Including smoking cessation program with treatment for PTSD shows higher rate of quitting

Nicotine dependence is more common among individuals with mental illness. "Posttraumatic stress disorder, a prevalent mental disorder, is highly associated with smoking (45 percent) and unsuccessful quit attempts. Individuals with PTSD smoke more heavily than smokers without PTSD and use tobacco to regulate mood and psychiatric symptoms. Tobacco dependence likely contributes to the high mortality, morbidity, and health care costs of persons with PTSD," according to background information in the article.

The U.S. Department of Veterans Affairs (VA) has enrolled more than 400,000 veterans with PTSD, with the majority of smokers among this group reporting having not received tobacco cessation treatment during the previous year. "An effective service delivery approach is needed to improve access to tobacco cessation treatment for patients with PTSD and other psychiatric illnesses," the authors write.

In a multisite randomized controlled trial, Miles McFall, Ph.D., of the Veterans Affairs Puget Sound Health Care System, Seattle, and colleagues hypothesized that integrating smoking cessation treatment into mental health care would improve long-term smoking abstinence rates in veterans with PTSD compared with referral for specialized cessation treatment. The trial included 943 smokers with military-related PTSD who were recruited from outpatient PTSD clinics at 10 Veterans Affairs medical centers and followed up for 18 to 48 months between November 2004 and July 2009. Participants received either smoking cessation treatment integrated within mental health care for PTSD delivered by mental health clinicians (integrated care [IC]) or were referred to Veterans Affairs smoking cessation clinics (SCC).

The researchers found that the IC group had a higher bioverified (verified from measures such as exhaled carbon monoxide or urine cotinine levels) prolonged abstinence (12 months) rate than the SCC group did, with 42 patients (8.9 percent) in IC and 21 patients (4.5 percent) in SCC achieving bioverified prolonged abstinence. The treatment effect was consistent across all subgroups. Differences in bioverified point prevalence abstinence between the IC and SCC groups were largest at 6 months for both 7-day (16.5 percent for IC vs. 7.2 percent for SCC) and 30-day (13.8 percent for IC vs. 5.9 percent for SCC) abstinence, and remained significant at 18 months (7-day abstinence: 18.2 percent for IC vs. 10.8 percent for SCC; and 30-day abstinence: 16.9 percent for IC vs. 9.3 percent for SCC). "Assuming a common treatment effect over time, patients in the IC group were twice as likely as patients in the SCC group to achieve 7-day and 30-day abstinence between 3 and 18 months," the authors write.

Patients in the IC group attended more cessation sessions than did patients in the SCC group and were more likely to use smoking cessation medications. "Number of counseling sessions received and days of cessation medication used explained 39.1 percent of the treatment effect. Between baseline and 18 months, psychiatric status did not differ between treatment conditions. Posttraumatic stress disorder symptoms for quitters and nonquitters improved," according to the researchers.

"Delivering cessation assistance as part of primary mental health treatment was both more effective than referral and led to greater intensity of treatment utilization, a major factor in treatment effectiveness. Integrated care could be applied to the sizable proportion of smokers among the approximately 400,000 veterans enrolled in VA care for PTSD. Study findings have further potential to extend to the 10 million individuals in the United States who receive mental health treatment annually, of whom an estimated 41 percent are smokers. Initiatives to disseminate IC as an evidence-based practice within the VA are under way to meet the challenge of making tobacco cessation treatments available to veterans who need them. These efforts take on particular salience with the cohort of younger Iraq and Afghanistan veterans with PTSD for whom stopping smoking now could prevent long-term adverse health sequelae," the authors conclude.

Editorial: Integrating Tobacco Treatment Into Mental Health Settings

In an accompanying editorial, Judith J. Prochaska, Ph.D., M.P.H., of the University of California, San Francisco, writes that the results of this trial demonstrate a significant treatment effect in a diverse group of patients with PTSD.

"This multisite trial, with the advantages of large sample size and enhanced external validity, represents a significant advance in the evidence base on the effectiveness of treating tobacco dependence in smokers with mental disorders and integration of tobacco treatment services into mental health care settings. Critically, integrated care treatments are needed to reverse the clinical practices that have served to maintain the high rates of tobacco use and tobacco-related morbidity and mortality among individuals with mental illness. Future study needs include application in broader community mental health care settings and diagnostic patient groups. The study by McFall et al represents a major step forward on the path to abating the previously overlooked epidemic of tobacco dependence that has plagued persons with mental illness."