Bridging the digital divide to help rural smokers quit

Rural adults are more likely to smoke than their urban counterparts. Increasing digital literacy and improving access to the internet and digital devices can make it easier for rural smokers to quit. These are the findings of a randomized, controlled pilot clinical trial from Mayo Clinic researchers published in Communication medicine.

Digital tools provide rural residents with a convenient way to access smoking cessation support. However, limited digital literacy and access to technology can be obstacles. The study tested a program to equip rural residents to take full advantage of these tools.

“Interventions in previous studies had a single focus and targeted one of three things: device access, internet access, or digital literacy,” says Christi Patten, Ph.D., a behavioral health researcher at the Mayo Clinic and senior author of the research. “We were curious whether pooling those resources would be more effective.”

The clinical trial included 90 adults living in rural Minnesota, Wisconsin and Iowa and was co-designed in collaboration with a rural health care advisory board. Before the trial, participants smoked an average of 16 to 17 cigarettes per day and 83% indicated that they were very willing to quit. Each person was enrolled in an online smoking cessation program and randomly assigned to one of three study groups:

The researchers evaluated participants’ involvement in the program to measure the effectiveness of the intervention. They also closely monitored smoking-related outcomes to evaluate the program’s ability to help participants quit smoking.

Coaching offers digital support during the quit process

The research found that there was a trend towards greater engagement among participants who received additional support, especially among those in the coaching group.

A total of 42% of participants completed a survey at the end of the study, with the coaching group being 57%, the loaner computer tablet group being 43% and the control group being 27%. This pattern also held true for other research activities, such as conducting remote tests to monitor smoking cessation progress.

Although the researchers acknowledged that engagement could have been improved, they found the response to the interventions encouraging, especially the response to coaching.

The researchers noted that coaching not only improved participant engagement, but also had an unexpected, positive “spillover effect” on smoking-related outcomes.

Participants who received the digital literacy coaching were more likely to report quitting smoking, generally abstaining from tobacco, and using online, evidence-based smoking cessation tools. These findings, they say, indicate a possible response to treatment linked to smoking, which should be tested in a larger clinical trial.

“Changing behavior is incredibly difficult,” says Andrea Cheville, MD, a physician of physical medicine and rehabilitation at the Mayo Clinic and senior author of the study. “The fact that they responded to the coaching was quite remarkable.”

In post-trial interviews, participants expressed appreciation for the personalized coaching support for their technology needs, saying it gave them “a feeling of being supported through their quitting process.”

Mary Anne Wolesky, a member of the community advisory board who helped design the study, says these types of studies tell rural residents that Mayo researchers are “in their corner” and want to help.

“There is still a lot of fear about technology in our rural communities,” Wolesky notes. “It sends a real message that Mayo would send participants iPads and invest the time to teach them how to use them to improve their health.”

Dr. Patten notes that overcoming barriers to improve digital equality often has less to do with the technology itself than with empowering people and giving them the confidence to use it.

Improving healthcare at a distance

The researchers note that few people who smoke are able to quit without help; however, people who use smoking cessation tools such as counseling tend to have more success. For this reason, the researchers say it is critical to improve access to smoking cessation services in rural communities.

“Rural residents potentially have the most to gain from geographically neutral remote delivery systems such as digital cessation programs,” says Dr. Cheville.

The researchers are encouraged by the results of their study, which show that digital access interventions, especially digital literacy coaching, can help bridge the digital divide for rural communities. These findings are especially important in today’s era of rapidly evolving digital healthcare.

“If we don’t develop strategies to broadly empower rural residents, we risk widening inequalities in smoking and in all aspects of health,” says Dr Cheville.

Looking to the future

The researchers are committed to advancing digital health interventions through ongoing, community-based research. In future studies, they plan to focus on refining their digital access and literacy interventions, validating smoking-related treatment responses, and exploring ways to target digital behavior and smoking behavior change.

They also plan to study the use of digital literacy coaching to individualize pain management for rural patients and improve remotely delivered cancer care.

The first author of this study is Sydney Kelpin, Ph.D., who is now a licensed clinical psychologist at Spectrum Health Medical Group in Grand Rapids, Michigan.

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