Despite the central role of smoking cessation in COPD management, tobacco dependence treatment (TDT) remains underutilized—particularly among rural residents and those facing longer travel times to reach pulmonary specialty care.
Those are key findings from a large retrospective cohort analysis of Veterans Affairs (VA) data throughout a seven-year period.
“This research is important because it reveals persistent gaps in tobacco dependence treatment for individuals with COPD, particularly those facing geographic barriers to accessing care,” said first author Arianne K. Baldomero, MD, MS, Staff Physician at the Minneapolis VA Health Care System, Minneapolis. “This highlights critical geographic disparities that hinder access to guideline-based care.”
For the study published in JAMA Network Open, researchers retrospectively evaluated the records of 238,433 individuals with COPD who concurrently used tobacco and received care from the VA between January 2012 and December 2019. Using geocoded residential addresses, investigators classified participants by rurality and calculated drive times to the nearest VA pulmonary specialty center, offering a granular assessment of geographic access. The main outcome of interest was the prescription of TDT pharmacotherapy or counseling.
The cohort had a mean age of 64.1 years; 93.9% were male, 77.9% were White, 33.8% had cardiovascular comorbidities, and 31.7% had a diagnosis of serious mental illness. Overall, 97,253 individuals (40.8%) lived in a rural area, and 65,105 (27.4%) reported drive times of 61 minutes or longer. Although 36.3% received some form of TDT, only 4.3% were prescribed both pharmacotherapy and counseling—the evidence-based standard for cessation. A clear distance-decay relationship emerged; receipt of any TDT fell from 38.1% among those living within 30 minutes to 32.4% among those >120 minutes away. “It was surprising to discover how low the rates of combined pharmacotherapy and counseling remained—just 4.3% overall—even in an integrated health system, as well as the persistent disadvantage for rural residents and those with longer drives to care,” Dr. Baldomero said.
After adjusting for sociodemographic characteristics and comorbidities, the study’s authors found that individuals living in rural areas were less likely to receive TDT compared with those in urban areas (34.7% [95% CI, 34.4%-35.0%] vs 37.0% [95% CI, 36.7%-37.2%]).
According to Dr. Baldomero, key limitations include reliance on administrative coding (risking underestimation of counseling encounters), inability to distinguish between offered and accepted treatment, and limited generalizability beyond the predominantly older, male VA population.
“This work emphasizes that enhancing tobacco dependence treatment for COPD is a priority, and reducing geographic barriers will require multidisciplinary approaches and innovative, equitable health care solutions,” she said. “Additional research is needed to explore tailored interventions to improve treatment uptake and to understand patient- and provider-level barriers to offering or accepting tobacco dependence treatment.”
Hasmeena Kathuria, MD, Director of the University of Wisconsin Center for Tobacco Research and Intervention, who was not involved with the study, said the work is important because it addresses the underutilization of TDT among people with COPD, a disease for which smoking is the leading cause and modifiable risk factor.
“Despite the well-established benefits of smoking cessation, including improved lung function, reduced exacerbations, and lower mortality, many individuals with COPD continue to smoke, and few receive evidence-based cessation support,” she said.
She added that future research should examine how remote treatment strategies such as telehealth and quitline referrals can help address geographic barriers.
“In addition to structural challenges, further research should examine how patient-level factors (eg, readiness to quit and knowledge of treatment options) influence engagement with tobacco dependence treatment,” Dr. Kathuria said. “Studies are also needed to understand how clinician attitudes, training, and resource limitations affect tobacco dependence treatment delivery, particularly in rural areas.”
Finally, she added, research should explore how to increase the use of varenicline, the most effective smoking cessation medication, in routine COPD care in the VA and all health systems.
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
