ABSTRACT Rural residents are both more likely to smoke cigarettes and less likely to quit than their urban counterparts. Consequently, individuals in rural areas have a 7% higher incidence of tobacco-associated cancers. Comprehensive smoking cessation treatment dissemination strategies are needed to increase utilization of evidence-based treatment, improve cessation outcomes, and ultimately decrease cancer incidence among rural smokers. Primary care providers (PCPs) see 70% of smokers annually, and rural residents are more likely than urban residents to have a usual source of health care. As such, primary care offers a ripe opportunity to deliver cessation treatment to rural smokers. All primary care practices that qualify for Centers for Medicare and Medicaid Services reimbursement are required to maintain electronic health records (EHRs) with coded smoking status data for adult patients. These data can be utilized to proactively identify smokers and deliver remote treatment. Our team recently completed a pilot study to develop, refine, and preliminarily evaluate a proactive asynchronous smoking cessation electronic visit (e-visit) delivered via the EHR. The goal of the e-visit is to automate best practice guidelines for cessation treatment via primary care to ensure that all smokers receive an evidence-based intervention. An initial baseline e-visit gathers information about smoking history and motivation to quit, followed by an algorithm to determine the best FDA-approved cessation medication to prescribe. A one- month follow-up e-visit assesses progress toward cessation. Clinical outcomes of our pilot (N=51 followed for three months) were promising. Among rural participants who received the e-visit (n=6), 17% reported 7-day point prevalence abstinence (PPA), 67% reduced their cigarettes per day (CPD) by >50%, and 50% used a cessation medication. E-visit participants, relative to treatment as usual (TAU), were 4.2 times more likely to report 7-day PPA, 4.1 times more likely to have reduced their CPD by >50%, and 4.7 times more likely to have used a cessation medication. Acceptability outcomes were strong, with 100% of rural e-visit participants reporting that they would use an e-visit again in the future. These data suggest that the e-visit may be a feasible, efficacious approach to extend the reach of evidence-based cessation treatment via rural primary care. We now propose a Hybrid Type I effectiveness-implementation trial to comprehensively assess e-visit effectiveness relative to TAU while simultaneously evaluating implementation when delivered across rural primary care settings. Effectiveness outcomes will be assessed through 6-months of follow-up and include: 1) biochemically verified 7-day PPA, 2) reduction in CPD, and 3) evidence-based cessation treatment utilization. Implementation outcomes will be assessed at patient, provider, and organizational levels. This trial has the potential to expand cessation treatment access in a manner scalable across rural healthcare systems and ultimately reduce rural cancer disparities.

PROJECT NARRATIVE Primary care providers are the gateway to reaching rural smokers but need resources to deliver evidence-based cessation treatment uniformly to all. The widespread adoption of Electronic Health Record (EHR) systems with coded smoking status data offers a ripe opportunity to proactively provide treatment. The present research project will test the clinical effectiveness and evaluate implementation of an asynchronous smoking cessation electronic visit that will be delivered proactively via the EHR to all rural smokers.