Background: Adult smoking prevalence and associated morbidity and mortality are higher in rural areas, compared to suburban and urban areas. Individuals residing in rural areas also experience structural barriers to accessing cessation services. Digital programs can help to increase access to cessation treatment and reduce smoking among this population.
Objective: To examine geographic representativeness of people who smoke among newly registered users of a free digital tobacco cessation program (‘EX’).
Methods: User-provided ZIP codes from EX registrants were mapped to Rural Urban Continuum Codes (RUCC). Data from the National Survey of Drug Use and Health (NSDUH) data from 2018-2020 were used to compare the geographic distribution of EX registrants with the geographic distribution of persons who smoke in the US. Reach Ratios (ReRas) and 95% confidence intervals were used to determine the extent to which rural representation in the EX sample was proportionate to their representation in the national population of persons who smoke. Under- and overrepresentation was demonstrated by ReRas <1 or >1, respectively.
Results: Persons who reported smoking residing in nonmetro rural areas were significantly overrepresented in 2018 [ReRa = 1.18 (95% CI: 1.15, 1.23)], 2019 [ReRa = 1.10 (95% CI: 1.07, 1.13)], and 2020 [ReRa = 1.10 (95% CI: 1.06, 1.13)]. When separating out nonmetro rural areas into urbanized, less urbanized, and completely rural groups, persons who reported smoking from less urbanized and completely rural areas were overrepresented from 2018 to 2020. Meanwhile, persons who reported smoking from urbanized nonmetro areas were proportionately represented in 2018 and 2020 but underrepresented in 2019 [ReRa = 0.95 (95% CI: 0.91. 0.99)]. Persons who reported smoking from small metro areas were also overrepresented from 2018 to 2020 [ReRas = 1.09 (95% CI: 1.06, 1.11); 1.06 (95% CI: 1.04, 1.08), and 1.05 (95% CI: 1.03, 1.08), respectively] and persons who reported smoking from large metro areas were underrepresented during the same time frame [ReRas = 0.87 (95% CI: 0.85, 0.89); 0.92 (95% CI: 0.91, 0.94), and 0.93 (95% CI: 0.91, 0.94), respectively].
Conclusions: Results suggest that people who report smoking from nonmetro rural areas and small metro areas are proportionally reached by a digital tobacco cessation program. However, there continues to be an underrepresentation of persons who smoke from large metro areas, which warrants further study.