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OPINION
published: 18 January 2021
doi: 10.3389/fpubh.2020.598905
Frontiers in Public Health | www.frontiersin.org 1 January 2021 | Volume 8 | Article 598905
Edited by:
Shikha Mittoo,
University of Toronto, Canada
Reviewed by:
Sonu Bhaskar,
Liverpool Hospital and South West
Sydney Local Health District
(SWSLHD), Australia
*Correspondence:
Ashley L. Merianos
ashley[email protected]
Specialty section:
This article was submitted to
Digital Public Health,
a section of the journal
Frontiers in Public Health
Received: 25 August 2020
Accepted: 21 December 2020
Published: 18 January 2021
Citation:
Merianos AL, Fevrier B and
Mahabee-Gittens EM (2021)
Telemedicine for Tobacco Cessation
and Prevention to Combat COVID-19
Morbidity and Mortality in Rural Areas.
Front. Public Health 8:598905.
doi: 10.3389/fpubh.2020.598905
Telemedicine for Tobacco Cessation
and Prevention to Combat COVID-19
Morbidity and Mortality in Rural
Areas
Ashley L. Merianos
1
*
, Bradley Fevrier
2
and E. Melinda Mahabee-Gittens
3,4
1
School of Human Services, University of Cincinnati, Cincinnati, OH, United States,
2
Department of Public and Allied Health,
Bowling Green State University, Bowling Green, OH, United States,
3
Division of Emergency Medicine, Cincinnati Children’s
Hospital Medical Center, Cincinnati, OH, United States,
4
College of Medicine, University of Cincinnati, Cincinnati, OH,
United States
Keywords: smoking, electronic nicotine delivery systems, smoking cessation, telemedicine, coronavirus
disease (COVID)-19
INTRODUCTION
The coronavirus disease 2019 (COVID-19) outbreak has reached pandemic proportions with a
large global footprint (
1). In December 2019, COVID-19 was first reported in Wuhan, Hubei
Province, China (1). On 28 January 2020, the National Health Commission of People’s Republic
of China released national strategies for assisting prevention efforts for rural areas and the older
adult population (
2). Nevertheless, this outbreak was not contained, and as of 16 December 2020 , it
has spread to 191 countries resulting in over 74 million cases and 1,646,687 deaths worldwide (3).
To date, over 16.9 million cases and 307,064 deaths have been reported in the United States
(U.S.), with numbers climbing disproportionately on a day-to-day basis (3). New epidemiologic
and clinical evidence is constantly evolving related to this infection while the pandemic is hastily
progressing worldwide. R api d efforts are needed to protect vulnerable populations including those
living in rural areas. For example, before th is pandemic, U.S. urban hospit a ls were over twice as
likely to have growth in number of intensive care unit (ICU) beds available over a 1-year period
compared to rural hospitals (4). Thus, rural hospitals are not as likely to have the higher level of
resources and medical care needed for this crisis. Preventive and resource allocation strategies [e.g.,
ventilator availability (5)] are needed to reach and care for vulnerable rural populations.
To help address this public he alth challenge, telemedicine efforts have greatly expanded to
provide a “safety-net” of medical and preventive care for vulnerable populations worldwide (6, 7).
Although offering telemedicine services in rural areas is encouraged to reduce in-person infection
risks, geographical disparities exist in the access and availability of telemedicine. This is in part due
to unreliable internet in some U.S. and international rural areas (
7, 8). Economic-related concerns
for offering virtual services in rural areas include we ak ened healthcare system infrastructures,
physician shortages, and a disproportionate number of residents having low-income, no health
insurance, or inadequate insurance coverage for telemedicine visits (
9).
Merianos et al. Telemedicine for Tobacco Cessation
TABLE 1 | Prevalence of current tobacco product use overall, and by rural-urban
geographical location among U.S. Adults >18 years old.
Current product use type
a
Overall Rural Urban
Any tobacco product 25.4% 35.0% 31.0%
Cigarettes 20.6% 28.5% 25.1%
Cigars 4.8% 2.6% 4.6%
Smokeless Tobacco 3.4% 8.6% 6.0%
E-Cigarettes
b
- 2.8% 2.1%
e-cigarettes, electronic cigarettes.
a
Data from SAMHSA, 2017 (
16).
b
Data from Mumford et al., 2019 (
17). Overall e-cigarette prevalence statistic was
not provided.
There is a call to action to address COVID-19 disparities
that are disproportionately affecting vulnerable communities,
including those: living in remote areas, with chronic diseases and
risk factors such as tobacco use, and from low socioeconomic
backgrounds (
10). An early systematic literature review (11)
hypothesized that smoking behavior may be associated with
adverse progression of COVID-19, and a subsequent meta-
analysis discovered that smokers were nearly two times more
likely to have severity progression than non-smokers (
12).
However, there are limited data available on the clinical
characteristics of COVID-19 infected individuals living in rural
areas. The purpose of this commentary is to rev iew information
on existing U.S. tobacco use disparities in rural areas and
knowledge available on tobacco use and COVID-19 outcomes.
We also provide suggestions on future directions for tobacco
cessation efforts reaching rural smokers during this pandemic.
