Providing intensive, evidence-based treatment for tobacco dependence in rural settings

Intensive, evidence-based treatment for tobacco dependence has been historically available only in academic medical centers in metropolitan areas. Implementation in rural areas faces a number of barriers including attracting enough patients to be cost-effective, attracting and supervising qualified personnel, and adherence to rigorous evaluation methods. This treatment has been implemented in 18 sites across Arkansas. The program is administered centrally, but delivered locally through local partnerships. The sites are located in large metropolitan areas (LMA; populations > 400,000), small metropolitan areas (SMA; populations 100,000-300,000), and rural incorporated cities (RIC; populations <100,000). The overall characteristics of the participants include: 16.3% African-American; average age of 43.6 years; average education of 12.5 years; average years using tobacco of 27.5 years.

Implementation faced the expected challenges. Outcomes from July 2005 through June 2008 will be presented. Preliminary outcomes from 12 sites and 2425 patients (7-2005 through 12-2007) suggest no significant differences between sites in Large Metropolitan Areas and Rural Incorporated Cities in: number of patients seen, reached for follow-up, and percentage of patients quit at 6-months post-discharge. The quit rates in suburban areas were lower than their rural and urban counterparts (p < 0.05). This was partially due to “tobacco interventionist” turnover at the sites in this classification.

6-Month Post-Discharge Follow-up Results

Of 507 patients eligible for follow-up in LMAs, 348 were contacted and 126 of those had quit. Percentage of patients quit: 24.85% ITT; 36.21% CNT. In SMAs, of 735 patients eligible, 458 were contacted and 113 had quit. Percentage of patients quit: 15.37% ITT; 24.62% CNT. In RICs, 679 patients were eligible, 412 were contacted and 134 had quit. Percentage of patients quit: 19.74% ITT, 35.52% CNT.

Satisfaction with treatment and usefulness of the treatment were also similar.

These results and others show that intensive, face-to-face, evidence-based treatment for tobacco dependence can be as effectively delivered in rural areas as in metropolitan areas as long as adequate systems exist to support the sites, the clinicians, and evaluation. Given the higher prevalence of tobacco use in rural areas, providing access to intensive cessation options is an important element of any tobacco control program.

*ITT=Intent to Treat. CNT=all patients contacted.