Geographic Disparities by Rural-Urban Status and Drive Time to Care in Tobacco Treatment for COPD

Many individuals with chronic obstructive pulmonary disease (COPD) who continue to use tobacco do not receive the key intervention of tobacco dependence treatment (TDT). Rurality and drive time to health care services may affect the provision of TDT.

To examine associations of rurality and drive time to care with provision of TDT among individuals with COPD.

This retrospective cohort study included individuals with COPD who received care from Veterans Affairs (VA) between January 2012 and December 2019. Administrative data from the Veterans Health Administration were used. Individuals with at least 2 encounters with International Classification Disease codes for COPD and current tobacco use were included. Data analysis was conducted in October 2023.

Rural vs urban home address and drive time to closest VA pulmonary specialty care facility using individual geocoded addresses.

The main outcome was prescription of TDT pharmacotherapy and/or counseling. Multivariable logistic regression models were used to assess associations of rurality and drive time with prescription of TDT.

Among 238 433 individuals with COPD and current tobacco use, the mean (SD) age was 64.1 (9.8) years; 81 189 (93.9%) were male; 2560 (1.1%) were American Indian or Alaska Native, 34 230 (14.3%) were Black or African American, and 185 791 (77.9%) were White. Overall, 97 253 (40.8%) lived in a rural area, and 65 105 (27.4%) had drive times of 61 minutes or longer. Overall, TDT was prescribed to 86 469 individuals (36.3%), but combined pharmacotherapy and counseling only to 10 302 (4.3%). Prescription of any TDT decreased with longer drive times to the closest pulmonary care (eg, 42 324 of 111 126 individuals [38.1%] with drive times ≤30 minutes; 4689 of 14 455 individuals [32.4%] with drive times >120 minutes). In models adjusted for sociodemographic characteristics (age, race and ethnicity, sex, and Area Deprivation Index) and comorbidities, individuals living in a rural area had lower probability of TDT compared with their urban counterparts (34.7% [95% CI, 34.4%-35.0%] vs 37.0% [95% CI, 36.7%-37.2%]). Prescription of TDT steadily decreased from drive time of 30 minutes or less (37.3% [95% CI, 37.0%-37.6%]) to drive times longer than 120 minutes (32.8% [95% CI, 32.1%-33.6%]).

In this cohort study of individuals with COPD who smoke, the overall provision of TDT-arguably the most important of all COPD interventions-was low. Additionally, rural residence and longer drive time to specialty care were associated with lower likelihood of receiving TDT. These findings highlight the need to address TDT for all individuals with COPD, especially those facing geographic disparities, to improve health outcomes.