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. 2025 Aug 1;8(8):e2528898.
doi: 10.1001/jamanetworkopen.2025.28898.

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

Arianne K Baldomero  1   2   3 , Anne C Melzer  1   2   3 , Ken M Kunisaki  1   2   3 , Chris H Wendt  1   2 , Orly Vardeny  3   4 , Hildi J Hagedorn  3   5 , Steven S Fu  3   6 , R Adams Dudley  1   2   3
Affiliations

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

Arianne K Baldomero et al. JAMA Netw Open. .

Abstract

Importance: 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.

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

Design, setting, and participants: 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.

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

Main outcomes and measures: 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.

Results: 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%]).

Conclusions and relevance: 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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Baldomero reported receiving grants the Patient-Centered Outcomes Research Institute during the conduct of the study. Dr Melzer reported grants from VA Health Systems Research, Lilly Quality Improvement Hub, and the Patient-Centered Outcomes Research Institute; personal fees from Inova Fairfax Health System; and serving as an unpaid site coinvestigator with Delfi Diagnostics outside the submitted work. Dr Kunisaki reported receiving personal fees from Nuvaira for data and safety monitoring board activities and serving on the American Thoracic Society Clinical Problems Assembly Planning Committee outside the submitted work. Dr Wendt reported receiving grants from Veterans Affairs and the National Institutes of Health; participating in the National Institutes of Health Observational Study Monitoring Board; and receiving salary from the Minneapolis VA Health Care System during the conduct of the study. Dr Vardeny reported receiving grants from the National Institutes of Health and the US Food and Drug Administration; receiving consulting fees from Bayer, Cytokinetics, Cardior, and Moderna; and serving as a board member for the Heart Failure Society of America outside the submitted work. Dr Fu reported receiving support from Veterans Affairs. Dr Dudley reporting receiving grants from the National Institutes of Health, the Agency for Healthcare Research and Quality, the US Centers for Disease Control and Prevention, and Veterans Affairs. No other disclosures were reported.

Figures

Figure.
Figure.. Tobacco Dependence Treatment Among Individuals With Chronic Obstructive Pulmonary Disease Who Smoke
NRT indicates nicotine replacement therapy.
See this image and copyright information in PMC

References

    1. Ford ES, Croft JB, Mannino DM, Wheaton AG, Zhang X, Giles WH. COPD surveillance—United States, 1999-2011. Chest. 2013;144(1):284-305. doi: 10.1378/chest.13-0809 - DOI - PMC - PubMed
    1. Ford ES, Murphy LB, Khavjou O, Giles WH, Holt JB, Croft JB. Total and state-specific medical and absenteeism costs of COPD among adults aged ≥ 18 years in the United States for 2010 and projections through 2020. Chest. 2015;147(1):31-45. doi: 10.1378/chest.14-0972 - DOI - PubMed
    1. Murphy SL, Xu J, Kochanek KD, Arias E. Mortality in the United States, 2017. National Center for Health Statistics. Accessed August 6, 2025. https://www.cdc.gov/nchs/products/databriefs/db328.htm
    1. Celli BR, Christenson SA, Rabe KF, et al. Current smoker: a clinical COPD phenotype affecting disease progression and response to therapy. Am J Respir Crit Care Med. 2025;211(5):729-736. doi: 10.1164/rccm.202407-1379CI - DOI - PMC - PubMed
    1. Pauwels RA, Rabe KF. Burden and clinical features of chronic obstructive pulmonary disease (COPD). Lancet. 2004;364(9434):613-620. doi: 10.1016/S0140-6736(04)16855-4 - DOI - PubMed

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