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

Digital tools offer a convenient way for rural residents to access support to quit smoking. However, limited digital literacy and technology access 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 sole focus, targeting one of three things: device access, internet access or digital literacy," says Christi Patten, Ph.D., a Mayo Clinic behavioral health researcher and a senior author of the study. "We were curious if bundling those resources would be more effective."

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

• Group 1 participants (the control) received a guide to accessing local computer and internet resources.
• Group 2 participants received a loaner computer tablet with internet connectivity and the guide.
• Group 3 participants received weekly telephone coaching to support their individual technology needs, a loaner computer tablet and the guide.

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

Coaching provides digital support on the quitting journey

The study revealed a trend toward higher engagement among participants who received additional support, particularly among those in the coaching group.

Overall, 42% of participants completed a survey at the end of the study, with the coaching group at 57%, the loaner computer tablet group at 43%, and the control group at 27%. This pattern held true for other study activities as well, such as the completion of remote testing to track smoking cessation progress.  Although the researchers acknowledged engagement could have been improved, they found the response to the interventions encouraging, particularly the response to coaching.

The researchers observed 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, abstaining from tobacco overall and using online evidence-based cessation resources. These findings, they say, point to a possible smoking-related treatment response that should be tested in a larger clinical trial.

"Changing behavior is incredibly hard," says Andrea Cheville, M.D., a Mayo Clinic physical medicine and rehabilitation physician and a 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 on their quitting journey."

Mary Anne Wolesky, a member of the community advisory board that co-designed the study, says studies like this tell rural residents that Mayo researchers are "in their corner" and want to help.

"There's still a lot of fear of technology in our rural communities," observes Wolesky. "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 equity is often less about the technology itself than it is about empowering people and giving them confidence to use it. 

Improving remote healthcare delivery

The researchers note that few people who smoke can quit without help; however, people who use smoking cessation resources such as counseling tend to be more successful. For this reason, the researchers say it is vital to improve access to smoking cessation services in rural communities.

"Rural residents have potentially 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 demonstrate that digital access interventions, particularly digital literacy coaching, can help bridge the digital divide for rural communities. These findings are especially important in the current era of rapidly evolving digital healthcare.

"If we don’t develop strategies to broadly enfranchise rural dwellers, we risk aggravating disparities 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-engaged research. In future studies they plan to focus on refining their digital access and literacy interventions, validating the smoking-related treatment response, 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 to 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. Review the study for a complete list of authors, disclosures and funding.

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