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The implementation of cigarette smoking abstinence reinforcement programs may be hindered by the time intensive burden placed on patients and treatment providers. The use of remote monitoring and reinforcement of smoking abstinence may enhance the accessibility and acceptability of this intervention, particularly in rural areas where transportation can be unreliable and treatment providers distant. This study determined the effectiveness of an Internet-based abstinence reinforcement intervention in initiating and maintaining smoking abstinence in rural smokers. Sixty-eight smokers were enrolled to evaluate the efficacy of an Internet-based smoking cessation program. During the 6-week intervention period, all participants were asked to record 2 videos of breath carbon monoxide (CO) samples daily. Participants also typed the value of their CO readings into web-based software that provided feedback and reinforcement based on their smoking status. Participants (n=35) in the Abstinence Contingent (AC) group received monetary incentives contingent on recent smoking abstinence (i.e., CO of 4 parts per million or below). Participants (n=33) in the Yoked Control (YC) group received monetary incentives independent of smoking status. Participants in the AC group were significantly more likely than the YC group to post negative CO samples on the study website (OR = 4.56; 95% CI = 2.18–9.52). Participants assigned to AC were also significantly more likely to achieve some level of continuous abstinence over the 6-week intervention compared to those assigned to YC. These results demonstrate the feasibility and short-term efficacy of delivering reinforcement for smoking abstinence over the Internet to rural populations.

Purpose: On average, adults aged 60 years or older have 2.2 chronic diseases, contributing to the over 60 million Americans with multiple morbidities. We aimed to understand the financial implications of the most frequent multiple morbidities among older adults. Design and Methods: We analyzed Health and Retirement Study data, determining out-of-pocket medical expenses from 1998 and 2002 separately and examining differences in the impact of multiplemorbidity constellations on these expenses. We paid particular attention to the most common disease constellations-hypertension, arthritis, and heart disease. Results: An increasing prevalence of multiple morbidity (58% compared with 70% of adults had two or more chronic conditions in 1998 and 2002, respectively) was accompanied by escalating out-ofpocket expenditures ($2,164 in 1998, increasing by 104% to $3,748 in 2002). Individuals with two, three, and four chronic conditions had health care expenditure increases of 41%, 85%, and 100%, respectively, over 4 years. Such patterns were particularly noticeable among the oldest old, those with higher educational attainment, and women, although having supplementary health insurance or Medicaid mitigated these expenses. Finally, there were significant differences in out-of-pocket expenditure levels among the multiple-morbidity combinations. Implications: Increasing rates of multiple morbidities in conjunction with escalating health care costs and stable or declining incomes among elders warrant creative attention from providers, researchers, and policy makers. Further understanding how specific multiple-morbidity constellations impact outof-pocket spending moves us closer to effective interventions to support vulnerable elders.

Researchers have long held that fatalism (the belief in a lack of personal power or control over destiny or fate) constitutes a major barrier to participation in positive health behaviors and, subsequently, adversely affects health outcomes. In this paper, we present two in-depth, ethnographic studies of rural women's health decisions surrounding cancer treatments to illustrate the complexity and contestability of the long-established fatalism construct. Narrative analyses suggest that for these women, numerous and complex factors-including inadequate access to health services, a legacy of self-reliance, insufficient privacy, combined with a culturally acceptable idiom of fatalism-foster the use of, but not necessarily a rigid conviction in, the notion of fatalism.

Approximately three quarters of middle aged and older adults have at least two simultaneously occurring chronic conditions ("multiple morbidity" or MM), a trend expected to increase dramatically throughout the world. Rural residents, who tend to have fewer personal and health resources, are more likely to experience MM. To improve our understanding of the ways in which vulnerable, rural residents in the U.S. experience and manage MM, we interviewed twenty rural Appalachian residents with MM. We identified the following themes; (a) MM has multifaceted challenges and is viewed as more than the sum of its parts; (b) numerous challenges exist to optimal MM self-management, particularly in a rural, under-resourced context; however, (c) participants described strategic methods of managing multiple chronic conditions, including prioritizing certain conditions and management strategies and drawing heavily on assistance from informal and formal sources.

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