Sustainable prevention requires culturally informed, community-driven strategies that address local realities while tackling broader determinants of health. These insights underscore the need for more tailored policies and interventions to reduce health disparities in rural populations.