Rurality, Long Travel Times Limit Access to Tobacco Treatment for Patients With COPD Who Smoke

Tobacco dependence treatment (TDT) use was low among patients with chronic obstructive pulmonary disease (COPD) and further reduced by rurality and longer drive times to specialty care, according to a study published in JAMA Network Open.1

Cigarette smoking is responsible for about 80% of COPD cases in the developed world and is the primary modifiable risk factor for disease onset and progression, with continued smoking post-diagnosis leading to worse lung function and outcomes.

Therefore, TDT is considered the most important intervention for patients with COPD who smoke.2 The researchers emphasized that failure to address tobacco use in this patient population represents a missed opportunity to reduce morbidity, mortality, and health care costs.1 Comprehensive TDT, which combines pharmacotherapy and behavioral counseling, is considered the “gold standard” for smoking cessation, yielding higher quit rates than either approach alone.

COPD outcomes are worse for patients in rural vs urban areas, possibly in part because smoking rates are higher in rural regions.3 The researchers noted this disparity may also reflect reduced access to COPD care and TDT.1 One key care barrier is travel distance, with median drive times more than twice as long for patients in rural areas compared with those in urban areas.4 To better understand these disparities, the researchers conducted a retrospective cohort study examining the associations of rurality and drive time to care with TDT provision among patients with COPD.1

Patients with chronic obstructive pulmonary disease (COPD) who smoke were less likely to receive tobacco dependence treatment (TDT) if they lived in rural areas or had longer travel times to care, highlighting persistent geographic disparities in access. | Image Credit: Nopphon - stock.adobe.com

The study included individuals with COPD who received care from the Veterans Affairs between 2012 and 2019. Eligible patients had at least 2 encounters with International Classification of Diseases codes for COPD and current tobacco use. The main outcome was the prescription of TDT pharmacotherapy and/or counseling, with multivariable logistic regression models used to assess associations of rurality and drive time with TDT prescription.

Of the 238,433 identified patients with COPD who currently use tobacco, the mean (SD) age was 64.1 (9.8) years, and 93.9% (n = 81,189) were male. As for race and ethnicity, 77.9% (n = 185,791) were White, 14.3% (n = 34,230) were Black or African American, and 1.1% (n = 2560) were American Indian or Alaska Native. Additionally, 40.8% (n = 97,253) lived in a rural area, and 27.4% (n = 65,105) had drive times of 61 minutes or longer.

TDT was prescribed to 36.3% (n = 86,469) of patients, but only 4.3% (n = 10,302) were prescribed comprehensive TDT. In models adjusted for sociodemographic characteristics and comorbidities, patients living in a rural area had a lower probability of TDT than their urban counterparts (34.7% [95% CI, 34.4%-35.0%] vs 37.0% [95% CI, 36.7%-37.2%]). TDT prescription also steadily decreased with longer drive times, from 37.3% (95% CI, 37.0%-37.6%) among patients with drive times of 30 minutes or less to 32.8% (95% CI, 32.1%-33.6%) among those with drive times longer than 120 minutes.

“These data highlight the need to target geographic disparities in COPD care to diminish the impacts of COPD on individuals living in rural areas,” the authors wrote. “However, while our findings support that decreased tobacco treatment may contribute to higher tobacco use rates among rural individuals with COPD, they support a large gap in care for COPD in general.”

The researchers acknowledged their limitations, including that the results may not be generalizable beyond the veteran population. Also, as an observational study, unmeasured confounding is possible, and causality cannot be established. Still, they expressed confidence in their findings, calling for interventions to improve COPD care.

“Improving COPD care for all individuals with COPD will require a multidisciplinary approach, with interventions tailored to those with additional geographic barriers to receiving health care services,” the authors concluded.

References

1. Baldomero AK, Melzer AC, Kunisaki KM, et al. Geographic disparities by rural-urban status and drive time to care in tobacco treatment for COPD. JAMA Netw Open. 2025;8(8):e2528898. doi:10.1001/jamanetworkopen.2025.28898
2. Jiménez-Ruiz CA, Andreas S, Lewis KE, et al. Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit. Eur Respir J. 2015;46(1):61-79. doi:10.1183/09031936.00092614
3. Gaffney AW, Hawks L, White AC, et al. Health care disparities across the urban-rural divide: a national study of individuals with COPD. J Rural Health. 2022;38(1):207-216. doi:10.1111/jrh.12525
4. Baldomero AK, Kunisaki KM, Wendt CH, et al. Drive time and receipt of guideline-recommended screening, diagnosis, and treatment. JAMA Netw Open. 2022;5(11):e2240290. doi:10.1001/jamanetworkopen.2022.40290