PROJECT SUMMARY While cigarette smoking has declined nationally, its prevalence remains higher among those living in rural areas, who experience a disproportionate number of the deaths caused by smoking. Directly contributing to the rural-urban smoking disparity is a lower rate of smoking cessation among rural residing people who smoke (RPWS). Limited access to cessation treatments like nicotine replacement therapies (NRT) because of reduced heath care access is an important contributing factor. Concerns about the high costs of NRT, along with misperceptions about NRT safety and efficacy, are also common. A pragmatic strategy to increase access to cessation services is the provision of a free NRT starter kit (with NRT education) to RPWS—an approach that could be adopted by local public health departments, health organizations, and insurance companies and that has the potential to impact multiple domains of influence (i.e., behavioral, health care system). Previous research supports the potential efficacy of providing people who smoke with free NRT starter kits, but research is needed to evaluate the effectiveness of such an approach when implemented outside of primary care, since RPWS are less likely to have routine healthcare encounters, and when NRT education is offered via digital modalities, consistent with available resources and preferences voiced by RPWS. On the other hand, NRT and traditional cessation methods may not work for all RPWS. For these individuals, education about reduced harm and exposure (RHE) tobacco products (e.g. e-cigarettes, snus) may be a secondary approach to smoking cessation and to harm reduction. Overall, our goal is to inform the evidence base on what works for rural America to quit smoking and to advance health equity. We will use a randomized controlled trial (Aim 1) to determine the efficacy of providing an NRT starter kit to RPWS referred to digital smoking cessation resources. We will randomize RPWS (n=544) interested in a quit smoking program to weekly referrals to an existing digital resource (Smokefree.gov) alone or with a mailed NRT starter kit. We hypothesize that directly mailing an NRT starter kit (linked with digital NRT education) will increase smoking abstinence from combustible tobacco products at a 3-month follow-up. For those not successful in quitting using either method, we will explore the efficacy of providing education about RHE tobacco products as a potential secondary pathway towards cessation and harm reduction (Aim 2). Leveraging a SMART design, we will re-randomize these individuals to receive RHE product education messaging or continued referrals to Smokefree.gov, hypothesizing that RHE product education will increase accurate RHE product risk perceptions and intent to use them for smoking cessation at a 3-month follow-up. Finally, we will conduct interviews with a subset of participants in each trial to contextualize responses to NRT starter kits, digital cessation resources, RHE product education, and barriers/ facilitators to smoking abstinence among RPWS (Aim 3). Across aims, we will explore potential differences by factors including race, education, sex, and degree of rurality, and be guided by an advisory board of RPWS.

PROJECT NARRATIVE Rural residing people who smoke (RPWS) have higher levels of cigarette smoking and lower rates of smoking cessation. Some barriers include a lack of access to nicotine replacement therapy (NRT) products (e.g., patches) which can help with quitting, and misperceptions about lower harm tobacco products, which are increasingly discussed in the public health community as providing potential alternative paths to smoking cessation. This study will evaluate if providing RPWS with free NRT starter kits can help them quit, and explore if providing education about lower harm tobacco products (to RPWS who have failed with traditional cessation approaches) can be another way to help them succeed.