• drug abuse;
  • epidemiology;
  • family medicine;
  • health promotion;
  • observational data


Purpose: As many smokers experience repeated failures with cessation attempts, it has been postulated that we may create a cadre of highly resistant smokers who are unlikely to engage in treatment or succeed in quitting. Our purpose was to follow a group of recalcitrant rural smokers and examine their ongoing engagement in smoking cessation activities.

Methods: At the end of a 24-month disease management program for rural smokers, we identified participants who reported ongoing daily smoking despite exposure to 4 previous cycles of smoking cessation interventions. At month 36 (1 year after conclusion of the study), we contacted these participants and assessed changes in smoking status and ongoing engagement in cessation activities over the preceding 6 months. We assessed quit attempts and use of pharmacotherapy during the prior 6 months, as well as smoking abstinence at 36 months.

Findings: Among 333 recalcitrant smokers, 49% reported at least one 24-hour quit attempt during the preceding 6 months, 29% tried smoking cessation pharmacotherapy, and 5% quit smoking. Significant predictors of having at least one 24-hour quit attempt were lower numbers of cigarettes smoked per day, being in preparation stage of change, and more pharmacotherapy-assisted quit attempts during the original 24-month trial. Higher motivation to quit and more previous pharmacotherapy-assisted quit attempts significantly predicted cessation medication use. Use of varenicline was strongly associated with cessation.

Conclusions: Many recalcitrant rural smokers continue to engage in treatment and make quit attempts even in the absence of active interventions.