TOBACCO USE AND COVID-19
Tobacco Use and COVID-19 Disparities
Among U.S. Rural Adults
Tobacco users living in U.S. rural areas may represent
an additional subgroup at risk for higher COVID-19-
related morbidity. Irrespective of COVID-19, individuals
living in rural areas have high rates of tobacco use and
related morbidity compared to urban or metropolitan
area dwellers due to several factors including: low income,
low educational attainment, higher social acceptability
to tobacco use, permissive tobacco control policies, and
lack of healthcare access (
13, 14). Rural communities are
heterogenous in nature, but low socioeconomic indicators
largely contribute to the rural-urban disparity gap of poor
health behaviors such as smoking and COVID-19 mortality
rates (15).
Table 1 shows that U.S. rural residents generally have
higher tobacco use rates and lower smoking cessation rates
than urban residents (16–19). Rural adult residents also
have a high prevalence of smoking-related, long-term health
consequences and causes of mortality (
20). Over one-quarter
(26%) of rural adult residents have one chronic health
condition (e.g., diabetes) and about 36% have two or more
conditions (
21). The top leading causes of death among rural
dwellers include cancer, heart disease, chronic lower respiratory
disease, and stroke (22). The Centers for Disease Control
and Prevention indicates that those deemed high risk for
severe COVID-19 are older adults, individuals with medical
conditions including those with lung disease, heart conditions,
and diabetes, and individuals living in rural communities
(
23). A meta-analysis (24) suggests smoking and chronic
health conditions are the most common underlying factors
reported among patients hospitalized for COVID-19. Given
that rural residents have high rates of combustible and non-
combustible tobacco/nicotine product use and related chronic
health conditions that place them at risk for poor health
outcomes and excess mortality, it is important to synthesize t he
evidence available on adverse COVID-19 specific outcomes in
this population.
Tobacco Use and COVID-19-Related
Morbidity and Mortality
The initial epidemiological and clinical data available
retrospectively assessed adult patients who sought treatment in
Wuhan where COVID-19 first emerged (
25–28). It is important
to note t hat approximately 45% of individuals in China reside in
rural areas and face similar issues to the U.S. rural population,
such as lack of healthcare access and affordability (29, 30). These
studies report that patients who presented with COVID-19 had
symptoms similar to commonly reported symptoms of tobacco
use (e.g., cough, respiratory-related symptoms) as outlined
by the U.S. Surgeon General (20). Patients presenting with
COVID-19 also had high rates of comorbidities (25–27, 31) that
have been causally linked to tobacco use including hypertension,
cardiovascular disease, and diabetes (20).
Recent literature reviews found that tobacco use is associated
with poor disease progression (32), and that severe COVID-19
outcomes among tobacco users are further perpetuated among
those with these pre-existing conditions (33). One study found
patients with a smoking history were over 14 times more likely
to experience disease progression than patients with no smoking
history after adjustment for important factors including patient
age (
27). Additional research reports that over one-fourth (26%)
of current smokers and about 8% of former smokers were
admitted to the ICU, needed mechanical ventilation, or died
(17). Concerning COVID-19 mortality-related risk factors, of
11 admitted patients who were current smokers in China, five
did not survive (28). A more recent U.S. study found that
current smokers, when compared to never smokers, were at
increased risk of needing mechanical ventilation, having severe-
to-critical illness, lower survival time in days, and more deat hs
(34). Concerning non-combustible tobacco products, a study
found that 13–24-year-olds who engaged in exclusive e-cigarette
use and dual-use of e-cigarettes and combustible cigarettes
were at significantly increased odds to have positive COVID-
19 diagnoses, while accounting for clustering by U.S. states and
regions (
35). Despite limitations of the rapidly emerging available
data, such as relying on electronic medical record data for
smoking status, it is likely that combustible and non-combustible
Frontiers in Public Health | www.frontiersin.org 2 January 2021 | Volume 8 | Article 598905
Merianos et al. Telemedicine for Tobacco Cessation
tobacco product use influences COVID-19 progression and
negative healt h outcomes including deat h . Thus, a recent review
concluded that smoking cessation is expected to reduce COVID-
19-related risks and severe complica tions, and acknowledged
telemedicine as one tool that can be employed to promote
quitting smoking (
36).
Telemedicine for the Treatment of Tobacco
Use and Dependence During and Beyond
COVID-19
A recent epidemiologic model that has informed related
policy suggests that public health measures including physical
distancing would be needed for 3 months to decrease the
COVID-19 peak impact on the healthcare system (
37).
The model suggests these measures should be maintained
intermittently over 12–18 months while the disease remains
detected in individuals and until a vaccine is made widely
available (
37). Social distancing mandates naturally reinforce
the need to rapidly implement or augment communication
modalities that can be used with individuals and groups who may
not be able to meet face-to-face and live in multiple locations
(38). Fortunately, there are many tobacco cessation programs
that have already expanded their reach to rural tobacco users
with high prevalence rates (39) who may have limited access
to in-person programs, irrespective of COVID-19 restrictions.
