School-Centered Tobacco Retailer Exposure and Neighborhood Opportunity Across Urban and Rural Tennessee

Authors

• Sima Namin Dr, University of Tennessee Health Science Center, College of Medicine-KnoxvilleFollow
• Jacob Black, Tennessee Department of Health, Division of Family Health & Wellness, Chronic Disease Prevention & Health Promotion SectionFollow
• Jennifer Ferris, University of Tennessee Health Science Center, College of Medicine-KnoxvilleFollow
• Robert E. Heidel Dr, University of Tennessee Health Science Center, College of Medicine-KnoxvilleFollow

Corresponding Author

Sima Namin, namin.sima@gmail.com

Author Affiliations

1. Sima Namin, PhD: Health Disparities Specialist, College of Medicine, University of Tennessee (Knoxville TN); E-mail: namin.sima@gmail.com; ORCiD: https://orcid.org/0000-0001-5217-5556
2. Jacob Black, MPH: Epidemiologist, Division of Family Health & Wellness, Tennessee Department of Health (Nashville TN)
3. Jennifer Ferris, MHS: Director of Research, College of Medicine, University of Tennessee; ORCiD: https://orcid.org/0009-0002-0902-0414
4. R. Eric Heidel, PhD: Professor of Biostatistics, College of Medicine, University of Tennessee; ORCiD: https://orcid.org/0000-0002-1518-8072

Author Area of Expertise

Sima Namin: Health Geography, primary care research. 

Jacob Black: Epidemiology, Health promotion

Jennifer Ferris: Health sciences

Eric Heidel: Biostatistics

Abstract

Introduction: Tobacco retailer availability contributes to youth tobacco use, and retailers are concentrated in socioeconomically disadvantaged communities. However, few studies have examined how school-centered retailer exposure intersects with neighborhood opportunity in a predominantly rural Appalachian state.

Purpose: The purpose of this study is to assess the association between neighborhood opportunity and school-centered tobacco retailer exposure across Tennessee (TN), including differences by rurality and Appalachian status.

Methods: We constructed a tract-level, school-centered youth tobacco exposure index for TN using tobacco retailer locations and public and private K-12 school data. The index incorporated retailer proximity, density, and distance-decay accessibility measures. Child Opportunity Index, a multidimensional measure of educational, health/environmental, and social/economic opportunity, was linked to each tract. Negative binomial models with county-clustered robust errors estimated associations between COI and retailer density near schools, adjusting for urbanicity and Appalachian status.

Results: Lower opportunity was associated with greater school-centered tobacco retailer exposure. A 1-SD increase in national Child Opportunity Index percentile was associated with fewer retailers per km² of school-adjacent area (IRR = 0.73; 95% CI, 0.66–0.81; p < .001). The Social/Economic domain showed the largest inverse correlation with exposure (Spearman ρ = −0.31). Retailer density was lower in rural than urban tracts (IRR = 0.56; 95% CI, 0.45–0.69; p < .001), while Appalachian status was not independently associated with exposure.

Implications: Incorporating place-based opportunity indices into tobacco control surveillance and policy can inform equitable, spatially targeted strategies, such as school-buffer or density limits, to reduce youth exposure in low-opportunity communities and guide targeted health education and prevention efforts.

DOI

https://doi.org/10.13023/jah.0802.03

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 License.

Recommended Citation

Namin S, Black J, Ferris J, Heidel RE. School-centered tobacco retailer exposure and neighborhood opportunity across urban and rural Tennessee. J Appalach Health 2026; 8(2):29-52. DOI: https://doi.org/10.13023/jah.0802.03