Individuals with chronic obstructive pulmonary disease (COPD) who live in rural areas of the United States have worse health outcomes compared with their non-rural counterparts, outcomes not completely explained by higher rates of cigarette smoking. Both ongoing cigarette exposure and environmental exposures other than cigarettes, including particulate matter (PM) air pollution, are associated with worse COPD morbidity. Use of solid fuels (e.g. wood and pellet) for heating is common in rural areas and can generate high concentration of indoor PM. However, there is a common belief is that rural areas are free from air pollution, and rural residents are often not aware of pollution sources within their own homes and communities. There are few studies that assess environmental exposures, their association with COPD morbidity, and the risk perceptions of such exposures in rural areas of the United States. There is thus a critical need to examine prevalence, predictors, and perceptions of environmental exposures in rural areas in order to inform development of targeted, rural-relevant interventions designed to mitigate exposure. Our long-term goal is to identify potentially modifiable environmental risk factors that contribute to greater COPD morbidity in rural US, leading to future targeted interventions designed to improve outcomes. Our overall objective for this application is to determine the association of environmental exposures with respiratory morbidity in individuals with COPD living in rural areas, and to explore the risk perceptions of such exposures. Our central hypothesis is that rural COPD patients are at increased risk of adverse respiratory outcomes due to environmental characteristics both inside and outside of the home, exposures which are influenced by social and economic factors that are common in rural areas. The rationale for this project is that identifying the sources, health effects, and risk perceptions of environmental exposures will inform development of a future comprehensive intervention that is sensitive to the needs and priorities in a population where continued inhalational exposures are associated with disease progression and death. We will recruit 75 individuals with COPD living in northern New England (NNE), and comprehensive environmental exposure assessment will be paired with extensive clinical outcomes to address the following aims: 1) To identify individual and community characteristics that are associated with environmental exposures (e.g. solid fuel use, tobacco use, PM concentration) among those with COPD living in NNE; 2) To quantify the relationship between environmental exposures (e.g. solid fuel use, tobacco use, PM concentration) and morbidity in individuals with COPD living in NNE; and 3) To use semistructured interviews and focus groups to explore risk perceptions, knowledge, attitudes, and behaviors surrounding environmental risk factors and potential strategies to mitigat...