Background: Smokeless tobacco (SLT) use remains prevalent in medically underserved communities where access to effective cessation programs is limited, leading to higher rates of tobacco-related chronic conditions. Text-based interventions offer a delivery approach with broad reach. This secondary analysis evaluated the influence of rurality on SLT cessation among participants of a randomized control trial assessing the efficacy of text-based cessation interventions in medically underserved communities.

Methods: Participants were 532 adults randomized to a text-based scheduled reduction intervention paired with text-based cessation support messages (#EnufSnuff.TXT, n=264) or intervention comprised of a cessation education booklet and bi-weekly motivational text messages (modified Enough Snuff, n=268). The outcome was SLT cessation based on self-reported 7-day abstinence at 3-months post-randomization. Rurality was determined using Rural-Urban Continuum Codes (RUCC), with rural defined as a RUCC of > 5. Logistic regression examined the influence of rurality on cessation, controlling for intervention, age of SLT use onset, and depression.

Results: Participant mean age was 45.0 years (range: 19-79), with 80% reporting age of SLT use onset as < 20 years, 13% with depression, and 27% living in rural areas. The primary efficacy analysis indicated that 3-month quit rate was significantly higher in #EnufSnuff.TXT compared to Enough Snuff (29.2% vs. 19.0%, OR=1.75, p=.0066). Secondary analyses demonstrated a greater #EnufSnuff.TXT vs. Enough Snuff effect on quit rate after controlling for rurality and other covariates (aOR=1.89, 95% CI=1.22-2.83, p=.0034). Although rurality did not moderate intervention effects (rural-by-intervention: p>.05), rurality was associated with quitting (rural-urban: OR=1.60, 95% CI=1.12-2.22, p=0.0419) covarying for intervention, onset age, and depression.

Conclusions: The findings suggest that rurality contributes to the efficacy of text-based interventions for SLT cessation in medically underserved communities. Within these communities, adults living in rural areas are more likely to quit than those living in urban areas when participating in SLT text-based cessation programs.