Tobacco Quitline utilization compared with cigarette smoking prevalence in Virginia across rurality and Appalachian Status, 2011-2019

Abstract

Introduction: While cigarette smoking rates have declined, rural and Appalachian populations in the United States have not seen similar decreases. Quitline programs are promising strategies in reducing disparities in these areas, but research on their usage is limited.

Methods: We employed Small Area Estimation on the Virginia Behavioral Risk Factor Surveillance System (2011-2019) to estimate county-level smoking prevalence and utilized The Quit Now Virginia Quitline data (2011-2019) to estimate Quitline users. We analyzed differences in Quitline utilization by rurality and Appalachian status using statistical t-tests. Stepwise regression assessed the absolute estimate of county features, including poverty rate, tobacco retailer density, physician availability, coal mining industry, and tobacco agriculture, on Quitline usage.

Results: While the average smoking rate overall was 15.3 %, only 7.4 % of smokers accessed Quitline services from 2011 to 2019. Appalachian regions exhibited higher smoking rates (20.9 %) and lower quitline usage (4.8 %) compared to non-Appalachian areas (14 % smoking prevalence, 8 % quitline usage). Rural regions had higher smoking prevalence (19.0 %) than urban areas (12.9 %), but no significant difference in Quitline utilization (7.6 % vs. 7.2 %, p = 0.7). Stepwise regression revealed counties with more tobacco agriculture had 3.2 % (p = 0.04) lower Quitline utilization. Also, more physicians availability in the county was associated with 3.9 % higher Quitline usage (p = 0.03) and Appalachian counties exhibited a 3.6 % lower Quitline usage rate compared to non-Appalachian counties.

Conclusion: A significant gap exists between cigarette smoking prevalence and Quitline utilization, particularly in underserved rural and Appalachian areas, despite no clear barriers to accessing this remote cessation resource.

Implication: The study underscores persistent disparities in smoking rates, with rural and Appalachian regions in the United States facing higher smoking prevalence and limited utilization of Quitline services. Despite no clear barriers to access, the gap between smoking prevalence and Quitline usage remains significant, particularly in underserved areas. Tailoring interventions to address regional disparities and factors like tobacco agriculture and physician availability is essential to reduce smoking rates and improve Quitline utilization in these communities.

Keywords: Cigarette smoking cessation programs; Cigarette smoking prevalence; Data visualization; Disparities; Rurality; Small Area estimations; Stepwise analysis.

Fig. 1

Quitline usage rate among cigarette smoker and cigarette smoking prevalence across Virginia by Appalachian status and Rurality between 2017 and 2019. Note: The cigarette smoking prevalence was estimated using the small area estimation method. The Quitline service utilization was obtained from the Quit Now Virginia Quitline (VAQL) collected between the years 2017 through 2019. We based urban–rural classifications on the 2013 urban–rural continuum codes developed by the Department of Agriculture and the Rural Health Research Center. Counties with code values of 1–3 are classified as urban, and those with code values of 4–9 are considered as rural. We obtained county centroid locations from US Census Bureau shapefiles.