These programs have demonstrated accept ability and efficacy
and include smokefree.gov and other internet-based programs
(
40, 41), telephone programs (e.g., tobacco Quitline) (42) and
mobile phone-based programs (e.g., texting) (43). Therefore, it
is important to expand the reach of telemedicine to address
the rural-urban geographic inequities and improve the access,
delivery, and efficiency of preventive healt h services among rural
areas globally (7).
Promoting Evidence-Based Treatment for
Tobacco Use and Dependence Delivered
via Telemedicine to Rural Areas During and
Beyond COVID-19
In light of the concerns t hat tobacco use increases the risk
of COVID-19-related morbidity and mortality, measures are
needed to mitigate illness progression in infected individuals.
Given concerns about contracting COVID-19 and evidence of
possible incre ased risk for smokers and vapers, this pandemic
may have a positive impact on decreasing smoking and
vaping rates. During this pandemic, telemedicine modalities
can continue to provide, expand, and improve the delivery of
evidence-based information, which includes the “5 A’s of tobacco
cessation (
44).” The first step is to Ask about tobacco use—this
would be complete if the smoker has enrolled into a program. The
second step is to Advise to quit—during this step, telemedicine-
based programs should capitalize on this “teachable moment”
(45) by incorporating messaging that leverages concerns about
COVID-19 and the benefits of quitting smoking and/or vaping
as a way to reinforce the “Advise” portion. There are increases
in smoking abstinence rates when cessation interventions are
conducted during “teachable moments” such as during children’s
visits for acute illnesses (
46), during cancer screenings (47), when
having a cancer diagnosis (48), when initiating HIV treatment
(49), and during pregnancy (50). The third step is to Assess
readiness to quit—this can be easily assessed by phone-, video-,
or web-based programs. The fourth step is to Assist in quitting—
this includes the recommendation to offer pharmacotherapy such
as nicotine replacement therapy, which has shown efficacy in
increasing cessation rates (
51). The fifth step is t o Arrange follow-
up—during this time of social isolation, tobacco users need help
and support. The knowledge that there are many options such as
online chat groups or telephone counselors that are available will
provide th em with much needed support and encouragement.
Incorporating telemedicine during this critical period
may increase its use among remote and hard-to-reach rural
populations over time. One U.S. cancer center successfully
used telemedicine to deliver individual and group tobacco
treatment virtually to tobacco-dependent cancer patients
(52). They reported improved attendance and engagement at
telehealth visits compared to prior in-person visits. Another
study conducted among current smokers <25 years old who
participated in the Youth Quitline services in Hong Kong
found that over 4-in-10 agreed the pandemic was a motivator
to quit tobacco use, over 7-in-10 changed their tobacco use
habits due to public health measures (e.g., wearing a mask), and
nearly 6-in-10 reduced their daily cigarette consumption (53).
Therefore, telemedicine has the potential to decrease patient-
level barriers to in-person tobacco cessation treatment among
all ages worldwide, such as lack of transportation, childcare,
and travel costs. Moreover, the opportunity to offer continuous
cessation encouragement and support may also increase quit
rates during and beyond COVID-19 restrictions.
DISCUSSION
Public health campaigns that reach vulnerable rural populations
are highly warranted to promote the availability of remote
tobacco cessation and prevention initiatives during this
pandemic. Rural populations have h igher rates of poverty,
chronic illnesses, poor healthcare access, and lack of insurance—
all of which are risk factors for COVID-19 (
8, 9). Thus,
they could greatly benefit from low-cost telemedicine
programs that are easily accessible to de c rease tobacco-
related morbidity. Some countries have implemented tobacco
product sales bans and other policy measures during the
pandemic to help mitigate possible viral transmission (e.g.,
sharing tob acco products), which provides an exceptional
opportunity to decrease the global tobacco use burden
(54). In addition to telemedicine services, these measures
include leveraging new te chnology to encourage and
support tobacco users to quit smoking with evidence-based
resources. For example, the tobacco Quitline number could
be promoted among rural smokers and vapers. Healthcare
professionals and tobacco treatment specialists who interact
with rural residents, for example, should be involved in
offering evidence-based tobacco cessation interventions via
telemedicine. Large-sca le public health interventions delivered
Frontiers in Public Health | www.frontiersin.org 3 January 2021 | Volume 8 | Article 598905
Merianos et al. Telemedicine for Tobacco Cessation
via telemedicine should be targeted to tobacco users who live in
rural are as.
AUTHOR CONTRIBUTIONS
AM conceptualized the article, drafted the manuscript, and
approved the final manuscript as submitted. BF conceptualized
the article, drafted the manuscript, and approved the final
manuscript as submitted. EM-G conceptualized t h e article,
drafted the manuscript, and approved the final manuscript as
submitted. All authors contributed to the article and approved
the submitted version.
FUNDING
This work was supported by the National Institute on
Drug Abuse (NIH Grant Number K01DA044313 to AM)
and National Insti tute of Environmental Health Sciences
(NIH Grant Numbers R01ES027815 and R01ES030743
to EM-G).
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Conflict of Interest: The authors declare that the research was conducted in the
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Frontiers in Public Health | www.frontiersin.org 5 January 2021 | Volume 8 | Article 598905
