Smoking cessation program plus PTSD treatment shows higher rate of quitting

Among smokers with military-related post-traumatic stress disorder (PTSD), integrating smoking cessation treatment with mental health care for PTSD resulted in higher rates of prolonged smoking abstinence, compared to referral for assistance with quitting smoking, according to a study in the 8 December issue of JAMA.

Nicotine dependence is more common among individuals with mental illness. “Post-traumatic stress disorder, a prevalent mental disorder, is highly associated with smoking (45 per cent) 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 US 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 randomised controlled trial, Miles McFall, PhD, of the Veterans Affairs Puget Sound Health Care System, Seattle, and colleagues hypothesised that integrating smoking cessation treatment into mental health care would improve long-term smoking abstinence rates in veterans with PTSD compared with referral for specialised cessation treatment. The trial included 943 smokers with military-related PTSD who were recruited from outpatient PTSD clinics at 10 Veterans Affairs medical centres 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 per cent) in IC and 21 patients (4.5 per cent) 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 per cent for IC vs. 7.2 per cent for SCC) and 30-day (13.8 per cent for IC vs. 5.9 per cent for SCC) abstinence, and remained significant at 18 months (7-day abstinence: 18.2 per cent for IC vs. 10.8 per cent for SCC; and 30-day abstinence: 16.9 per cent for IC vs. 9.3 per cent 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 counselling sessions received and days of cessation medication used explained 39.1 per cent of the treatment effect. Between baseline and 18 months, psychiatric status did not differ between treatment conditions. Post-traumatic 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 utilisation, a major factor in treatment effectiveness. Integrated care could be applied to the sisable 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 per cent 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.

(Source: JAMA/Archives: JAMA)